Comprehensive Shoulder Physical Examination Technique
A systematic shoulder examination should be performed with the patient seated, elbow flexed to 90°, and hand supinated on the thigh, incorporating inspection, palpation, range of motion testing with dynamic internal/external rotation, and specific provocative maneuvers to evaluate the rotator cuff, labrum, and glenohumeral stability 1, 2, 3.
Patient Positioning
Position the patient in a sitting position with specific arm placement 1:
- 90° flexion of the elbow joint
- Hand positioned in supination on top of the patient's thigh
- For dynamic examination: perform active and/or passive external and internal rotation of the humerus through full range of motion with the elbow maintained at 90°
This standardized positioning allows systematic evaluation of anterior, lateral, and posterior shoulder structures while enabling dynamic assessment of rotator cuff function and impingement 1.
Systematic Examination Sequence
Inspection
Observe for asymmetry, muscle atrophy (particularly supraspinatus and infraspinatus fossae), deformity, swelling, or scapular dyskinesis 2, 3. Scapular positioning is critical—abnormal scapular rotation or posterior tilting during arm elevation contributes to rotator cuff impingement 4.
Palpation
Systematically palpate bony landmarks and soft tissues 2, 3:
- Sternoclavicular joint (medially)
- Clavicle (along its length)
- Acromioclavicular joint (laterally)
- Acromion and subacromial space
- Bicipital groove (anterior, with shoulder in neutral then internal rotation)
- Greater tuberosity (lateral)
- Coracoid process (anterior)
Tenderness over the proximal humerus, particularly the lateral aspect, may indicate physeal injury in skeletally immature patients 4.
Range of Motion Assessment
Evaluate both active and passive motion 2, 3:
- Forward flexion (normal: 160-180°)
- Abduction (normal: 160-180°)
- External rotation at 0° and 90° abduction (normal: 60-90°)
- Internal rotation (document by vertebral level reached with thumb behind back)
- Cross-body adduction (evaluates posterior capsule and AC joint)
Critical caveat: Perform dynamic examination with internal and external rotation at 90° elbow flexion to assess rotator cuff integrity and impingement 1. Loss of motion, particularly external rotation, suggests adhesive capsulitis or posterior capsular contracture.
Strength Testing
Test rotator cuff muscles individually 2, 3:
- Supraspinatus: Empty can test (arm at 90° abduction, 30° forward flexion, thumb down)
- Infraspinatus/teres minor: External rotation strength at side with elbow flexed 90°
- Subscapularis: Lift-off test or belly-press test
- Deltoid: Resisted abduction at 90°
Focal weakness with decreased range of motion during abduction with external or internal rotation suggests rotator cuff dysfunction 4.
Provocative Testing for Impingement
Neer impingement sign: Passively forward flex the arm while stabilizing the scapula—pain suggests subacromial impingement 5, 6.
Hawkins-Kennedy test: Forward flex shoulder to 90°, then internally rotate—pain indicates rotator cuff or subacromial bursa pathology 5, 6.
Instability Testing
Anterior apprehension test: With patient supine or seated, abduct arm to 90° and externally rotate—apprehension (not just pain) suggests anterior instability 6, 3.
Relocation test: Apply posterior force to humeral head during apprehension position—relief of apprehension confirms anterior instability 6.
Load and shift test: Translate humeral head anteriorly and posteriorly while stabilizing scapula—excessive translation indicates laxity 6, 3.
Labral Pathology Assessment
O'Brien's test (Active Compression): Forward flex arm to 90° with elbow extended, adduct 10-15° across body, internally rotate (thumb down), then resist downward force—pain relieved with supination suggests SLAP lesion 5, 6.
Acromioclavicular Joint Evaluation
Cross-body adduction test: Passively adduct arm across chest—pain localized to AC joint indicates AC pathology 5, 2.
Direct palpation of the AC joint with focal tenderness confirms AC joint involvement 2.
Biceps Tendon Assessment
Speed's test: Resist forward flexion with arm supinated and elbow extended—pain in bicipital groove suggests biceps tendinopathy 5, 6.
Yergason's test: Resist supination with elbow flexed 90°—pain in bicipital groove indicates biceps pathology 5.
Key Clinical Pearls
For inflammatory conditions: Anterior, lateral, and posterior scans with rotation are most helpful for detecting inflammatory lesions 1. The axillary longitudinal scan is particularly sensitive for small shoulder effusions, though arm elevation may not be possible in advanced disease 1.
For rotator cuff tears: Pain during throwing typically occurs at release and during deceleration/follow-through phases 4. Undersurface tears from overuse are common in younger athletes, while older patients develop tears from primary impingement 4.
For pediatric patients: In skeletally immature pitchers (ages 11-early teens), tenderness over the proximal humerus with radiographic physeal widening indicates "Little League shoulder"—a Salter-Harris type I injury requiring minimum 3 months rest from throwing 4.
Common Pitfalls to Avoid
Missing scapular dyskinesis: Always observe scapular motion during arm elevation—poor coordination contributes to impingement and rotator cuff injury [4, @26@].
Inadequate dynamic assessment: Static examination alone misses rotator cuff pathology that manifests only with motion 1.
Confusing pain with apprehension: True instability produces apprehension (fear of dislocation), not just pain, during provocative testing 6, 3.
Overlooking cervical spine: Cervical radiculopathy can mimic shoulder pathology—always assess cervical range of motion and perform Spurling's test when presentation is atypical 5.