Shoulder examination for physiotherapy students and practicing professional

1. CLINICAL EXAMINATION OF
THE SHOULDER
PRESENTED BY
Mr. MOHAMED NAINAR .A
SENIOR PHYSIOTHERAPIST
DEPARTMENT OF PMR
CHETTINAD HOSPITAL AND RESEARCH
INSTITUTE

2. OBJECTIVES
REVIEW CLINICAL HISTORY AND
PHYSICAL EXAMINATION OF THE
SHOULDER
OBSERVATION,PALPATION,
ASSESSMENT OF RANGE OF MOTION,
STRENGTH AND NEUROVASCULAR
INTEGRITY
DESCRIBE THE SPECIFIC TESTS USED
TO EVALUATE COMMON SHOULDER
CONDITIONS TO FACILITATE ACCURATE
DIAGNOSIS
IDENTIFYING A SPECIFIC SHOULDER
PATHOLOGY
MAKING AN ACCURATE DIAGNOSIS AND
DISTINGUISHING CERTAIN
PATHOLOGIES OF THE SHOULDER

3. CLINICAL HISTORY
CHARACTERIZE PAIN
LOCATION OF PAIN
NIGHT PAIN
WEAKNESS
DEFORMITY
INSTABILITY
LOCKING / CLICKING / CLUNKING
SPORT / OCCUPATION
PREVIOUS TREATMENTS
ALLEVIATING / EXACERBATING
ACUTE VS CHRONIC
TRAUMATIC VS OVERUSE
HISTORY OF PRIOR INJURY

5. PHYSICAL EXAM
 OBSERVATION
 PALPATION
 ACTIVE & PASSIVE
ROM
 STRENGTH TESTING
 SPECIAL TESTS
 NEURO VASCULAR
EXAMINATION

6. OBSERVATION
SYMMETRY OF THE SHOULDER
JOINT DEFORMITY
SKIN CHANGES
MUSCLE ATROPHY
SUPRASPINATUS
INFRASPINATUS
DELTOID
ATROPHY OF THE SUPRASPINATUS AND INFRASPINATUS IS
COMMON WITH MASSIVE ROTATOR CUFF TEARS, ALTHOUGH
IT IS ALSO SEEN IN PATIENTS WITH SUPRASCAPULAR NERVE
COMPRESSION AT THE SUPRASCAPULAR OR SPINOGLENOID
NOTCHES.

7. POSTERIOR OBSERVATION
Posterior Observation of The Patient
Should Begin with Identification of The
Contour of the Trapezius and Deltoid, the
Medial and Inferior Border of The
Scapula, The Supraspinatus and The
Infraspinatus
Winging of the Scapula is Usually
Indicative of a Scapulothoracic
Dysfunction and results in Significant
Shoulder Pain And Dysfunction
Medial Scapula Winging is Far More
Common and Suggests Serratus Anterior
(Long Thoracic Nerve) Dysfunction.
Lateral Winging (Spinal Accessory
Nerve) indicates Trapezius Dysfunction

8. ANTERIOR OBSERVATION
Anterior observation of the patient
should begin with identification of
the sternoclavicular joint.
The AC joint, axillary fold and
assessment for deformity or
asymmetry
Any deformity, swelling or
asymmetry anteriorly could be
indicative of sternoclavicular and
AC joint pathology.

9. LATERAL OBSERVATION
Laterally, look for deltoid
atrophy, which results in
squaring of the shoulder and is
often easily observed.
The posture including
alignment of the head and neck
as well as the relative height
and station of the shoulders.
 Also be noted that cervical
pathology as a referred etiology
for a patient’s shoulder pain

10. PALPATION
Any tenderness, crepitus, muscle tone changes or bone deformities
should be noted
At the sternoclavicular joint, any asymmetry could suggest
subluxation, dislocation and degenerative changes in the joint. Anterior
dislocation of the joint is more common.
Laterally across the clavicles, noting the change from the convex to
concave curvature two-thirds across the length of the clavicles.
Increased prominence, crepitus, pain or motion can indicate a fracture.
At the AC joint, any asymmetry, step-off or tenderness may suggest
injury or arthritis, which are common.
Palpate the biceps tendon by palpating inferior to the anterior tip of the
acromion with the arm in external rotation. Tenderness or snapping of
the tendon suggests tendinitis, subluxation or tearing of the tendon.

