Orthopedic shoulder examination

Last updated: October 9, 2023

Summary

The shoulder consists of three joints: the glenohumeral joint (commonly referred to as “shoulder joint”), the sternoclavicular joint, and the acromioclavicular joint. While the glenohumeral joint possesses three degrees of freedom of motion, the range of motion as a whole is further increased by the glenohumeral joint's interaction with the acromioclavicular joint and the sternoclavicular joint. Unlike in other joints, the shoulder's dynamic stability and control are provided primarily by muscles (the rotator cuff in particular) rather than ligaments. Exposure to a great deal of stress from constant movement and the fact that it is stabilized primarily by muscles with little ligament support make the shoulder susceptible to dislocation and degenerative changes. Clinical examination is the core element in orthopedic shoulder diagnostics. Besides basic anatomy and function of the shoulder, this article discusses the most important clinical examinations and tests of the shoulder, the shoulder girdle joints, muscles, and capsuloligamentous complex.

For anatomy and function of the shoulder, see "Shoulder, axilla, and brachial plexus."

Patient history

Symptoms
- Shoulder pain
  - How long?
  - Onset (acute/insidious)?
  - Chronological sequence (persistent/intermittent/change in pain intensity over time? Night pain?)
  - Radiation of pain
- Restricted range of motion
  - Which movements are restricted in particular?
  - Which activities can no longer be performed on a daily basis?
  - Ask the patient to describe situations/movements.
Possible causes
- In accidents: inquire about the circumstances of the accident
  - How or where did the accident occur?
  - What part of the body was injured?
  - Type and duration of force?
- Occupational history: relevant especially if the patient presents with chronic complaints, e.g., repetitive overhead work is a typical cause of shoulder lesions
- Pre-existing conditions: Family history for joint disease?
Other
- Previous imaging
- Previous treatment

Inspection of the shoulder region

General information

Be attentive to patient habitus and movement upon entering the room:
- Uneven arm swing
- Relieving posture
- Unusual reactions to handshake
Ask the patient to undress so that both shoulders can be examined.

Procedure

Skin assessment: signs of injury (e.g., hematoma, excoriations), scars, signs of inflammation (e.g., redness or swelling can be a sign of subacromial bursitis)
Muscle contour inspection: Muscle contour asymmetry can indicate injury (e.g., distal muscle belly of the biceps brachii muscle in a proximal biceps tendon rupture) or neurological disorders (e.g., muscular atrophy of the deltoid muscle due to an axillary nerve injury).
Shoulder symmetry inspection
- Procedure
  - Anterior inspection should follow an imaginary line from the left to the right acromion. Alternatively, inspection is made by comparing the outline of both clavicles from the sternoclavicular joint to the acromioclavicular joint.
  - Dorsal inspection should follow an imaginary line between both scapular spines
- Findings and assessment
  - Horizontal asymmetry of the shoulder which can be:
    - Neurological (e.g., paralysis of the trapezius muscle in a damaged accessory nerve)
    - Posture-related (in habitual loading of the shoulder)
    - Structural (e.g., due to pelvic misalignment or scoliosis)
  - Vertical asymmetry of the shoulder (e.g., from a winged scapula)

Inspection of the Shoulder Region - Part 1 - Clinical Examination

Finger sign test and palm sign test

Short description: The patient is asked to point to the painful area with the palm or finger of the opposite (healthy) hand. The finger sign test and the palm sign can provide important information on the location of shoulder pathology in the early stages.
Findings and assessment
- The patient points to the lateral clavicle with the index finger (positive finger sign): AC joint pathology (e.g., trauma with ligamentous lesions or osteoarthritis of the AC joint) is likely
- The patient points to the lateral upper arm with the palm of the hand (positive palm sign): pathologies of the glenohumeral joint and/or subacromial region (e.g., subacromial impingement with supraspinatus tendonitis) are likely

Finger sign and palm sign

Palpation of the shoulder region

The shoulder region is initially palpated for signs of inflammation (warmth, swelling). A more detailed palpation of the muscle and bone structures of the shoulder region should be performed afterward.

