Shoulder Physical Examination

Physical Exam Components

The shoulder examination is typically organized into the following sections:
Inspection – Palpation – Range of Motion (ROM) – Neurovascular Examination – Provocative Tests

General principles

·       Always compare both shoulders (dominance, posture, pain behavior, and compensatory patterns).

·       A practical sequence is: inspection → palpation → ROM → neurovascular assessment → provocative maneuvers.

·       During provocative testing, distinguish pain reproduction from true weakness or a sense of instability.

·       Because “normal” ROM and strength vary among individuals, the contralateral side is often the most reliable reference.

1) Inspection

·       Perform a comparative visual assessment from the front, side, and back.

·       Skin and superficial findings:

o   Scars from prior surgery or trauma; other cutaneous changes

o   Ecchymosis or erythema (suggesting acute injury or inflammation)

·       Symmetry:

o   Shoulder height, clavicular contour, and AC joint prominence

·       Swelling:

o   Fullness around the subacromial or AC region; deltoid contour changes

·       Muscle bulk:

o   Atrophy (supraspinatus/infraspinatus fossae, deltoid)

o   Hypertrophy related to compensatory recruitment

·       Scapular winging:

o   Medial winging (serratus anterior dysfunction/long thoracic nerve)

o   Lateral winging (trapezius dysfunction/spinal accessory nerve)

·       Scapular dyskinesis and posture:

o   Protraction, increased thoracic kyphosis, anteriorly rounded shoulders

2) Palpation

A) Bony landmarks

·       Cervical spinous processes (to assess potential cervical sources of shoulder pain)

·       Sternoclavicular joint (SC)

·       Clavicle along its entire length

·       Acromioclavicular joint (AC)

·       Acromion

·       Coracoid process

·       Scapular spine

B) Muscles and soft tissues

·       Paraspinal musculature

·       Periscapular region (trapezius/rhomboids/serratus anterior)

·       Deltoid

·       Rotator cuff tendon insertions at the greater tuberosity

·       Long head of the biceps tendon within the bicipital (intertubercular) groove

Clinical note

·       A combination of focal tenderness and a corresponding positive provocative maneuver increases suspicion for pathology in that region
(e.g., AC joint tenderness plus pain with cross-body adduction).

3) Range of Motion (ROM)

A) Cervical spine ROM

·       Flexion

·       Extension

·       Lateral flexion

·       Rotation

B) Shoulder ROM

·       Assess both active and passive motion bilaterally.

·       Interpret “normal” values in the context of the patient’s baseline; use the opposite side as the primary comparator when possible.

Six planes of motion should be assessed and documented

1.     Forward elevation: ~180° is generally considered normal

2.     Abduction with scapular stabilization: ~90°

o   Technique: stabilize the scapula with the examiner’s hand to isolate glenohumeral abduction

3.     External rotation at 90° of abduction

4.     External rotation at the side: ~80°

5.     Internal rotation to vertebral level: typically T4–T8

6.     Internal rotation at 90° of abduction

Clinical notes

·       Document the symptom pattern during motion: painful arc, catching/clicking, or a subjective sense of instability.

·       If passive ROM is restricted, consider capsular stiffness (e.g., adhesive capsulitis).
If active ROM is more limited than passive, pain inhibition or a structural lesion (e.g., rotator cuff tear) may be contributing.

4) Neurovascular Examination

A) Motor and sensory assessment

·       Evaluate motor function and sensation across the C4–T1 distribution (dermatomal and myotomal screening as appropriate).

B) Vascular assessment

·       Palpate brachial, radial, and ulnar pulses.

Clinical note

·       In trauma or suspected instability, a documented vascular examination is essential.

5) Provocative Tests

A) Impingement Tests

1) Neer Impingement Sign

·       Suggests impingement of the rotator cuff tendons and/or subacromial bursa against the coracoacromial arch.

·       Potential mimickers: stiffness, glenohumeral osteoarthritis, instability, or osseous lesions.

Technique

·       Use one hand to stabilize the scapula.

·       With the other hand, move the arm into forced elevation (in the flexion–abduction plane).

·       Pain typically provoked between 70–110° is considered positive.

·       Interpretation note: a “true” positive is best assessed when full ROM is available.

2) Neer Impingement Test (post-injection)

·       A significant reduction in pain after the Neer maneuver following subacromial local anesthetic injection supports subacromial pain generation.

3) Hawkins Test

Technique

·       Flex the shoulder to 90° and the elbow to 90°.

·       Apply forced internal rotation, which drives the greater tuberosity under the coracoacromial structures.

4) Internal Impingement

Technique

·       Position the shoulder in 90° abduction with maximal external rotation (late cocking position), often with extension.

·       Reproduction of the patient’s posterior throwing-type pain is considered positive.

·       Supportive finding: symptom relief with a relocation maneuver (pain decreases when the humeral head is stabilized posteriorly; in some descriptions, pain diminishes when ER is performed with the elbow maintained anterior to the body plane).

B) Rotator Cuff Pathology

1) Subscapularis Tests

Note: Isolated internal rotation strength testing with the arm at the side can be misleading due to contributions from the pectoralis major and latissimus dorsi.

• Internal Rotation Lag Sign

·       Often regarded as one of the most sensitive and specific maneuvers for subscapularis dysfunction.

Technique

·       Stand behind the patient.

·       Flex the elbow to 90°; position the shoulder at ~20° elevation and 20° extension.

