Shoulder OSCE Examination

Contents

1. Introduction
2. General Inspection
3. Look (Inspection)
4. Feel (Palpation)
5. Move (Range of Movement)
6. Special Tests – Rotator Cuff
7. Special Tests – Impingement
8. Special Tests – ACJ, Biceps and Instability
9. Neurovascular Assessment
10. Completing the Examination
11. Quiz

Introduction

Wash your hands before approaching the patient.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient's details taking 3 points of identification usually; full name, date of birth and NHS/hospital number.

Obtain consent for the examination, ensuring to explain what the examination will entail.

Expose both shoulders fully — the patient should remove enough clothing that both shoulder girdles, the upper chest and both scapulae are visible, as comparison with the unaffected side is essential.

Position the patient standing, or sitting on the edge of the couch, so that you can walk around them and inspect the shoulders from the front, the side and behind.

Ask the patient if they have any pain before you begin, and to tell you if anything you do is uncomfortable. This is particularly important in the shoulder, where pain often limits movement before any true mechanical block is reached.

General Inspection

Begin with a brief inspection of the patient and the area around the bed. Note whether the patient appears comfortable or in distress, and how they are holding the arm — a patient with an acutely painful shoulder will often support the affected limb against their body to splint it.

Look for walking aids, a sling or shoulder immobiliser, and any analgesia at the bedside, all of which give clues to the severity and chronicity of the problem. Observe how the patient removes their clothing during exposure, as a reluctance to move the arm overhead or to reach behind the back is a useful early functional sign.

Look (Inspection)

Inspect both shoulders systematically from the front, the side and behind, always comparing one side with the other.

From the front, look for:

• Scars — suggesting previous surgery such as rotator cuff repair, stabilisation or joint replacement.
• Asymmetry or deformity — a step deformity at the acromioclavicular joint suggests ACJ dislocation, while loss of the normal rounded deltoid contour ('squaring' of the shoulder) suggests anterior glenohumeral dislocation.
• Swelling or erythema — which may indicate effusion, infection or inflammatory arthritis.
• A visible 'Popeye' deformity — a bulge in the upper arm caused by distal retraction of the muscle belly after rupture of the long head of biceps.

From the side, assess the patient's posture and the contour of the shoulder, looking for a thoracic kyphosis or a protracted ('rounded') shoulder, both of which alter the position of the scapula and can contribute to impingement.

From behind, look for muscle wasting. Wasting of the deltoid may follow axillary nerve injury, while wasting of the supraspinatus and infraspinatus fossae of the scapula suggests a chronic rotator cuff tear or suprascapular nerve pathology.

Ask the patient to push against a wall with both hands to test for scapular winging. The scapula lifts away from the chest wall when the serratus anterior is weak, most commonly due to a long thoracic nerve palsy.

Image - Winging of the scapula, where the medial border lifts away from the chest wall. This indicates weakness of serratus anterior, classically from a long thoracic nerve palsy

Creative commons source by Lukelahood [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Feel (Palpation)

Before palpating, ask again about pain and watch the patient's face throughout. First assess temperature by running the back of your hand over both shoulders and comparing sides — increased warmth suggests active inflammation, infection (septic arthritis) or crystal arthropathy.

Then palpate the bony and soft-tissue landmarks in a logical sequence, starting medially and working laterally:

• Sternoclavicular joint — tenderness or swelling here may reflect dislocation or arthritis.
• Clavicle — palpate along its length for tenderness or a step suggesting a fracture.
• Acromioclavicular joint (ACJ) — localised tenderness or a prominent step here points to ACJ arthritis or disruption.
• Acromion and coracoid process.
• Greater tuberosity of the humerus and the subacromial space — tenderness over the subacromial region is typical of subacromial impingement or rotator cuff disease.
• Head of humerus and the surrounding muscle bulk.

The scapular spine and borders should also be palpated posteriorly. Localising the point of maximal tenderness is one of the most useful steps in distinguishing ACJ pathology from rotator cuff or glenohumeral problems.

