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ORTHOPAEDIC SHOULDER ASSESSMENT

Patient Position for Examination

References: S. Das - A Manual on Clinical Surgery, 13th Ed; Campbell's Operative Orthopaedics, 15th Ed 2026; Miller's Review of Orthopaedics, 9th Ed; Firestein & Kelley's Textbook of Rheumatology; Bailey and Love's Short Practice of Surgery, 28th Ed

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1. OBSERVATION (Inspection)

A. Attitude / Posture at Rest

• Fracture clavicle: Patient typically enters supporting the flexed elbow of the injured side with the opposite hand.
• Anterior dislocation of shoulder: Patient supports the flexed elbow with the other hand; elbow held slightly away from the body.
• Note drooping of the shoulder, asymmetry, or guarded posture. (Das, Manual on Clinical Surgery, 13th Ed)

B. Contour and Deformity

C. Muscle Wasting

• Compare bulk of deltoid, supraspinatus fossa, and infraspinatus fossa bilaterally.
• Deltoid wasting = apparent flattening (but greater tuberosity still palpable, unlike true dislocation).
• Supraspinatus/infraspinatus wasting suggests rotator cuff pathology or suprascapular nerve injury.
• Ecchymosis over shoulder may suggest rotator cuff rupture or long head of biceps rupture. (Campbell's Operative Orthopaedics, 15th Ed 2026)

D. Scapular Winging

• Ask patient to push against a wall with arms outstretched.
• Winging = serratus anterior weakness (long thoracic nerve palsy).

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2. GONIOMETRY - Range of Motion

Instrument Setup

• Use a standard 360° goniometer.
• Stationary arm aligned with trunk/bony landmark; moving arm follows the limb segment.
• Measure both Active ROM (AROM) and Passive ROM (PROM); note any painful arc.

Normal Values

Clinical Notes on ROM

• Active and passive ROM are assessed in all planes.
• When active deficit cannot be improved passively: suggests capsular contracture or glenohumeral arthritis.
• Stabilize the scapula to isolate glenohumeral motion from scapulothoracic motion.
• Internal rotation is clinically assessed by asking the patient to bring the hand up behind the back, recording the highest vertebral level reached (normal = approx. T7/inferior scapular border level).
• For rotation assessment at 90° abduction: measure with shoulder abducted and elbow at 90°.
• When Hawkins-Kennedy test, painful arc sign, AND infraspinatus (Jobe) test are ALL positive, likelihood of impingement exceeds 95%. If all three negative, likelihood drops below 24%. (Campbell's Operative Orthopaedics, 15th Ed 2026)

Painful Arc

• Pain between 60°-120° of abduction = subacromial impingement or rotator cuff pathology.
• Sensitivity: 73.5%, Specificity: 81.1% for impingement (PPV 88.2%).

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3. MANUAL MUSCLE TESTING (MMT)

Grading Scale - MRC Scale (Medical Research Council)

Shoulder Muscle Testing

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4. PALPATION

A. Bony Structures (Systematic sequence - examiner behind patient)

• Both thumbs placed on sternal ends of both clavicles simultaneously.
• Abnormal anterior prominence = sternoclavicular dislocation.

• Palpate medial to lateral; any break in line or local bony tenderness = fracture clavicle.
• Conoid and trapezoid ligaments almost always torn in AC dislocation.

• Undue upward prominence of distal clavicle = AC joint dislocation.
• Undue tenderness over AC joint = AC joint pathology.

• Slide fingers from acromion downward.
• Disappearance of greater tuberosity + loss of resistance = shoulder dislocation.
• Local bony tenderness + irregularity at surgical neck = fracture neck of humerus.

• One hand in axilla, one hand over deltoid.
• Head of humerus can be palpated bimanually; absence in socket = dislocation.

• Abnormal tenderness at coracoid = coracoid fracture, coracobrachialis/biceps short head pathology.

• Palpate spine, inferior angle, medial border.
• Medial to glenoid cavity tenderness = fracture neck of scapula (no tenderness at upper end of humerus in this case). (Das, Manual on Clinical Surgery, 13th Ed)

B. Soft Tissue Palpation

C. Bony Landmark Relationships (Palpation Measurements)

• A straight ruler resting on the lateral arm normally cannot touch both the lateral epicondyle and the acromion simultaneously (due to the greater tuberosity intervening).
• If the ruler CAN connect both points = dislocation of shoulder (greater tuberosity displaced medially). (Das, Manual on Clinical Surgery, 13th Ed)

• Vertical circumference of axilla is increased in shoulder dislocation.
• Lowering of anterior axillary fold confirms anterior dislocation.

• From angle of acromion to lateral epicondyle of humerus.
• Shortened arm = subcoracoid dislocation, fracture neck/shaft of humerus.
• Lengthened arm = subglenoid dislocation, fracture neck of scapula.

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5. SPECIAL TESTS

A. Impingement Tests

B. Rotator Cuff Tests

C. Instability Tests

D. Labrum / Biceps Tests

E. AC Joint Test

F. Neurological Test - Axillary Nerve

• Do NOT test deltoid abduction alone (arm injury limits this anyway).
• Test cutaneous sensation over the "regimental badge" area (lower part of deltoid, lateral arm).
• Loss of sensation = axillary nerve injury (complication of shoulder dislocation, humeral neck fracture). (Das, Manual on Clinical Surgery, 13th Ed)

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6. NEUROVASCULAR EXAMINATION

• Peripheral pulse (radial artery) - vascular injury in fracture-dislocations.
• Neurological screen of entire upper extremity (C5-T1):
  • C5: Deltoid, biceps; sensation over lateral arm
  • C6: Wrist extensors; thumb and index finger sensation
  • C7: Triceps, wrist flexors; middle finger
  • C8/T1: Intrinsics; ring/little fingers
• Check axillary nerve (see above).
• Brachial plexus screen if high-energy trauma. (Campbell's Operative Orthopaedics, 15th Ed 2026)

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7. MEASUREMENTS (Objective Documentation)

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8. SPECIAL INVESTIGATIONS (to supplement assessment)

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REFERENCES

1. Das S. - A Manual on Clinical Surgery, 13th Edition. Chapter 13: Examination of Injuries About the Shoulder, pp. 182-185.
2. Campbell's Operative Orthopaedics, 15th Edition 2026 (Azar, Beaty, Canale) - Chapter 51: Physical Examination of the Shoulder; Table 51.2.
3. Miller's Review of Orthopaedics, 9th Edition - Table 4.7: Shoulder Key Examination Points.
4. Firestein & Kelley's Textbook of Rheumatology, 2-Volume Set - Chapter 46: Physical Examination of the Shoulder, Fig 46.3.
5. Rheumatology, 2-Volume Set (Elsevier 2022) - Movements and palpation of the shoulder.
6. Bailey and Love's Short Practice of Surgery, 28th Edition - Clinical Examination of the Shoulder.
7. Bradley and Daroff's Neurology in Clinical Practice - Table 28.1: MRC Scale for Grading Muscle Strength.