How will you conduct a physical examination in a patient with atraumatic shoulder pain to determine the diagnosis and any special tests to be done to aid in diagnosis?

Physical Examination for Atraumatic Shoulder Pain

A systematic physical examination approach focusing on specific tests for rotator cuff pathology, labral tears, and impingement syndrome is essential for accurate diagnosis of atraumatic shoulder pain, followed by appropriate imaging studies only when indicated by clinical findings. 1

Initial Assessment

• Inspection:

  • Look for muscle atrophy (especially supraspinatus and infraspinatus)
  • Assess scapular positioning and symmetry
  • Note any obvious deformities or asymmetry between shoulders

• Palpation:

  • Acromioclavicular (AC) joint tenderness
  • Greater tuberosity tenderness (rotator cuff insertion)
  • Bicipital groove tenderness (biceps tendon)
  • Subacromial space tenderness

• Range of Motion Assessment:

  • Active and passive motion in all planes
  • Document limitations in forward flexion, abduction, internal/external rotation
  • Note pain arcs during movement (pain between 60-120° suggests impingement)

Special Tests for Specific Diagnoses

Rotator Cuff Pathology Tests

• Neer Impingement Test: Forward flex the arm with scapula stabilized
• Hawkins-Kennedy Test: Flex shoulder to 90°, then internally rotate
• Empty Can Test (Jobe Test): Arm at 90° abduction, 30° forward flexion, thumbs down
• Drop Arm Test: Patient lowers arm slowly from 90° abduction
• External Rotation Lag Sign: Test for infraspinatus integrity

Labral Tear/Instability Tests

• O'Brien's Active Compression Test: Arm flexed 90°, adducted 10-15°, internally rotated
• Anterior Apprehension Test: Abduct and externally rotate the arm
• Relocation Test: Apply posterior force during apprehension test
• Load and Shift Test: Assess anterior/posterior translation of humeral head
• Crank Test: Arm in 90° abduction, apply axial load while rotating

Biceps Tendon Tests

• Speed's Test: Forward flex arm against resistance with elbow extended
• Yergason's Test: Elbow flexed 90°, resist supination

Adhesive Capsulitis Tests

• Global ROM restriction: Note proportional limitation in all planes
• Capsular pattern: External rotation most limited, followed by abduction and internal rotation

Diagnostic Algorithm

1. For suspected rotator cuff pathology:

   • If positive impingement signs (Neer, Hawkins) and weakness in specific muscle testing
   • Next step: Plain radiographs to assess for acromial morphology, calcifications

2. For suspected labral tear/instability:

   • If positive O'Brien's test, apprehension, or crank test
   • Next step: MR arthrography (gold standard) for patients under 35 years 1, 2

3. For suspected adhesive capsulitis:

   • If global ROM restriction in capsular pattern
   • Next step: Plain radiographs to rule out other pathology

Imaging Recommendations Based on Physical Exam Findings

• Initial imaging for all atraumatic shoulder pain: Standard radiographs including AP views in internal and external rotation 1

• For suspected rotator cuff pathology:

  • MRI without contrast (rated 7/9 for appropriateness) 1
  • Ultrasound is an alternative for evaluating rotator cuff tears 2

• For suspected labral tear/instability:

  • MR arthrography (rated 9/9 for appropriateness) 1, 2
  • Standard MRI without contrast if MR arthrography unavailable (rated 7/9) 1
  • CT arthrography if MRI contraindicated (rated 5/9) 1

Common Pitfalls to Avoid

• Overreliance on imaging: Physical examination should guide imaging decisions; MRI should not be used as a screening tool before comprehensive clinical evaluation 3

• Incomplete examination: Failure to assess all potential pain generators (rotator cuff, labrum, AC joint, biceps tendon)

• Focusing only on patho-anatomical diagnosis: Consider pain mechanisms and psychosocial factors that may influence symptoms 4

• Neglecting scapular assessment: Scapular dyskinesis can contribute to shoulder pain and should be evaluated

• Premature imaging: The American College of Radiology recommends clinical evaluation before advanced imaging 1, 5

By following this systematic approach to physical examination and selective use of imaging studies, clinicians can accurately diagnose the cause of atraumatic shoulder pain and develop appropriate treatment plans to improve outcomes.