1. Physical Examination of the
Shoulder

2. Examination of shoulder
Anatomy
History
Inspection
Palpation
Range of Motion
Special tests – Impingement tests
Labral tests
Instability tests
Rotator Cuff tests
Strength tests
Acromio-clavicular joint tests
Measurements
Cervical Spine and Neurological Examination

3. Shoulder pain
Common in all age groups
Intrinsic disorder (85%) vs referred pain
C-spine nerve impingement (disc herniation or
spinal stenosis)
Peripheral nerve entrapment distal to spinal
column (long thoracic, suprascapular)
Diaphragm irritation, intrathoracic tumors, and
distension of Gleason’s capsule/gall bladder
Myocardial ischemia
Pancoast tumor

4. Review of shoulder anatomy

5. Review of shoulder anatomy
Bones
Scapula
Clavicle
Humeral head
Posterior rib cage
Joints
Sternoclavicular
Acromioclavicular
Glenohumeral
Scapulothoracic

6. Glenohumeral joint
25% humeral head surface in contact with
glenoid
Joint space thinning seen with OA

7. Glenohumeral joint
Humeral head coverage increased to 75% with
glenoid labrum

8. More shoulder anatomy
Ligaments
Coracoclavicular
Acromioclavicular
Glenohumeral
Superior GH
Middle GH
Inferior GH
Coracohumeral
Subacromial bursa
Subdeltoid bursa

9. Rotator cuff muscles
Supraspinatus,
infraspinatus, teres
minor, subscapularis
Form cuff around
humeral head
Keep humeral head
within joint (counteract
deltoid)
Abduction, external
rotation, internal rotation

10. Muscles of the Rotator Cuff
The four major muscles of the rotator cuff rotate the
humerus and properly orient the humoral head in the
glenoid fossa (socket).
The tendons of these four muscles merge, forming a cuff
around the glenohumeral joint.
Supraspinatus: abducts the humeral head and acts as a
humeral head depressor
Infraspinatus: externally rotates and horizontally extends
the humerus
Teres minor: externally rotates and extends the humerus
Subscapularis: internally rotates the humerus

11. History
Ask questions pertaining to the following:
 Chief complaint
 Mechanism of injury - Thrower, RTA,Thrower, RTA,
sudden traction, repetitive overhead workersudden traction, repetitive overhead worker
 Unusual sounds or sensations
 Previous injury
 Previous injury to opposite extremity for
bilateral comparison

12. History - PainHistory - Pain
Type and location of pain or symptoms
Onset of pain (traumatic, insidious)Onset of pain (traumatic, insidious)
Location of painLocation of pain
Alleviating/Aggravating factorsAlleviating/Aggravating factors
Night painNight pain
Pain/weakness overhead activitiesPain/weakness overhead activities

13. PainPain
 Where is the pain?(C4 or C5)
 How Long for?
 Other Joints?
1. Able to lie on that side?
2. Pain at rest?
3. Pain down the arm? (how far)
 The last 3 questions determine the
irritability of the joint

14. Pain
The shoulder is derived from the fifth
cervical segment and therefore refers pain
into the C5 dermatome.
The acromio-clavicular joint is a C4
structure and refers pain into the C4
dermatome.

15. Pain
The extent of reference is governed by a
number of factors.
The depth of the structure beneath the
skin.
The position of the structure within the
dermatome.
The severity of the lesion

16. Pain
The shoulder is deep and proximal in the
C5 dermatome, hence it can potentially
refer pain a great distance.
Conversely the acromio-clavicular joint is a
superficial structure at the distal end of the
dermatome causing it to give rise to
accurate, local pain

17. Pain
Typically pain of gleno-humeral origin is
felt in the upper arm, often at the insertion
of the deltoid.
Severe shoulder problems can cause pain to
radiate as far as the radial side of the wrist.
Other potential sources of pain at the
shoulder need to be eliminated (angina,
pleuritic pain or neck pain.)