Palpation of the most important shoulder regions
	Method	Findings and significance
Anterior examination
Sternoclavicular joint	The examiner holds the patient's clavicle between the ball of the thumb and index finger and moves the clavicle while the fingers of the other hand are firmly placed on the sternum.	Pain or strong movement in the joint occur as a result of trauma or in osteoarthritis or connective tissue disorders. Dislocations in this region are very rare (∼ 3% of all dislocations in the shoulder region) ^[1]
Clavicular, AC joint, and acromion	Palpation should be performed along the sternoclavicular joint to the acromion. The upper, lower, and front edge of the clavicle, the AC joint line, as well as the acromion, can be palpated.	Watch out for signs of a fracture such as pain, swelling, or displacement. The presence of a piano key sign (cranial dislocation of the lateral end of the clavicle) in the AC joint region can indicate injury to the AC joint.
Coracoid process	The examiner palpates the coracoid process with the middle and index fingers underneath the lateral clavicle (in the infraclavicular fossa). The coracoid process can be easily felt during anteflexion of the patient's arm.	Pain in this region may indicate insertional tendonitis of the short head of the biceps tendon, pectoralis minor muscle, or coracobrachialis muscle.
Bicipital groove	The bicipital groove is best palpated ∼ 9 cm below the glenohumeral joint. The greater tubercle, which forms the lateral border of the bicipital groove and is well-palpable and can help with orientation. The patient's arm should be rotated internally and externally during palpation, which makes tendon movement palpable.	Pain indicates a degenerative or inflammatory lesion of the long head of the biceps tendon. Palpable snapping indicates a tendon dislocation.
Lesser and greater tubercle	The lesser tubercle can be palpated lateral to the coracoid process or medial to the bicipital groove. From here, the laterally located greater tubercle can be palpated. The greater tubercle can be palpated by passive internal and external rotation of the patient's arm. The greater tubercle can be palpated as a movable protuberance.	Pain in the greater tubercle region may indicate a pathological condition of the rotator cuff muscles that insert into the greater tubercle, e.g., supraspinatus tendonitis as a result of subacromial impingement syndrome.
Posterior examination
Palpation of the scapula	Palpate along the scapular spine from medial to lateral. Palpate the contour of the scapula: the medial border of the scapula, inferior angle of the scapula, and lateral border of the scapula	Muscular atrophy and evident shoulder malpositioning can indicate traumatic nerve damage or neuralgic amyotrophy of the shoulder.

Palpation techniques of the shoulder Dorsal palpation of the scapula Palpation of the Shoulder Region - Part 2 - Clinical Examination

Shoulder mobility testing

Combined movements can be assessed in a preliminary examination, which provides a rough indication of potential pathological conditions. In subsequent detailed examinations, specific tests are used to examine individual joint components and their pathologies.

Combined shoulder joint movements

Apley scratch test ^[2]
- Procedure: The patient is asked to make a fist with the hands and stretch out the thumbs. The hands are placed behind the neck or the back.
  - Back: tests for internal rotation, extension, and adduction of the shoulder
  - Neck: tests for external rotation and abduction of the shoulder
- Findings and assessment: the test is positive if pain, side asymmetry appear, and/or limited range of motion occur

Apley scratch test (neck) Apley scratch test (back)

Range of motion of the shoulder

Active range of motion (the patient moves the shoulder without help from the examiner) should be performed before passive range of motion (with help from the examiner). Physiological range of motion in the shoulder (with movement of the scapula) comprises:

Glenohumeral joint (isolated)
- Flexion/extension: 90°/0°/30°
- Adduction/abduction: 20°/0°/90°
  - Abduction of 0–15°: supraspinatus muscles (suprascapular nerve)
  - Abduction of 15–90°: deltoid muscle (axillary nerve)
- Internal/external rotation (in the neutral position): 70°/0°/60°
- Internal/external rotation (with the upper arm abducted by 90°): 70°/0°/70°
Glenohumeral joint (shoulder girdle involvement)
- Flexion/extension: 170°/0°/40°
- Adduction/abduction: 40°/0°/180°
  - Abduction of > 90°: trapezius muscle (accessory nerve)
  - Abduction of > 100°: serratus anterior (long thoracic nerve)
- Internal/external rotation: 95°/0°/80°

Range of motion of the shoulder

Examination of the rotator cuff

See also “Soft tissue lesions of the shoulder.”

