Teaching the GP registrars
Dr Kenneth Cutbush gave a teaching session to GP registrars on shoulder and upper limb examination. The registrars were preparing for their final examinations to become fully qualified general practitioners.
Examination skills matter disproportionately in general practice: a GP seeing a painful shoulder generally has to reach a working diagnosis from history and examination before deciding whether imaging or referral is warranted, and most shoulder problems never need to go further than that.
What a GP registrar is
A GP registrar is a qualified doctor who has completed an internship and resident years and has entered the general practice training programme, working in a practice under supervision while preparing for the examinations that lead to fellowship of a general practice college. The registrar years are where the breadth of general practice is actually learned, and musculoskeletal presentations make up a sizeable part of that work.
What a shoulder examination covers
Examination of the shoulder follows a sequence, and most of the diagnosis comes out of it rather than out of a scan.
- Inspection, for wasting of muscle, asymmetry, and the position in which the arm is held.
- Range of movement, tested both actively, where the patient moves the arm, and passively, where the examiner moves it. The difference between the two is one of the more informative findings in the whole examination.
- Strength testing of the rotator cuff muscles individually, since each tendon can be tested in a position that isolates it.
- Specific tests for impingement, for instability, for the acromioclavicular joint and for the biceps tendon.
- Examination of the neck, because a considerable proportion of pain felt in the shoulder originates there.
Individual results vary, and examination findings are interpreted alongside the history and, where it is warranted, imaging.
Why examination comes before imaging
A scan of an adult shoulder will nearly always show something, particularly past middle age, and a good deal of what it shows is not the cause of the pain. A clinician who has examined the shoulder and formed a view before ordering the scan can judge which findings are relevant. A clinician who orders the scan first is left working backwards from a report, which is how a patient can end up being treated for an incidental finding.
Related information
See our shoulder injuries, shoulder anatomy and consultation pages, and our post on speaking at the St Andrew's General Practice Day.