How to Perform a Physical Examination for Shoulder Pain
Inspection should be from all views and should note muscle mass and tone, deformities, scars, masses, bruising, discoloration and swelling. Symmetry of right and left sides should also be noted.
Inspection of the shoulder requires adequate visualization of the entire upper extremity, shoulder girdle, chest, and back. Examination is performed with the shirt off for male patients, and a sleeveless shirt for female patients. The examiner should inspect muscle tone, symmetry, and deformity, especially at the acromioclavicular and sternoclavicular joints, shoulder, scapula, and clavicle. Scapular thoracic rhythm should be assessed from a posterior vantage point with the arms fully abducted.
Palpation of anatomic landmarks is critical to determine sites of tenderness. The shoulder girdle should be palpated for warmth, tenderness, deformity and crepitus. Structures that should be examined include the cervical spinous processes, medial scapula, posterior rotator cuff, anterior rotator cuff, deltoid, AC joint, SC joint, coracoacromial arch and biceps tendon.
Range of Motion
The first step is to document active range of motion of the neck, including flexion, extension, lateral bending, and rotation. Next, assess active and passive range of motion of the shoulder. If active range of motion is full, passive range of motion tests do not need to be performed.
Ranges of motion that need to be documented are forward elevation (in the sagittal plane), abduction (in the coronal plane), and internal and external rotation.
Internal rotation can be documented by vertebral level according to how high up the back the patient can place his or her thumb. External rotation should be documented at both 0° and 90° of abduction. Generally speaking, forward flexion and abduction are 0° to 180°, internal rotation is to ~T5 to T7, and the arm will externally rotate to 45°.
With Spurling’s test, the neck is positioned in lateral flexion and rotation with axial compression. Reproduction of radicular type pain to the ipsilateral side is a positive test. This position closes down the neural foramina, which compresses the cervical nerve roots as they exit the foramen. With a herniated nucleus pulposus or foraminal stenosis, this decrease in foraminal space is likely to reproduce radicular type pain.
Muscle Strength Testing
Muscle groups to concentrate on are the trapezius, serratus anterior, deltoid, and rotator cuff.
The deltoid is tested in forward flexion for the anterior third, straight abduction for the middle third, and in extension for the posterior third. The serratus anterior is evaluated by having the patient push off a wall while standing.
Winging of the scapula during this maneuver is classic when paralysis of the long thoracic nerve is involved. The supraspinatus can be tested by applying a downward force to the arms abducted 90°, forward flexed 30°, and internally rotated so that the thumbs are pointing down. The posterior cuff muscles (infraspinatus and teres minor) are evaluated by external rotation strength with the arm at the side and the elbow flexed to 90°. The subscapularis is tested by internal rotation strength with the arm in the same position.
To test the function of the subscapularis muscle, the patient internally rotates and extends the arm so that it lies on the patient’s back — about the level of the waist line. The patient then attempts to lift the arm posteriorly away from the back. If this is not possible, then the test is considered positive. A modification of this test is to have the examiner hold the patient’s arm posteriorly away from the patient’s back. When the examiner releases the arm and the patient is unable to actively maintain this position, the test is considered positive.
Impingement Sign and Impingement Test
Impingement sign, commonly referred to as impingement syndrome, is a mechanical impingement of the rotator cuff between the coracoacromial arch and the humeral head. Anything that decreases the volume of this space can cause impingement.
Typically, calcifications in the acromioclavicular ligament and anterior acromial spur formation are the cause of impingement, which may or may not be associated with tears of the rotator cuff. Hypertrophy of the acromioclavicular joint secondary to arthritis has also been implicated in the cause of impingement.
Arm positions that cause the humeral greater tuberosity to impinge against the inferior aspect of the acromion will reproduce pain in patients with impingement syndrome.
Neer Impingement Sign
Neer described the impingement sign as the reproduction of pain with passive elevation of the arm. The examiner uses one hand to stabilize the scapula, while the other hand raises the patient’s arm in forced forward elevation with slight abduction. If pain is relieved after injection of 10 cc of 1% lidocaine into the subacromial space, then it is referred to as a positive impingement test.