Examination of the supraspinatus muscle: empty can test (Jobe test)

Procedure (dorsal examination)
1. The patient's upper arm should be passively abducted (∼ 90°) and flexed horizontally with the elbow extended.
2. The arm is internally rotated (thumb pointing downwards).
3. Check the patient's ability to maintain the arm in this position.
4. If the patient is able to maintain this position, the examiner applies pressure to the patient's arm and the patient is asked to resist.
Findings and significance: Inability to maintain the arm's position against resistance or pain when doing so (positive Jobe test) indicates a functional disorder of the supraspinatus muscle (e.g., tendon rupture, tendinopathy, or subacromial bursitis).

Jobe test Examination of the Rotator Cuff - Jobe Test - Clinical Examination

Examination of the subscapularis muscle: lift-off test

Procedure (dorsal examination)
1. Place the patient's hand behind the lower back with the palm facing outwards.
2. Check the patient's ability to lift the hand away from the back.
3. If the patient is able to perform this movement, the examiner applies resistance to the patient's palm.
4. The patient is asked to move the hand against resistance applied by the examiner.
5. Check the other arm.
Findings and significance: Pain when returning the hand to the starting position or the inability to move the hand against resistance (positive lift-off test) indicates a functional disorder of the subscapularis tendon (e.g., rupture).

The lift-off test Examination of the Rotator Cuff - Lift-off Test - Clinical Examination

Examination of the subscapularis muscle: belly press test (abdominal compression test, Napoleon test)

Procedure (dorsal examination)
1. The patient's hand is placed flat on their abdomen with the hand, wrist, and elbow in a straight line.
2. The patient's elbow is flexed to 90°.
3. The examiner places the patient's flat hand onto the abdomen.
4. The examiner checks that the angle between the patient's hand and forearm is 0°.
5. The examiner asks the patient to firmly press the palm against the abdomen.
Findings and significance
- Mechanism: Internal rotation of the shoulder is necessary to maintain pressure exerted through this action. If the subscapularis tendon is injured, pressure against the abdomen is only possible if the triceps brachii muscle and posterior sections of the deltoid muscle compensate for the injured subscapularis muscle. The upper arm is flexed and adducted and the wrist is flexed.
- Negative belly press test (physiological): pressure against the abdomen without a flexed wrist (intact subscapularis muscle)
- Positive belly press test: Pressure against the abdomen that is associated with a flexed wrist indicates a functional disorder of the subscapularis tendon.
  - Wrist flexion < 30° indicates a low-degree subscapular lesion < ⅓.
  - Wrist flexion > 60° indicates a high-degree subscapular lesion > ⅔.

Belly press test Assessment of injury to the subscapularis muscle using the belly press test Examination of the Rotator Cuff - Belly Press Test - Clinical Examination

Examination of the infraspinatus muscle: infraspinatus test

Procedure
1. The test can be performed in two positions:
  - Position 1: The patient's elbow is bent to 90°.
  - Position 2: The patient's arm is abducted to 90° and the humerus is medially rotated to 30°.
2. The examiner applies resistance against the back of the patient's hand. The patient is asked to maintain his or her position.
Findings and significance: Inability to perform external rotation against resistance (positive infraspinatus test) indicates an impaired infraspinatus muscle, e.g., in suprascapular nerve lesion.

Infraspinatus test Examination of the Rotator Cuff - Infraspinatus Test - Clinical Examination

Examination of the long head of the biceps tendon

The long head of the biceps tendon traverses from the supraglenoid tubercle of the scapula through the bicipital groove of the humerus, a common site of tendon irritation. The most common pathologies, whose symptoms may be apparent upon clinical examination, include degenerative changes of the tendon with concomitant biceps tendonitis, fibromyalgia, and dislocation derived from the bicipital groove. After palpation of the biceps tendon in the bicipital groove, which should be performed with upper arm rotation, specific tests can be performed for further evaluation of biceps tendinopathy.

