What are the key physical exam findings to document when evaluating a patient with shoulder pain?

Physical Exam Findings for Shoulder Pain Documentation

Document a systematic shoulder examination including inspection for asymmetry/atrophy, palpation of bony landmarks and soft tissues, active and passive range of motion in all planes with specific degree measurements, rotator cuff strength testing with individual muscle assessment, and special tests targeting impingement, instability, and labral pathology based on clinical suspicion. 1

Patient Positioning

• Position the patient sitting upright with the elbow flexed to 90° and hand supinated resting on the thigh for static examination 1, 2
• For dynamic assessment, have the patient perform active and passive external and internal rotation through full range of motion while maintaining 90° elbow flexion 1, 2

Inspection

• Observe for muscle atrophy, particularly in the supraspinatus and infraspinatus fossae, which suggests chronic rotator cuff pathology 1
• Assess scapular position and movement for winging or dyskinesia, which may contribute to rotator cuff injury 1
• Identify visible swelling, asymmetry, or deformity compared to the contralateral shoulder 1

Palpation

• Palpate the proximal humerus and lateral aspect for tenderness 1
• Examine the acromioclavicular joint, sternoclavicular joint, and bicipital groove for point tenderness 1
• Assess for warmth, swelling, or crepitus indicating inflammation 1
• Document areas of soft tissue tenderness in the surrounding musculature 1

Range of Motion Assessment

• Active Range of Motion: Document forward flexion (normal 0-180°), external rotation (normal 0-90°), and internal rotation (document vertebral level reached up the back) 1
• Passive Range of Motion: Assess the same movements passively to differentiate between mechanical restriction versus pain-limited motion 1
• Loss of both active and passive range of motion suggests adhesive capsulitis or glenohumeral arthritis, while preserved passive motion with limited active motion suggests rotator cuff pathology 3

Strength Testing - Rotator Cuff Muscles

• Supraspinatus: Perform empty can test (Jobe's test) with arm at 90° abduction in scapular plane, internally rotated with thumb down, and test resisted elevation 1
• Infraspinatus and Teres Minor: Test external rotation strength with arm at side and elbow flexed to 90° 1
• Subscapularis: Perform lift-off test (hand behind back, lift away from body against resistance) or belly press test (press hand into abdomen while maintaining wrist extension) 1
• Deltoid: Test resisted abduction at various angles 1

Special Tests for Specific Pathology

• For impingement: Perform Neer's test and Hawkins-Kennedy test when clinical suspicion exists 1, 4
• For labral pathology: Conduct O'Brien's test or anterior slide test if instability or labral tear is suspected 4
• For biceps pathology: Perform Speed's test and Yergason's test to assess biceps tendon involvement 4
• For instability: Conduct apprehension and relocation tests for anterior instability, and specific posterior instability maneuvers if indicated 4, 5

Special Population Considerations

• Athletes/throwers: Assess shoulder motion, flexibility, strength, and evaluate the entire kinetic chain 1
• Post-stroke patients: Document tone, strength, soft tissue changes, joint alignment, and pain levels with attention to hemiplegic shoulder pain 1
• Cancer patients: Assess range of motion restriction, strength deficits, impingement signs, and scapular mobility 1

Neurovascular Assessment

• Document distal pulses, capillary refill, and sensation in the affected extremity 6
• This is particularly critical in traumatic presentations or suspected dislocation 6

Common Pitfalls to Avoid

• Failing to assess both active and passive range of motion separately can miss the distinction between mechanical restriction and rotator cuff pathology 3
• Relying on a single special test rather than a combination of examination findings, as no single test provides definitive diagnosis 2
• Overlooking scapular dyskinesis, which frequently contributes to rotator cuff pathology 1
• Not documenting specific degree measurements for range of motion, which limits ability to track progress 1
• Attempting to examine through severe acute pain without considering analgesics first, which limits examination accuracy 1