Download Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan

Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
Time
(Session 1)
13.30 – 13.35
(5mins)
13.35 – 13.45
(10 mins)
13.45 – 14.55
(1 hour 10
mins)
14.55-15.00
(5mins)
Activity
Introduction
 Learning Objectives
o To perform a competent shoulder exam& elbow exam, relating this to
the anatomy of the shoulder
 Clinical relevance
o Orthopaedics, rheumatology, paediatrics, geriatrics, GP, sports
medicine
Exercises
 Students had anatomy session this morning – should be thinking about the
anatomy as they perform the clinical examination to think about which
structures they are testing
Core learning activity
 Stages 2 and 4
Practice with feedback
 Split the group into threes to practice and provide feedback to one another
 Monitor and provide constructive feedback
Closure
 Provide any clarification needed
 Reminder about on-going practice with feedback
o SDL room
 Encourage self-directed learning
Time
(Session 2)
15.30 – 15.35
(5mins)
15.35 – 15.45
(10 mins)
15.45 – 16.55
(1 hour 10
mins)
16.55 – 17.00
(5mins)
Learning outcomes
By the end of this session you should:
 Be able to describe the anatomy of the shoulder and elbow joints
 Be able to perform a competent shoulder and elbow examination
Clinical relevance
The shoulder and elbow work together moving the arm in space so that the hand can be positioned for
activities such as reaching, dressing and feeding etc. Both joints are active in many sporting activities
such as cricket, tennis and golf. In addition, conditions like osteoarthritis, impingement syndrome and
rotator cuff tears are also very common causes for patients to present to their GPs.
Shoulder pain is a common symptom – it is estimated that 1 in 300 of the population each year
present to a doctor with shoulder pain.
Chaperones and supervision
Due to the level of exposure necessary, the shoulder examination should be regarded as an intimate
examination, and you should offer a chaperone and explain that your supervisor will repeat the
examination.
Related Basic Sciences
Applied anatomy
To fully understand and benefit from this session you will need to be familiar with the anatomy of the
shoulder and elbow. Please look up a diagram of the bones and muscles that make up the shoulder
and elbow joints to help with the text below (see references at the end of this session chapter).
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
The Shoulder
The shoulder is made up of three bones: the scapula, the humerus and the clavicle.
Remember that there are 3 joints:
1. The gleno-humeral joint
2. Acromio-clavicular joint
3. Sterno-clavicular joint – though this is rarely the source of symptoms
Gleno-humeral joint:
 This is a ball (head of humerus) and socket (glenoid fossa of the scapular) joint and is the most
mobile joint in the body. It therefore lacks stability, despite support of the glenoid labrum,
ligaments, capsule and the action of the rotator cuff muscles.
 It is supplied by C5 and pain is therefore referred to and felt in the upper arm (C5 dermatome).
 Movements at the gleno-humeral joint itself do not allow full abduction / adduction and flexion. In
order to do these, the scapula needs to move around the chest wall – this is sometimes called the
scapulothoracic joint. Scapular movement normally contributes about 60% of arm movement.
To assess gleno-humeral movement accurately the scapula must be immobilised by fixing the
acromion.
A-C joint
 The clavicle articulates laterally with the acromion process of the scapular at the acromioclavicular joint. Movement occurs here during the final stages of full abduction and full adduction
(across the body). These will therefore be the movements which cause pain at the AC joint.
 The plane of this joint passes downwards and medially so there is a tendency for the clavicle to
ride up over the acromion. It is held down by a very strong ligament attached to the coracoid
process of the scapular and undersurface of the lateral part of the clavicle – the coraco-clavicular
ligament. A severe fall on the point of the shoulder can force the acromium under the clavicle
tearing this ligament, resulting in dislocation.
 The AC joint differs from the gleno-humeral joint in being supplied by C4. Pain is therefore
localised to the top of the shoulder. The joint is superficial so tenderness and swelling can usually
be directly palpated.
