II. Exam: Telemedicine

  1. See Telemedicine
  2. Patient should expose both Shoulders for exam (e.g. tank top, sports bra)
  3. Perform observation (see below) with patient turning a full 360 degrees and comparing opposite side
  4. Patient palpates Shoulder joint at specifically directed points (see below)
  5. Patient should perform Shoulder Range of Motion (forward flexion, abduction, rotation)
  6. Test specific Shoulder strength (see below)
    1. Use Household Item Weights for resistance
  7. Example: Rotator Cuff Testing
    1. Supraspinatus Tests
      1. Patient lifts an object in Shoulder forward flexion (with elbow flexed at 30 degrees)
      2. Drop arm sign
        1. Patient fully abducts arm and then adducts arm back into position
        2. Positive for Rotator Cuff Tear if arm drops suddenly due to pain or weakness
    2. Infraspinatus and teres minor test (external rotation against resistance)
      1. Patient lies on unaffected side and externally rotates Shoulder against gravity or with weight
    3. Subscapularis Test (Apley Scratch Test)
      1. Patients stands with affected lateral side facing camera
      2. Patient internally rotates arm with hand against the Scapula
      3. Patient pushes hand away from the back

III. Exam: Inspection and Observation (from all angles and with Shoulder fully exposed)

  1. General appearance (comparing with opposite side)
    1. Erythema
    2. Deformity
    3. Swelling or joint effusion
    4. Ecchymosis (recent Trauma)
    5. Overlying skin changes
    6. Scars suggesting old Trauma
  2. Observable deformity
    1. Sternoclavicular Joint
    2. Clavicle
    3. Acromioclavicular joint
    4. Glenohumeral joint (in acute dislocations)
  3. Asymmetry
    1. Disuse atrophy of the supraspinatus Muscle
      1. Chronic Rotator Cuff Tear or Shoulder Impingement
      2. Efficacy of atrophy as test for Rotator Cuff Syndrome
        1. Test Sensitivity: 56%
        2. Test Specificity: 73%
    2. Shoulder sag
      1. Cranial Nerve 11 disorder
    3. Sulcus at glenohumeral joint
      1. Seen with acute Shoulder Dislocation

IV. Exam: Palpation

  1. Grading of pain
    1. No pain: 0
    2. Mild pain: 1
    3. Moderate: 2
    4. Severe: 3
  2. Technique
    1. Both Shoulders exposed
    2. Palpate for atrophy or swelling
    3. Assess contour of Shoulder
    4. Palpate for deformity and focal tenderness (palpate for tenderness in both Shoulders)
    5. Palpate landmarks in order (anterior, medial to lateral, then to Scapular and spine)
      1. Sternoclavicular Joint
      2. Clavicle
      3. Acromioclavicular joint
        1. Acromioclavicular Joint Osteoarthritis or
        2. AC Seperation
      4. Coracoid Process
      5. Humeral Head
      6. Glenohumeral joint (in acute dislocations)
      7. Greater Tuberosity
      8. Lesser Tuberosity
      9. Bicipital Groove and Biceps tendon (Bicipital Tendonitis)
      10. Scapular Spine
      11. Cervical Spine
    6. Palpate fibromyalgia Tender Points at occiput and medial trapezius Muscle
      1. Assess for comorbid Myofascial Pain

V. Exam: Specific Shoulder Tests (see categories below for full descriptions)

  1. Shoulder Range of Motion
    1. See Shoulder Range of Motion (forward flexion, abduction, rotation)
    2. Apley Scratch Test (internal and external Shoulder rotation)
    3. Evaluate passive and active range of motion
  2. Shoulder Strength Exam
    1. French Horn Shoulder Test
    2. Lift-Off Subscapularis Test
    3. Empty Cans Test or Full Cans Test (Supraspinatus)
    4. Drop Arm Test (Supraspinatus)
    5. Speeds Test (Bicipital tendon)
    6. Yergason Test (Bicipital tendon)
    7. Rotator Cuff Triad Test (Rotator Cuff Tear)
    8. Wall Push Up (evaluate for Scapular Winging)
  3. Shoulder Instability Exam
    1. Shoulder Apprehension Test (and Relocation)
    2. Shoulder Crossover Maneuver (AC Joint disease)
  4. Shoulder Impingement Signs
    1. Neer Test (Shoulder Internal Rotation and forward flexion)
    2. Hawkins Test (Internal and external rotation)
    3. Empty Cans Test (Supraspinatus)
  5. Cervical Spine Test (cervical radicular pain radiating to Shoulder)
    1. Spurling Test

VI. Exam: Neurovascular exam

  1. Radial Pulses and distal Capillary Refill
  2. Sensory Exam
    1. C6: Thumb, Index Finger, lateral Forearm (Radial Nerve)
      1. Dorsal first web space Sensation
    2. C7: Index, Middle and Ring Fingers, triceps (Median Nerve)
      1. Thenar eminence Sensation
    3. C8: Middle, Ring and Little Finger (pinky), medial Forearm (Ulnar Nerve)
      1. Hypothenar eminence Sensation
  3. Motor Exam
    1. Radial Nerve (C5-C6, C7-C8): Wrist Drop
      1. Dorsiflexion wrist, fingers against resistance (extensor carpi radialis, extensor digitorum)
    2. Median Nerve (C7, C8, T1): Cannot make 'OK' Sign
      1. Opposition of thumb and index finger against resistance
    3. Ulnar Nerve (C8-T1): Claw Hand
      1. Finger abduction against resistance

VII. References

  1. Kiel and Koneru (2019) Crit Dec Emerg Med 33(9): 17-27
  2. Yedlinsky (2021) Am Fam Physician 103(3):147-54 [PubMed]

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