11. Palpate the pectoralis major muscle belly medially and palpate its
insertion into the shoulder laterally. Any pain or deformity may be
indicative of muscle rupture or tendinitis.
Posterior palpation should begin with the spine of the scapula,
beginning at the posterior acromion and progressing medially.
The supraspinatus and infraspinatus should be located superior and
inferior to the spine of the scapula, respectively.
 Along the medial border of the scapula, the levator scapulae,
rhomboids and trapezius insertions should be palpated and assessed.
Finally, the inferior angle of the scapula should be palpated and
assessed for winging.
Swelling - may indicate effusion, tumor, nodule or bone changes
Crepitus with movement - occurs in osteoarthritis, tendinopathy and
fracture.

12. RANGE OF MOTION
Assessment of the active and passive ROM of the affected shoulder should
always be compared with the opposite shoulder to determine the normal
ROM for the patient
Perform the examination and stabilize the scapula to accurately assess of
motion
Active ROM always be performed before passive testing because pain
from passive testing may have an impact on the patient’s active ROM.
Pain with loss of passive rom is seen in
 Patients with conditions such as arthritis and adhesive capsulitis.
When there is loss of active rom, the causes can be Secondary to pain,
rotator cuff tear, neurologic lesions and Adhesive capsulitis

13. ACTIVE MOVEMENTS OF THE SHOULDER
COMPLEX ROM
Elevation through abduction 170°-180°
Elevation through forward flexion 160°-180°
Elevation through the plane of the scapula 170°-180°
Lateral (external) rotation 80°-90°
Medial (internal) rotation 60°-100°
Extension 50°-60°
Adduction 50°-75°
Horizontal adduction/abduction (cross-flexion/
cross-extension)
130°
Circumduction 200°

14. DYSFUNCTION - Affecting movements. Which movements are
limited as this can help isolate the problem.
Consider the following if movements are limited by:
Pain: tendinopathy, impingement, sprain/strain, labral pathology
Mechanical block: labral pathology, frozen shoulder
Night pain (lying on affected shoulder): rotator cuff pathology, anterior
shoulder instability, ACJ injury, neoplasm (particularly unremitting)
Sensation of ‘clicking or clunking’: labral pathology, unstable shoulder
(either anterior or multidirectional instability)
Sensation of stiffness or instability: frozen shoulder, anterior or
multidirectional instability

15. MUSCLE STRENGTH
Resistive testing of the shoulder muscles typically includes the
following motions:
Shoulder flexion
Shoulder extension
Shoulder abduction
Horizontal abduction
Horizontal adduction
Internal rotation
External rotation
Resistive testing of the scapular stabilisation muscles may include:
Upper trapezius
Middle trapezius
Lower trapezius
Serratus anterior
Rhomboids
Levator scapulae

16. PHYSICAL EXAMINATION TEST
 Physical examination tests of the shoulder are performed for
diagnosing various shoulder diseases. Sensitivity, specificity and
likelihood Ratios are used to provide data on the diagnostic accuracy of
these tests.
 Sensitivity represents the proportion of actual Positive results
 Specificity represents the proportion of negative results.
 Likelihood ratio (LR) is used to assess the clinical usefulness of a
diagnostic test.
 The sensitivity and the specificity are combined in the LR into a ratio
that Quantifies the probability of the presence or absence of a disease
in a negative or positive test.
 The diagnostic accuracy of physical examination tests is usually
considered Acceptable if LR+ ≥2 or LR− ≤0.50 (25).

18. PROVOCATIVE TESTS
Subacromial impingement test
Subacromial impingement refers to the rotator cuff tendons and bursa being pinched between
the greater tuberosity of the humerus, acromion and coracoacromial ligament with arm
elevation.
Painful arc test
The patient is instructed to elevate the arm in the scapular plane. Provocation of pain between
70° and 120° during elevation yields a positive test.

19. NEER’S IMPINGEMENT TEST
The examiner using one hand to
fix the scapula, while with the
other hand, the patient’s arm is
elevated and internally rotated .
The pain is provoked as the
greater tubercle contacts the
roof of the shoulder joint and
the volume of the subacromial
space is decreased.
The test result is positive if pain
is present around the anterior
shoulder.

20. HAWKINS-KENNEDY IMPINGEMENT
TEST
The patient’s arm and
elbow flexed to 90°. The test
result is positive when there is
pain around the anterior or
lateral shoulder as the examiner
internally rotates the arm. This
test narrows the subacromial
space between the greater
tubercle and the coracoacromial
ligament.

