What physical exam tests can be done for an elderly female patient with chronic right shoulder pain?

Physical Examination Tests for Chronic Right Shoulder Pain in an Elderly Female

For an elderly female with chronic shoulder pain, perform a systematic examination including range of motion assessment (active and passive forward flexion 0-180°, external rotation 0-90°, internal rotation reaching up the back), rotator cuff strength testing (empty can test, external rotation resistance, lift-off test, belly press test), impingement signs (Hawkins' and Neer's tests), and palpation of key structures including the acromioclavicular joint, bicipital groove, and assessment for muscle atrophy in the supraspinatus and infraspinatus fossae. 1, 2, 3, 4

Initial Observation and Positioning

• Position the patient sitting with 90° elbow flexion and hand in supination resting on the thigh for standardized examination 1
• Observe for visible muscle atrophy, particularly in the supraspinatus and infraspinatus fossae, which suggests chronic rotator cuff pathology 3
• Assess scapular position and movement for winging or dyskinesia, as scapular dysfunction significantly contributes to rotator cuff injury 1, 3
• Note any antalgic posturing or protective positioning of the affected shoulder 5

Range of Motion Testing

Active and Passive Assessment

• Evaluate forward flexion (normal 0-180°) using a goniometer for precise measurement 2
• Test abduction (normal 0-180°) and external rotation (normal 0-90°) with goniometric measurement 2
• Assess internal rotation by having the patient reach up the back, documenting the vertebral level reached 1, 2
• Perform dynamic examination with active and passive external and internal rotation through full range with 90° flexed elbow 1

Critical distinction: Preserved passive motion with painful/weak active motion suggests rotator cuff pathology, while limited and painful passive motion indicates adhesive capsulitis 3

Rotator Cuff Strength Testing

Supraspinatus Assessment

• Empty can test (Jobe's test): Resist abduction at 90° with the arm in the scapular plane (30° forward of coronal plane), thumb pointing down 1, 2
• This test is a key component of the clinical decision rule for rotator cuff tears when combined with pain during overhead activity and positive impingement signs 4

Infraspinatus and Teres Minor

• Test external rotation strength with the arm at the side and elbow flexed to 90° 1
• Weakness on external rotation testing is part of the validated clinical decision rule for rotator cuff tears 4

Subscapularis Assessment

• Lift-off test: Have the patient place the hand behind the back and lift it away from the body against resistance 1
• Belly press test: Patient presses the palm against the abdomen; inability to maintain wrist extension indicates subscapularis weakness 1
• Pain with internal rotation and extension (arm behind back) specifically implicates subscapularis and posterior rotator cuff structures 3

Deltoid Testing

• Assess resisted abduction at various angles to evaluate deltoid function 1

Impingement Testing

• Hawkins' test: Forward flex the shoulder to 90°, then forcibly internally rotate the arm; positive if pain is reproduced (92% sensitivity) 3
• Neer's test: Passively forward flex the arm while stabilizing the scapula; positive if pain occurs (88% sensitivity) 3
• Pain during abduction between 70-120° suggests supraspinatus impingement in the subacromial space 3

Clinical pearl: The combination of positive Hawkins' test, positive Neer's test, weakness on empty can test, and pain with overhead activity forms a validated clinical decision rule for rotator cuff pathology 3, 4

Palpation

• Palpate the acromioclavicular joint for tenderness, which when combined with pain on cross-body adduction test indicates AC joint pathology 1, 3
• Examine the bicipital groove for tenderness suggesting biceps tendinopathy 1, 3
• Palpate the proximal humerus and lateral aspect for focal tenderness 1
• Assess for areas of swelling, warmth, or crepitus indicating inflammation 1

Instability Testing (Less Common in Elderly)

• While shoulder instability is more common in patients under 35-40 years, in elderly patients over 35 years, rotator cuff disease and degenerative changes predominate 6, 3
• If instability is suspected, perform apprehension and relocation tests, though this is uncommon in the geriatric population 4

Pain Mapping

• Document precise pain location: anterior shoulder suggests rotator cuff or biceps pathology; superior shoulder indicates acromioclavicular joint disease; scapular region may indicate referred cervical spine pain 3
• Patients with rotator cuff-related shoulder pain predominantly refer pain to the anterior and lateral deltoid area 5

Special Considerations for Elderly Patients

• In patients over 50 years, glenohumeral osteoarthritis presents with gradual pain and progressive loss of motion 4
• Assess for adhesive capsulitis (frozen shoulder), which is associated with diabetes and thyroid disorders, presenting with diffuse pain and restricted passive range of motion 4
• Screen for neurological symptoms including numbness, tingling, or radiation down the arm suggesting cervical radiculopathy 3

Common Pitfalls to Avoid

• Do not assume normal imaging excludes pathology—approximately 10% of rotator cuff tears are asymptomatic, so clinical correlation is essential 2
• Avoid relying on a single test; use the combination of findings to establish diagnosis 3, 4
• Remember that shoulder pain in elderly patients can be referred from cervical spine pathology 3
• Do not overlook systemic causes—screen for constitutional symptoms that may indicate infection or malignancy 3