- With the shoulder fully exposed, inspect the patient from the front, from the side and from behind, checking for symmetry, posture, muscle wasting and scars.
- Assess the temperature over the front of the shoulder.
- Palpate the bony landmarks for tenderness, starting at the sternoclavicular joint, then the clavicle, acromioclavicular joint, acromion process and around the scapula.
- Palpate the joint line – anterior and posterior.
- Palpate the muscle bulk of the supraspinatus, infraspinatus and deltoid muscles.
- Ask the patient to put their hands behind their head to assess external rotation, and then behind their back to assess internal rotation, comparing one side with the other. If there is a restriction in the latter movement, describe how far the patient can reach – for example, to the lumbar, lower thoracic or mid-thoracic level.
- With the elbow flexed at 90º and tucked into the patient’s side, assess external rotation of the shoulder. Loss of external rotation may indicate a frozen shoulder.
- Ask the patient to raise their arms behind them and to the front. Assess flexion and extension.
- Ask the patient to abduct the arm to assess for a painful arc (between 10º and 120º) (see Figure 12). Can you passively take the arm further? Be sure to assess abduction from behind the patient and observe scapular movement. Restricted glenohumeral movement can be compensated for by scapular/thoracic movements.
- Function of the shoulder includes getting the hands behind the head and back. This is important in washing and grooming. If this has not been assessed during the screening examination it should be done now.
Examination of the shoulder: checklist
- Introduce yourself/gain consent to examine
- Inspect shoulders from in front, from the side and from behind
- Assess skin temperature
- Palpate bony landmarks and surrounding muscles
- Assess movement and function: hands behind head, hands behind back
- Assess (actively and passively) external rotation, flexion, extension and abduction
- Observe scapular movement
CMC(J) carpometacarpal (joint); CT computerized tomography; DEXA dual-energy x-ray absorptiometry; DIP(J) distal interphalangeal (joint); ESR erythrocyte sedimentation rate; GALS gait, arms, legs and spine; MCP(J) metacarpophalangeal (joint); MRI magnetic resonance imaging; MTP(J) metatarsophalangeal (joint); NSAID non-steroidal anti-inflammatory drug; OA osteoarthritis; PIP(J) proximal interphalangeal (joint); RA rheumatoid arthritis; REMS regional examination of the musculoskeletal system.