22. PROVOCATIVE TESTS - ROTATOR CUFF
PATHOLOGY
Subscapularis Tests
Internal Rotation Lag Sign
Most sensitive and specific test for subscapularis pathology.
Technique
stand behind patient, flex elbow to 90°, hold shoulder at 20° elevation and
20°extension. Internally rotate shoulder to near maximum holding the wrist by
passively lifting the dorsum of the hand away from the lumbar spine then supporting the
elbow, tell patient to maintain position and release the wrist while looking for a lag.
Increased Passive ER
A person with a subscapularis tear may have increased Passive ER rotation when
compared to contralateral side

23. BELLY PRESS (NAPOLEON SIGN)
Patient presses abdomen with
palm of hand, maintaining
shoulder in internal rotation.
If elbow drops back (does not
remain in front of trunk), the test
is positive for subscapularis
weakness.
More accurate for superior
portion of subscapularis

24. BEAR HUG
Asking patient to grasp the
contralateral Shoulder with
the affected arm in forward
flexion and elbow flexion
across the anterior chest.
 A positive result is inability
to maintain a downward
force as the examiner
Applies resisted pull-off .

25. LIFT OFF TEST (GERBER TEST)
Hand brought around back to region of lumbar spine, palm facing outward; test
patient’s ability to lift hand away from back (internal rotation). Inability to do this
indicates subscapularis pathology.
The lift-off and the belly press tests showed high specificities and LR+, and thus
recommended as confirmatory tests. The belly-off test showed high LR+ (9.67) and
low LR− (0.14), supporting the diagnosis of a subscapularis tear

26. SUPRASPINATUS TESTS
Supraspinatus strength
Jobe’s test
Tests for supraspinatus weakness and/or
impingement
Technique
Abduct arm to 90°, angle forward 30°
(bringing it into the scapular plane), and
internally rotate (thumb pointing to floor).
Then press down on arm while patient
attempts to maintain position testing for
weakness or pain.

27. Drop sign
Tests for function/integrity of
supraspinatus
Technique
Passively elevate arm in scapular
plan to 90°. Then ask the patient to
slowly lower the arm. The test is
positive when weakness or pain
causes them to drop the arm to their
side.
Most specific test for full thickness
rotator cuff tear (specificity 98%)

28. INFRASPINATUS
The external rotation lag sign
The arm positioned in 20° of
flexion and the elbow flexed to
90°. A positive lag sign is marked
when the examiner externally
rotates the arm to its maximum
extent and patient is unable to
maintain the arm in this position .
It was reported to be useful in
detecting a combined full-
thickness tear of the supraspinatus
and infraspinatus with high LR+
(13.36) and low LR− (0.03) (33).

29. TERES MINOR
Teres minor strength
External rotation tested with the arm
held in 90 degrees of abduction
Hornblower's sign (patte test)
The arm is passively abducted with
elbow flexion to 90° with the examiner’s
support.
The patient is asked to rotate the arm
externally. A positive result is the
inability to maintain the position

31. SUPERIOR LABRUM ANTERIOR TO
POSTERIOR LESIONS
O'brien's test
The patient’s arm is flexed to 90° and
slightly adducted with the forearm
pronated and internally rotated, making
the thumb pointing down.
A positive result is pain or weakness
when the examiner applies downward
force on the arm.
The test is continued by externally
rotating the arm with forearm supination,
making the thumb point upwards again,
the examiner applies downward force on
the arm.
If pain is reduced in this position, labral
pathology may be suspected

32. CRANK TEST
The patient lies supine with the arm
elevated to 160° in the scapular plane. An
axial load is applied to the glenohumeral
joint as the humerus is internally and
externally rotated. A positive result is pain
with or without a click.
Both tests are commonly used as
examination tests for slap tears but both
tests showed insufficient evidence to
accurately predict slap lesions with
moderate sensitivities and specificities
across previous studies

33. LESIONS IN THE BICEPS TENDON
 Lesions in the long head of the biceps tendon can cause pain in the
anterior shoulder
Speed's test
 Patient’s shoulder flexed, elbow extended, and forearm supinated .
 The examiner applies a downward force to the arm. If pain is
present along the biceps tendon or within the bicipital groove, the
test result is considered positive.
Yergason's sign
 The patient’s arm adducted in neutral rotation and elbow flexed to
90°. The test result is considered positive if pain is present in the
biceps tendon or bicipital groove with resisted supination,
Popeye sign
 Present when there is a large bump in the area of the biceps
muscle belly. Consistent with long head of biceps proximal tendon
rupture.

35. AC JOINT PATHOLOGY
Crossbody adduction test
The arm and elbow are extended
across. The chest by the examiner. A
positive test result is anterior Shoulder
pain or pain around the AC joint
Obrien's test
In SLAP lesions, the pain is felt deep
inside the shoulder, whereas in AC
joint disorder, pain is felt on top of the
shoulder, on testing with the thumb
pointing downwards.
Acromioclavicular joint tenderness
Tenderness on palpation of the AC
joint, which seems to be the easiest
and the most effective method, was
recommended as a screening test for
AC joint disease as it showed high
sensitivity (96%) and low LR− (0.4)
(31,45).

