Physical Examination of Shoulder

1. Shamima Akter
B. Sc (Honors) in Occupational Therapy
& M. Sc in Rehabilitation Science
Assistant Professor,
Department of Occupational Therapy
Bangladesh Health Professions Institute (BHPI)
Centre for the Rehabilitation of the Paralysed (CRP)
Chapain, Savar

2. Bony Palpation area of Shoulder
1. Suprasternal notch
2. Sternoclavicular joint
3. Clavicle
4. Coracoid process
5. Acromioclavicular joint
6. Acromion
7. Acromion process
8. Spine of scapula
9. Greater tuberosity
10.Lesser tuberosity
11.Bicipital groove
12.Border of scapula
13. Superior medial angle
14. Inferior angle
15. Supraglenoid tubercle
16. Infraglenoid tubercle

7. Suprasternal Notch
Position: Behind the seated patient
Instruction: Move hands medially from their
position on the deltoid and acromion until you
feel suprasternal notch.

8. Sternoclavicular joint
Position: Behind the seated patient
Instruction: Immediately lateral to
suprasternal notch.

9. Clavicle
Position: Behind the seated patient
Instruction: Move laterally from the
sternoclavicular joint and palpate in a sliding
motion along the smooth anterior superior
surface of the clavicle.
First palpate the convex medial 2/3, then
palpate along the concave lateral 1/3.
Convex
medial 2/3
Concave
lateral 1/3

11. Coracoid
process
Position: Behind the
seated patient
Instruction: At the
portion of the
clavicular concavity,
lower the fingers
distally about one inch
from the anterior edge
of the clavicle, press
laterally and posteriorly
in an oblique line until
you feel the coracoid
process. The process
One
inch
below
to
clavicular
concavity

14. Acromioclavicular articultation
Position: Behind the seated patient
Instruction: Palpate clavicle laterally for
approximate one inch to the subcutaneous
acromioclavicular articulation.
During flexion and extension of shoulder it can
be easily palpated.
If you place three fingers (of the opposite hand) on
top of the shoulder the AC joint will be beneath
them. If you now swing the arm forward and back
you will appreciate movement (rotation) between
the acromion and the collarbone.

18. Continue…
Acromion (part of scapula)
Position: Behind the seated patient
Instruction: The rectangular acromion,
sometimes referred as the shoulder’s summit.
Palpate its bony dorsum and anterior portion.
Acromion Process (part of scapula)
Position: Behind the seated patient
Instruction: Located on the lateral part of the
shoulder, right above the shoulder joint.

32. Greater tuberosity
Position: Beside the seated patient
Instruction: From the lateral lip of the
acromion, palpate laterally to the greater
tuberiosity of the humerous, this lies inferior to
the acromion’s lateral edge.
Located just below acromion when arm is
resting by the side. (proximal end of humerus).

35. Lesser Tuberiosity
Position: Beside the seated patient
Instruction: Easiest to palpate with arm in
shoulder external rotation. located medial to
greater tuberosity on proximal end of
humerus.

36. Bicipital groove
Position: Beside the seated patient
Instruction: The bicipital groove is located
anterior and medial to the greater tuberosity
and is bordered laterally by the greater
tuberosity and medially by the lesser tuberosity,
easiest to palpate with arm in external rotation.

37. Position: Back of the patient
Spine of scapula
Instruction: Move posteriorly and medially and
palpate the acromion as it tapers to the spine of the
scapula.
Medial (vertebral) border
Instruction: The edge of the scapula closest to the
vertebral column (about 2 inches from the spinous
processes). The medial border runs in a superior-
inferior direction.
Lateral (axillary) border
Instruction: The lateral (or outer) edge of the
scapula located between the inferior angle and the

39. Superior medial angle
Located above the vertebral border or medial
aspect of scapula, level T2.
Inferior angle
Located between vertebral and axillary borders.
The “point” at the bottom of scapula, level T7.

42. Zones of shoulder
The examination of the soft tissue structures of
the shoulder has been divided into four clinical
zones:
Zone 1: Rotator cuff
Zone 2: Subacromial and subdeltoid
bursa
Zone 3: Axilla
Zone 4: Prominent muscle of shoulder
girdle

43. Zone 1- Rotator cuff
 The cuff is composed of four muscles, three of
which are palpable at their insertions into their
greater tuberiosity of the humerous.
 These three, the supraspinatus, the
infraspinatus and the teres minor,, are called
the SIT muscles, since, in the order of their
attachment, their initials spell ‘sit’.

44. Continue…
 In a modified anatomical position (with the arm
hanging at the side), the supraspinatus lies
directly under the acromion; the infraspinatus is
posterior to the supraspinatus and the teres
minor is immediately posterior to the other two
muscles.
 The forth muscle in the rotator cuff, the
subscapularis, is located anteriorly and is not
palpable.