 The medial end of the clavicle articulates with the sternum and first costal cartilage at the sternoclavicular joint which is reinforced by the sternoclavicular and costoclavicular ligaments.
The Elbow
 The elbow joint is a hinge joint, articulations occurring between the trochlea and capitulum of the
humerus and the trochlear notch of the ulna and the head of the radius. Because of the
arrangement of the bones and the presence of strong ligaments it is a relatively stable joint.
 The superior radio-ulnar joint is a pivot joint between the circumference of the head of the radius
and the radial notch on the ulna.
 The capsule includes all three articulations.
 The upper end of the ulna is large and is known as the olecranon process, there is a small
subcutaneous bursa overlying this.
 The lower end of the humerus possesses the medial and lateral epicondyles onto which
muscles attach.
 The common flexor tendon attaches to the medial epicondyle. Muscles including pronator
teres (humeral head), flexor carpi radialis, and flexor carpi ulnaris (humeral head) arise from
this tendon.
 The common extensor tendon attaches to the lateral epicondyle. Muscles including
extensor carpi radialis brevis, extensor carpi ulnaris and supinator arise from this tendon.
The musculocutaneous nerve (C5-C7), the radial nerve (C5-T1) and the ulnar nerve (C8-T1) supply
humeroradial and humeroulnar articulations of the elbow joint. The median nerve crosses the elbow
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
joint anteriorly and supplies the pronator muscles at the radioulnar joint. Dermatomes C5 to T1 all
cover the elbow joint: C6 laterally, C5 and T1 anteriorly, and C8 medially. C7 dermatome covers the
posterior aspect of the elbow.
Shoulder examination: General Notes
When looking:
 It is important to look at the shoulders from all angles. Start with the patient standing, you may
need to sit the patient down as well so that you can see the supraspinatus muscle.
 The gleno-humeral joint is deeply situated so you are unlikely to see any swelling (unless it is very
large) or erythema arising from the joint itself.
When feeling:
 Tenderness in the bicipital groove is particularly important as it may indicate bicipital tendonitis a
common inflammatory condition
When moving:
 The shoulder moves in all three planes:
 Abduction / adduction
 Flexion / extension
 External / internal rotation
 Active movements are tested in all directions and need to be demonstrated. Doctors often
combine several movements in order to test function here. For educational reasons we will do
these separately today.
 Passive and resisted movements at the gleno-humeral joint require stabilization of the acromium
(to eliminate scapular movement). There is no need to test flexion and extension.
Function:
Test combination movements associated with grooming and dressing.
Special tests:
Numerous tests described for suspected impingement are beyond the scope of this session.
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
Shoulder examination: STEPS
Introduction and preparation
 Introduce yourself fully and check patient’s name
 Explain the examination and need to undress above the waist (apart from a bra)
 Obtain consent
 Offer a chaperone and explain that your supervisor will repeat the examination
 Ask about pain, and (if present) ask the patient to locate it. Ask the patient to tell you if the
examination causes any pain
 Allow patient to undress in privacy
 Clean your hands
 Position patient standing
Look
 General inspection:
 is the patient in obvious pain or discomfort?
 bedside inspection: any painkillers/walking aids or frames present?
 Symmetry / asymmetry – stand back and compare the two sides – the arms should hang at the
same level and the outlines of the AC joints should look identical.
 Deformity – at the shoulder deformity has to be quite advanced before it looks obvious.
 Muscle wasting – look particularly at the deltoids, supraspinatus and infraspinatus,
 Colour - bruising is suggestive of trauma
 Scars – there may be tiny scars from arthroscopy at different sites around the shoulder.
Feel
 With the patient still standing, ask the patient to report any tenderness, and palpate:
 sterno-clavicular joint
 clavicle
 acromio-clavicular joint
 acromion
 subacromial bursa (between the acromion and the greater tuberosity)
 glenohumeral joint line anteriorly and posteriorly
 greater and lesser tuberosity of humerus
 bicipital groove
 coracoid process
 Note any sites of tenderness, swelling or deformity
Move
Active
 Abduction and adduction –demonstrate first, then examine from behind
 Stand with arms by sides and palms facing forwards. Abduct arms sideways to full elevation
above head finishing with hands palm to palm. Then adduct arms bringing them down to cross
in front of the body.