Hawkins Impingement Test
The arm is elevated forward to 90° with slight adduction. The examiner then internally rotates the arm, which brings the greater tuberosity, rotator cuff, and biceps tendon under the acromioclavicular arch. If pain is elicited with this maneuver then it is considered a positive test for impingement.
Instability patterns of the shoulder include anterior, posterior, inferior, and a combination of the 3 referred to as multidirectional. The examination is used to assess possible directions of instability and to correlate these with apprehension and symptom reproduction. It is performed with the patient upright and supine, both positions with the scapula stabilized.
For inferior instability, the arm is positioned along the side of the body and inferior traction is applied. A depression produced between the edge of the acromion and the humeral head is referred to as a sulcus sign.
To assess passive anteroposterior translation, the load and shift test is performed. First an axial load is applied to the humerus, which seats the humeral head in the glenoid fossa if there is inherent subluxation. The examiner then applies posterior and anterior stresses to the humeral head and attempts to translate the head out of the glenoid fossa.
After translation patterns are evaluated, symptom reproduction and apprehension with provocative maneuvers are assessed. To evaluate anterior apprehension of the left shoulder, the examiner stands behind the patient placing the left hand on the patient’s elbow. With the right hand, the thumb is positioned on the posterior humeral head to provide an anterior force while the fingers are placed anterior to help control any sudden instability. The arm is abducted to 90° with the elbow flexed. With increasing external rotation and forward pressure on the humeral head, the patient may express an apprehensive look, try to resist with muscular contractions, or simply state that the shoulder is beginning to dislocate. This is a positive apprehension sign. These maneuvers are repeated with the patient supine and with the edge of the table stabilizing the scapula. Again the arm is abducted to 90° and externally rotated while applying an anterior force. If apprehension or pain is encountered, then a posterior force is applied. If the apprehension and/or pain disappears, then it is a positive relocation test.
O’Brien’s Test for Superior Labral Anteroposterior (SLAP) Lesions
With the patient standing, the arm is forward flexed to 90° with the elbow straight. The patient adducts the arm 15° to 20° and fully internally rotates the shoulder so that the thumb is pointing down. The examiner then applies a downward force on the arm with the patient resisting. Next, the arm is externally rotated so that the thumb is pointing up. The examiner again applies a downward force to the arm while the patient resists. If pain is elicited with the thumb down and decreased or eliminated with the thumb up, then it is a positive test suggestive of a superior labral anteroposterior lesion.
The major part of the physical examination is performed with the examiner facing the patient and dictating movement in a “Simon says” fashion. This seems to be the most reproducible way to get the patient to follow the movements desired.
When the examiner is looking for muscle asymmetry he needs to view the patient from the back to watch the movement of the scapula and shoulder. A male patient should have his shirt off, and a female patient should be wearing a sleeveless shirt or tank top. The first part of the examination is to duplicate active neck motion, which includes flexion-extension (chin on chest, chin all the way up), lateral rotation (chin on left shoulder, chin on right shoulder), and lateral bending (ear on left shoulder, ear on right shoulder). Abnormal motions could be caused by trapezius spasm, nerve root irritation (either from a narrowed foramen or herniated disk), or degenerative changes.
The examiner should then focus on active shoulder motion in forward flexion, abduction, external-internal rotation, and composite motions where the patient places an arm behind the back and then lifts the arm up and externally rotates it as if to throw a ball or to serve. If these motions are abnormal, passive range of motion of only the glenohumeral cavity is assessed.
If passive range of motion is normal, the deficits could be pain, rotator cuff tear, or nerve deficit or injury. If the passive range of motion is abnormal, results could be indicative of pain (the patient will not adequately relax), a frozen shoulder (adhesive capsulitis) or degenerative changes that would be observed on x-ray.
Finally, the examiner should perform a passive cross-arm adduction test, which pinches the subacromion space and is positive with impingement syndromes and also tests the acromioclavicular joint and is positive with acromioclavicular joint pain.
Proceed with palpation of anatomic sites. Begin with the sternoclavicular joint followed by the acromioclavicular joint and then the biceps tendon. In relatively thin individuals, the greater tuberosity can be palpated separately from the lateral edge of the acromion.
Next, observe rotator cuff strength and evaluate the subscapularis, supraspinatus, infraspinatus, and teres minor muscles.
