Master Shoulder Exam with Picmonic for Medicine

Always inspect the skin over the shoulder and surrounding structures first. This inspection should include but is not limited to looking for new and old scars, incisions, rashes, skin temperature, areas, erythema, etc. Do not forget to check in the axilla!

Inspect the shape of the shoulders bilaterally for symmetry. Inspect from the front, the side, and the back of the patient and look for head and neck postural discrepancies, symmetry over the shoulders, or even deltoid muscle wasting. In addition, you may notice trapezius or paravertebral muscle wasting, scoliosis, or even a long thoracic nerve injury and winged scapula when inspecting from behind.

Palpate the humeral head in relation to the glenoid. Commonly tested on the exams are humeral head dislocations. A posterior dislocation classically occurs secondary to a seizure or shock. Here, patients will have flattening over the anterior shoulder, pain with external rotation, and will internally rotate and adduct their arm. An anterior dislocation commonly occurs from direct trauma. Patients will abduct and externally rotate the shoulder and may present with numbness and loss of contour over the deltoid muscle. Lastly, an inferior shoulder dislocation is the rarest of the three and occurs secondary to hyper-abduction. These patients will have an arm that is held upwards or behind their head for symptomatic relief.

The acromioclavicular (AC) joint motion can be tested to assess for primary somatic dysfunctions with internal and external rotation. Repetitive overhead arm use resulting in inflammation, sprains, or strains, can limit its inherent motion. On a physical exam, a physician may palpate tenderness or crepitus over the joint and visualize a “step-off” deformity, indicating an AC separation. In addition, the patient may have a positive crossed-arm adduction test.

The rotator cuff is a group of four muscles that protect the shoulder joint and the head of the humerus within the glenoid fossa. Commonly known as the SITS muscles, these muscles include: supraspinatus, infraspinatus, teres minor, and subscapularis. Repetitive stress is the main cause of injury to the rotator cuff.

The clavicle is one of the most recognizable bones on the anterior aspect of the shoulder. It is the only bony attachment between the upper limb and the axial skeleton. Also, it is part of two of the three synovial joints, the acromioclavicular and the sternoclavicular joints. Palpate this bone to assess for common somatic dysfunctions, including AC joint internal and external rotation dysfunctions, as well as SC joint abduction, adduction, and horizontal flexion or extension dysfunctions. Each end of the clavicle moves in opposite directions, similar to a seesaw. For example, if the medial clavicle moves inferiorly, then the lateral end will move superiorly. Keep in mind that the SC joint and the AC joint motions are coupled together. SC joint abduction is coupled with AC joint external rotation and SC joint adduction is coupled with AC joint internal rotation. Also, SC joint horizontal flexion is coupled with posterior translatory glide, and SC joint horizontal extension is coupled with anterior translatory glide.

The borders of the scapula and the scapular spine can be palpated bilaterally along the upper back. While the patient performs an active range of motion, feel for the degree of smoothness or any crepitus. Don’t forget that the spine is typically used to identify the T3 vertebral spinous process and help physicians assess the surrounding spinal segments.

Flexion or forward elevation can be performed using the anterior part of the deltoid and the coracobrachialis with up to 180 degrees of normal range of motion. Of this, 120 degrees of flexion is provided by the glenohumeral joint, and 60 degrees of flexion is provided by the scapulothoracic joint. Don’t forget that the scapula begins to move at around 30 degrees elevation. Here, the physician holds down the scapula and shoulder with one hand and holds the forearm with the other hand. Then, they guide the patient to swing the arm forward and compare the motion to the other extremity.

Extension or backward elevation can be performed using the latissimus dorsi, teres major, and posterior part of the deltoid with up to 40 degrees of normal range of motion. Here, the physician holds down the scapula and shoulder with one hand and holds the forearm with the other hand. Then, they guide the patient to swing the arm backward and compare the motion to the other extremity.

Abduction can be performed using the middle portion of the deltoid and supraspinatus with up to 180 degrees of normal range of motion. Of this, 120 degrees of flexion is provided by the glenohumeral joint, and 60 degrees is provided by the scapulothoracic joint. Don’t forget that the scapula begins to move at around 30 degrees elevation. Here, the physician holds down the scapula and shoulder with one hand and holds the forearm with the other hand. Then, they guide the patient to swing the arm laterally and upward with the palm facing downward throughout the movement and compare the motion to the other extremity. A painful arc may assess for impingement of the supraspinatus.

Adduction can be performed using the pectoralis major and the latissimus dorsi with 30 degrees of normal range of motion. Here, the physician holds down the scapula and shoulder with one hand and holds the forearm with the other hand. Then, they guide the patient to swing their arm across the front of the body to the opposite side and compare the motion to the opposite extremity.

Internal Rotation can be performed using the subscapularis, pectoralis major, and latissimus dorsi with up to 80 degrees of normal range of motion. Here, the physician will abduct the patient’s arm to 90 degrees and flex the elbow to 90 degrees. Then, the physician will hold the shoulder joint with one hand and hold the wrist with the other hand. Afterward, the physician will guide the arm into internal rotation by rotating the hand and forearm forward while preventing movement from the upper arm. They will repeat this on the opposite extremity and compare the motions. Pain in this movement may suggest tendonitis or even a tear in the subscapularis.

External Rotation can be performed using the infraspinatus and the teres minor with up to 90 degrees of normal range of motion. Here, the physician will abduct the patient’s arm to 90 degrees and flex the elbow to 90 degrees. Then, the physician will hold the shoulder joint with one hand and hold the wrist with the other hand. Afterward, the physician will guide the arm into external rotation by rotating the hand and forearm backward while preventing movement from the upper arm. They will repeat this on the opposite extremity and compare the motions. Pain in this movement may suggest tendonitis or even a tear in the infraspinatus.