What components should be included in a comprehensive shoulder physical exam?

Comprehensive Shoulder Physical Examination Components

A thorough shoulder examination must include assessment of tone, strength, soft tissue changes, joint alignment, pain levels, and orthopedic changes to properly identify and diagnose shoulder pathology. 1

Patient Positioning

• Position patient sitting with 90° elbow flexion and hand in supination on top of the thigh 2
• For dynamic examination, have patient perform active and/or passive external and internal rotation of the humerus through full range of motion with 90° flexed elbow 2

Standard Examination Sequence

1. Inspection

• Observe for asymmetry, muscle atrophy, swelling, and abnormal positioning 3
• Assess scapular position and movement for winging or dyskinesia 2
• Look for visible deformities that may indicate fracture, dislocation, or chronic pathology 4

2. Palpation

• Palpate the proximal humerus, lateral aspect of proximal humerus, and surrounding soft tissues for tenderness 2
• Assess the acromioclavicular joint, sternoclavicular joint, and bicipital groove 2
• Identify areas of swelling, warmth, or crepitus that may indicate inflammation 2

3. Range of Motion Assessment

• Evaluate both active and passive range of motion in all planes 1:
  • Forward flexion (0-180°)
  • Abduction (0-180°)
  • External rotation (0-90°)
  • Internal rotation (ability to reach up the back)
  • Horizontal adduction/cross-body adduction 5

4. Strength Testing

• Test rotator cuff muscles individually 1, 5:
  • Supraspinatus (empty can test/Jobe's test)
  • Infraspinatus and teres minor (external rotation)
  • Subscapularis (lift-off test, belly press test)
  • Deltoid (resisted abduction)
• Compare strength bilaterally using a dynamometer when available 5

5. Special Tests

Impingement Tests

• Neer impingement sign (passive forward elevation with scapula stabilized) 5
• Hawkins-Kennedy test (passive internal rotation with arm at 90° forward flexion) 5
• Cross-body adduction test 6

Instability Tests

• Anterior apprehension test and relocation test 6
• Load and shift test (anterior, posterior, and inferior translation) 6
• Sulcus sign for inferior instability 6

Labral Tests

• O'Brien's active compression test 6
• Crank test 6
• Biceps load test II 6

Rotator Cuff Tests

• Empty can test (supraspinatus) 5
• External rotation lag sign (infraspinatus) 5
• Lift-off test and belly press test (subscapularis) 5
• Horn blower's sign (teres minor) 5

6. Neurovascular Assessment

• Evaluate peripheral pulses, sensation, and motor function 4
• Assess for signs of cervical radiculopathy that may mimic shoulder pain 6
• Check for thoracic outlet syndrome if indicated 4

Special Considerations

For Athletes/Throwers

• Assess shoulder motion, flexibility, strength, and other components of the kinetic chain 2
• Evaluate for scapular dyskinesis which may contribute to rotator cuff injury 2
• Review throwing biomechanics when relevant 2

For Post-Stroke Patients

• Evaluate for hemiplegic shoulder pain with special attention to tone, strength, and joint alignment 2
• Assess for Complex Regional Pain Syndrome (CRPS) with signs including pain/tenderness of metacarpophalangeal and proximal interphalangeal joints, edema, trophic skin changes, hyperesthesia, and limited range of motion 2

For Cancer Patients

• In breast cancer patients, assess shoulder range of motion restriction, strength, impingement signs, and scapular mobility 2
• In head and neck cancer patients, examine for cervical and shoulder range of motion restriction and scapular winging or dyskinesia 2

Common Pitfalls to Avoid

• Failing to differentiate between shoulder and cervical spine pathology 6
• Not performing a complete examination of all shoulder components (glenohumeral joint, acromioclavicular joint, scapulothoracic articulation, and rotator cuff) 3
• Overlooking subtle signs of instability in patients with hyperlaxity 6
• Missing scapular dyskinesis which can contribute to rotator cuff pathology 2