Image - The bony anatomy of the shoulder, showing the glenohumeral joint, the acromioclavicular joint, the clavicle and the acromion — the key landmarks palpated during examination

Creative commons source by OpenStax College [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)]

Move (Range of Movement)

Start with two quick compound (functional) movements that screen the whole shoulder at once: ask the patient to place both hands behind their head (testing abduction and external rotation) and then to reach both hands up the middle of their back (testing adduction and internal rotation). If these combined movements are full and pain-free, significant restriction is unlikely; if either is limited, the individual movements below will localise the problem.

Always assess active movement first (the patient moves the arm themselves), as this screens for pain and weakness while keeping the patient in control. If active movement is restricted or painful, repeat the movement passively (you move the arm for them), feeling for crepitus as the joint moves — a grinding sensation that often accompanies glenohumeral osteoarthritis. The pattern of restriction is highly informative:

• If both active and passive movement are restricted, the problem is likely within the joint itself — for example adhesive capsulitis ('frozen shoulder') or glenohumeral osteoarthritis.
• If active movement is restricted but passive movement is preserved, the problem is more likely a muscular or tendon issue, such as a rotator cuff tear.

Assess the main movements, comparing both sides:

• Flexion (arm forward and up) — normally around 180°.
• Extension (arm backwards) — normally around 40–60°.
• Abduction (arm out to the side and up) — normally around 180°. As the patient abducts, rest a hand on the inferior pole of the scapula to assess the scapulohumeral rhythm: smooth abduction relies on coordinated glenohumeral movement and scapular rotation (roughly a 2:1 ratio), with the early range being predominantly glenohumeral. Early or excessive scapular movement ('scapular hitching') suggests the patient is compensating for a restricted or painful glenohumeral joint.
• Adduction (arm across the body) — normally around 30–45°.
• External rotation — with the elbow flexed to 90° and tucked into the side, ask the patient to rotate the forearm outwards (normally around 70–90°). Loss of external rotation is characteristic of frozen shoulder and glenohumeral osteoarthritis.
• Internal rotation — ask the patient to reach behind their back and move their thumb as far up the spine as possible, recording the vertebral level reached.

During abduction, look specifically for a painful arc: pain felt between roughly 60° and 120° of abduction, which then eases at the extremes. This occurs because, in this mid-range, the inflamed supraspinatus tendon and subacromial bursa are compressed beneath the acromion, and is the hallmark of subacromial impingement. By contrast, pain in the final last few degrees (around 170–180°) points instead to acromioclavicular joint pathology, where the ACJ is maximally loaded.

Special Tests – Rotator Cuff

The rotator cuff is made up of four muscles — supraspinatus, infraspinatus, teres minor and subscapularis — which together stabilise the humeral head within the shallow glenoid and initiate and control movement. Each special test isolates one part of the cuff so that a weak or painful response localises the lesion.

• Supraspinatus – 'empty can' (Jobe's) test: ask the patient to abduct the arms to 90° in the plane of the scapula, with the thumbs pointing down as if emptying a can, then resist as they push up. Pain or weakness suggests supraspinatus tendinopathy or tear, as this position isolates and stresses the supraspinatus.
• Infraspinatus and teres minor – resisted external rotation: with the elbows flexed to 90° and tucked in, ask the patient to push their hands outwards against resistance. Weakness indicates a problem with the infraspinatus/teres minor, the main external rotators.
• Subscapularis – Gerber's lift-off test: ask the patient to place the back of the hand against the lower back and then lift it away from the back against resistance. The subscapularis is the principal internal rotator, so an inability to lift off suggests subscapularis dysfunction or rupture. The belly-press test (pressing the palm into the abdomen while keeping the elbow forward) is an alternative for patients who cannot reach behind the back.

The drop arm test assesses the integrity of the cuff as a whole: passively abduct the arm to 90° and ask the patient to lower it slowly. If the arm drops suddenly or the patient cannot control the descent, this suggests a large rotator cuff (typically supraspinatus) tear, as the cuff can no longer support the weight of the arm.