Types of biceps tendon rupture Inspection and Palpation of the Biceps Muscle - Clinical Examination

Palm-up test

Procedure (ventrolateral examination)
1. The examiner extends the patient's elbow and supinates the arm. The shoulder is abducted to 90° and horizontally flexed to 30°.
2. The examiner exerts downward pressure on the palmar side of the patient's wrist.
Findings and significance: Inability to move against resistance or the occurrence of pain in the bicipital groove (positive palm-up test) indicates possible causes such as tendonitis/subluxation of the long head of the biceps tendon, a glenoid labrum lesion (e.g., SLAP lesion), and/or anterior subacromial impingement.

Palm-up test

Speed test ^[2]

Procedure (ventrolateral examination)
1. The examiner slightly abducts the patient's arm with the elbow at 90° flexion and the forearm supinated.
2. The patient is asked to bend the elbow against the examiner's resistance.
Findings and significance
- Inability to flex the elbow against resistance or the occurrence of pain (positive Speed test) indicates pathologies of the long head of the biceps tendon and/or SLAP lesions
- The biceps muscle is not tested by abduction of the glenohumeral joint against resistance (tested in palm-up test) but by elbow flexion.

Speed's test

O'Brien test (active compression test)

Procedure (ventrolateral examination)
1. The examiner fully extends the patient's elbow. The arm to be tested is in 90° flexion and 10–15° adduction. The patient fully internally rotates the arm with the thumb pointing downwards.
2. The examiner exerts downward pressure on the proximal lower arm while the patient resists.
3. The patient's arm is then externally rotated. The examiner exerts downward pressure again while the patient resists.
Findings and significance
- Pain (and sometimes clicking) while attempting to resist the pressure exerted on the arm by the examiner (positive O'Brien test) indicates loss of integrity of the long head of the biceps tendon at the glenoid labrum (biceps anchor) in maximal internal and external rotation.
  - Pain located deep in the shoulder that is reduced or absent with supination (compared with pronation) indicates a SLAP lesion.
  - Pain located in another area or pain that is not reduced with supination (negative O'Brien test) is a nonspecific sign.

Yergason test ^[2]

Procedure (ventrolateral examination)
1. The patient's elbow is flexed at 90°.
2. Examiner grasps the patient's arm above the elbow and the wrist.
3. The patient actively attempts to supinate the forearm and to flex the elbow against resistance.
Findings and significance: :Pain while flexing the elbow against resistance (positive Yergason test) indicates biceps tendon inflammation (concomitant biceps tendonitis commonly occurs in patients with rotator cuff inflammation) or instability.

Shoulder impingement tests

Painful arc test

Procedure: The examiner instructs the patient to abduct and raise the extended arm.
Findings and significance
- Negative test (physiological): The patient's arm can be repeatedly raised and lowered between 0–180°.
- Positive test: painful arc
  - Pain between 60–120° indicates subacromial impingement
  - Pain from abduction/elevation at 120–170° indicates a pathology of the AC joint
  - Pain during the entire movement (0°–180°) nonspecific indication of a glenohumeral pathology (e.g., osteoarthritis or frozen shoulder)
- Impingement syndrome can make an assessment of the actual range of motion in the shoulder difficult due to pain. To nullify the effects of, e.g., subacromial impingement, abduction in external rotation can be performed. As a result of this, the space between the acromion and the supraspinatus tendon is enlarged, leading to reduced pain.

Normal range of shoulder abduction and pain in impingement Impingement Syndrome - Painful Arc Test - Clinical Examination

Neer test

Procedure (dorsal examination)
1. The examiner places the patient's arm in the internal rotation position and uses the hand to stabilize the patient's scapula.
2. Using the other hand, the examiner raises the patient's arm and moves it in a scapular range of motion.
Findings and significance: Pain during flexion between 90–120° (positive Neer test) and pain reduction in external rotation is a nonspecific indication of impingement syndrome.

Impingement Syndrome - Neer Test

Hawkins-Kennedy test

Procedure (ventral examination)
1. The examiner places the patient's arm in 90° flexion and flexes the elbow to 90°.
2. The examiner places one hand on the patient's distal lower arm, while the other hand is placed under the elbow.
3. The patient's lower arm is internally rotated similar to a clockhand, resulting in internal rotation of the shoulder. ^[3]
Findings and significance: Pain during internal rotation (positive Hawkins-Kennedy test) is a nonspecific indication of impingement syndrome.