18. Pain
Pain behaves in a predictable manner.
There are several 'rules of referral'
Pain is generally referred distally.
Pain is felt deeply.
Pain does not cross the mid—line.
Pain may occupy any part of the
dermatome.
Pain is felt segmentally.

19. Pain
The exception to the rules of referred pain
is the dura mater which will give rise to
extrasegmental referred pain.

20. Painful Arc
This is not a diagnosis but a localising sign.
There are 4 common causes of a painful arc
at the shoulder joint.
All involve soft tissues being pinched
between the humerus and the underside of
the acromion.

21. Painful Arc
These are:
supraspinatus (pain on resisted abduction)
infraspinatus (pain on resisted lateral
rotation).
subscapularis (pain on resisted medial
rotation).
sub-acromial bursa (pain at extremes of all
passive ranges

22. Examination of the Shoulder
1. Observe the whole
patient, front and back.
2. Observe the shoulder.
3. Observe the axilla.
View from rear with
patient standing straight
and look for lateral
symmetry, swelling,
position of scapula and
signs of muscle wasting.

23. Inspection
Posture: Cervical lordosis, thoracicPosture: Cervical lordosis, thoracic
kyphosis, and rounded shoulderskyphosis, and rounded shoulders
Relative elevation or depression shoulderRelative elevation or depression shoulder
Muscle atrophyMuscle atrophy
Prominent AC jointProminent AC joint
Scapula motion during arm elevationScapula motion during arm elevation
Active/Passive range of motionActive/Passive range of motion

24. Inspection
Visible facial expressions of pain
Swelling, deformity, abnormal contours, or
discoloration
Does the arm hang and swing, or does he hold or
splint the arm?
Overall position, posture, and alignment
Muscle development—are there areas of muscular
atrophy?
Bilateral comparison of acromions, SC joints,
inferior border of scapula, and scapular spine
Is the inferior tip of scapula level with T7 and the
superior medial ridge level with T2?

25. Observe shoulder
abduction from in
front and behind,
through the entire
range of movement.
Note the presence of
difficulty in initiation
or a painful arc.

26. Palpation
Bilaterally palpate for pain,
tenderness, and deformity over
the following:
 SC joint, clavicle, AC joint,
acromion, coracoid process,
subacromial bursa, greater
tuberosity, lesser tuberosity,
bicipital groove
 Spine, superior and inferior
angles of scapula, lower
cervical and upper thoracic
spinous processes

27. Palpation
Rotator cuff insertion
Sternocleidomastoid,
pectoralis
Biceps tendon and
muscle
Trapezius, rhomboid,
latissimus dorsi,
serratus anterior
Axillary structures

28. Range of Motion Tests
conducted both actively and passively
The reason for this is that if the patient is
experiencing pain, he/she may restrict
movement.
Furthermore, the opposing limb should be
examined in an identical fashion in order to
evaluate bilateral symmetry.

29. External Rotation
patient is positioned
sitting and the elbow
is flexed 90 degrees.
While the elbow is
held against the
patient's side, the
examiner externally
rotates the arm as
permitted.

30. Internal Rotation
The patient should be
positioned sitting.
Again with the elbows at
the patient's side, the
examiner should raise the
thumb up the spine, and
record the position in
relation to the spine
(reaching T7 is normal,
unless bilateral symmetry is
observed).

31. Internal Rotation at 90 degrees of Forward
flexion
The patient is positioned
sitting with the elbow and
shoulder supported to
prevent muscle contraction.
The arm is at 90 degrees with
the fingers pointing
downward and palm facing
posteriorly.
The examiner attempts to
rotate the forearm posteriorly
as far as possible.

32. Forward flexion
The arm is kept
straightened and brought
upward through the frontal
plane, and moved as far as
the patient can go above his
head.
Note: for recording
purposes, 0 degrees is
defined as straight down at
the patient's side, and 180
degrees is straight up.