45. Clinical significance of rotator
cuff
 Rotator cuff tear
 Overuse injuries for repetitive movement
 Shoulder pain
 Shoulder subluxation due to paralysis of
rotator cuff muscle

46. SUPRASPINATUS
ORIGIN:
 Supraspinatous fossa of
the scapula
INSERTION:
 Superior facet on the
greater tubercle of the
humerus
ACTION: initiation of
abduction (15*) & lateral
Rotation
N.SUPPLY: Suprascapular.N
(C5,C6)

47. INFRASPINATUS
ORIGIN:
 Infraspinatous fossa of the
scapula
INSERTION:
 Middle facet on the
gr.tubercle of the humerus
ACTION:
 Lateral rotation of shoulder,
strengthen the shoulder by
bracing the head of
humerus.
N.SUPPLY:
 Suprascapular Nerve
(C5,C6)
INFRASPINATUS

48. TERES MINOR
ORIGIN:
 lateral border of the
scapula
INSERTION:
 Inferior facet on the
greater tubercle of the
humerus
ACTION:
 Ext.rotator & weak
adductor
N.SUPPLY:
 Axillary .N.(C5,C6)

49. SUBSCAPULARIS
ORIGIN:
 Medial 2/3 subscapular fossa,
lateral border of tha scapula
INSERTION:
 Lesser tubercle of the
humerus
ACTION:
 Stabilise the shoulder &
prevents anterior
displacement of the shoulder
(med. rotation, adduction of
arm)
N.SUPPLY:
 Upper &Lower Subscapular .N

50. Zone 2- Subacromial and subdeltoid bursa
 At points just below the anterior edge of the
acromion, the bursa may extend as far as
the bicipital groove.
 The subacromial bursa is a sac of fluid that
separates the acromion from the rotator cuff.
 The bursa is underneath the coracoacromial
ligament, acromion bone, and the deltoid muscle
as shown in the illustration.

51. Clinical significance of Shoulder
Zone- II
Subacromial bursitis- It is a common cause of
shoulder pain that is usually related to shoulder
impingement of your bursa between rotator cuff
tendons and bone (acromion)
Subacromial impingement- Shoulder
impingement syndrome, also called subacromial
impingement, painful arc syndrome,
supraspinatus syndrome, swimmer's shoulder,
and thrower's shoulder, is a clinical syndrome
which occurs when the tendons of the rotator cuff
muscles become irritated and inflamed as they
pass through the subacromial space, the passage
beneath the acromion.

54. Zone 3- Axilla
 The axilla (also, armpit, underarm or oxter) is
the area on the human body directly under the
joint where the arm connects to the shoulder.
 The axilla is quadrilateral pyramidal structure
through which vessels and nerves pass to the
upper extremity.
 It also provides the under-arm sweat gland.

55. Palpation process
 Stand in front of the patient and
abduct his arm with one hand as you
gently insert your index and middle
fingers into the axilla.

56. Boundary of axilla
 The fleshy anterior wall of axilla is formed by the
pectoralis major muscle, it can be palpated
during abduction (away from midline).
 The posterior wall formed by latissimus dorsi
muscle, can be grasped by index and middle
finger during abducted arm away from the
midline.
 The medial wall is defined by ribs two to six and
the overlying serrstus anterior muscle and
 The lateral wall by the bicipital groove of the
humerous.

57. Contents of axilla
 Axillary artery and its branches
 Axillary vein and its tributaries
 Infraclavicular part of the brachial plexus
 Long thoracic and intercostobrachial nerves
 Five groups of axillary lymph nodes and the
associated lymphatics
 Axillary fat and areolar tissue in which the other
contents are embedded

58. Clinical significance of axilla
 Lymphogenic spread of breast cancer
 Breast cancer typically spreads via lymphatic
vessels to the lymph nodes found in the axilla.
 Axillary intertrigo
 Excessive perspiration can result in axillary
intertrigo.
 Intertrigo is an inflamed skin condition caused by
heat, friction, and moisture.
 A warm, wet underarm may accommodate the
growth of pathogenic bacteria, yeasts, and fungi.

59. Axillary artery

60. Axillary vein

61. Brachial Plexus

64. Continue..

67. Zone 4- the prominent muscles of shoulder girdle
The muscles that
move the shoulder
girdle and
glenohumearl joint can
be divided into three
 Sternocleidomastoid
muscle
 Pectoralis major
 Biceps

68. Continue…
Sternocleidomastoid muscle
The muscle will be more prominent on the site of
opposite that to which the head is turned, and
The muscle can be palpated at its distal origin more
easily if the patient turns his head first to one side,
then to the other.
Pectoralis major
To plapate pectoralis major muscle, instruct the
client to adduct the arm at the shoulder joint against
resistance. Feel the contraction of sternocostal head
and palpate toward its proximal attachment.
Biceps
The biceps become more prominent and more
easily palpable when the elbow is flexed.

72. Possible Question
 Describe physical examination/ soft tissue
palpation of shoulder zone 1/2/3/4
 Describe the physical examination procedure
of axilla/ rotator cuff/ subacromial or subdeltoid
bursa/ prominent muscle of shoulder
 In which shoulder zone, one can palpate axilla,
describe the palpation procedure of axilla.
 Write down the names of shoulder zone with
their corresponding clinical significance.