How do you perform physical exam maneuvers for shoulder pain?

Physical Examination Maneuvers for Shoulder Pain

The most effective approach to examining shoulder pain involves performing specific, evidence-based physical exam maneuvers including Neer's test, Hawkins test, painful arc test, empty can test, and external rotation resistance test, which together significantly improve diagnostic accuracy for common shoulder pathologies. 1

Key Physical Examination Maneuvers

Impingement Tests

1. Neer's Test

   • Technique: Stabilize the scapula with one hand while fully elevating the patient's arm in forward flexion with the other hand
   • Positive sign: Pain reproduction in the anterior or lateral shoulder
   • Diagnostic value: High sensitivity (88.7%) but low specificity (33%) for subacromial impingement 1

2. Hawkins Test

   • Technique: Forward flex the patient's arm to 90°, then forcibly internally rotate the shoulder
   • Positive sign: Pain reproduction in the subacromial space
   • Note: Combining with other impingement tests improves diagnostic accuracy 1

3. Painful Arc Test

   • Technique: Have the patient actively abduct the arm from 0° to 180°
   • Positive sign: Pain between 60° and 120° of abduction
   • Indicates: Subacromial impingement or rotator cuff pathology

Rotator Cuff Tests

1. Empty Can Test (Jobe Test)

   • Technique: Position the patient's arms at 90° of abduction and 30° of forward flexion with thumbs pointing downward
   • Action: Resist downward pressure on the arms
   • Positive sign: Weakness or pain
   • Tests: Primarily supraspinatus function

2. External Rotation Resistance Test

   • Technique: Position the patient's arms at sides with elbows flexed to 90°
   • Action: Patient attempts external rotation against resistance
   • Positive sign: Weakness or pain
   • Tests: Infraspinatus and teres minor function

Labral Tear Tests

For suspected labral tears, which can cause pain, clicking, instability, and limited range of motion 1:

1. O'Brien's Test (Active Compression Test)

   • Technique:
     • Arm positioned at 90° forward flexion, 10-15° adduction, and full internal rotation (thumb down)
     • Apply downward force while patient resists
     • Repeat with palm up (external rotation)
   • Positive sign: Pain inside the shoulder in first position that improves in second position
   • Indicates: SLAP (Superior Labrum Anterior to Posterior) lesion

2. Anterior Apprehension Test

   • Technique: With patient supine or seated, abduct the arm to 90° and externally rotate
   • Positive sign: Patient expresses apprehension or fear of dislocation
   • Indicates: Anterior instability or labral tear

Comprehensive Shoulder Examination Approach

1. Inspection

   • Observe for asymmetry, muscle atrophy, swelling, or deformity
   • Assess scapular positioning and movement

2. Palpation

   • Palpate key structures: AC joint, bicipital groove, greater tuberosity, coracoid process
   • Note areas of tenderness or crepitus

3. Range of Motion Assessment

   • Active and passive: forward flexion, abduction, external/internal rotation, cross-body adduction
   • Compare with contralateral side

4. Strength Testing

   • Test each rotator cuff muscle: supraspinatus, infraspinatus, teres minor, subscapularis
   • Assess deltoid and periscapular muscles

5. Special Tests

   • Select appropriate tests based on history and initial findings
   • Combine multiple tests for improved diagnostic accuracy 1, 2

Clinical Pearls and Pitfalls

• Combine multiple tests: Using a combination of impingement tests significantly improves diagnostic accuracy compared to single tests 1

• Consider imaging selectively: Plain radiographs (AP view, external rotation view, and axillary or scapular Y view) should be obtained first; MRI without contrast is preferred if symptoms persist despite normal radiographs 1

• Avoid overreliance on a single test: No single physical examination maneuver has perfect sensitivity and specificity 3, 2

• Evaluate the entire kinetic chain: Always assess cervical spine and scapular function as these can refer pain to the shoulder 4, 5

• Document baseline function: Quantify range of motion and strength to track progress during treatment 2

By systematically applying these physical examination maneuvers and understanding their diagnostic value, clinicians can more accurately diagnose common shoulder pathologies and develop appropriate treatment plans.