Shoulder instability tests

Anterior/posterior drawer test of the shoulder

Procedure (dorsal or supine examination)
1. The examiner fixates the scapula by placing his hand firmly on the coracoid process and the spine of the scapula.
2. The humeral head is drawn in an anterior and posterior direction.
Findings and significance: A significant translocation or a difference between the two sides (positive drawer test) indicates hyperlaxity of the glenohumeral joint.

Sulcus sign (inferior drawer test of the shoulder)

Procedure (dorsal examination in a sitting position)
1. The patient's arm is relaxed and placed on the lap or on the examiner's arm.
2. The examiner stabilizes the patient's shoulder with one hand and grasps the patient's arm just above the elbow with the other.
3. The examiner applies a distal force to the patient's arm and inspects the patient's shoulder for the appearance of depression between the acromion and humerus (sulcus).
Findings and significance: A visible depression between the edge of the acromion and the humeral head (positive sulcus sign) indicates hyperlaxity of the glenohumeral joint.

Eliciting the sulcus sign

Shoulder apprehension tests

Anterior apprehension test

Procedure (dorsal examination in a sitting position)
1. The examiner stabilizes the patient's scapula with one hand.
2. The patient's shoulder is abducted to 90° and the elbow flexed to 90°.
3. The examiner positions the patient's arm to 90° abduction and external rotation and observes the patient's reaction upon inspection and palpation of the shoulder.
Findings and significance: A palpable shoulder subluxation (anterior shoulder instability), a sense of apprehension against external rotation, or a look of concern or discomfort by the patient that the shoulder will dislocate (positive anterior apprehension test) indicate capsuloligamentous complex lesions.

Posterior apprehension test

Procedure (optimally in a supine position)
1. The patient's arm is passively flexed to 90° and rotated maximally internally. The elbow is flexed to 90°.
2. The examiner places one hand on the patient's scapula and applies posterior force on the patient's elbow.
Findings and significance: A palpable shoulder subluxation (posterior shoulder instability), a sense of apprehension against external rotation, or a look of concern or discomfort by the patient that the shoulder will dislocate (positive posterior apprehension test) indicate capsuloligamentous complex lesions.

Relocation test

Procedure
1. The patient's arm is passively externally rotated.
2. The examiner places one hand on the patient's scapula and applies posterior force on the patient's humerus.
Findings and significance: A palpable shoulder subluxation (anterior shoulder instability), a sense of apprehension against external rotation, or a look of concern or discomfort by the patient that the shoulder will dislocate (positive relocation test) indicate capsuloligamentous complex lesions.

References:^[2]

References

Woodward TW, Best TM. The painful shoulder: part I. Clinical evaluation.. Am Fam Physician. 2000; 61 (10): p.3079-88.
Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis.. Am Fam Physician. 2009; 80 (5): p.470-6.
Morell DJ, Thyagarajan DS. Sternoclavicular joint dislocation and its management: A review of the literature.. World journal of orthopedics. 2016; 7 (4): p.244-50.doi: 10.5312/wjo.v7.i4.244 . | Open in Read by QxMD

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Orthopedic shoulder examination

Summary

Patient history

Inspection of the shoulder region

General information

Procedure

Finger sign test and palm sign test

Palpation of the shoulder region

Shoulder mobility testing

Combined shoulder joint movements

Range of motion of the shoulder

Examination of the rotator cuff

Examination of the supraspinatus muscle: empty can test (Jobe test)

Examination of the subscapularis muscle: lift-off test

Examination of the subscapularis muscle: belly press test (abdominal compression test, Napoleon test)

Examination of the infraspinatus muscle: infraspinatus test

Examination of the long head of the biceps tendon

Palm-up test

Speed test [2]

O'Brien test (active compression test)

Yergason test [2]

Shoulder impingement tests

Painful arc test

Neer test

Hawkins-Kennedy test

Shoulder instability tests

Anterior/posterior drawer test of the shoulder

Sulcus sign (inferior drawer test of the shoulder)

Shoulder apprehension tests

Anterior apprehension test

Posterior apprehension test

Relocation test

References

3 free articles remaining

Speed test ^[2]

Yergason test ^[2]