Inspection of the Shoulder Region - Part 1 - Clinical Examination

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Every shoulder examination includes inspection, which already begins as the patient enters the room. An anomalous posture with a lack of arm swing or avoidance of a handshake may both be early signs of a pathological shoulder condition. Inspection should always be performed with the upper body undressed. Undressing in itself is already a part of the examination, since taking off a shirt requires a variety of complex movements that are all affected by shoulder joint conditions. Pain, limited range of motion, or the inability to undress without assistance can thus yield the first diagnostic clues.

Now, a detailed inspection follows.

Examine the symmetry of both shoulders by observing the outline of the trapezius muscle and comparing the height of both acromions. Significant asymmetry can be a sign of, for example, scoliosis, muscular atrophy or an anomalous posture because of discrepancies in limb length. This patient is only notable for a discretely elevated right shoulder.

Afterwards, inspect the outline of the neck and shoulder muscles, especially of the trapezius muscle. All three of its parts should be considered: the ascending, the transverse and the descending part. Any sign of atrophy should be noted, since it can hint at an underlying disease affecting either the muscles or the nerves. Inspection may also reveal hypertrophy as a sign of overuse.

Inspection of the scapula can be facilitated by palpating its outline. This patient’s scapula is unremarkable and does not protrude from the back, as seen in winged scapula, also called scapula alata.

Lateral inspection allows examination of the pectoralis major and deltoid muscles. Note any asymmetries, which can hint at injuries or neurological deficits- for example, a lesion of the axillary nerve resulting in atrophy of the deltoid muscle.

The symmetry of the shoulders can also be evaluated from the front. Ideally, you should be able to draw a horizontal line from one acromion to the other. Additionally, the outline and course of the clavicles should be checked for any signs of fracture, such as swelling, hematoma or wounds. If visible deformity is present in the area of the lateral clavicle, both a clavicular fracture or an acromioclavicular joint injury should be considered.

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