What is the recommended approach for a comprehensive shoulder exam?

Comprehensive Shoulder Examination Approach

A comprehensive shoulder examination should follow a systematic approach including inspection, palpation, range of motion assessment, strength testing, special tests for impingement and instability, and neurovascular evaluation, as recommended by the American Academy of Orthopaedic Surgeons and American Physical Therapy Association. 1

Initial Assessment

Inspection

• Observe for:
  • Muscle atrophy (particularly deltoid, supraspinatus, infraspinatus)
  • Scapular winging or dyskinesia
  • Shoulder asymmetry or deformity
  • Swelling or ecchymosis
  • Posture and shoulder positioning

Palpation

• Systematically palpate:
  • Acromioclavicular (AC) joint
  • Sternoclavicular (SC) joint
  • Greater and lesser tuberosities
  • Bicipital groove
  • Coracoid process
  • Subacromial space
  • Scapular borders

Range of Motion Assessment

Active Range of Motion

• Forward flexion (0-180°)
• Abduction (0-180°)
• External rotation (0-90°)
• Internal rotation (ability to reach up the back)
• Horizontal adduction/cross-body adduction

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

Rotator Cuff Assessment

• Supraspinatus: Empty can test/Jobe's test (arm at 90° abduction, 30° forward flexion, and internal rotation)
• Infraspinatus: External rotation with arm at side (Patte's test)
• Subscapularis: Lift-off test or belly-press test
• Teres minor: External rotation with arm at 90° abduction

Other Strength Tests

• Biceps: Speed's test (resisted forward flexion with supinated forearm)
• Deltoid: Resisted abduction at different angles
• Scapular stabilizers: Assess for proper scapular control during arm elevation

Special Tests

Impingement Tests

• Neer impingement sign (passive forward flexion with scapula stabilized)
• Hawkins-Kennedy test (passive internal rotation with arm flexed to 90°)
• Painful arc test (active abduction noting pain between 60-120°)

Instability Tests

• Anterior apprehension test
• Load and shift test
• Sulcus sign (for inferior instability)
• Posterior stress test

Labral Tests

• O'Brien's active compression test
• Anterior slide test
• Crank test
• SLAP test (Superior Labrum Anterior to Posterior)

Biceps Tests

• Speed's test
• Yergason's test
• Upper cut test

Neurovascular Assessment

• Test sensation in all dermatomes (C5-T1)
• Assess reflexes (biceps, brachioradialis, triceps)
• Evaluate distal pulses and capillary refill
• Screen for thoracic outlet syndrome if indicated

Radiographic Evaluation

When imaging is indicated, follow this approach 2, 1:

• Start with plain radiographs including:

  • Anteroposterior (AP) view
  • Grashey view (true AP of glenohumeral joint)
  • Axillary view (essential for detecting dislocations)
  • Scapular Y view

• Consider specialized views for specific pathologies:

  • Stryker notch view for Hill-Sachs lesions
  • West Point view for Bankart fractures
  • Rockwood view for impingement

• Advanced imaging based on clinical suspicion:

  • MRI (preferred for rotator cuff and soft tissue injuries)
  • MR arthrography (gold standard for labral tears)
  • CT (for complex fractures or bone loss assessment)
  • Ultrasound (for rotator cuff evaluation with appropriate expertise)

Special Considerations

For Cancer Patients

• In breast cancer patients, pay particular attention to shoulder mobility, rotator cuff strength, and scapular mechanics due to high risk of shoulder morbidity 2
• In head and neck cancer patients, examine for cervical and shoulder ROM restrictions and assess for scapular winging due to possible spinal accessory nerve injury 2

For Elderly Patients

• Focus on rotator cuff integrity and degenerative changes
• Assess for adhesive capsulitis, especially in diabetic patients

For Athletes

• Evaluate sport-specific demands and throwing mechanics if applicable
• Assess for subtle instability patterns that may not be apparent in non-athletes

Common Pitfalls to Avoid

1. Incomplete examination: Always examine both shoulders for comparison
2. Missing cervical pathology: Remember to screen the cervical spine as a potential source of referred shoulder pain
3. Overreliance on single tests: No single test has perfect sensitivity or specificity; use combinations of tests 3, 4
4. Failure to correlate findings: Integrate history, physical exam, and imaging findings
5. Inadequate strength testing: Test each rotator cuff muscle individually in positions that isolate their function

By following this systematic approach, clinicians can accurately diagnose shoulder pathology and develop appropriate treatment plans that address the underlying cause of shoulder dysfunction.