Shoulder Examination

Shoulder Examination follows the standard ‘look, feel, move’, in addition to special tests that must be performed during physical examination.

Based on the initial shoulder examination and the patient’s history, the examiner will focus on the area of concern and utilize special tests to confirm or rule out a probable or differential diagnosis. For instance, if a patient reports shoulder pain localized to the acromioclavicular joint (AC), the first special test performed would be the Scarf test.

The five most common pathologies found during a shoulder physical exam are instability, rotator cuff tear, arthritis, AC joint pathology, and impingement. Additionally, cervical spine problems should be ruled out as a potential source of pain. It’s important to include a thorough assessment of neurology in a complete upper limb examination.

History Taking

It is important to gather information on age, occupation, and dominant hand when assessing the musculoskeletal system.

Age can provide valuable insights into the nature of the issue. For instance, individuals in their second and third decades of life may experience instability, while frozen shoulder is commonly observed in diabetics and those in their fourth decade. Inflammatory joint diseases tend to occur in individuals in their fifth decade, while degenerative joint diseases and rotator cuff tears are more commonly seen in those in their sixth and seventh decades.

During the medical history, it is important to ask specific questions related to pain, weakness, stiffness, clicking, and instability. Additionally, the onset and duration of symptoms should be determined.

Shoulder Joint Inspection

To inspect the patient’s shoulder, follow a step-by-step approach:

• Ask the patient to stand and remove their clothes from the waist up. Women should wear a strapless garment or a drape to cover their breasts. Take note of any difficulty the patient experiences while undressing as this can be related to the severity of the symptoms.
• Look for scars, sinuses or redness around the shoulder area and document them. Start from the front and check for any joint subluxation, old fractures, or wasting.
• From the side, check for swelling that might indicate an infection or inflammation. From the back, check for any abnormalities in the scapula and whether it’s positioned correctly. From above, check for any swelling, deformities, or asymmetry of the supraclavicular fossae.

Shoulder Joint Palpation

Shoulder physical exam should always include palpation, it is important to do it systematically like inspecting. It is helpful to have the patient face a mirror and stand behind them to see their facial expressions while using only one hand to press on one point at a time.

Begin by examining the sternoclavicular joint and moving along the clavicle from front to back, noting any point tenderness in the AC joint and long head of biceps. Diffuse tenderness may indicate infection or supraspinatus tendinitis.

Palpate the coracoid and surrounding area, with tenderness to the side of the coracoid suggesting inflammatory arthropathy or frozen shoulder. Continue the palpation downwards, with tenderness at the intertubercular sulcus approximately 7 cm distal to the acromion indicating bicipital tendinitis.

However, tenderness in a specific area is not specific to any diagnosis and must be considered along with other clinical findings and patient history.

Shoulder Movement

Begin by evaluating the patient’s active movement, then their passive movement. For greater efficiency, ask the patient to perform an active movement first and then assess if the range can be extended by passive movement. You can record both active and passive movements at once (such as ‘active abduction to 120° and further passive abduction to 170°’).

Check for scapulohumeral rhythm, and if it’s restricted, repeat with the scapula fixed to assess the amount of glenohumeral movement passively. It’s also important to do a quick examination of the cervical spine to make sure that any symptoms in the shoulder area are not referred from the cervical spine.

Shoulder Exam Tests

There are many special tests that can be done during shoulder examination depending on the patient symptoms and pain localization, these may include based on the case:

See Also: Shoulder Special Tests

Subacromial impingement

1. Hawkin test
2. Neer’s sign

AC joint pathology

1. Cross Body Adduction Test

Rotator cuff tears

1. Jobe’s test
2. External rotation lag test
3. Patte’s test
4. The Hornblower’s sign
5. Gerber’s lift-off test
6. Napoleon/LaFosse Belly Press Test

Biceps Tendon

1. Popeye sign
2. Speed’s test
3. Yergason’s test

Shoulder Instability

1. Anterior Drawer Tests
2. Sulcus Sign
3. Apprehension Test

References & More

1. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
2. Varacallo M, El Bitar Y, Mair SD. Comprehensive Shoulder Evaluation Strategies. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538309/
3. Gismervik SØ, Drogset JO, Granviken F, Rø M, Leivseth G. Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance. BMC Musculoskelet Disord. 2017 Jan 25;18(1):41. doi: 10.1186/s12891-017-1400-0. PMID: 28122541; PMCID: PMC5267375.
4. Yang S, Kim TU, Kim DH, Chang MC. Understanding the physical examination of the shoulder: a narrative review. Ann Palliat Med. 2021 Feb;10(2):2293-2303. doi: 10.21037/apm-20-1808. Epub 2021 Feb 2. PMID: 33549026.