What is the recommended approach for a comprehensive shoulder examination?

Comprehensive Shoulder Examination Approach

A systematic shoulder examination should begin with the patient seated with 90° elbow flexion and hand supinated on the thigh, followed by inspection, palpation of key anatomic landmarks, range of motion testing in all planes, rotator cuff strength assessment, and special provocative tests based on suspected pathology. 1, 2

Patient Positioning and Initial Inspection

• Position the patient sitting upright with the elbow flexed to 90° and the hand placed in supination resting on top of the thigh for the static examination 1, 2
• Observe for visible asymmetry, muscle atrophy (particularly deltoid and supraspinatus), swelling, or deformity 1
• Assess scapular position and movement for winging or dyskinesia, which may indicate nerve injury or contribute to rotator cuff pathology 1

Systematic Palpation

• Palpate the proximal humerus and lateral aspect for tenderness, which is particularly important in younger patients at risk for growth plate injuries 1, 3
• Examine the acromioclavicular joint, sternoclavicular joint, and bicipital groove for point tenderness 1
• Identify areas of swelling, warmth, or crepitus that may indicate inflammation or joint pathology 1

Range of Motion Assessment

• Evaluate both active and passive range of motion in all planes to differentiate true restriction from pain-limited motion 1
• Test forward flexion (normal 0-180°), external rotation (normal 0-90°), and internal rotation (assess ability to reach up the back) 1
• For dynamic examination, have the patient perform active and passive external and internal rotation of the humerus through full range of motion with the elbow maintained at 90° flexion 1, 2

Rotator Cuff Strength Testing

• Test the supraspinatus using the empty can test (Jobe's test) with the arm at 90° abduction in the scapular plane and internally rotated 1
• Assess the infraspinatus and teres minor by testing resisted external rotation with the arm at the side 1
• Evaluate the subscapularis using the lift-off test or belly press test to assess internal rotation strength 1
• Test deltoid function with resisted abduction 1

Special Provocative Tests

• Use specific examination maneuvers to isolate and differentiate pathologies based on clinical presentation, as no single test provides definitive diagnosis 2
• Include tests for impingement, rotator cuff integrity, and labral pathology when clinically indicated 2
• The combination of multiple tests improves diagnostic accuracy compared to relying on a single maneuver 4, 5

Neurovascular Assessment

• Assess neurovascular integrity as part of the comprehensive examination 1, 4
• This is particularly important in trauma cases or when neurologic symptoms are present 4

Age-Specific and Population-Specific Considerations

Common Pitfall: Failing to adjust the examination based on patient age and activity level can lead to missed diagnoses.

• For athletes and throwers, assess shoulder motion, flexibility, strength, and other components of the kinetic chain 1
• In children aged 11 to early teenage years, pay particular attention to proximal humeral tenderness as a hallmark finding of Little League shoulder (proximal humeral epiphysiolysis) 3
• For post-stroke patients, evaluate for hemiplegic shoulder pain with special attention to tone, strength, joint alignment, and signs of Complex Regional Pain Syndrome including pain, edema, trophic skin changes, hyperesthesia, and limited range of motion 1
• For cancer patients, assess shoulder range of motion restriction, strength, impingement signs, and scapular mobility 1

Imaging Guidance Based on Examination Findings

• Standard radiographs (anteroposterior views in internal and external rotation, plus axillary or scapula-Y view) should be the initial imaging study for traumatic shoulder pain 1, 3
• For suspected rotator cuff pathology, MRI without contrast, MR arthrography, or ultrasound are all appropriate depending on local expertise 1
• In patients under 35 years with instability or questionable labral pathology, MRI or MR arthrography are the modalities of choice 6
• CT is superior for characterizing fracture patterns but inferior to MRI for soft tissue injuries 1