What is the recommended systematic step‑by‑step shoulder examination, including inspection, palpation, active and passive range of motion, strength testing, and special provocative maneuvers?

Systematic Shoulder Examination: Step-by-Step Approach

Begin with standard radiographs (AP in internal and external rotation plus axillary or scapular Y view) for any traumatic presentation, then proceed with a structured physical examination sequence including inspection for muscle atrophy, palpation of bony landmarks, active and passive range of motion testing in all planes, rotator cuff strength testing with specific maneuvers (empty can, lift-off, external rotation resistance), and provocative tests for impingement (Hawkins' and Neer's tests). 1, 2, 3

Initial Assessment and Patient Positioning

• Position the patient sitting upright with 90° elbow flexion and hand supinated resting on the thigh for the baseline examination 2
• Expose both shoulders completely to allow bilateral comparison and identify asymmetries 4, 5
• Document the mechanism of injury if traumatic: exact fall details, height, landing position, work-relatedness, and time since injury 1

Inspection Phase

• Assess for muscle atrophy in the supraspinatus and infraspinatus fossae, which indicates chronic rotator cuff pathology 3
• Evaluate scapular position and look for winging or dyskinesia during arm movement, as scapular dysfunction contributes significantly to rotator cuff injury 1, 2
• Identify swelling, deformity, or asymmetry compared to the contralateral shoulder 2
• Note any skin changes, warmth, or trophic changes that may suggest Complex Regional Pain Syndrome, particularly in post-traumatic or post-stroke patients 1, 2

Palpation Sequence

• Palpate the sternoclavicular joint, moving laterally along the clavicle to the acromioclavicular joint 2
• Assess the acromion, coracoid process, and greater tuberosity of the proximal humerus 2
• Palpate the bicipital groove with the arm in 10° internal rotation to position the groove anteriorly 2
• Identify areas of focal tenderness, warmth, crepitus, or swelling 1, 2

Range of Motion Assessment

Active Range of Motion

• Forward flexion: normal 0-180° 2
• External rotation with arm at side: normal 0-90° 2
• Internal rotation: assess ability to reach up the back, documenting the highest vertebral level reached 2
• Abduction: normal 0-180° 2
• Cross-body adduction (horizontal adduction) 1

Passive Range of Motion

• Perform passive motion in all planes to distinguish rotator cuff pathology (preserved passive motion with painful/weak active motion) from adhesive capsulitis (restricted passive motion) 1
• Limited passive external rotation and abduction specifically suggest adhesive capsulitis 1

Dynamic Assessment

• Have the patient perform active and passive external and internal rotation with 90° flexed elbow through full range of motion 2
• Observe for painful arc between 70-120° of abduction, which indicates subacromial impingement 1

Strength Testing: Rotator Cuff Muscles

Supraspinatus Testing

• Empty can test (Jobe's test): Patient abducts arm to 90° in scapular plane (30° anterior to coronal plane) with thumb pointing down (internal rotation), examiner applies downward pressure 2
• Weakness or pain indicates supraspinatus pathology 1, 2

Infraspinatus and Teres Minor Testing

• External rotation strength: With arm at side and elbow flexed 90°, patient externally rotates against resistance 2
• Weakness indicates infraspinatus or teres minor pathology 1, 2

Subscapularis Testing

• Lift-off test: Patient places hand behind back at waist level and attempts to lift hand away from back against resistance 2
• Belly press test: Patient presses palm against abdomen; inability to maintain elbow anterior to trunk indicates subscapularis weakness 2

Deltoid Testing

• Resisted abduction at various angles to isolate anterior, middle, and posterior deltoid 2

Special Provocative Maneuvers

Impingement Tests

• Hawkins' test (92% sensitive): Forward flex shoulder to 90°, then forcibly internally rotate the arm 1
• Neer's test (88% sensitive): Passively forward flex the arm while stabilizing the scapula, bringing arm into full overhead position 1
• Pain with either test suggests rotator cuff tendinopathy or subacromial impingement 1

Instability Testing

• Perform comprehensive instability assessment in patients under 40 years, as instability is the predominant pathology in younger patients 6
• Anterior apprehension test: With patient supine, abduct and externally rotate the arm; apprehension indicates anterior instability 4
• Posterior instability testing: Apply posterior force to humeral head with arm in forward flexion and internal rotation 4
• Document any history of shoulder "giving way" or subluxation events 1

Biceps Tendon Tests

• Speed's test: Resisted forward flexion with arm supinated and elbow extended 4
• Yergason's test: Resisted supination with elbow flexed 90° 4

Neurovascular Assessment

• Palpate radial and ulnar arterial pulses; absence requires immediate vascular imaging (duplex ultrasound or CT angiography) after high-energy trauma or dislocation 1
• Assess sensation in axillary nerve distribution (lateral deltoid) and other peripheral nerve territories 1
• Test motor function of major nerve distributions if neurological compromise is suspected 1

Age-Specific Examination Modifications

Patients Over 35-40 Years

• Focus examination on rotator cuff disease, degenerative changes, and impingement syndrome as these are the predominant pathologies 6, 1
• Carefully assess for full-thickness rotator cuff tears, which are more common in this age group 6
• Look for signs of chronic pathology including muscle atrophy and fatty infiltration 6

Patients Under 35 Years

• Prioritize instability testing and labral pathology assessment, as these are the predominant causes in younger patients 6, 1
• Detailed history of sports-related injuries and throwing mechanics 1
• Assess the entire kinetic chain in athletes, including scapular mechanics and core stability 2

Common Pitfalls to Avoid

• Failure to obtain axillary or scapular Y views in trauma cases leads to missed posterior dislocations in over 60% of cases 3
• Relying on AP radiographs alone will miss glenohumeral dislocations, particularly posterior dislocations 3
• Assuming absence of trauma means absence of fracture, especially in elderly patients with osteoporotic bones 1
• Performing overhead pulley exercises in rotator cuff pathology, which encourages uncontrolled abduction and worsens the condition 1
• Mistaking shoulder instability pain for impingement, cervical disk disease, or acromioclavicular joint disease 6
• Overlooking scapular dyskinesis, which may be both cause and effect of rotator cuff pathology 1, 2

Pain Location and Diagnostic Implications

• Anterior shoulder pain suggests rotator cuff or biceps pathology 1
• Superior shoulder pain indicates acromioclavicular joint disease 1
• Scapular region pain may indicate referred pain from cervical spine or rotator cuff pathology 1
• Pain with internal rotation and arm behind back specifically implicates subscapularis tendon and posterior rotator cuff structures 1

Integration with Imaging

• Standard radiographs (AP in internal and external rotation plus axillary or scapular Y view) are mandatory initial imaging for traumatic presentations 1, 3
• MRI without contrast is preferred for rotator cuff disorders in patients over 35 years with suspected tendinopathy or tears 1
• MR arthrography is recommended for patients under 35 years with instability or questionable labral pathology 6, 3
• Ultrasound with appropriate local expertise is equivalent to MRI for rotator cuff evaluation (85% sensitivity, 90% specificity) and allows dynamic assessment 1, 3
• CT is reserved for characterizing complex fracture patterns when surgical planning is needed 1, 3