This post is an outline of the examination of the shoulder that is required for the rheumatology and orthopaedics part of the medical school course. Different sites and schools include different things so I’ve tried to make this one as comprehensive as possible by compiling my favourite things from a few sources, and hope it’s of some use.

OSCEs are interesting beasts. They’re designed to measure one’s clinical prowess, although end up being a very artificial process that requires specific attention to learn, rather than just clinical experience. As a result, examinations in particular end up becoming a rehearsed routine that can be rattled off under intense pressure, without much actual thought as to what one is looking for in the first place. What I’ve tried to do here is write the ‘script’ but also give an idea of what to be thinking along the way, to help answer examiner questions and also to help be an actual doctor (which I’m hoping is the ultimate goal). Of course everyone will have their own style, and this is simply my own, but hopefully it might provide a useful framework for you to base your own technique upon.

I like to talk to the patient, as this is what I do in a clinical setting, especially as patients sometimes ask what I’m testing. This also looks better than trying to narrate what you’re doing to the examiner. I also find it much easier to demonstrate movements rather than trying to describe them, and it helps build rapport between you and the patient if they’re playing a game of copying you #psychologywin.

The Dance

BEFORE ENTERING – what age is the patient, are they male or female, what’s their occupation, are they right or left handed, what side is the problem on?

Introduction

*Student enters cubicle, washes hands and smiles*

“Good morning, my name is Will Sloper, I’m one of the fourth year medical students, I’ve been asked to do a quick examination of your shoulder, would that be alright?”

*Patient says yes*

“Thank you, may I ask your name? And how old are you if you don’t mind me asking”

(exposure – please could I ask you to remove your shirt?/put the cat down?)

*Student washes hands and asks patient to stand*

“Before I begin, are you in any pain at the moment?”

*Patient says no/a little/yes my shoulder hurts*

“Great/Okay well I’ll be quick and do my best not to cause you any (more) pain. Is there anywhere that’s really sore to touch?”

*patient points at specific point*

“Alright, I’ll avoid that finger/bruise/bleeding open fracture as much as I can”

“Are you right or left handed?”

*Patient responds (unless they don’t have any hands in which case poor choice of question)*

LOOK


“Do you have anything with you such as a sling or any medications?”

*Student looks around – trying not to appear suspicious of patients*

“Firstly I’ll have a look from the front…”

*Student looks intently at sternum, clavicle and then shoulders*

“…the sides…”

*it may be easier to ask the patient to rotate, rather than try to climb around them*

“…and the back.”

*Student stares blindly at shoulder blades contemplating exactly what it is they’re doing with their life*

“Lovely, please could you turn to face me again?”

*smiles*

FEEL

Now if it’s alright I’ll have a quick feel of your shoulders”

*Student feels temperature with back of hands.

“Ok, now please let me know if any of these parts are tender, I don’t want to cause you any pain.”

*Student palpates touches both sternoclavicular joints, clavicles, acromioclavicular joints, coracoid processes, greater tuberosities, joint lines, deltoid bulk and insertions, acromion processes, scapular spines, supraspinatus, infraspinatus, borders of the scapulae, and paraspinal muscles*


Now I’ll have a quick feel for the tendons in your shoulder”

*Student passively flexes patient’s arm and feels along biceps for the tendons. Then extends the shoulder (pushes elbow back) to tilt the head of humerus forward, and palpate for the supraspinatus tendon*

“Thank you, have you noticed any tingling or numbness around your shoulder?”

*no/yes/just on the tip of the shoulder/where this knife has been inserted*

“Could you please close your eyes and say yes if you can feel me touch your shoulder?”

*Student lightly touches regimental patch and skin over trapezius*

*yes*

“Thank you”

*smiles – customer service-style, not Willem Dafoe*


MOVE

“Now I’d like to test some movements if that’s alright”

*Patient nods*

“Please could you copy what I do with both hands?”

*Student puts both hands behind head, then behind back*

*Patient copies*

*While patient’s hands are behind back, student places hands on patient’s*

“Now push my hands away” (subscapularis power)

*Patient pushes hands away. Student hovers one hand in front of patient in case they push themselves forwards*


Great, now if you copy me, and I’ll help you at the end of each movement”

*Student then abducts arms above head, patient copies, meanwhile student places hand on patient’s scapula to assess rotation*

*adducts them across the chest*

*flexes forward to 170 degrees*

*extends to 40 degrees*

*Patient copies, and student adds passive movement at the end of each one*

“Any discomfort?”

*Patient says ‘no/yes/screams’*



“Thank you, now hold your hands out like you’re holding a dinner tray

*Student externally and internally rotates arms and patient copies*

*Student applies passive force at the end of each. At the point of maximum external rotation, ask patient to hold their hands there, and let go – see if arm drifts back to centre (Lag sign)*



Specific muscle tests

(Subscapularis has already been tested earlier with hands behind the back, to make it more convenient for the patient)


“Now could you do the same, but push against me?”

*Patient externally rotates against resistance*


And now place your arms by your sides

*Student holds patient’s arms by their sides*

“Push out against me?”

“Thank you, now could you do this?”

