How will you conduct a physical examination in a patient with an atraumatic shoulder complaint?

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Physical Examination for Atraumatic Shoulder Pain

A comprehensive physical examination for atraumatic shoulder pain should include inspection, palpation, range of motion assessment, strength testing, and specific provocative tests to identify the underlying pathology.

Initial Assessment

Inspection

  • Observe for:
    • Shoulder asymmetry
    • Muscle atrophy (particularly deltoid, supraspinatus, infraspinatus)
    • Scapular winging
    • Abnormal posture or positioning
    • Skin changes or discoloration

Palpation

  • Systematically palpate:
    • Acromioclavicular (AC) joint
    • Sternoclavicular joint
    • Bicipital groove
    • Greater and lesser tuberosities
    • Subacromial space
    • Posterior capsule
    • Note areas of tenderness, swelling, or crepitus

Range of Motion Assessment

Active Range of Motion

  • Forward flexion (0-180°)
  • Abduction (0-180°)
  • External rotation with arm at side (0-90°)
  • Internal rotation (measured by highest vertebral level reached by thumb)
  • Cross-body adduction
  • Extension

Passive Range of Motion

  • Compare to active ROM to identify pain limitations versus mechanical restrictions
  • Note any painful arcs of motion (typically 60-120° in impingement)

Strength Testing

  • Test the following muscle groups:
    • Supraspinatus (empty can test)
    • Infraspinatus/teres minor (external rotation)
    • Subscapularis (lift-off test, belly press)
    • Deltoid
    • Biceps
    • Trapezius and rhomboids

Special Tests

Rotator Cuff Tests

  • Neer Impingement Test: Forward flexion of the arm with scapula stabilized
  • Hawkins-Kennedy Test: Forward flexion to 90° and internal rotation
  • Empty Can Test (Jobe Test): Arm at 90° abduction, 30° forward flexion, and internal rotation
  • Full Can Test: Similar to empty can but with thumb up
  • External Rotation Lag Sign: Test for infraspinatus tear
  • Lift-off Test and Belly Press: Tests for subscapularis function
  • Drop Arm Test: Test for rotator cuff integrity

Instability Tests

  • Apprehension Test: Abduction and external rotation to test anterior instability
  • Relocation Test: Posterior pressure on humeral head during apprehension test
  • Sulcus Sign: Downward traction on arm to assess inferior instability
  • Load and Shift Test: Assessment of anterior/posterior translation
  • Posterior Stress Test: Forward flexion, adduction, and internal rotation

Labral Tests

  • O'Brien's Active Compression Test: Arm forward flexed to 90°, adducted 10-15°, and internally rotated
  • Crank Test: Arm in 90° abduction with axial load and rotation
  • Clunk Test: Circumduction of the arm with compression
  • Biceps Load Test: Elbow flexion against resistance with shoulder in apprehension position

Biceps Tests

  • Speed's Test: Forward flexion against resistance with supinated forearm
  • Yergason's Test: Supination against resistance with elbow flexed at 90°

Neurovascular Assessment

  • Test sensation in all dermatomes (C5-T1)
  • Test reflexes (biceps, triceps)
  • Assess distal pulses and capillary refill
  • Perform Spurling's test to rule out cervical pathology

Scapular Assessment

  • Observe scapular motion during arm elevation
  • Scapular assistance test
  • Scapular retraction test

Documentation and Interpretation

After completing these tests, document:

  1. Which tests were positive
  2. Pattern of pain and limitations
  3. Most likely diagnosis based on constellation of findings

The American College of Radiology recommends that the physical examination should guide subsequent imaging decisions, with radiography as the initial imaging modality for most shoulder complaints 1.

Common Diagnostic Patterns

  • Rotator cuff pathology: Positive impingement signs, weakness in specific muscle testing, painful arc
  • Instability: Positive apprehension, relocation, and load-shift tests
  • Labral tears: Positive O'Brien's, clunk, or crank tests
  • Biceps pathology: Positive Speed's and Yergason's tests with bicipital groove tenderness
  • AC joint pathology: Pain with cross-body adduction, point tenderness at AC joint

Remember that no single test is perfectly sensitive or specific, so clinical diagnosis should be based on a combination of history, physical examination findings, and appropriate imaging when necessary.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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