Test the subscapularis initially in internal rotation, the infraspinatus and teres minor in external rotation with the arm at the side, then the supraspinatus with the arm in the empty-can position. If rotator cuff strength is abnormal, this could be caused by pain (which can be evaluated by a diagnostic lidocaine test), or it could be weak because of an observed tear (which can be diagnosed by MRI or arthroscopy). A finding can be abnormal secondary to neurologic injury as a result of a nerve root, peripheral nerve, burner, or plexus injury.
Impingement signs are then evaluated. The two preferred methods are the Hawkins impingement test and the forced impingement test, which takes the elbow and gently forces the rotator cuff up against the lateral edge of the acromion. A positive test is indicative of pain, which suggests inflammation in the subacromion space. Determine whether this inflammation is tendinitis, bursitis, or a tear. Tendinitis or bursitis that is isolated would result in the remainder of the physical examination being normal or a proven lidocaine test.
Tears should be assessed whether they are partial or complete and can be evaluated by MRI or arthroscopy. Partial tears can be clinically significant in a competitive overhead or functioning overhead athlete, whereas in a non overhead athlete these tears may be clinically silent. The patient’s activity level should be factored into the decision for further diagnostic workup.
The final part of the examination evaluates glenohumeral instability and labral tears. This is the most difficult part of the examination and requires an extreme degree of skill on the part of the examiner as well as patient relaxation to determine if instability and/or labral tears exist. The patterns of instability that should be examined include anterior (with apprehension test), posterior (with a posterior drawer), and inferior (by applying a downward pressure on the arm). The position of instability by history as well as a physical examination and the component of multidirectional instability should be documented.
The table below demonstrates a stepwise approach for evaluating shoulder pain that begins at the neck, proceeds to the sternoclavicular, acromioclavicular, and scapulothoracic components of the shoulder joint, then focuses on particular anatomic sites, rotator cuff strength, and impingement signs, followed by glenohumeral tests. The physician should list all positive findings because multiple diagnoses are quite possible.
Cervical Spine Examination
- Abnormal findings
- Trapezius muscle spasm
- Nerve root symptoms
- Degenerative joint disease on examination or x-ray
- Continue assessment of cervical spine
- Normal cervical spine findings
- Proceed to shoulder assessment
- Abnormal active range of motion
- Normal passive range of motion
- Causes include:
- Rotator cuff tear
- Nerve deficit
- Restricted passive range of motion
- Causes include:
- Adhesive capsulitis (Frozen Shoulder), normal x-ray
- Degenerative joint disease, abnormal x-ray
- Pain due to impingement, AC arthritis
- Chronic dislocation
- Normal active range of motion
- Palpate for areas of tenderness to refine diagnosis
- SC joint
- AC joint
- Biceps tendon
- Adjacent labral injury
- Evaluate Rotator Cuff Strength
- Administer subacromial Xylocaine (Impingement test)
- Consider rotator cuff tear
- Neurologic injury
- No weakness
- Evaluate for subacromial impingement
- Impingement signs
- Consider tendinitis or bursitis
- Treat with anti-inflammatory medications, activity modification, home exercises or physical therapy
- Possible rotator cuff tear- partial or complete
- Evaluate with MRI or arthroscopy
- Consider glenohumeral instability or glenoid labrum tear
- Glenohumeral instability / Labral tests
- Anatomic lesion confirmed by physical exam, x-ray, MRI, Examination under anesthesia, arthroscopy
- Functional instability
- Internal impingement
- Secondary impingement
- Labral signs confirmed by physical examination, MRI, arthroscopy
- With instability
- Without instability
- No evidence of instability or labral pathology
- Training error
- Normal adaptation to increased loads
How to Use an X-Ray to Evaluate Shoulder Pain
The appropriate selection of x-ray views is dependent upon the diagnosis being considered. At the very least AP and lateral views are required. With the exception of localizing rotator cuff calcium deposits, these views are inadequate to evaluate injuries and disorders of the shoulder joint.
Patients sent for evaluation with AP and lateral views of the affected shoulder may require additional properly performed views depending on their diagnosis.
While the technique for taking these x-rays is not included on this page, the type of view required for different diagnoses is listed below.