*Student holds arms flexed to 90 degrees and slightly abducted so that supraspinatus is aligned with the humerus, with thumbs towards the ceiling*

*Patient copies*

“Now resist me”

*Student pushes down*

And now the same with thumbs down?”

*Same again*


“Thank you”

Impingement tests


“I’m now going to lift your arm up, please hold it there”

*Student passively abducts patient’s arm to maximum abduction and lets go*

“Now could you slowly lower it down to your side, and let me know whether there is any pain”


Now let me take your arm, and let it go all floppy, letting me take all the weight”

*Student flexes shoulder to 90 degrees, elbow to 90 degrees, and then internally rotates the shoulder*

Any pain?”

*no*

*Student repeats motion at varying degrees of abduction, watching patient’s face each time”


Ok, thank you, let your arm go loose again”

*Student stabilises scapula with one hand, and uses the other to internally rotate the patient’s arm and passively flexes it*

Any pain?”

*Patient says ‘no’*


“Finally, please could you do this for me?”

*Student places own hand on contralateral shoulder, with elbow moving across midline*

*Patient copies*

Are you able to get the elbow all the way across?”

*Student looks, showing that she is checking whether elbow has crossed midline*


“And just to finish off, I’ll take your arm, let it go nice and loose, and let me know if this is uncomfortable”

*Student takes patient’s arm, moves it into the ‘POLICE – HANDS UP!’ position (correct anatomical name) and gently externally rotates*

“Does that feel wobbly or unstable?”

*Patient says ‘no’/shoulder dislocates*

Conclusion


“Well thank you very much, I’ve finished my examination, do you have any questions for me?”

*Patient says no*


“Thanks again”

*Student smiles, washes hands and turns to examiner*



Presentation

“I performed an examination of the shoulder on Mrs Bananas who reported tenderness in her….. and upon inspection, noted the presence of a longitudinal scar/slight bruise over the clavicle. The rest of the examination was normal, with good movement and function of all muscles”

(Obviously this bit is going to vary hugely – practice making up a bunch of different presentations and you might find that in the exam, you can adapt one you’ve already made to fit your current patient)

“To complete my examination, I would like to:

  • take a full history
  • do a regional musculoskeletal exam of the elbow and spine
  • do a neurological and peripheral vascular exam of the upper limbs

If asked what management you would do, you can’t really go wrong with:

In accordance with local trust guidelines, this condition can be managed:

  • Conservatively
    • physiotherapy
    • modification of daily activities
  • Medically
    • nsaids
    • steroid injections
  • Surgically
    • manipulation under anaesthesia (adhesive capusilitis)
    • surgical stabilisation (dislocation)
    • arthroscopy (impingement)

I would also want to ensure I am aware of the patient’s desires and concerns, what activities they would like to be able to do, and what their outlook on the issue is like.

Why do the exam?

The main purpose of the shoulder exam is to elicit whether the patient has any:

  • pain/impingement
  • stiffness
  • reduction of function
  • evidence of previous disease/surgery

And as with all musculoskeletal examinations, it’s a good idea to follow a structure of:

  • look
  • listen
  • feel
  • move
  • special tests

And always, always, always…

  • ask about pain
  • compare the two sides
  • watch the patient’s face during movement

The things to look out for in the shoulder exam are as follows:

  • Looking
    • swelling
    • muscle wasting
    • deformity
      • internally rotated at rest suggests posterior dislocation of the shoulder
    • skin changes
      • bruising
      • thinning
      • rashes
    • scars
    • Winging of scapular
      • long thoracic nerve
  • Feeling
    • Temperature
      • inflammation
    • muscle wasting
      • may suggest nervous injury
    • sensation
      • axillary nerve lesion
    • joint palpation
      • warm, rubbery swollen joints are suggestive of active synovitis
    • Bony deformity
      • previous fracture
    • Tendons
      • feel for tendon rupture/sensitivity
  • Moving
    • failure of movement could be:
      • muscular
      • neurological
      • tendinous
      • articular
    • Passive movement:
      • feel for crepitus
      • tells you if problem is muscular or intra-articular
    • Pain on movement suggests impingement or inflammation
    • Muscles to test:
      • Deltoid
        • abduct beyond 15 degrees
      • Rotator cuff
        • subscapularis
          • lift off test
        • supraspinatus
          • empty can test
          • abduction first 15 degrees
        • infraspinatus
          • external rotation
          • Lag sign 
        • teres minor
          • external rotation
          • Lag sign
      • Teres Major
        • internal rotation
  • Special tests
    • Subscapularis
      • lift off test
    • Supraspinatus
      • empty can – impingement if pain
      • Neer’s test
      • Hawkin’s test
      • Scarf test
    • Instability
      • Crank apprehension test

Common pathologies to watch out for:

  • Adhesive capsulitis
    • ‘frozen shoulder
      • loss of external rotation
      • loss of abduction
      • pain on active movement
      • reduced active and passive range of movement
  • Impingement
    • Pain on impingement tests
    • may have reduced abduction
    • Painful arc 60-120 degrees
  • Rotator cuff injury
    • pain on external rotation
    • supraspinatus tests show weakness/pain
    • subscapularis tests may also
  • Instability
    • repeated previous dislocation
    • apprehension test
    • may have deformity
  • Osteoarthritis
    • pain on movement
    • reduced range of movement

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