What are the key components of a thorough shoulder exam, including special tests?

Shoulder Examination and Special Tests

A thorough shoulder examination should begin with the patient seated with 90° elbow flexion and hand supinated on the thigh, followed by systematic assessment of range of motion, strength testing of individual rotator cuff muscles, palpation of key structures, and targeted special tests based on clinical suspicion. 1

Patient Positioning and Initial Setup

• Position the patient sitting upright with the elbow flexed to 90° and the hand placed in supination resting on top of the thigh 1, 2
• Expose both shoulders completely to allow for bilateral comparison during inspection 1
• For dynamic assessment, have the patient perform active and passive external and internal rotation of the humerus through the full range of motion while maintaining 90° elbow flexion 1, 2

Inspection

• Assess scapular position and movement for winging or dyskinesia, which may contribute to rotator cuff injury 1
• Look for muscle atrophy, particularly in the supraspinatus and infraspinatus fossae, which suggests chronic rotator cuff pathology 3
• Identify areas of swelling, warmth, or visible deformity that may indicate inflammation or structural abnormality 1
• In athletes and throwers, pay special attention to scapular dyskinesis as part of kinetic chain dysfunction 1

Palpation

• Palpate the acromioclavicular joint for tenderness, which suggests AC joint pathology 1, 4
• Assess the bicipital groove along the anterior proximal humerus for tenderness indicating biceps tendinopathy 1
• Palpate the sternoclavicular joint for instability or tenderness 1
• Examine the proximal humerus and lateral aspect for focal tenderness suggesting fracture or bone pathology 1
• Identify crepitus during palpation, which may indicate inflammation or degenerative changes 1

Range of Motion Assessment

• Evaluate both active and passive range of motion in all planes to differentiate true glenohumeral restriction from pain-limited motion 1, 4
• Forward flexion: Normal range is 0-180°; measure with a goniometer for objective documentation 1
• External rotation: Normal range is 0-90°; test with arm at side and with 90° abduction 1
• Internal rotation: Assess ability to reach up the back; document the vertebral level reached (e.g., T7, L1) 1
• Abduction: Normal range is 0-180°; observe scapulohumeral rhythm for abnormal scapular movement 1

Strength Testing of Rotator Cuff Muscles

• Supraspinatus: Perform the empty can test (Jobe's test) with arm at 90° abduction in the scapular plane, thumb pointing down, and resist further elevation 1
• Infraspinatus and teres minor: Test external rotation strength with arm at side and elbow flexed to 90°, resisting external rotation 1
• Subscapularis: Use the lift-off test (hand behind back, lift away from body) or belly press test (press hand into abdomen while maintaining wrist extension) 1
• Deltoid: Resist abduction at 90° to isolate deltoid function and differentiate from rotator cuff weakness 1
• Consider using a dynamometer for objective strength measurements when available 5

Special Tests for Impingement

• Neer impingement sign: Passively flex the arm overhead while stabilizing the scapula; pain suggests subacromial impingement 5, 6
• Hawkins-Kennedy test: Flex shoulder to 90°, then internally rotate the arm; pain indicates impingement of the supraspinatus tendon under the coracoacromial arch 5, 6
• Painful arc: Pain between 60-120° of active abduction suggests subacromial pathology 5, 6

Special Tests for Labral Pathology and Instability

• Apprehension test: With patient supine, abduct arm to 90° and externally rotate; apprehension or pain suggests anterior instability 7, 8
• Relocation test: Apply posterior force to humeral head during apprehension test; relief of symptoms confirms anterior instability 7, 8
• O'Brien's test (active compression test): Forward flex arm to 90° with elbow extended and thumb down, then resist downward force; pain suggests labral tear or AC joint pathology 5, 6
• Crank test: With arm elevated to 160°, apply axial load and rotate the humerus; pain or clicking suggests labral tear 8

Special Tests for Biceps Pathology

• Speed's test: Resist forward flexion of the shoulder with elbow extended and forearm supinated; pain in the bicipital groove suggests biceps tendinopathy 5, 6
• Yergason's test: Resist supination of the forearm with elbow flexed to 90°; pain suggests biceps tendinopathy or instability 5, 6

Neurovascular Assessment

• Assess sensation in the axillary nerve distribution (lateral deltoid) and other peripheral nerve territories if neurologic symptoms are present 4, 8
• Palpate radial pulse and assess capillary refill if vascular compromise is suspected 9, 8
• Test for thoracic outlet syndrome with Adson's test or Wright's test if symptoms suggest neurovascular compression 9, 8

Population-Specific Considerations

• Athletes and throwers: Assess the entire kinetic chain including shoulder motion, flexibility, strength, and scapular control 1
• Post-stroke patients: Evaluate for hemiplegic shoulder pain with special attention to tone, strength, joint alignment, and signs of Complex Regional Pain Syndrome (pain, edema, trophic skin changes, hyperesthesia, limited ROM) 1
• Cancer patients: Assess shoulder range of motion restriction, strength, impingement signs, and scapular mobility related to treatment effects 1
• Patients under 35 years: Focus on instability and labral pathology with detailed history of recurrent subluxation, "dead arm" sensation, or mechanical symptoms 4

Critical Examination Pitfalls to Avoid

• No single test is definitive: Use a multimodal approach combining multiple examination findings rather than relying on one special test 2
• Bilateral comparison is essential: Always examine the contralateral shoulder to establish the patient's baseline 6, 9
• Pain may limit examination: Distinguish between true mechanical restriction and pain-limited motion by assessing passive range after active range 1, 4
• Scapular dyskinesis is often overlooked: Always assess scapular movement as it contributes significantly to rotator cuff pathology 1
• Red flags require urgent evaluation: Fever with joint effusion (septic arthritis), acute neurologic deficits, or acute trauma with suspected fracture demand immediate attention 4

Integration with Imaging

• Standard radiographs (AP in internal and external rotation, plus axillary or scapular Y view) should be the initial imaging for all patients with shoulder pain 4
• For suspected rotator cuff pathology after noncontributory radiographs, MRI without contrast or ultrasound are equivalent first-line studies depending on local expertise 3, 1, 4
• For questionable bursitis or biceps tenosynovitis based on physical examination, both MRI and ultrasound are rated as highly appropriate (rating 9) 3
• For patients under 35 with instability or labral pathology, MRI or MR arthrography are the modalities of choice 1, 4

Time Efficiency

• A comprehensive shoulder examination protocol including range of motion with goniometer, strength testing with dynamometer, and select special tests can typically be completed in 15 minutes 5
• Prioritize tests based on clinical suspicion rather than performing every possible maneuver 2, 5