Physical Examination of the Shoulder

The shoulder is the most flexible joint in the body. Three bones namely the humerus (upper arm bone), the scapula (shoulder blade) and the clavicle (collar bone) together make the shoulder joint. The structural arrangement of shoulder joint resembles ball and socket system, the ball of the upper arm bone moves on the narrow and small cavity of the shoulder blade, much like the golf ball on the tee placer. This structural arrangement enables a range of movements of the hands, however, it is the most unstable joint as per the bone structure, but ligaments, muscles and tendons support the joint giving the required stability to the joint.

Owing to the structural arrangement and range of motion, the shoulder joint is more susceptible to injuries. The ligaments may tear, the joint may dislocate, or bones may fracture. In all these conditions, the most common symptom you experience is an acute severe pain, chronic dull pain or pain only on motion in a specific manner. In some cases, the problem in the chest or spine may also cause shoulder pain, but a true shoulder pain does not extend below the elbow. You may also have swelling, deformity, muscle wasting and limited range of motion of the injured shoulder. You may have hurt your shoulder during sports, driving a car or an accidental fall on a slippery floor. Injuries cause pain and limit the activities. On approaching an orthopaedic physician or surgeon with the complaint of shoulder injury, the physician starts examining you and has many questions for you.

• What is the cause for your concern?
• When and where did you get hurt?
• How severe is the pain?
• Do you hear a clicking sound on overhead activities or have limited range of movement?
• Did you have any first aid or use pain medications?
• Did you have any injuries or surgeries of the shoulder in the past?

The questions continue on history of any illness, medication diary, nature of work, daily activities, and much more.

Your answers give insights to the physician in diagnosing the condition. Then the process of physical examination starts.

Physical examination is a part of diagnosis where in the physician evaluates the type and severity of injury by inspection, palpation, range of motion exercises, strength evaluation exercises and some special tests for specific shoulder problems. During the physical examination, your physician examines both affected and unaffected shoulder. Therefore, women must wear a tube top or special gown that exposes both the shoulders. Men must take off their shirt during the shoulder examination.

Doctor inspects the shoulder from front, back and the side for visual signs such as bruises, redness and swelling, drooping, winged shoulder blade, big abnormal bicep muscle resembling Popeye, thinning or wasting of the shoulder muscles and various other deformities. Any uneven findings noted in one shoulder are compared with the unaffected shoulder to have clear demarcation and conclude the abnormality.

Inspection is followed by palpation. Palpation or the touch-and-feel assessment gives more information on the type of injury. Your physician palpates different areas of the shoulder and the back including bones, joints and soft tissues both in the rest position as well as while moving the joint to assess the areas of tenderness or pain on touching.

Next phase is evaluation of range of motion possible in the affected shoulder. Shoulder is evaluated for active motion and passive motion. In active motion, the physician assesses the range of motion possible by you without any assistance in stretching the hand in various directions and movements. The movements assessed include external rotation; internal rotation; internal rotation at 90°of forward flexion, forward flexion, extension, abduction, and adduction. Ability to raise the arm to the highest point above the head is an important test, known as painful arc test, and is done frequently.

In the passive test, you need to move the shoulder joint with the assistance of another person. Passive test includes abduction, resisted internal rotation, resisted external rotation, empty can test and adduction.

Range of motion exercises helps the physician to assess the degree and smoothness of motion possible and also to know the degree of pain experienced by these movements. The difference in the ability to do a particular motion between active test and passive test is noted.

After the inspection, palpation and range of motion assessment, the physician performs certain specific tests that help in more detailed and accurate diagnosis. The two most common causes of shoulder pain are rotator cuff injuries, a group of tendons surrounding the shoulder joint, and instability of the shoulder joint. The rotator cuff disorders are characterised by positive Neer sign, Hawkins sign and painful arc test. Apprehension and relocation test concludes the shoulder dislocation; O’Brien test indicates bicep detachment; and bicep resistance test suggests bicep tendonitis.

Physical examination is an important part of diagnosis and gives more information to the physician in diagnosing the conditions. Based on the various tests done during the physical examination, your physician arrives at a decision on the type and severity of the injury. Further, if required, your physician recommends special diagnostic tests such as X-ray, CT and MRI scans to finally assess the injury.

Talk to your doctor to know more about the shoulder examination and significance of various tests.