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

  1. Swelling and Bruising in recent Trauma
  2. Scars suggesting old Trauma
  3. Observable deformity
    1. Sternoclavicular Joint
    2. Clavicle
    3. Acromioclavicular joint
    4. Glenohumeral joint (in acute dislocations)
  4. 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

III. 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 tenderness in both Shoulders
    5. Deformity and focal tenderness: 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
        1. 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

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

  1. Shoulder Range of Motion
    1. See Shoulder Range of Motion (forward flexion, abduction)
    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)
  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

V. 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

VI. References

  1. Kiel and Koneru (2019) Crit Dec Emerg Med 33(9): 17-27

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