 Look at scapular movement to see if it is symmetrical.
 Test each shoulder separately for adduction with the arm flexed at the shoulder and elbow to
reach over the opposite shoulder.
 Flexion and extension
 Raise both arms at the front to full elevation (180° flexion) and then behind (60° extension)
 Look at scapular movement to see if it is symmetrical.
 External and internal rotation in adduction
 Flex both elbows to 90 degrees
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
 Externally rotate shoulders (ensuring that no abduction occurs) and then internally rotate
crossing arms in front of body. The normal range of external rotation is 70°.
Passive
 Abduction
 Elevate each arm as above, from behind looking at the scapular movement
 Now repeat stabilizing the scapula by pressing down on the acromion and passively abduct the
upper arm until the acromion starts to move – this assesses the limit of glenohumeral
abduction more accurately
 Adduction
 From the front adduct each arm in a flexed position across the body over the opposite shoulder
stabilizing the acromion with the other hand.
 External and internal rotation
 Same position as for active testing. Stabilize the acromion.
Resisted
 Abduction and adduction
 Ask the patient to abduct the shoulder to about 45°
 Abduction - “keep your arm there, don’t let me push it down” – apply pressure just above the
elbow on the lateral side, stabilize the acromion with the other hand
 Adduction - “keep your arm there, don’t let me push it out” – apply pressure just above the
elbow on the medial side, stabilize the acromion with the other hand
 External and internal rotation – test from the front both arms together.
 Ask the patient to flex the elbows to 90°
 External rotation - “keep your arms there, don’t let me push them in” – apply pressure from the
lateral sides of the forearms
 Internal rotation- “keep your arm there, don’t let me turn them out” - apply pressure from the
medial side of the forearms.
Special tests Numerous tests described for suspected impingement are beyond the scope of this
session.
Related structures
 Biceps tendon
 Test resisted flexion at the elbow. Ask patient to flex elbow to about 120° palm facing
upwards (supination) - “keep your arm bent, don’t let me straighten it” - hold forearm above
wrist and apply force using your flexors.
 Discomfort may be due to bicipital tendonitis. Specific tests (Speed’s test, Yergason’s test) for
bicipital tendonitis are beyond the scope of this session.



Serratus anterior
 This muscle stabilizes the scapular by anchoring it against the rib cage. It is supplied by the
long thoracic nerve. Pathology involving the nerve or muscle results in “winging of the
scapular”.
 Ask the patient to do a “push-up against the wall”. If the scapular wings, it’s medial border slips
away from the chest wall and protrudes out like a wing
Check cervical spine movement for range, symmetry and pain
Check the neurological and vascular integrity of the upper limb
Function


Can they get their hands to the back of their head /neck?
Can they reach up between the scapulae as if to scratch their back or as if to fasten a bra?
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
Closure
 Thank the patient, leave them dressed (help if necessary) and comfortable
 Clean your hands, report / record your findings
Examination of the elbow- General Notes
Remember that you will have taken a history and should have a differential diagnosis in mind.
When looking:
 It is important to look at the elbows from behind and in front with the patient standing
 If the joint is distended with fluid, the posterior aspect of the joint becomes swollen.
 A swelling posteriorly may also be due to an inflamed bursa.
 In patients with rheumatoid arthritis is likely to be bilateral and you may see rheumatoid nodules
along the posterior aspect of the ulna.
When feeling:
 The elbow joint is superficial and it is relatively easy to feel abnormalities.
 Tenderness at the epicondyles is suggestive of epicondylitis (tennis/golfer’s elbow)
When moving:
 Movements at the elbow joint are flexion/extension through 150° - 0°.