Image - The four rotator cuff muscles (supraspinatus, infraspinatus, teres minor and subscapularis), each of which is isolated by a specific special test

Creative commons source by InjuryMap [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Special Tests – Impingement

Impingement tests reproduce compression of the rotator cuff and subacromial bursa beneath the coracoacromial arch, and are positive in subacromial impingement syndrome.

• Neer's test: stabilise the scapula with one hand, then passively flex (forward elevate) the patient's internally rotated arm. Pain as the arm is raised indicates impingement, because this manoeuvre drives the greater tuberosity and supraspinatus tendon against the underside of the acromion.
• Hawkins–Kennedy test: flex the shoulder and elbow to 90°, then internally rotate the shoulder by lowering the forearm. Pain on internal rotation suggests impingement, as the supraspinatus tendon is forced against the coracoacromial ligament.

A positive painful arc on abduction (see above) supports the same diagnosis. Impingement is often associated with a painful but full passive range and normal strength, which helps distinguish it from a complete cuff tear.

Image - Subacromial impingement, where the supraspinatus tendon and subacromial bursa are compressed beneath the acromion, producing a painful arc and positive Neer's and Hawkins tests

Creative commons source by LA323 [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]

Special Tests – ACJ, Biceps and Instability

The scarf (cross-arm adduction) test assesses the acromioclavicular joint. Passively flex the shoulder to 90° and bring the arm across the body towards the opposite shoulder. Pain localised to the top of the shoulder is positive and suggests ACJ pathology, because this position compresses the joint surfaces together.

Speed's test assesses the long head of biceps. With the elbow extended and the forearm supinated, ask the patient to flex the shoulder against resistance. Pain in the front of the shoulder (over the bicipital groove) suggests biceps tendinopathy and complements the Popeye deformity looked for on inspection, which indicates a complete rupture of the tendon.

Yergason's test is a useful adjunct for the same structure: with the elbow flexed to 90° and tucked into the side, ask the patient to supinate the forearm against resistance while you palpate the bicipital groove. Pain reproduced here also points to long head of biceps tendinopathy or instability of the tendon within its groove.

Tests of glenohumeral instability are usually reserved for younger patients or those with a history of dislocation:

• Anterior apprehension test: with the patient lying down, abduct the shoulder to 90° and externally rotate the arm. A feeling of apprehension that the shoulder is about to dislocate (rather than pain) suggests anterior instability, often following a previous anterior dislocation that has damaged the labrum and capsule.
• Relocation test: applying a posteriorly directed force to the front of the humeral head during the apprehension test relieves the apprehension, confirming anterior instability.

These tests should be performed gently, as forcing the manoeuvre in a truly unstable shoulder risks provoking a dislocation.

Neurovascular Assessment

Because shoulder problems and their treatment can affect surrounding nerves and vessels, complete the examination with a brief neurovascular check of the upper limb.

Assess sensation over the 'regimental badge' area on the lateral upper arm, which is supplied by the axillary nerve. This nerve is vulnerable in anterior shoulder dislocation and surgical neck of humerus fractures, so reduced sensation here is an important finding.

Confirm intact distal pulses (radial pulse) and adequate capillary refill in the fingers to ensure the limb is well perfused, and check gross power and sensation in the rest of the arm and hand.

Image - Sensory dermatomes of the upper limb. The 'regimental badge' over the lateral upper arm corresponds to the C5 dermatome and axillary nerve territory, which is tested after shoulder dislocation

SimpleMed original

Completing the Examination

Thank the patient and ask them to redress, then wash your hands.

Summarise your findings and state whether the examination was normal or abnormal.

To complete the examination, say you would examine the joint above and below (the cervical spine and the elbow), as shoulder pain is frequently referred from the neck. You would also perform a full neurovascular examination of the upper limb if not already done, assess function (for example asking the patient to comb their hair or reach into a back pocket), and consider relevant imaging such as plain radiographs for bony injury, ultrasound or MRI for rotator cuff and soft-tissue pathology.

Quiz

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