Orthopedics Examination Guide

EXAMINATION EXAMPLES :-

SHOULDER JOINT EXAMINATION

INTRODUCTION
Introduce yourself to the patient
Wash your hands
Briefly explain to the patient what the examination involves
Ask the patient to remove their top clothing exposing the shoulders fully
Offer the patient a chaperone as necessary
Always start with inspection and proceed as below unless instructed otherwise; be prepared to be instructed to move on quickly to certain sections by the examiner.

INSPECTION
Assess for

Skin changes (e.g. erythema that may indicate septic arthritis*)
Scars (i.e. previous surgery)
Swelling (suggesting potential joint effusion*)
*As the shoulder is a deep structure both skin changes from erythema and joint swelling from effusions are not always apparent

PALPATION
Check temperature
Compare both sides
Feel for muscle bulk
Especially the deltoid supraspinatous and infraspinatous
Feel for bone and joint tenderness working systematically from medial to lateral:
SCJ → clavicle → ACJ → coracoid process → acromion process → scapular spine →
greater tuberosity of the humerus

MOVEMENT
Check active movements
Flexion and Extension
Abduction and Adduction
Observe the patient from the back to note symmetry and smoothness of scapula-thoracic movements
Internal rotation (hands behind back) and external rotation (hands behind head)
Assess rotator cuff muscles
Supraspinatous (by ‘Empty Can’ test)
Shoulder flexed forwards to 90 degrees and slightly abducted with internal rotation so that thumb is pointing to the ground (as if emptying a can) and attempt to continue bringing the arm up against resistance
Subscapularis (by Gerber’s ‘Lift Off’ test)
Hand placed in the small of the back with palm facing outwards and attempt to push against examiners hand
Infraspinatus
Assess resisted external rotation. Ask the patient to tuck their elbows into sides and externally rotate their forearm against your hand
Teres Minor (by ‘Hornblowers tests’)
Abduct the shoulder to 90 degrees and flexing elbow to 90 degrees and attempting to externally rotate against resistance

SPECIAL TEST
‘Painful Arc’ test (positive in supraspinatous tendinopathy subacromial bursitis and ACJ osteoarthritis)
When the patient abducts their shoulder the pain is worst during the middle arc

Scarf Test (positive in ACJ osteoarthritis)
Ask the patient to place the hand of the side you are examining on the contralateral shoulder and then push the elbow superiorly to compress the acromium against the lateral end of the clavicle

Hawkins-Kennedy test (positive in shoulder impingement)
Flex the shoulder to 90owith the elbow flexed to 90o. Internally rotate the shoulder – pain is indicative of impingement.

Neer test (positive in for shoulder impingement)
Maximally internally rotate the shoulder and the passively forward flex it. Pain is indicative of impingement.

Winging of the scapula (positive in long thoracic nerve palsy)
Get the patient to push hand against a wall whilst standing and look for lifting of the scapula off the thoracic wall due to weak serratus anterior muscle

ETC

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