 Biceps muscle bulk will reduce the ability to fully flex.
 Hyperextension (beyond 0°) indicates hypermobility which is abnormal.
 Supination/pronation of the forearm occurs at the superior radio-ulnar joint through 180°
 Active, passive and resisted movements are tested in all four directions
 Active movements need to be demonstrated
 Passive and resisted movements require stabilization of the arm.
 When testing resisted movements remember that supination is stronger than pronation.
Special tests:
 These relate to medial and lateral epicondylitis
Related structures:
 The ulna nerve lies in close proximity to the medial aspect of the elbow and can be damaged in
trauma and dislocations.
Function:
Test ability to lift something up to mouth as in drinking/feeding and repeated pronation/supination as if
using a screwdriver.
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
Elbow Examination: STEPS
Introduction and preparation
 Introduce yourself fully and check patient’s name
 Explain the procedure and need to uncover the arms.
 Obtain consent.
 Ask the patient if they have any pain, and to localise it if they do. Ask the patient to tell you if any
part of the examination causes pain.
 Allow patient to undress
 Clean your hands
 Position patient standing
Look
 General inspection:
 is the patient in obvious discomfort?
 bedside inspection: any painkillers/walking aids or frames present?
With the patient standing look from behind and in front. Report on:
 Symmetry / asymmetry – stand back and compare the two sides
 Deformities
 Swelling.
 Generalised or localised
 Near the olecranon- olecranon bursitis
 Posterior aspect of the ulna for rheumatoid nodules
 Muscle wasting – look particularly at the biceps and triceps
 Colour
 Bruising is suggestive of trauma
 Erythema is suggestive of inflammation.
 Rashes - a psoriatic rash may accompany a psoriatic arthropathy.
 Scars – from trauma or previous surgery
Feel
 With the patient still standing, ask the patient to report any tenderness, and palpate the following
for any tenderness, swelling or deformity:
 Olecranon, medial and lateral epicondyles
 Along the posterior border of the ulna for rheumatoid nodules
 Temperature. Use the back of your hand on the back of the elbow, compare both sides
Move – when assessing movement, ensure that the shoulder is not abducted
Active
 Flexion and extension
 Note range
 Supination/pronation
 Note range
Passive
 Flexion and extension
 Note range
 Supination/pronation
 Start with hands in the neutral position and hold patient’s hand as if to shake hands
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
Resisted
 Flexion
 Ask patient to flex forearm to about 120° palm facing upwards (supination) - “keep your arm
bent, don’t let me straighten it”- hold forearm above wrist and apply force using your flexors.
 Extension
 As above - “keep your arm there, don’t let me bend it” - hold forearm above wrist and apply
force using your extensors.
 Supination/pronation
 As above, hold patient’s hand as if to shake hands
 Supination – “keep your hand still, don’t let me turn it” – apply pronating force
 Pronation – “keep your hand still, don’t let me turn it” – apply supination force
Special tests
 Lateral epicondylitis – Tennis elbow.
 Cozen's test (resisted wrist extension)
Stabilize the elbow, resting your thumb on the lateral epicondyle. With the forearm in pronation
and parallel to the ground ask the patient to make a fist, deviate a little radially and then keep it
cocked back whilst you resist this. A positive sign is indicated by sharp, sudden, severe pain in
the area of lateral epicondyle of the humerus.
Resisted wrist extension in radial
deviation.

Medial epicondylitis – Golfer’s elbow.
 Resisted wrist flexion (No named tests exist). Stabilize the elbow, resting your thumb on the
medial epicondyle. Ask the patient to straighten their arm and bring the hand down into a
flexed position and keep it there whilst you resist this. The test is positive if pain is reproduced
in the region of the medial epicondyle
Related structures
 Full neurological and vascular examination of the arm
 Examine the joint above (shoulder) and joint below (wrist)
Function
 Can they lift up a cup or bottle?
 Can they get their hands to their mouth as if to drink?
 Can they simulate using a screwdriver?
