Why Shoulder Examination Is a High-Yield OSCE Station
The shoulder is the most mobile and most frequently injured joint in the body. Shoulder examination OSCE stations test your ability to systematically examine a complex joint and perform targeted special tests. The examiner wants to see you identify the likely structure at fault — rotator cuff, acromioclavicular joint, biceps tendon, or labrum — through a logical examination sequence.
Setup
- Wash hands, introduce, confirm name and DOB, gain consent
- Expose both shoulders and arms fully — comparison is essential
- Ask about pain before touching: "Before I start, can you show me where it hurts?"
- Start with the patient standing
Look — Inspect From Front, Side, and Behind
From the front:
- Asymmetry of shoulder height, deltoid contour and bulk
- Scars: small arthroscopic portals, larger open incisions, AC joint
- Swelling: AC joint (dislocation), glenohumeral joint, biceps rupture (Popeye sign — biceps bunches up distally)
From the side:
- Posture: forward head carriage, thoracic kyphosis (contributes to impingement)
From behind:
- Scapular winging: ask patient to push against a wall — winging = serratus anterior weakness (long thoracic nerve palsy)
- Infraspinatus and supraspinatus wasting: rotator cuff tear or suprascapular nerve palsy
- Asymmetry of muscle bulk
Feel — Palpate Systematically Front to Back
- 1Sternoclavicular joint
- 2Clavicle along its full length
- 3Acromioclavicular joint — step deformity in AC dislocation
- 4Acromion
- 5Bicipital groove (anterior, just medial to greater tuberosity) — tenderness = biceps tendinopathy
- 6Greater tuberosity (supraspinatus insertion)
- 7Posterior glenohumeral joint line
💡 Tip
To find the bicipital groove reliably, rotate the arm to neutral — the groove is anterior and palpable with the thumb. Reproduce the patient's pain with direct pressure to confirm biceps tendinopathy before performing Speed's test.
Move — Active Then Passive Range of Motion
| Movement | Normal | Clinical note |
|---|---|---|
| Flexion | 0–180° | Reduced in adhesive capsulitis (frozen shoulder) |
| Extension | 0–60° | |
| Abduction | 0–180° | Painful arc 60–120° = subacromial impingement |
| External rotation | 0–90° | Markedly reduced in frozen shoulder |
| Internal rotation | Thumb to T10 vertebra | |
| Cross-body adduction | Full | Pain at AC joint = AC pathology |
💎 Clinical Pearl
In frozen shoulder (adhesive capsulitis), both active and passive movements are globally restricted in a capsular pattern: external rotation is the most severely limited, followed by abduction, then internal rotation. The pain is usually worse at night.
Special Tests
Subacromial Impingement
- Hawkins-Kennedy test: flex shoulder to 90°, elbow at 90°, then internally rotate — positive if pain reproduced (impinges supraspinatus under coracoacromial arch)
- Neer's sign: stabilise scapula, passively flex the arm — positive if pain at 90–120° flexion
Supraspinatus (Rotator Cuff)
- Empty can test (Jobe's): arm at 90° abduction, 30° forward flexion, internally rotated (thumb pointing down). Apply downward resistance — weakness or pain = supraspinatus pathology
- Full can test: same position but thumb up — less painful, better tolerated
Subscapularis
- Lift-off test: patient places dorsum of hand on lower back, then lifts it away — inability = subscapularis weakness
- Belly-press test: patient presses palm against abdomen with elbow forward — elbow falling back = subscapularis weakness
🧠 Mnemonic
Testing each rotator cuff muscle:
Supraspinatus — Empty can (resisted abduction, thumb down)
Infraspinatus — resisted External rotation
Teres minor — resisted External rotation (same test, distinguishes by neurological supply)
Subscapularis — Lift-off test
SIET = the four rotator cuff muscles
Acromioclavicular Joint
- Cross-body adduction test: actively adduct arm fully across chest — pain localised to AC joint confirms AC pathology
Biceps Tendon
- Speed's test: arm supinated and at 90° flexion, resist forward flexion — pain in bicipital groove = biceps tendinopathy or SLAP lesion
- Yergason's test: elbow at 90°, resist supination — pain or click in groove = biceps tendinopathy
Glenohumeral Instability
- Anterior apprehension: arm at 90° abduction and 90° external rotation, apply anterior force — positive if patient feels apprehension (not just pain)
- Relocation test: relieve anterior force — positive if apprehension is relieved
To Complete
- Neurovascular: deltoid sensation (axillary nerve, "regimental badge" area), distal pulses
- Cervical spine: Spurling's test to exclude C5/C6 nerve root referral
- Investigations: AP, scapular Y, and axillary X-ray views; MRI for rotator cuff and labral pathology
Frequently Asked Questions
"What is a painful arc and what does it mean?"
A painful arc is pain specifically between 60° and 120° of shoulder abduction, with relief below 60° and above 120°. This pattern is characteristic of subacromial impingement — the greater tuberosity compresses the supraspinatus tendon against the undersurface of the acromion through this range.
"How do I test the rotator cuff in an OSCE?"
Test each component individually: supraspinatus with the empty can test (resisted abduction in the scapular plane, thumb pointing down), infraspinatus and teres minor with resisted external rotation, and subscapularis with the lift-off test. Weakness against resistance — not just pain — indicates a significant tear.
"What is the difference between impingement and a rotator cuff tear on examination?"
Both can show a painful arc and a positive Hawkins-Kennedy test. The key difference is the empty can test: pain with normal strength suggests impingement (tendinopathy or bursitis); pain with significant weakness suggests a rotator cuff tear. MRI is required to confirm and characterise any tear.
"What does scapular winging indicate?"
Scapular winging — the medial border of the scapula lifting away from the chest wall when pushing against a wall — indicates serratus anterior weakness, usually from long thoracic nerve palsy (C5–C7). Causes include trauma, viral illness, or repetitive overhead activity.
"How do you examine for AC joint pathology?"
Palpate directly over the AC joint for localised tenderness and a step deformity (indicating AC dislocation). Perform the cross-body adduction test: active full adduction across the chest — pain localised to the AC joint confirms AC pathology, distinct from subacromial or glenohumeral pain.
Related guides: [Musculoskeletal History OSCE](/blog/musculoskeletal-history-osce) · [Knee Examination OSCE](/blog/knee-examination-osce) · [Hand Examination OSCE](/blog/hand-examination-osce)