import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, MedicalImage, ContentSection, SpecialTestCard, VideoEmbed } from '@/components/content' # Shoulder Examination The shoulder examination is one of the most commonly tested clinical stations. Examiners expect a fluent, systematic approach demonstrating Look-Feel-Move-Special Tests-Neurovascular assessment without rushing or causing patient discomfort. ## Quick Reference One-Pager ## Introduction and Setup **Patient Positioning:** Standing initially for inspection, then seated for detailed examination **Exposure:** Both shoulders exposed, patient in gown or with shirt removed. Ensure adequate exposure from neck to mid-arm bilaterally. **Consent Script:** "I'd like to examine your shoulders today. I'll need to look at both sides for comparison, then feel around the joints, and finally test the movements. Please let me know if anything is painful." **Essential Equipment:** None required for basic examination ## Look (Inspection) - **Deltoid contour**: Loss of rounded contour suggests wasting (axillary nerve injury, cuff tear arthropathy) - **Muscle bulk**: Compare deltoid symmetry bilaterally - **Scars**: Previous surgery (arthroscopy portals, open approach) - **Skin changes**: Bruising (acute injury), erythema (infection) - **Shoulder position**: Internally rotated (posterior dislocation), square appearance (anterior dislocation) - **Squaring**: Loss of normal rounded contour (dislocation, severe cuff tear) - **Acromial prominence**: May indicate downward subluxation - **Posture**: Forward shoulder position (protraction) - **Supraspinatus fossa**: Wasting above spine of scapula (suprascapular nerve, massive cuff tear) - **Infraspinatus fossa**: Wasting below spine of scapula (suprascapular nerve, cuff tear) - **Scapular winging**: Medial border prominence (long thoracic nerve palsy) - **Scapular position**: Asymmetry, SICK scapula - **Spine of scapula**: Palpable bony landmarks **Key Inspection Findings by Pathology:** - Anterior dislocation: Square shoulder, arm held in slight abduction and external rotation - Massive cuff tear: Supraspinatus wasting, pseudoparalysis - Long thoracic nerve palsy: Medial scapular winging on push-up ## Feel (Palpation) Start at the sternoclavicular joint and work laterally in a logical sequence: 1. **Sternoclavicular joint**: Swelling, tenderness, instability 2. **Clavicle**: Full length for fracture, tenderness 3. **Acromioclavicular joint**: Step deformity (separation), tenderness (OA, osteolysis) 4. **Acromion**: Anterior, lateral edges 5. **Greater tuberosity**: Rotator cuff insertion tenderness 6. **Bicipital groove**: Biceps tendon tenderness (between tuberosities) 7. **Coracoid process**: Deep anterior, below clavicle lateral to chest wall 8. **Spine of scapula**: Posterior landmark **Also assess:** - Temperature with back of hand - Effusion (rare in shoulder - deep joint) - Crepitus during passive movement ## Move (Range of Motion) **Painful Arc:** Pain during mid-range abduction (60-120°) suggests subacromial impingement. Pain at end range (above 120°) suggests ACJ pathology. ## Special Tests ### Rotator Cuff Tests ### Instability Tests ### Impingement Tests ### ACJ and Biceps Tests ## Neurovascular Assessment **Key Nerves:** | Nerve | Motor | Sensory | How to Test | |-------|-------|---------|-------------| | Axillary (C5,6) | Deltoid | Regimental badge area | Resisted abduction, sensation lateral shoulder | | Musculocutaneous (C5,6) | Biceps | Lateral forearm | Resisted elbow flexion | | Suprascapular (C5,6) | Supra/infraspinatus | None reliably | External rotation weakness | | Long thoracic (C5,6,7) | Serratus anterior | None | Push against wall for winging | **Reflexes:** - Biceps (C5,6): Tap biceps tendon at antecubital fossa - Brachioradialis (C5,6): Tap distal radius, observe elbow flexion - **Pulses**: Brachial (medial arm), radial and ulnar at wrist - **Capillary refill**: Normal less than 2 seconds - **Temperature**: Compare both hands - **Thoracic outlet**: Consider if numbness with arm elevation ## Complete the Examination **Always state to the examiner:** "To complete my examination, I would like to: - Examine the **cervical spine** for referred pain - Examine the **elbow** as the joint below - Perform a complete **neurovascular assessment** of the upper limb - Examine the **contralateral shoulder** for comparison - Obtain **X-rays** (AP, lateral, axillary views)" ## Summary Presentation ## Common Conditions Table ## Examiner Tips