Approach to Physical Examination of the Shoulder
A comprehensive shoulder examination should follow a systematic approach including inspection, palpation, range of motion assessment, strength testing, and special tests to evaluate specific pathologies. This structured approach ensures thorough evaluation while prioritizing detection of conditions that may affect morbidity, mortality, and quality of life.
Systematic Examination Sequence
1. Patient Positioning
- Patient should be seated with 90° flexion of the elbow joint
- Hand positioned in supination on top of the patient's thigh
- Ensure adequate exposure of both shoulders for comparison 1
2. Inspection
- Compare bilateral shoulders for:
- Muscle atrophy (particularly deltoid, supraspinatus, infraspinatus)
- Deformity or asymmetry
- Scapular winging
- Erythema or ecchymosis
- Previous surgical scars
3. Palpation
- Systematically palpate:
- Sternoclavicular joint
- Clavicle
- Acromioclavicular joint
- Greater and lesser tuberosities
- Bicipital groove
- Coracoid process
- Scapular borders
- Note areas of tenderness, crepitus, or instability
4. Range of Motion Assessment
- Evaluate both active and passive motion:
- Forward flexion (0-180°)
- Abduction (0-180°)
- External rotation with arm at side (0-90°)
- External rotation with arm abducted 90° (0-90°)
- Internal rotation (measured by highest posterior vertebral level reached)
- Cross-body adduction
- Compare with contralateral side
5. Strength Testing
- Assess key muscle groups:
- Deltoid (abduction)
- Supraspinatus (scaption - abduction in plane of scapula)
- Infraspinatus/teres minor (external rotation)
- Subscapularis (internal rotation)
- Biceps
- Trapezius and rhomboids
6. Special Tests
For Rotator Cuff Pathology:
- Neer impingement test
- Hawkins-Kennedy test
- Empty can test (supraspinatus)
- Lift-off test (subscapularis)
- External rotation lag sign (infraspinatus)
- Drop arm test
For Instability:
- Apprehension test
- Relocation test
- Load and shift test
- Sulcus sign
- Posterior stress test
For Labral Pathology:
- O'Brien's active compression test
- Anterior slide test
- Crank test
- Biceps load test
For AC Joint Pathology:
- Cross-body adduction test
- AC joint compression test
For Biceps Pathology:
- Speed's test
- Yergason's test
Dynamic Examination
- For a dynamic examination, assess:
- Active and passive external and internal rotation with 90° flexed elbow
- Scapulohumeral rhythm during arm elevation
- Any catching, clicking, or pain during movement 1
Important Clinical Considerations
Common Pitfalls to Avoid
- Failing to expose both shoulders for comparison
- Not assessing cervical spine as a potential source of referred pain
- Overlooking neurological examination (axillary, suprascapular nerves)
- Inadequate strength testing due to improper positioning
Radiographic Correlation
- Physical exam findings should guide appropriate imaging:
- Standard radiographs for trauma should include at least three views: anteroposterior views in internal and external rotation and an axillary or scapula-Y view 1
- For suspected labral tears, MR arthrography is the gold standard imaging modality 1
- For rotator cuff evaluation, MRI without contrast or ultrasound (if expertise available) are appropriate 1
Examination Modifications
- For acute trauma, limit provocative maneuvers to avoid exacerbating injury
- For patients with limited mobility, assess passive range before active testing
- For suspected instability in younger patients, perform instability tests first
- For elderly patients with suspected rotator cuff pathology, prioritize rotator cuff testing
By following this systematic approach to shoulder examination, clinicians can effectively identify pathologies that may impact patient morbidity, mortality, and quality of life, allowing for appropriate treatment planning and improved outcomes.