Both the knee and the shoulder examinations follow the same simple structure - Look, Feel, Move, Special Tests, Function. In an OSCE situation, make sure to check the card as to which shoulder/knee you've been asked to examine, either one or both. In all situations you'll be comparing the 'normal' joint to the 'problem' joint, so the following steps are to be done on both sides, beginning with the normal joint.
As with all the examinations, begin with the same opening sequence. Being friendly and rewording questions to make them sound less rehearsed will make your bedside manner appear much more natural and confident.
- Wash hands
- Introduce yourself
- Confirm their name, age and date of birth (try and remember the first 2 for your closing summary!)
- Consent eg. I've been asked to examine your shoulder today which will involve having a look, feel and move around of your shoulder - is that alright with you? - Again, rephrase to what you feel most natural saying.
- Check for pain or problems in movement
- Expose the patient appropriately (remove shirt for shoulder exam)
It is up to you how you position your patient. Some people prefer their patient to be standing the whole way through the exam, whereas others prefer them sat on a chair/at the side of the bed for the inspection steps, and then standing up for movement. Either way, you need make it clear that you're examining the back of the joint as well as the front, so don't have them lying down!
There are number of things that you need to look for and comment on their presence or absence. Although you will probably learn the list of what to say, make sure you're actively looking all around both shoulders, they'll know if you're just rattling out a list and not paying any attention to the patient.
- Asymmetry or abnormal posture
- Erythema or any other discolouration/skin changes
- Muscle wasting
Remember before touching the patient to always ask their permission. I'm now going to feel over both of your shoulders starting with the 'normal' side, is that ok? If you feel any pain during the examination then please let me know. Remember also to maintain eye contact with the patient so you can show the examiner you are focused on the patient and any potential pain or discomfort.
- Compare TEMPERATURE over both shoulders using the back of your hand. The temperature is normal and equal over both shoulder joints and the surrounding areas.
- Use two fingers to palpate over the shoulder joint, checking for any TENDERNESS as you go. Different people will demonstrate this technique in different ways, but make sure that you hit all the main parts - sternoclavicular joint, clavicle, acromioclavicular joint, acromium, coracoid process, scapula borders and the biceps tendon.
- Palpate the MUSCLE BULK of both shoulders, you can do both together as a direct comparison. Make sure you cover supraspinatus, infraspinatus and deltoid muscles while checking for pain in the patient's face.
All the movements below need to be covered both actively and passively, again asking them if they feel any pain. Firstly, passively, where you ask them to copy your movements. Actively follows the same set of movements, but you move the arm yourself with your other hand placed on top of the shoulder joint to feel for any crepitus.
- ABDUCTION (out horizontally all the way up)
- ADDUCTION (back in to the sides of the body)
- FLEXION (out forwards as high as they can)
- EXTENSION (out back as far as they can stretch)
- INTERNAL ROTATION (elbows tucked into the side and both arms rotating towards the body)
- EXTERNAL ROTATION (elbows tucked in and arms rotating outwards)
Remember to do the active movements on both shoulders, starting with the 'normal' side.
Explain to the patient that they are going to perform some of the same movements again, but this time you are going to try and resist their movement as they push against your hand.
- ABDUCTION (as they move their arms out, push down on the top of each in turn feeling for the power against resistance)
- EXTERNAL ROTATION (with their elbows tucked in, ask them to rotate their arms out as you push against them - it is easier if you line up your arm next to theirs with your hand on their elbow)
- INTERNAL ROTATION (same as above)
WINGING OF THE SCAPULA is a step which is often forgotten as it doesn't fit directly into any of the subheadings. Can you please place your palms against this wall and push? Remember that damage to the long thoracic nerve would cause the winging - this is an common and easy question for the examiners to ask.
I would now like to look at your ability to do normal activities of daily living, is that alright with you? Can you copy me please.
- Hands behind the head
- Hands behind the back as high up as possible
- Touch each hand to the opposite shoulder
As always, end your examination by thanking the patient, allowing them to cover themselves up, and washing your hands.
SUMMARY - as at the end of every examination you will be asked to summarise your findings. Begin with their name and age, and then briefly comment on each section before finishing with an overall statement such as this was a normal shoulder examination.