Shoulder examination is a practical skill which requires background knowledge of anatomy, of normal shoulder function and of abnormalities affecting the shoulder. The likely diagnosis will have been derived from the history. The necessary skills can be developed by examining colleagues or patients. The background knowledge can be learned with the help of pictures and video clips. These can be found under 'Document references', below, and viewed in conjunction with the article.

Inspection

View from the rear, with the patient standing straight, and look for lateral symmetry, swelling, position of scapula and signs of muscle wasting.¹

Palpation

Palpate all over the shoulder girdle, acromioclavicular joint, deltoid and supraspinatus muscles and scapular borders feeling for pain and tenderness, crepitus, effusions, deformities and abnormal muscle development.²

Range of movement

Perform the following with the patient seated:^1,3

• External rotation - with the patient's elbow at right angles and held into side, turn the arm outwards as far as possible.
• Internal rotation - with the patient's elbow held into side, raise the arm as far as possible up the patient's back.
• Internal rotation with 90° forward flexion - support the patient's elbow and shoulder, with their elbow at right angles pointing vertically downwards and palm facing backwards, turn the forearm as far backwards as possible (see Figure 2B).⁴
• Forward flexion - start with the patient's arm at their side and lift the arm forwards and upwards as far as possible.
• Extension - with the arm by the patient's side, lift the arm backwards as far as possible.
• Abduction - with the arm at the patient's side, lift the arm away from the body as far as possible, continuing past the horizontal by allowing the shoulder to rotate externally, bringing the hand behind the head.
• Adduction - draw the patient's arm across the anterior chest wall as far as possible.

Signs in individual joint problems²

• Acromioclavicular joint - ask the patient to place their hand on their opposite shoulder. If gentle pressure on the joint elicits pain, this is indicative of acromioclavicular joint inflammation (cross-arm horizontal adduction test).
• Glenohumeral joint - with the patient lying on their back and their arm at right angles over the edge of the couch, gently push their wrist downwards. The patient will complain if the joint is unstable (apprehension test). With the patient lying on their back and the scapula stable, support their elbow and gently move the humeral head up and down in the glenoid fossa, by pressing anteriorly and posteriorly on the upper humerus, to assess laxity.
• Impingement tests - turn the patient's arm so that the thumb points downwards and lift their arm outwards and upwards. With the patient standing and their arm abducted at right angles, support the elbow and rotate the forearm internally. In both tests, pain on movement indicates impingement of the rotator cuff.
• Rotator cuffs - with the patient seated and elbows tucked into their sides, ask the patient to push both outwards and inwards, against resistance, in order to assess strength.
• Supraspinatus - ask the patient to hold both arms stretched out straight and level with the shoulders and thumbs pointed downwards. Assess strength by asking the patient to push the forearms both upwards and downwards against resistance.
• Bicipital groove - palpate the bicipital groove with the patient flexing their bicep (see Biceps Tendon Palpation picture).²

Document references

1. Shoulder Examination - videos; North East Valley Division of General Practice Victoria Australia
2. University of California; Shoulder Examination A Practical Guide to Clinical Medicine 2005; photographs
3. Range of Movement, Sports Coach, 2009
4. Lamar D, Williams G, Iannotti J et al, Posterior Instability of the Glenohumeral Joint: Diagnosis and Management, University of Pennsylvania Orthopaedic Journal 2001;14:2001 5-14