What anatomical sites should be palpated during a physical exam for shoulder pain?

Key Anatomical Sites for Shoulder Pain Physical Examination

When examining a patient with shoulder pain, systematic palpation of specific anatomical sites is essential to identify the source of pain and guide appropriate management.

Primary Anatomical Sites for Palpation

Glenohumeral Joint and Related Structures

• Anterior Glenohumeral Joint - Palpate in the anterior aspect of the shoulder, below the acromion process
• Posterior Glenohumeral Joint - Examine the posterior aspect of the shoulder joint
• Biceps Tendon Long Head - Palpate in the bicipital groove on the anterior humerus
• Coracoid Process - Located on the anterior aspect of the scapula, often tender in anterior capsular pathology

Acromioclavicular Joint Area

• Acromioclavicular (AC) Joint - Palpate the joint between the acromion and distal clavicle
• Acromion Process - Examine the lateral extension of the scapular spine
• Distal Clavicle - Palpate for tenderness, especially at the AC joint

Rotator Cuff Insertion Sites

• Supraspinatus Insertion - Palpate on the greater tuberosity of the humerus
• Infraspinatus Insertion - Located on the posterior aspect of the greater tuberosity
• Subscapularis Insertion - On the lesser tuberosity of the humerus, best accessed anteriorly
• Teres Minor Insertion - Posterior-inferior aspect of the greater tuberosity

Additional Important Sites

• Scapular Border - Examine the medial and lateral borders for tenderness
• Sternoclavicular Joint - Palpate where the clavicle meets the sternum
• Subacromial Space - Located beneath the acromion, often tender in impingement syndrome
• Greater and Lesser Tuberosities - Bony prominences on the proximal humerus

Examination Technique

1. Positioning: Examine the patient in both seated and standing positions 1
2. Systematic Approach: Follow the ABSIS protocol (Acromioclavicular joint, Biceps, Subscapularis, Impingement, Supraspinatus) 2
3. Comparative Assessment: Always compare findings with the contralateral shoulder

Special Considerations

For Traumatic Shoulder Pain

• Focus on bony landmarks to assess for fractures or dislocations
• Include axillary or scapula-Y views in radiographic assessment as these are vital in evaluating traumatic injuries 1
• Palpate for specific injuries based on mechanism:
  • Anterior instability: Anterior glenohumeral joint and labrum
  • AC separation: AC joint and coracoid process
  • Rotator cuff tears: Greater tuberosity and subacromial space

For Non-Traumatic Pain

• Pay particular attention to the rotator cuff insertion sites and subacromial space
• Assess for tenderness at the AC joint, which may indicate arthritis 3
• Examine the biceps tendon for signs of tendinopathy or instability

Common Pitfalls to Avoid

• Incomplete Examination: Failing to palpate all relevant anatomical sites
• Inadequate Pressure: Using insufficient pressure to elicit deep tenderness
• Overlooking Referred Pain: Shoulder pain may originate from cervical spine or visceral sources
• Neglecting Bilateral Comparison: Always compare with the unaffected side

By systematically palpating these key anatomical sites, clinicians can effectively localize the source of shoulder pain and guide appropriate management decisions, ultimately improving patient outcomes related to morbidity, mortality, and quality of life.