33. Shoulder Abduction: Active Test
The arm is again kept
straightened, while raised
and abducted.
Observe the twisting of hand
-- facing outward, not
forward, as in forward
flexion.
The ROM is measured in
degrees as decribed for
forward flexion.
As pictured, this test is being
done actively by the patient,
but may be performed by
the examiner as well.

34. Other movements
Extension-with arm by the patient’s side,
lift the arm back wards as far as possible.
Adduction-draw the arm across the
anterior chest wall as far as possible.

35. Functional examination- Thirteen tests:
Bilateral elevation through abduction:— pain? / R.O.M?
Passive elevation:- pain? / R.O.M? / end feel?
Painful ARC:— (active elevation, encourage beyond pain)
Passive abduction:- fix scapula, cf other side
Passive lat. rotn:— fix other shoulder R.O.M? / end feel?
Passive med. rotn:- fix other shoulder R.O.M? / end feel?
Resisted adduction:- (pec major, lat dorsi, teres maj, teres min)
Resisted abduction:- (SUPRASPINATUS, deltoid)
Resisted lateral rotation:- (INFRASPINATUS, teres minor)
Resisted medial rotation:- (SUBSCAPULARIS, P.macj.
L.Dor. T.maj)
Resisted elbow flexion:- (BICEPS long head)
Resisted elbow extension:- (SUB ACROMIAL BURSA,
TRICEPS)
Passive horizontal adduct ion:- (A-C joint, subscapularis)

36. Special TestsSpecial Tests
A variety of tests have been described forA variety of tests have been described for
examination of the shoulderexamination of the shoulder
A positive test is usually associated withA positive test is usually associated with
pain in a specific location for each testpain in a specific location for each test
No single test is diagnostic, but several testsNo single test is diagnostic, but several tests
together along with the history is usuallytogether along with the history is usually
very accurate at locating the source ofvery accurate at locating the source of
pathologypathology

37. Special tests
Impingement tests
Labral tests
Instability tests
Rotator Cuff tests
Strength tests
Acromio-clavicular joint tests

38. Tests Used in Shoulder Evaluation and Significance of
Positive Findings
Test Maneuver Diagnosis
suggested by
positive result
Apley
scratch test
Patient touches superior
and inferior aspects of
opposite scapula
Loss of range of
motion: rotator cuff
problem
Neer's sign Arm in full flexion Subacromial
impingement
Hawkins'
test
Forward flexion of the
shoulder to 90 degrees
and internal rotation
Supraspinatus
tendon
impingement

39. Tests Used in Shoulder Evaluation and Significance of
Positive Findings
Test Maneuver Diagnosis
suggested by
positive result
Drop-arm
test
Arm lowered slowly to
waist
Rotator cuff tear
Cross-arm
test
Forward elevation to 90
degrees and active
adduction
Acromioclavicular
joint arthritis
Spurling's
test
Spine extended with
head rotated to affected
shoulder while axially
loaded
Cervical nerve root
disorder

40. Tests Used in Shoulder Evaluation and Significance of
Positive Findings
Test Maneuver Diagnosis
suggested by
positive result
Apprehensi
on test
Anterior pressure on the
humerus with external
rotation
Anterior
glenohumeral
instability
Relocation
test
Posterior force on
humerus while externally
rotating the arm
Anterior
glenohumeral
instability
Sulcus sign Pulling downward on
elbow or wrist
Inferior
glenohumeral
instability

41. Tests Used in Shoulder Evaluation and Significance of
Positive Findings
Test Maneuver Diagnosis
suggested by
positive result
Yergason
test
Elbow flexed to 90
degrees with forearm
pronated
Biceps tendon
instability or
tendonitis
Speed's
maneuver
Elbow flexed 20 to 30
degrees and forearm
supinated
Biceps tendon
instability or
tendonitis
"Clunk"
sign
Rotation of loaded
shoulder from extension
to forward flexion
Labral disorder

