What are the most effective shoulder physical exam maneuvers?

Most Effective Shoulder Physical Examination Maneuvers

The most effective shoulder physical examination maneuvers include the Neer impingement sign, Hawkins-Kennedy test, Jobe's test, and Patte's maneuver, which demonstrate high reproducibility with almost perfect agreement (kappa coefficients 0.91-1.00) when performed with standardized techniques, though they have limited ability to discriminate specific structural pathologies. 1

Impingement Tests

• The Neer impingement sign involves forward flexion of the arm with the shoulder in internal rotation, demonstrating 72% sensitivity and 60% specificity for subacromial impingement syndrome 2
• The Hawkins-Kennedy test (internal rotation of the shoulder in 90° forward flexion) shows higher sensitivity (79%) but similar specificity (59%) compared to Neer's test for impingement syndrome 2
• The painful arc test (active abduction between 60° and 120°) demonstrates better specificity (76%) but lower sensitivity (53%) for impingement syndrome 2
• Hawkins position results in significantly greater subacromial space narrowing and rotator cuff contact than the Neer position, with subacromial contact observed in 7 of 8 subjects during Hawkins maneuver versus none during Neer's test 3

Rotator Cuff Tests

• Jobe's test (empty can test) evaluates the supraspinatus by positioning the shoulder at 90° abduction, full internal rotation, and 30° forward flexion against resistance, though it does not isolate the supraspinatus as previously thought 4
• Patte's test assesses infraspinatus function by testing external rotation with the arm at 90° abduction 5
• The lift-off test evaluates subscapularis function 5
• The belly-off and modified belly press tests for subscapularis tendinopathy show promising diagnostic value with high sensitivity and specificity in low bias studies 2
• The lateral Jobe test for rotator cuff tears demonstrates both high sensitivity and specificity in low bias studies 2

Labral Tear Tests

• For SLAP (Superior Labral Anterior to Posterior) tears, the relocation test shows the best sensitivity (52%) 2
• Yergason's test demonstrates the best specificity (95%) for SLAP tears 2
• The compression-rotation test has the best positive likelihood ratio (2.81) for SLAP tears 2
• The passive distraction test for SLAP lesions shows high specificity (>80%, LR+ ≥5.0) and may be useful to rule in a SLAP lesion when positive 2
• The dynamic labral shear test may be sensitive for SLAP lesions specifically, or when modified, for labral tears generally 2

Clinical Approach

• A multimodal approach is required to accurately assess shoulder pathology, as no single test provides definitive diagnosis 6, 2
• Standard shoulder examination should include tests for impingement, rotator cuff integrity, and labral pathology based on the clinical presentation 6
• The shoulder shrug sign demonstrates high sensitivity (>80%, LR- ≤0.20) for stiffness-related disorders (osteoarthritis and adhesive capsulitis) and rotator cuff tendinopathy 2
• Combinations of physical examination tests provide better accuracy than individual tests, though the improvement is marginal 2

Examination Technique

• For optimal reliability, standardized positioning and technique are essential when performing shoulder examination maneuvers 1
• Patient positioning for shoulder ultrasound examination (which can complement physical exam) should include sitting position with 90° flexion of the elbow joint and the hand positioned in supination on the patient's thigh 6
• Dynamic examination should include active and passive external and internal rotation of the humerus over the full range of motion with 90° flexed elbow 6

Limitations and Pitfalls

• While sensitivity of many shoulder tests is satisfactory, specificity is often poor, particularly for determining the location and type of rotator cuff lesions 5
• The severity of functional impairment during Jobe's and Patte's maneuvers does not reliably correlate with the size of rotator cuff tears 5
• Many promising tests have been introduced with excellent diagnostic statistics in initial studies but failed to replicate these results in subsequent research 2
• No single shoulder physical examination test can provide a pathognomonic diagnosis with complete confidence 2