What physical exams should be performed when someone presents with shoulder pain?

Physical Examination for Shoulder Pain

A comprehensive shoulder examination for patients with shoulder pain should include inspection, palpation, range of motion assessment, specific provocative tests based on suspected pathology, and a thorough neurovascular evaluation. 1

Initial Assessment

• Inspection: Observe for:

  • Muscle atrophy (especially deltoid and supraspinatus)
  • Deformity suggesting fracture or dislocation
  • Swelling or ecchymosis
  • Scapular positioning and symmetry

• Palpation: Examine:

  • Acromioclavicular (AC) joint
  • Sternoclavicular joint
  • Greater tuberosity
  • Bicipital groove
  • Coracoid process
  • Areas of tenderness that may indicate specific pathology

Range of Motion Assessment

• Assess both active and passive range of motion in:

  • Forward flexion
  • Abduction
  • External rotation
  • Internal rotation
  • Cross-body adduction

• Compare with the contralateral side to identify limitations

Specific Provocative Tests

For Rotator Cuff Pathology

• Empty can test (supraspinatus)
• External rotation strength test (infraspinatus)
• Lift-off test (subscapularis)
• Hornblower's test (teres minor)

For Labral Tears

• O'Brien's active compression test
• Anterior slide test
• Crank test
• Speed's test (also for biceps pathology)

For Instability

• Apprehension test
• Relocation test
• Load and shift test
• Sulcus sign

Neurovascular Examination

• Motor and sensory assessment of the upper extremity
• Cervical spine examination to rule out referred pain
• Thoracic outlet assessment if vascular symptoms are present

Imaging Considerations

After physical examination, appropriate imaging should be selected based on clinical findings:

• Standard radiographs (AP views in internal/external rotation, axillary or scapula-Y view) are recommended as initial imaging for acute shoulder pain 1

• For suspected rotator cuff tears:

  • MRI shoulder without IV contrast or ultrasound is usually appropriate 2
  • MRI might be preferred with large body habitus, restricted range of motion, or suspected intra-articular pathologies 2

• For suspected labral tears:

  • MRI shoulder without IV contrast in acute settings (when effusion is present) 2
  • MR arthrography in subacute or chronic settings (gold standard with 86-100% sensitivity) 1
  • CT arthrography if MRI is contraindicated 2, 1

Common Pitfalls to Avoid

• Failing to include axillary or scapula-Y views in radiographic assessment, which can lead to missed dislocations 1
• Overlooking cervical spine pathology as a source of referred shoulder pain
• Prolonged immobilization, which can lead to adhesive capsulitis and muscle atrophy 1
• Overreliance on a single provocative test rather than using a combination of tests to improve diagnostic accuracy

Follow-up Recommendations

• Initial follow-up should occur 1-2 weeks after treatment initiation 1
• Clinical reassessment at 6 weeks to evaluate progress 1
• Consider imaging or surgical consultation if symptoms worsen or do not improve by 3 months 1

Physical examination findings should guide appropriate imaging selection and treatment planning, with the goal of improving function and reducing pain while minimizing unnecessary interventions.