Timing: * Reading Time: 2 minutes

  • Station Duration: 8 minutes (10 minutes total)

Learning Objectives

  • Perform a structured Musculoskeletal (MSK) examination of the shoulder.
  • Execute and name diagnostic special tests accurately.
  • Formulate a differential diagnosis based on physical findings.
  • Communicate the findings and management plan using patient-centered language.

Patient Profile

  • Name: Mr. David Miller
  • Age: 52 years old
  • Ethnicity: Caucasian
  • Occupation: Carpenter (self-employed)
  • Social History: Right-hand dominant. Lives with his wife; hobbies include swimming.

Presenting Complaint

  • Right shoulder pain for the last 3 months, worsening over the last 3 weeks, especially when reaching overhead at work.

Contextual Information (HPC)

  • Onset: Gradual. No acute injury or fall.
  • Character: Dull ache at rest, sharp “catching” pain when lifting the arm.
  • Site: Outer aspect of the right shoulder, radiating to the deltoid insertion.
  • Aggravating: Overhead lifting, sleeping on the right side.
  • Relieving: Rest, Ibuprofen (partial relief).
  • Red Flags: No fever, no weight loss, no history of malignancy, no neurological symptoms in the hand.
  • PMH: Type 2 Diabetes (well-controlled, HbA1c 6.8%).
  • Medications: Metformin 500mg BD. No known allergies.

Candidate Instructions

  • You are a GP seeing David for a follow-up regarding his shoulder pain.
  • Take a focused history (approx. 2-3 minutes).
  • Perform a focused physical examination of the right shoulder.
  • State your diagnosis to the examiner and explain the management plan to the patient.
  • Note: You do not need to examine the unaffected side unless you believe it is clinically necessary for the diagnosis.

Standardised Patient (SP) Instructions

  • Demeanor: You are frustrated because the pain is affecting your ability to work as a carpenter. You are worried about “rotator cuff tears” because a friend had surgery for one.
  • Pain Scale: 4/10 at rest; 8/10 on movement.
  • Physical Findings (Simulated): * Wince when the doctor tries to lift your arm sideways (abduction) between 60 and 120 degrees.
    • Express tenderness specifically over the lateral aspect of the shoulder (subacromial space).
    • If the doctor performs “Special Tests,” follow their instructions but show pain on resisted movements.

Examiner Checklist & Marking Guide

TaskClinical Requirement
HistoryUses open-ended questions; assesses impact on work/life; screens for red flags.
Inspection (Look)Mentions S-R-R-B-W-D (Swelling, Redness, Rashes, Bruises, Wasting, Deformity).
Palpation (Feel)Uses T-C-P-T (Temp, Cap refill, Pulses, Tenderness) and identifies subacromial tenderness.
Movement (Move)Assesses Active movement (Flexion, Abduction, Internal/External Rotation).
Special TestsCrucial: Must perform and name Neer’s Test and Hawkins-Kennedy Test.
DiagnosisCorrectly identifies Subacromial Impingement Syndrome (or Rotator Cuff Tendinopathy).
CommunicationAvoids jargon; uses Murtagh’s “Summarising” technique; addresses work concerns.

Communication Triggers (Murtagh’s Approach)

  • Open-ended Opening: “David, tell me more about how this shoulder pain is affecting your day-to-day life.”
  • Summarising: “So, to make sure I’ve got this right: the pain is mostly on the outside of your shoulder, it’s worse when you’re hammering overhead, and it’s starting to keep you awake at night. Is that correct?”
  • Lay Language: Instead of “Subacromial Impingement,” say, “There is a small space in your shoulder where tendons slide through. At the moment, those tendons are getting pinched or ‘nipped’ when you lift your arm.”

Sample Model Performance

1. Inspection (The “Look”)

“I am inspecting the right shoulder for any S-R-R-B-W-D: specifically looking for muscle wasting in the supraspinatus or infraspinatus fossa, and any swelling or deformity like Genu Valgum—though that’s for the knee, I’m checking for ‘Step-deformity’ here.”

2. Palpation (The “Feel”)

“I’ll check the Temperature, Capillary refill, and Pulses. Now, I’ll palpate for Tenderness over the AC joint, the bicipital groove, and the subacromial space. (SP winces over subacromial space).”

3. Movement (The “Move”)

“David, please copy me. Reach up to the sky (Flexion), out to the sides (Abduction), and touch your mid-back (Internal rotation). Candidate Note: Skip passive movement to save time as active movement is restricted by pain.“

4. Special Tests (The “Deal Breakers”)

“I will now perform the Hawkins-Kennedy Test for impingement (internally rotating the flexed arm). This is positive. I will also perform the Neer’s Test and the Empty Can Test (Jobes) to assess the supraspinatus tendon.”

5. Management Plan

  • Explanation: “This looks like impingement syndrome, likely due to the repetitive overhead nature of your work.”
  • Conservative: Rest from overhead activities, NSAIDs for 2 weeks.
  • Allied Health: Referral to Physiotherapy for rotator cuff strengthening.
  • Follow-up: Review in 4–6 weeks. If no improvement, consider a corticosteroid injection or ultrasound.