42. Impingement SignsImpingement Signs
Neer (maximal forward flexion)Neer (maximal forward flexion)
Hawkins (90o flexion, internal rotation,Hawkins (90o flexion, internal rotation,
adduction)adduction)

43. Neer's Test (Neer's impingement sign )
is elicited when the patient's
rotator cuff tendons are pinched
under the coracoacromial arch.
The test is performed by placing
the arm in forced flexion with the
arm fully pronated.
The scapula should be stabilized
during the maneuver to prevent
scapulothoracic motion.
Pain with this maneuver is a sign
of subacromial impingement.

44. Hawkins' Test
performed by elevating
the patient's arm
forward to 90 degrees
while forcibly internally
rotating the shoulder.
Pain with this maneuver suggests subacromial
impingement or rotator cuff tendonitis.
One study found Hawkins' test more sensitive for
impingement than Neer's test.

45. Hawkin's Test
Position the patient
standing with the
shoulder abducted 90
degrees, and internally
rotate the forearm.
The presence of pain
with movement is
indicative of possible
pathology

46. Labral TestsLabral Tests
RelocationRelocation
Active Compression (O’Brien’s)Active Compression (O’Brien’s)
Abduction external rotationAbduction external rotation
Load and shiftLoad and shift
ShearShear
Anterior SlideAnterior Slide
Clunk SignClunk Sign

47. InstabilityInstability
ApprehensionApprehension
SulcusSulcus
RelocationRelocation
Load and shiftLoad and shift

48. 'Clunk' Sign
Glenoid labral tears are assessed with the
patient supine.
The patient's arm is rotated and loaded
(force applied) from extension through to
forward flexion.
A "clunk" sound or clicking sensation can
indicate a labral tear even without
instability.

49. Drawer Test
The patient is seated with the forearm resting on
the lap and the shoulder relaxed.
The examiner stands behind the patient.
One of the examiner's hands stabilizes the
shoulder girdle (scapula and clavicle) while the
other grasps the proximal humerus.
These tests are performed with
(1) a minimal compressive load (just enough to
center the head in the glenoid) and
(2) with a substantial compressive load (to gain a
feeling for the effectiveness of the glenoid
concavity).

50. Drawer Test
Starting from the centered position with a
minimal compressive load, the humerus is first
pushed forward to determine the amount of
anterior displacement relative to the scapula.
The anterior translation of a normal shoulder
reaches a firm end-point with no clunking, no pain
and no apprehension.
 A clunk or snap on anterior subluxation or
reduction may suggest a labral tear or Bankart
lesion.

51. Drawer Test
The test is then repeated with a substantial
compressive load applied before translation is
attempted to gain an appreciation of the
competency of the anterior glenoid lip.
The humerus is returned to the neutral position
and the posterior drawer test is performed, with
light and again with substantial compressive loads
to judge the amount of translation and the
effectiveness of the posterior glenoid lip,
respectively.(Silliman and Hawkins, 1993)

52. InstabilityInstability
ApprehensionApprehension
SulcusSulcus
RelocationRelocation
Load and shiftLoad and shift

53. Apprehension TestHave the patient in the
supine position, with
the arm abducted 90
degrees.
Rotate the shoulder
externally by pushing
the forearm
posteriorly.
If patient feels
instability, they
typically will balk when
the test is performed.

54. Apprehension
Test
The anterior apprehension
test is performed with the
patient supine or seated and
the shoulder in a neutral
position at 90 degrees of
abduction.
apply slight anterior
pressure to the humerus
(too much force can
dislocate the humerus) and
externally rotates the arm.
Pain or apprehension about the feeling of impending
subluxation or dislocation indicates anterior
glenohumeral instability.