Closure
 Thank the patient, leave them dressed (help if necessary) and comfortable
 Clean your hands, report / record your findings
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
SUMMARY OF SHOULDER EXAMINATION
INTRODUCTION AND PREPARATION
 Introduction+ check patient’s name
 Explain examination and exposure
 Obtain consent
 Chaperone+ supervisor will repeat examination
 Pain
 Exposure
 Clean your hands
 Position standing
INSPECTION
 Pain/obvious discomfort
 Bedside inspection: any painkillers/walking aids/frames
 Symmetry
 Deformities
 Muscle wasting
 Colour
 Scars
PALPATE
 Tenderness/swelling/deformity
 sterno-clavicular joint
 clavicle
 acromio-clavicular joint/acromion/subacromial bursa
 glenohumeral joint line
 tuberosities of humerus
 bicipital groove.
 coracoid process
MOVEMENT:
Active
 Abduction and adduction
 Flexion and extension
 Maximum flexion = 180 degrees
 Maximum extension = 60 degrees
 External and internal rotation in adduction
 Normal range of external rotation = 70 degrees
Passive + resisted
 Abduction and adduction
 External and internal rotation
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
RELATED STRUCTURES
 Biceps tendon
 Flex elbow to 120° and in supination (palms up)
 Test resisted flexion at elbow

Serratus anterior
 ‘‘Push-up against the wall” winging


CERVICAL SPINE
NEUROLOGICAL+VASCULAR EXAMINATION OF UPPER LIMB
FUNCTION
 Hands to the back head /neck
 Reach up between scapulae
CLOSURE
 Thank patient, leave them dressed+comfortable
 Clean your hands
 Report / record your findings
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
SUMMARY OF ELBOW EXAMINATION
INTRODUCTION AND PREPARATION
 Introduce yourself + check patient’s name
 Explain examination
 Obtain consent
 Pain
 Ensure exposure
 Clean hands
 Position patient standing
INSPECTION
 Pain/discomfort
 Bedside inspection: painkillers/walking aids/frames
 Symmetry
 Deformities
 Swelling
 Muscle wasting
 Colour
 Rashes
 Scars
PALPATE
 Tenderness/swelling/deformity
 Olecranon
 Epicondyles
 Posterior border of ulna
 Temperature
MOVEMENT
Active
 Flexion and extension
 Supination/pronation
Passive
 Flexion and extension
 Supination/pronation
Resisted
With elbow flexed to about 120 degrees, and in supination (palms up)
 Flexion
 Extension
 Supination/pronation
Special tests
 Lateral epicondylitis/tennis elbow: Cozen's test (resisted wrist extension)
 Medial epicondylitis/golfer’s elbow: resisted wrist flexion
Related structures
 Neurological + vascular examination of arm
 Shoulder (joint above) and wrist (joint below)
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
Function
 Lift cup or bottle
 Hands to mouth as if to drink
 Use a screwdriver
Closure
 Thank the patient+leave comfortable
 Clean your hands
 Report / record your findings
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
Self directed learning
The Shoulder: common problems
Clinical assessment starts with a detailed clinical history.
 Pain, stiffness and restricted movements are common shoulder symptoms.
 Systemic symptoms may suggest a rheumatogical condition.
 Consider primary neurological conditions if there are relevant symptoms.
Shoulder pain can be referred or local.
 Remember that pain usually refers distally not proximally.
 Pain in the trapezius and up the side of the neck is therefore probably of C. spine origin.
 Pain in the scapular region is probably from the thoracic spine but consider thoracic and upper
abdominal sources.
 Remember that shoulder tip pain may come from the diaphragm.
 Remember that local pathology e.g. lung disease can cause shoulder pain
 Exclude systemic symptoms which may suggest a rheumatological condition. Consider primary
neurological conditions if there are relevant signs/symptoms.
 Pain arising from the shoulder girdle articular structures is generally described as an “aching”
pain - exacerbated by use, particularly with the arm abducted, and characteristically prevents
the patient sleeping on the affected side.
