What Can You Learn Through a Telehealth Shoulder Exam?

Samuel A. Taylor, MD, an orthopedic surgeon and sports medicine specialist at the Hospital for Special Surgery (HSS) in New York City, discusses techniques and strategies for conducting an orthopedic exam of the shoulder via a video call visit in this video from HSS. Taylor is a coauthor on a related article appearing in HSS Journal: The Musculoskeletal Journal of Hospital for Special Surgery. You can see other related videos and articles on orthopedic telehealth exams at the HSS' E-Academy site. This transcript has been edited for clarity.

Samuel A. Taylor, MD: Our next case scenario is a 55-year-old patient who is not near me. He has a right shoulder injury from shoveling, which has resulted in pain and weakness. Through the telehealth exam, what can I do to decide whether this person needs to be seen in person, or what my thresholds are for obtaining additional imaging based upon what I see?

We basically divide the physical exam of the shoulder into what we call a core exam. The core exam is going to go through a shoulder exam that we would do for every patient, regardless of the chief complaint. These are just some screenshots of Dr Joe Lamplot, appropriately garbed in a tank top. He does not have any financial interest in Under Armor, though he's working on it.

We start our core exam with an examination of the cervical spine. As a shoulder surgeon, I want to know some general details about the cervical spine. You can clearly check for range of motion. There are pictures; video formats; and, to the left, layman's terms describing what the patient is to do to allow you, as a clinician, to give a uniform message to patients that they can understand. You can clearly get a range of motion here and a general sense for a Spurling exam by asking whether their symptoms are reproduced.

Clearly, you can inspect the shoulders from the front and from the back, looking for things like atrophy — in other words, the same way that you would do this in your office. Tenderness and palpation are obviously a little bit more challenging, but you can ask the patient to point to their location of pain or deformity. Shoulders are a little bit trickier than some other body parts like the knee, but in general, patients can at least help to clue you in about where the problem may be.

In terms of range of motion, we can get a ton of information. All of these things are things that you do in the office, so why can't you just do it under observation virtually? We have the patient do forward elevation. We're asking them to do this actively. To the right, you would see that if they can only actively elevate here to 110 degrees, they can use their other arm to actively assist and see where their passive motion is to give you some additional sense regarding range of motion. You can do the same thing for abduction, external rotation, internal rotation, looking at their scapulothoracic motions, and scapulohumeral rhythm.

We have a series of other tests that can be kind of problem-specific based upon their history of present illness. We can certainly take the classic Neer and Hawkins tests to look for impingement and modify these to be completed by an individual alone or even with somebody else. You can see we've modified the Neer as number one and the Hawkins exam to the right to be able to get some sense for impingement testing.

We certainly can't adequately grade strength the way we can in an office, right? Even grading strength in some of the findings that we do in the office have a subjectivity to them. Dr Toresdahl and I may grade strength slightly differently on the exact same patient in the exact same exam. What we're looking for and what we can do virtually is get a general sense for what degree of weakness may be present from using the contralateral side for examination. We have canned goods, which have a known weight, in a plastic bag, and we can progressively add cans to be able to get some sense for a degree of weakness.

In practice, how often am I doing this? Not that often for something like this, but my point is that there is much more that we can do than we initially gave ourselves credit for. As you can see here, Dr Lamplot has fear in his eyes because he was afraid that he may not actually be able to lift up those six cans of soup.

Again, we can modify our strength using these canned goods. We do the Jobe test to test our supraspinatus. You can ask the patient to lift canned goods in that position. It will give you a sense of pain, if not actual weakness.

Joseph D. Lamplot, MD: That was eight cans there, Sam.

Taylor: You're right, but they were the small cans. Remember, we had to return the jumbo double cans.

You can also test external and internal rotation by modifying this to allow gravity to work. Again, are these perfect solutions? No, they're not perfect solutions, but that's okay. What we're trying to do is gauge how this person examines. We're looking for gross deficits. We're taking that guy who shoveled the snow, and we recognize that he hit something hard and avulsed his cuff. What do we need to do to be able to get the appropriate imaging, get the appropriate next steps, and facilitate his care? That's our goal here.

Again, we can assess our subscapularis gap with the belly press. I'll just play this video. As you can see, these are some videos that we put together that are available for download.

I won't belabor this point too hard because, agreeably, it's a little bit painful to listen to me say these things over the video. The point is that we have many resources available to us through media and otherwise to help instruct our patients. If you can provide patients with some information beforehand or during the exam to ask them to do what you want to do, you can achieve more.

For example, I play these videos forward-facing. I share the screen and hit play, and then I'm just filling out a note as they're following the exam on the screen. Again, we can do many of our standard things like our acromioclavicular (AC) joint tests and we can do the Speed test using weights. We can even do things like the O'Brien sign active compression test, both with internal rotation and with the forearm and humerus externally rotated.

We can get a good sense of many things. Instability is obviously a little bit harder to discern from an apprehension standpoint. There are many things that we can do, including Beighton score and laxity score.

What I've collectively learned over the last year is that there is so much more that we can actually achieve from an exam standpoint that I otherwise wouldn't have thought possible — and would have completely resisted — had I not been forced into this by the COVID-19 pandemic.

We can continue to move forward and think about ways to make this more of a facile and effective approach to asynchronous exams so that we take the whole interaction completely out of it and have the ability to examine the patient and have data before we actually see them. We can try to plan ahead for the patient to have completed these tasks and tests before we see them so that we already have the data we want when the telehealth visit occurs. This may help to avoid problems that occur if, for example, the patient makes the visit on his cell phone in his car. It can be achieved.

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