What is the systematic shoulder examination for an adult presenting with shoulder pain, limited range of motion, or functional deficit, including inspection, palpation, range of motion, strength testing, special orthopedic tests, neurologic assessment, functional assessment, and red‑flag screening?

Systematic Shoulder Physical Examination

A systematic shoulder examination should follow a structured sequence: inspection, palpation, range of motion testing, strength assessment, special orthopedic tests for specific pathologies (rotator cuff, impingement, instability, labral tears), neurovascular examination, and red flag screening—performed in this order to avoid missing critical pathology. 1, 2

Inspection

• Observe both shoulders simultaneously from anterior, lateral, and posterior views to identify asymmetry, muscle atrophy (particularly supraspinatus or infraspinatus wasting suggesting chronic rotator cuff pathology), deformity, or abnormal positioning 2, 3
• Look specifically for scapular winging, which indicates serratus anterior weakness or long thoracic nerve injury 1
• Note any visible swelling, ecchymosis, or skin changes that may indicate acute trauma, infection, or inflammatory conditions 3
• Document shoulder position at rest—a patient holding the arm in adduction and internal rotation suggests anterior dislocation or significant pain 3

Palpation

• Systematically palpate bony landmarks in sequence: sternoclavicular joint, clavicle shaft, acromioclavicular (AC) joint, acromion, coracoid process, greater and lesser tuberosities of the humerus, and scapular spine 2, 3
• Palpate the AC joint specifically with cross-body adduction, as focal tenderness here indicates AC joint pathology 3
• Assess the bicipital groove for tenderness by rotating the humerus while palpating anteriorly, which suggests biceps tendinopathy 4
• Palpate soft tissue structures including the subacromial space and rotator cuff insertion sites for focal tenderness 2

Range of Motion Assessment

• Test active range of motion first, then passive range of motion to distinguish between true mechanical restriction versus pain-limited or weakness-limited motion 2, 4
• Measure forward flexion (normal 160-180°), abduction (normal 160-180°), external rotation with arm at side (normal 60-90°), and internal rotation documented by vertebral level reached behind the back (normal T6-T8) 2, 3
• Pain with active motion but preserved passive motion suggests rotator cuff pathology or tendinopathy; restricted passive motion indicates adhesive capsulitis or glenohumeral arthritis 5
• Document the painful arc: pain between 70-120° of abduction specifically implicates supraspinatus impingement under the coracoacromial arch 5

Strength Testing

• Test rotator cuff muscles individually: supraspinatus with empty can test (abduction to 90° in scapular plane with thumbs down), infraspinatus and teres minor with resisted external rotation at 0° abduction, and subscapularis with lift-off test or belly-press test 2, 4
• Grade strength using the standard 0-5 scale, noting that weakness may indicate either pain inhibition or true structural tear 1
• Focal weakness during abduction with external or internal rotation is the key finding for rotator cuff pathology 5
• Test deltoid strength with resisted abduction at 90°, as deltoid weakness suggests axillary nerve injury, particularly after anterior dislocation 1

Special Orthopedic Tests

Rotator Cuff and Impingement Tests

• Hawkins test (92% sensitive): Forward flex shoulder to 90°, then forcibly internally rotate—positive if pain occurs, indicating supraspinatus impingement 5
• Neer test (88% sensitive): Forcibly forward flex the arm while stabilizing the scapula—positive if pain occurs, suggesting impingement 5
• Empty can test: Abduct arms to 90° in scapular plane with thumbs down, resist downward pressure—weakness or pain indicates supraspinatus pathology 5, 4
• External rotation lag sign: Passively position arm in 90° elbow flexion and maximum external rotation, ask patient to maintain position—arm drops into internal rotation if infraspinatus/teres minor torn 4

Instability Tests

• Apprehension test for anterior instability: With patient supine, abduct shoulder to 90° and externally rotate—positive if patient expresses apprehension or fear of dislocation 4
• Relocation test: Apply posterior force to humeral head during apprehension test—relief of apprehension confirms anterior instability 4
• Posterior instability examination: Apply posterior force to the humeral head with arm in 90° forward flexion and internal rotation—pain or apprehension indicates posterior instability 4
• Sulcus sign: Pull arm inferiorly while patient relaxed—visible sulcus below acromion indicates inferior instability or multidirectional laxity 2, 4

Labral Pathology Tests

• O'Brien test (active compression test): Forward flex arm to 90° with elbow extended and thumb down, resist downward force—pain relieved with palm up suggests superior labral anterior-posterior (SLAP) lesion 2
• Crank test: Abduct shoulder to 90°, apply axial load and rotate humerus—pain or clicking suggests labral tear 2

Biceps Tendon Tests

• Speed test: Resist forward flexion with elbow extended and forearm supinated—pain in bicipital groove indicates biceps tendinopathy 2, 4
• Yergason test: Resist supination with elbow flexed to 90°—pain in bicipital groove suggests biceps pathology 4

Neurovascular Examination

• Test sensation in axillary nerve distribution (lateral shoulder over deltoid), which is commonly injured with anterior dislocation or proximal humerus fractures 1
• Assess radial, median, and ulnar nerve function distally with two-point discrimination, motor testing, and specific nerve distribution sensory testing 1
• Palpate radial and ulnar pulses—absent pulses mandate immediate vascular imaging, particularly after high-energy trauma or dislocation 6
• Document any numbness, tingling, or radiation of pain down the arm, which suggests cervical radiculopathy rather than primary shoulder pathology 5, 7

Red Flag Screening

• Screen for systemic symptoms including fever, chills, or constitutional symptoms that may indicate septic arthritis, which requires emergent arthrocentesis and antibiotics 5, 8
• In bilateral shoulder pain with nausea, cardiac evaluation is mandatory as this can represent atypical angina or myocardial infarction, particularly in women and elderly patients—obtain immediate ECG and cardiac biomarkers 8
• Assess for signs of complex regional pain syndrome in chronic post-traumatic pain without clear etiology 6
• Document any history of malignancy, as shoulder pain can be the presenting symptom of metastatic disease 5
• In elderly patients, do not assume absence of recalled trauma means absence of fracture—osteoporotic fractures occur with minimal or unrecognized trauma 5

Functional Assessment

• Observe the patient performing functional tasks such as reaching overhead, reaching behind the back, and lifting objects to assess real-world limitations 1
• Assess scapular dyskinesis during arm elevation—abnormal scapular motion (winging, tilting, or dysrhythmia) contributes significantly to rotator cuff injury and should be documented 5
• Document specific functional deficits such as inability to comb hair (overhead activities), difficulty with dressing (internal rotation), or problems with lifting (strength limitations) 3

Common Pitfalls to Avoid

• Do not perform only active range of motion testing—passive motion must be assessed to distinguish adhesive capsulitis (restricted passive motion) from rotator cuff pathology (preserved passive motion) 5, 2
• Avoid attributing all shoulder pain to "muscle tension" without ruling out structural pathology, particularly cervical radiculopathy in patients with arm radiation 7
• Do not overlook posterior shoulder structures—posterior instability and posterior labral tears are frequently missed because examination focuses on anterior pathology 4
• Never assume normal radiographs exclude significant pathology in patients over 35-40 years with chronic symptoms—rotator cuff tears and labral pathology require MRI or ultrasound for diagnosis 5
• In patients with neurological symptoms, always examine the cervical spine—cervical radiculopathy commonly mimics primary shoulder pathology 7