 The acromio-clavicular (AC) joint is supplied by C4 - pain is therefore localised to the top
of the shoulder. The AC joint moves mainly during the final stages of abduction and on
adduction of the arm across the body. Difficulty throwing a scarf over the opposite
shoulder, for example) may be suggestive of pain from this joint. (Passive adduction of the
arm in a flexed position is often referred to as the Scarf test)
 The gleno-humeral joint is supplied by C5 - pain is therefore localised to the upper arm.
Movements are often restricted first or most markedly in a direction characteristic of the
joint concerned – the “capsular pattern” of that joint. In the gleno-humeral joint
external rotation is most limited (although internal rotation and abduction tend also to be
involved) in capsulitis. Difficulties with activities of daily living such as hair washing are
consistent with this.
 Any abnormal narrowing between the acromion process and the head of the humerus may
result in impingement syndrome. The most common symptoms are pain, weakness and a
loss of movement at the affected shoulder. The onset of the pain may be acute if it is due to
an injury or may be insidious if it is due to a gradual process such as an osteoarthritic spur.
After taking a clinical history you may have a differential diagnosis in mind following which
the source of the problem can usually be differentiated by clinical examination.
After examination, ask yourself if your findings are consistent with the differential diagnosis,
Then consider likely pathology:
Acromio-clavicular joint:
The acromioclavicular(AC) joint is a common spot for osteoarthritis to develop in middle age.
Osteophytes may damage the underlying rotator cuff causing impingement.
Gleno-humeral joint:
Stiffness may result from arthritis, or from prolonged immobility of the joint as a result of pain. There is
also a specific condition of 'adhesive capsulitis' colloquially known as “frozen shoulder”.
Shoulder & Elbow Examination
Tutor Notes 2014-2015: Lead Lecturer: Dr Hamed Khan
Subacromial bursa:
This is a common source of shoulder pain. The bursa is pinched against the under surface of the
acromion as the shoulder is abducted causing a painful arc (see impingement syndrome below).
Rotator cuff:
The rotator cuff muscles are often the source of pain. There is limited space in this region and the
supraspinatus tendon in particular has a poor blood supply. Acute inflammation of any of the
constituent tendons may arise spontaneously or following minor trauma.
Degenerative disease will cause attenuation of the cuff, which may wear through completely and tear.
Tears may also follow trauma - a sudden fall onto the tip of the shoulder, causing pain and weakness
on resisted movements
Impingement syndrome
This usually results from narrowing between the acromion process and the head of the humerus. A
painful arc of movement may be present during forward elevation of the arm from 60° to 120° with
pain-free range above and below the arc.
The elbow: common problems
Lateral epicondylitis, also known as tennis elbow, shooter's elbow and archer's elbow, is an
inflammatory overuse injury, commonly associated with playing tennis and manual workers, such as
builders using the same repetitive extensor motion for many years.
Medial epicondylitis is in some ways similar to tennis elbow. The condition is also called golfer's
elbow because in making a golf swing the flexor tendons are stressed.
Joint hypermobility
When assessing movements at the elbow it is important to note any hyperextension (beyond 0°) as
this indicates hypermobility which is abnormal. Joint hypermobility is also present in patients with
Marfans syndrome and Ehlers-Danlos syndrome.
Further Reading and References
Douglas G, Nicol F, Robertson C. (2005) Macleod’s Clinical Examination 11th edition. Churchill
Livingstone, Edinburgh
Magee D J, (1997) Orthopaedic Physical Assessment 3rd Edition, Saunders
McRae (2004) Clinical Orthopaedic examination 5th Edition Churchill Livingstone
Moore K L, Dalley A F (2006) Clinically Oriented Anatomy 5th Edition, Lippincott, London.
Ombregt L, Bisschop P. (1999) Atlas of orthopaedic examination of the peripheral joints. Saunders.
www.shoulderdoc.co.uk