What physical examination should be performed for a 35-year-old patient with shoulder pain and no red‑flag findings?

Physical Examination for Shoulder Pain in a 35-Year-Old Without Red Flags

For a 35-year-old patient with shoulder pain and no red-flag findings, perform a systematic physical examination that includes inspection, palpation, range of motion testing, and provocative maneuvers to identify specific soft-tissue pathology—particularly rotator cuff injuries, labral tears, and instability—before considering any imaging. 1

Essential Components of the Physical Examination

Inspection and Palpation

• Observe for asymmetry, muscle atrophy, swelling, or deformity by comparing both shoulders with the patient undressed from the waist up 1
• Palpate specific anatomical landmarks including the acromioclavicular joint, sternoclavicular joint, bicipital groove, greater tuberosity, and coracoid process to localize tenderness 1
• Assess for point tenderness that may indicate specific pathology such as AC joint separation, biceps tendinitis, or rotator cuff insertion inflammation 2

Range of Motion Assessment

• Evaluate both active and passive range of motion in all planes: forward flexion, abduction, internal rotation, and external rotation 1
• Document any limitations or pain with specific movements, as restricted passive motion suggests adhesive capsulitis while pain only with active motion suggests rotator cuff pathology 2
• Compare the affected shoulder to the contralateral side to establish baseline normal motion for the patient 1

Neurovascular Examination

• Perform a thorough sensorimotor examination of the entire upper extremity, including assessment of deltoid, biceps, triceps, wrist extensors, and intrinsic hand muscle strength 1
• Test sensation in all dermatomes to exclude cervical radiculopathy or peripheral nerve injury 1
• Assess distal pulses and capillary refill to rule out vascular compromise 3

Provocative Testing for Specific Pathology

Rotator Cuff Assessment

• Perform strength testing of the rotator cuff muscles, particularly supraspinatus (empty can test), infraspinatus, and subscapularis 4
• Execute impingement tests including Neer's sign (passive forward flexion with internal rotation) and Hawkins-Kennedy test (passive internal rotation at 90° flexion) to identify subacromial impingement 4
• Assess for painful arc between 60-120° of abduction, which suggests rotator cuff tendinopathy or impingement 2

Instability Testing

• Perform apprehension and relocation tests with the arm in 90° abduction and external rotation to assess for anterior instability 2
• Test for sulcus sign by applying inferior traction to the arm to evaluate for multidirectional instability 2

Labral Pathology

• Execute O'Brien's test (active compression test) to identify superior labral tears, particularly SLAP lesions 4
• Perform Speed's test and Yergason's test to assess for biceps tendon pathology and superior labral involvement 2

Adjacent Structure Examination

• Examine the cervical spine with range of motion testing and Spurling's maneuver to exclude referred pain from cervical pathology 1, 5
• Evaluate the elbow to rule out referred pain from distal pathology 1
• Assess for thoracic outlet syndrome if symptoms suggest neurovascular compression 6

Clinical Decision-Making Based on Examination Findings

When Physical Examination Suggests Specific Pathology

• If examination reveals localized rotator cuff tenderness with positive impingement signs and weakness, the diagnosis is likely rotator cuff tendinopathy or tear, and conservative management should be initiated before imaging 4
• If instability maneuvers reproduce symptoms or demonstrate excessive translation, consider labral injury or capsular laxity requiring further evaluation 2
• If examination is consistent with labral tear (positive O'Brien's test, clicking, or catching), advanced imaging may be warranted after initial conservative treatment fails 7

Important Caveats

• Physical examination alone has limited diagnostic accuracy for specific shoulder pathology, and clinical correlation with imaging is essential when advanced studies are obtained 7
• Do not rely solely on provocative tests, as they have variable sensitivity and specificity; integrate findings with the complete clinical picture 1
• Exclude non-shoulder sources of pain including cervical radiculopathy, thoracic outlet syndrome, and referred pain from diaphragmatic irritation before attributing symptoms to primary shoulder pathology 2, 5, 6
• Document neurovascular status completely to avoid missing associated nerve or vascular injuries 3