55. Relocation Test
The relocation test is performed
immediately after a positive result on the
anterior apprehension test.
With the patient supine, the examiner
applies posterior force on the proximal
humerus while externally rotating the
patient's arm.
A decrease in pain or apprehension
suggests anterior glenohumeral instability.

56. Sulcus Sign
With the patient's arm in a
neutral position, pull downward
on the elbow or wrist while
observing the shoulder area for
a sulcus or depression lateral or
inferior to the acromion.
The presence of a depression
indicates inferior translation of
the humerus and suggests
inferior glenohumeral instability
remember that many
asymptomatic patients,
especially adolescents, normally
have some degree of instability.

57. Rotator CuffRotator Cuff
Lift-offLift-off
Napoleon (belly push)Napoleon (belly push)
Whipple (resisted elevation with cross bodyWhipple (resisted elevation with cross body
adduction)adduction)
External rotation arm at sideExternal rotation arm at side
(infraspinatus)(infraspinatus)
Empty can (supraspinatus)Empty can (supraspinatus)

58. Rotator cuff tears

59. Drop-Arm Test
A possible rotator cuff tear can be evaluated with
the drop-arm test.
This test is performed by passively abducting the
patient's shoulder, then observing as the patient
slowly lowers the arm to the waist.
Often, the arm will drop to the side if the patient
has a rotator cuff tear or supraspinatus
dysfunction.
The patient may be able to lower the arm slowly to
90 degrees (because this is a function mostly of the
deltoid muscle) but will be unable to continue the
maneuver as far as the waist.

60. Rotator cuff strength testing
Supraspinatus
“Pour out a Coke”
Infraspinatus and teres minor
“Act like a penguin”
Subscapularis
“Scratch your back”

61. Strength Tests
Position the patient sitting,
with his arms at his sides
and elbows at 90 degrees.
It is important to maintain
the elbow positioning at the
sides while the external
rotation is attempted by the
patient (the examiner applies
internal resistance).
External Rotator Cuff (RC) Strength

62. Internal RC Strength
Same as above,
but the patient is
attempting to
rotate internally
(and examiner
resisting
externally).

63. Supraspinatus Strength
The patient is
positioned sitting with
arms straight out,
elbows locked, thumbs
down, and arm at 30
degrees (in scapular
plane).
The patient should
attempt to abduct his
arms against the
examiner's resistance.

64. Acromioclavicular (AC) Joint Testing
Palpation of AC Joint
The patient's arm is kept at his side and the
examiner palpates the AC joint for
discomfort/pain and gapping.

65. Cross-Arm Horizontal Adduction Test
The patient places his hand on the opposite
shoulder, while the examiner exerts force
horizontally. Again, the presence of pain
indicates possible pathology.

66. Cross-Arm Test
Patients with acromioclavicular joint dysfunction
often have shoulder pain that is mistaken for
impingement syndrome.
The cross-arm test isolates the acromioclavicular
joint.
The patient raises the affected arm to 90 degrees.
Active adduction of the arm forces the acromion
into the distal end of the clavicle .
Pain in the area of the acromioclavicular joint
suggests a disorder in this region.

67. Cervical Spine and Neurologic ExamCervical Spine and Neurologic Exam
Cervical spine range of motionCervical spine range of motion
Hyperextension of cervical spineHyperextension of cervical spine
Comparison of bilateral upper extremityComparison of bilateral upper extremity
strength, sensation, and reflexesstrength, sensation, and reflexes
Spurling’s maneuverSpurling’s maneuver

68. Spurling's Test
In a patient with neck
pain or pain that
radiates below the elbow,
a useful maneuver to
further evaluate the
cervical spine is
Spurling's test.

69. Spurling's Test
The patient's cervical spine is placed in
extension and the head rotated toward the
affected shoulder.
An axial load is then placed on the spine
Reproduction of the patient's shoulder or
arm pain indicates possible cervical nerve
root compression and warrants further
evaluation of the bony and soft tissue
structures of the cervical spine.