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Documenting Shoulder Examination in Orthopedics

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1. Patient Setup and Preliminaries

• Patient stripped to the waist, standing in good daylight
• Both shoulders fully exposed for comparison
• Dominant hand (Right/Left)
• Attitude on entry: note how the patient carries the arm (e.g., supporting flexed elbow with the opposite hand - suggests clavicle fracture or anterior dislocation)

"Patient examined standing with both shoulders exposed. Right/left dominant. Patient was/was not supporting the affected limb on entry."

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2. LOOK (Inspection)

Skin

• Surgical scars (anterior = deltopectoral approach; lateral = deltoid split or arthroscopic portals; posterior = arthroscopic portals)
• Bruising (ecchymosis), swelling, sinuses

Soft Tissues

• Wasting of deltoid (suggests axillary nerve injury post-dislocation)
• Wasting of supraspinatus / infraspinatus (suggests rotator cuff pathology)
• Pectoralis position and scapular position

Bony Contour & Deformity

• Normal roundness of shoulder formed by greater tuberosity + deltoid
• Flattening of shoulder contour = anterior dislocation (inward displacement of humeral head), or deltoid wasting
• Squaring of the shoulder = anterior dislocation (loss of normal deltoid roundness)
• Prominence over clavicle = fracture of middle third (most common)
• Prominence at acromial end of clavicle = AC joint dislocation
• Prominence at sternal end = sternoclavicular dislocation
• Drooping of shoulder with lengthening of arm = fracture neck of scapula
• Swelling in deltopectoral groove + acromion prominence = subcoracoid dislocation

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3. FEEL (Palpation)

Skin

• Temperature (warmth = inflammation)
• Sensation at the "regimental badge area" (upper lateral arm) - loss = axillary nerve damage (C5)

Bony Points - Document tenderness at each:

Relative Position of 3 Bony Points (compare both sides):

• Tip of coracoid process
• Acromial end of clavicle
• Greater tuberosity of humerus

Special Palpation Tests

• Bryant's test: Increased vertical circumference of axilla = any dislocation or proximal humerus fracture
• Hamilton's ruler test: A straight ruler normally cannot touch both the acromion process and the lateral epicondyle simultaneously (greater tuberosity prevents this). If it can, the humeral head is displaced medially (positive = dislocation)

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4. MOVE (Range of Motion)

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5. SPECIAL TESTS

Rotator Cuff / Impingement

Shoulder Instability

SLAP Lesion / Biceps

AC Joint

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6. MEASUREMENTS

1. Length of arm: Angle of acromion to lateral epicondyle of humerus
   • Shortened in subcoracoid dislocation, fracture neck of humerus/shaft
   • Lengthened in subglenoid dislocation, fracture neck of scapula
2. Vertical circumference of axilla: Increased in any dislocation or proximal humerus fracture

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7. NEUROVASCULAR EXAMINATION

• Axillary nerve (C5): Sensation over regimental badge area; deltoid power (abduction 0-15°)
• Musculocutaneous nerve: Biceps power, sensation over lateral forearm
• Radial pulse: Distal vascular integrity (especially in anterior dislocation)
• Distal capillary refill and sensation in all fingers

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8. SUMMARY BOX (Bailey & Love Format)

SHOULDER EXAMINATION SUMMARY
Inspection (standing):
  - Front: [asymmetry, deformity, swelling]
  - Side:  [muscle wasting]
  - Back:  [wasting, scapular position/winging]

Inspection (supine):
  - Skin/scars: [present/absent, describe]
  - Soft tissue: [wasting of deltoid/rotator cuff muscles]
  - Deformity: [present/absent]

Palpation (sternum → scapula):
  - SCJ: [tender/non-tender]
  - Clavicle: [tender/non-tender, step deformity]
  - ACJ: [tender/non-tender, prominent]
  - Acromion: [tender/non-tender]
  - Greater tuberosity: [tender/non-tender]
  - Bicipital groove: [tender/non-tender]
  - Axillary nerve territory sensation: [normal/reduced]

Movements (AROM / PROM, degrees):
  - Flexion:           R ___° / L ___°
  - Extension:         R ___° / L ___°
  - Abduction:         R ___° / L ___°
  - External rotation: R ___° / L ___°
  - Internal rotation: R T___/ L T___
  - Painful arc: [present ___°-___° / absent]

Special Tests:
  - Neer's sign:          [+/-]
  - Hawkins-Kennedy:      [+/-]
  - Jobe's (Empty Can):   [+/-]
  - Drop-arm test:        [+/-]
  - Lift-off test:        [+/-]
  - Apprehension test:    [+/-]
  - Relocation test:      [+/-]
  - Sulcus sign:          [+/-]
  - O'Brien test:         [+/-]
  - Speed's test:         [+/-]
  - Cross-body adduction: [+/-]

Measurements:
  - Arm length (acromion to lat. epicondyle): R ___ cm / L ___ cm
  - Hamilton's ruler test: [positive/negative]

Neurovascular:
  - Axillary nerve: [intact/impaired]
  - Radial pulse: [present/absent]
  - Distal sensation: [normal/impaired]

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Key Documentation Pearls

• Always compare bilaterally - document the normal side first as reference
• Apprehension (not just pain) is the positive finding for instability tests
• Painful arc must state the arc range (60-120° is the classic impingement arc)
• Document which scapula is stabilized during glenohumeral ROM to ensure you're measuring true glenohumeral movement
• In trauma, always document neurovascular status before and after any manipulation (axillary nerve and brachial plexus)
• Use Miller's Key Examination Points table as a quick reference grid

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