·       Passively bring the shoulder toward near-maximal internal rotation, lifting the dorsum of the hand away from the lumbar spine.

·       Support the elbow and ask the patient to maintain the position as you release the wrist.

·       A visible lag (loss of position) is positive.

• Increased passive external rotation

·       Compared with the contralateral side, increased passive ER may be observed in subscapularis tears.

• Lift-off Test

·       Place the hand behind the back (dorsum against the lumbar region, palm facing outward) and ask the patient to lift the hand away.

·       Inability suggests subscapularis dysfunction; accuracy improves when the hand can reach the contralateral scapula.

·       Considered more reflective of the inferior subscapularis.

• Belly-press Test

·       The patient presses the abdomen with the palm while maintaining shoulder internal rotation.

·       If the elbow drops posteriorly (fails to remain anterior to the trunk), the test is positive.

·       Often used for the superior subscapularis.

• Bear-hug Test

·       The patient places the ipsilateral palm on the opposite shoulder and resists the examiner pulling the hand away.

·       A strength deficit of ≥20% compared with the opposite side is considered positive.

2) Supraspinatus Tests

• Supraspinatus strength

·       Commonly assessed with the Jobe (empty can) test.

·       Pain may reflect subacromial irritation rather than a tear; a tear is more strongly suggested by true functional drop.

• Jobe (Empty Can) Test

·       Abduct the arm to 90°, then bring it 30° forward into the scapular plane.

·       Internally rotate (thumb down) and apply downward resistance as the patient holds position.

·       Record pain and/or weakness.

• Drop Sign (Drop Arm)

·       Passively elevate the arm in the scapular plane to 90°.

·       Ask the patient to slowly lower the arm.

·       Inability to control descent or sudden dropping due to weakness/pain is positive.

·       High specificity for full-thickness rotator cuff tear (~98%).

3) Infraspinatus

• Strength testing

·       With the elbow flexed to 90°, arm at the side (often with slight IR), assess resisted external rotation.

• External Rotation Lag Sign

·       Passively place the shoulder in maximal external rotation.

·       Ask the patient to maintain the position as you release.

·       Drift into internal rotation indicates a positive test.

4) Teres Minor

• Strength testing

·       Assess external rotation strength with the arm held in 90° abduction.

• Hornblower’s Sign

·       Position the shoulder in 90° abduction and 90° external rotation.

·       Inability to hold the position, with collapse into internal rotation, is positive.

C) Labral and SLAP Lesions

• Active Compression (O’Brien) Test

·       Suggestive of SLAP pathology when pain is deep in the glenohumeral joint with the forearm pronated and improves when supinated.

Technique

·       Flex the arm to 90° with the elbow extended; adduct 10–15°.

·       Pronate the forearm (thumb down) and apply downward force as the patient resists.

·       Repeat with supination (palm up).

·       Compare symptom quality and location.

• Crank Test

·       With the arm abducted, apply axial load and passive rotation.

·       Clicking or pain is positive.

D) Long Head of the Biceps (LHBT) Pathology

·       Bicipital groove tenderness can occur with LHBT inflammation and may coexist with SLAP lesions.

• Speed Test

·       Elbow extended, forearm supinated; resist forward elevation.

·       Pain localized to the bicipital groove is positive.

• Yergason Sign

·       Elbow flexed to 90°, forearm pronated; resist active supination.

·       Pain in the bicipital groove is positive.

• Popeye Sign

·       Prominent distal muscle belly (“bulge”) is consistent with proximal LHBT rupture.

E) AC Joint Pathology

·       AC joint tenderness on palpation supports AC involvement.

• Cross-Body Adduction

·       With the arm flexed to 90°, adduct across the body.

·       Pain localized to the AC joint is positive.

• O’Brien for AC joint

·       Superficial pain over the AC joint in pronation that improves with supination suggests AC pathology.

F) Instability

1) Anterior Instability

Anterior Load-and-Shift

·       Position: Supine; shoulder in 40–60° abduction and forward flexion

·       Technique: Axial load followed by anterior translation

·       Positive: Increased translation or symptoms vs contralateral side

Apprehension–Relocation

·       Position: Supine; 90° abduction + external rotation

·       Positive: Apprehension with ER that improves with posterior pressure

Anterior Release (Surprise Test)

·       Technique: Sudden release of posterior stabilizing force

·       Positive: Return of apprehension/instability

·       Note: If positive, apprehension and relocation are also positive

2) Posterior Instability

Posterior Load-and-Shift

·       Position: Supine; 40–60° abduction and forward elevation

·       Technique: Axial load with posterior translation

·       Positive: Increased posterior translation vs contralateral side

Jerk Test

·       Position: Seated; 90° forward elevation + internal rotation

·       Positive: Painful clunk during posteriorly directed axial load

Kim Test

·       Position: Seated; 90° abduction

·       Technique: Axial load with posteroinferior force during ~45° forward flexion

·       Positive: Posterior shoulder pain

3) Multidirectional Instability (MDI)

Sulcus Sign

·       Position: Standing; arms relaxed

·       Technique: Inferior traction on the arm

·       Positive: Visible sulcus below the acromion

·       Pathologic: Sulcus persists or increases with external rotation

Sulcus Grading

·       1+: < 1 cm

·       2+: 1–2 cm

·       3+: > 2 cm

References

·       Rockwood and matsen's the shoulder, 6th edition

·       Fundamentals of the Shoulder, https://doi.org/10.1007/978-3-030-94702-6