Which shoulder examination tests should a primary‑care clinician know and be proficient in?

Essential Shoulder Examination Tests for Primary Care

Primary care clinicians should master a focused set of shoulder examination maneuvers that can be completed in approximately 15 minutes, prioritizing range of motion assessment, rotator cuff strength testing (empty can test, external rotation lag sign, lift-off test), and impingement testing (Neer's and Hawkins-Kennedy tests), as these provide the highest diagnostic yield for the most common shoulder pathologies encountered in primary care. 1, 2

Core Examination Components You Must Know

Patient Positioning and Initial Assessment

• Position the patient sitting upright with 90° elbow flexion and hand supinated resting on the thigh 1
• Assess scapular position for winging or dyskinesia, which contributes to rotator cuff pathology 1
• Evaluate both active and passive range of motion in all planes: forward flexion (0-180°), external rotation (0-90°), and internal rotation (ability to reach up the back) 1

Critical Palpation Points

• Palpate the acromioclavicular joint, sternoclavicular joint, and bicipital groove systematically 1
• Assess the proximal humerus and surrounding soft tissues for tenderness, swelling, warmth, or crepitus 1
• These findings help differentiate inflammatory conditions from mechanical pathology 1

High-Yield Special Tests by Pathology

For Rotator Cuff Tears (Most Common in Patients >40 Years)

The External Rotation Lag Sign at 90° is the single most accurate test for ruling in rotator cuff tears (diagnostic odds ratio 12.70), making it your most valuable maneuver. 3

Additional high-value rotator cuff tests include:

• Empty Can Test (Jobe's Test) for supraspinatus pathology: Patient abducts arm to 90° in scapular plane with thumb pointing down, resist downward pressure 1, 2
• External Rotation Strength Testing for infraspinatus and teres minor: Test resisted external rotation with elbow at side 1
• Lift-Off Test and Belly Press Test for subscapularis: Patient places hand behind back and lifts off or presses into belly against resistance 1, 2
• Internal Rotation Lag Sign has moderate diagnostic accuracy for rotator cuff tears 3

For Subacromial Impingement/Bursitis

• Neer's Impingement Sign: Passively flex arm overhead while stabilizing scapula 2, 4
• Hawkins-Kennedy Test: Forward flex shoulder to 90°, then internally rotate the arm 2, 4
• Yergason's Test has the highest diagnostic accuracy for subacromial impingement (diagnostic odds ratio 4.71) 3
• Painful Arc Test: Pain between 60-120° of active abduction suggests subacromial pathology 2, 4

For Labral Pathology and Instability (Especially in Patients <35 Years)

• Assess for history of recurrent subluxation, "dead arm" sensation, or mechanical symptoms 5
• Perform dynamic examination with active and passive external/internal rotation through full range with 90° flexed elbow 1
• Note: Labral tears require MR arthrography for definitive diagnosis, so clinical suspicion drives imaging rather than specific physical exam findings 5

For Biceps Tendon Pathology

• Speed's Test: Resisted forward flexion with arm supinated and elbow extended 2, 4
• Yergason's Test: Resisted supination with elbow flexed to 90° 2, 4, 3
• Palpate the bicipital groove for focal tenderness 1, 4

Practical Examination Algorithm

Start with observation and range of motion, then proceed to strength testing, followed by special tests based on your clinical suspicion from the history. 1, 2

1. Observe for muscle atrophy (especially supraspinatus/infraspinatus fossae suggesting chronic rotator cuff pathology), scapular winging, and asymmetry 1, 6

2. Test range of motion actively and passively in all planes using a goniometer for objective measurement 2

3. Assess strength of individual rotator cuff muscles using a dynamometer when available, or manual muscle testing 2

4. Perform targeted special tests based on age and mechanism:

   • Age >40 with atraumatic pain: Focus on rotator cuff tests (External Rotation Lag Sign, Empty Can, Lift-Off) 7, 3
   • Age <35 with instability history: Focus on dynamic stability assessment and consider labral pathology 5
   • Overhead athletes: Include scapular dyskinesis assessment and kinetic chain evaluation 1

Critical Pitfalls to Avoid

• Do not rely on a single test: Rotator cuff pathology often requires multiple positive findings for accurate diagnosis 2, 8
• Do not skip the axillary or scapular Y view on radiographs: AC joint and glenohumeral pathology can be completely missed on AP views alone 9, 6
• Do not dismiss neuropathic symptoms (electric shock sensations, allodynia) as normal shoulder pain—these require specific evaluation and neuromodulating medications 5
• Do not order MR arthrography acutely: Standard MRI without contrast is appropriate for acute trauma; MR arthrography is for subacute/chronic labral concerns 5

When Physical Examination Is Not Enough

After completing your focused examination, obtain standard radiographs (minimum 3 views: AP in internal rotation, AP in external rotation, and axillary or scapular Y view) as the initial imaging for all shoulder pain presentations 9, 6, 5

If radiographs are noncontributory:

• For suspected rotator cuff tears: MRI without contrast or ultrasound are equivalent first-line studies (choice depends on local expertise) 9, 5
• For suspected labral tears or instability: MR arthrography is the reference standard 5
• For suspected impingement/bursitis: MRI without contrast or ultrasound are both rated 9/9 appropriateness 6