37. INSTABILITY
Instability is a pathologic process that involves a symptomatic increase in humeral
head translation relative to the glenoid. This leads to pain, impairment of physical
function, and weakness .
when shoulder instability is suspected, the examiner should also look for evidence of
excessive laxity and translation. The beighton score is used to quantify joint laxity
and hypermobility. It is a nine-point scale and its diagnostic thresholds vary from 4 to
6 or above.

38. ANTERIOR/POSTERIOR INSTABILITY
APPREHENSION TEST
 The evaluation of anterior instability is
performed with the apprehension test. The
patient stands or lies supine with the arm in
abduction and elbow flexion to 90°.
 The arm is placed off of the bed as the
examiner applies external rotation force,
stabilizing the scapula the evaluation of
posterior instability is performed with the
shoulder flexed forward to 90°maximally and
internally rotated as the examiner applies a
posteriorly directed force on the patient’s
elbow.
 A positive test is patient’s report of
apprehension or pain

39. JOBE RELOCATION TEST
The patient is positioned supine,
with the elbow flexed to 90 degrees
and abducted to 90 degrees.
The therapist then applies an
external rotation force to the
shoulder, if the patient reports
apprehension in any way, the
apprehension test is considered to be
positive.
At this point, the therapist may
apply a posteriorly directed force to
the shoulder - if the patient's
apprehension or pain is reduced in
this position, the jobe relocation test
is considered to be positive.

40. THE LOAD AND SHIFT TEST
 The patient seated with the hand resting on the thigh, the
examiner’ stabilizes the scapula with one hand and uses
the other hand to push the humeral
 Head into the glenoid, generating the “load”. The
examiner Shifts the humeral head anteriorly and
posteriorly.
 A positive Result is excessive translation or feeling of
apprehension.
 These tests showed high sensitivity (71.7% to 98.3%),
 Specificity (71.6% to 96%), and LR+ (3.46 to 20.22) and
 Low LR− (<0.5), and were useful for diagnosing
shoulder
 Instability (36-38).

41. POSTERIOR DRAWER TEST
The patient lies supine, with the shoulder in 80–
120° abduction, 0–20° flexion, and 0–30° external
rotation.
The Examiner places one hand in the patient’s axilla
with the Fingers around the humerus and the other
hand is placed over the lateral aspect of the upper
arm.
Then the examiner pulls the humerus
anteromedially (anterior Glide) or posterolaterally
(posterior glide).
A positive test is pain, apprehension, and/or
increased ROM. This test was recommended as a
confirmatory test with high specificity and LR+
(37,38).

42. INFERIOR INSTABILITY
• The sulcus sign is evaluated to
detect the presence of inferior
instability of the glenohumeral
joint.
• The examiner applies a
downward force at the elbow
on the patient’s relaxed upper
arm .
• A positive test is a sulcus or a
depression visible between the
lateral edge of the acromion
and the head of the humerus

44. SCAPULOTHORACIC ASSESSMENT
Medial scapular winging
Test for serratus anterior weakness or long
thoracic nerve dysfunction.
Positive if the inferior border of the scapula
migrates medially
Technique
While standing, have the patient forward
flex their arm to 90 degrees and push against
a wall (or other stationary object).
Lateral scapular winging
Test for trapezius weakness or spinal
accessory nerve (CNXI) dysfunction
Positive if the inferior boarder of the
scapula migrates laterally
Technique
While standing, have the patient forward
flex to 90 degrees and push against a wall (or
other stationary object).

45. CERVICAL EXAMINATION
Shoulder pain can be the direct result of cervical
pathology, which can occur in isolation or coexist with
shoulder pathology.
Pain referred from the cervical spine is common and
presents as pain radiating down the shoulder from the
neck.
The cervical spine examination consists of palpation of
the entire cervical spine and assessing for pain or
deformity.
Flexion, extension, rotation, and side bending should be
observed, and any pain or decreased rom should be
noted.
Spurling’s test should also be conducted to test for cervical radiculopathy (cervical
nerve root problem). The patient’s neck is extended and laterally flexed toward the
involved side, and downward axial pressure is applied on the head . the test is
considered positive if radicular pain or a tingling sensation in the involved side upper
extremity.

46. NEUROVASCULAR EXAMINATION
 A comprehensive neurological examination may be
warranted in patients that present with a primary
complaint of shoulder pain. The presence of
neurological symptoms including numbness and
tingling may warrant this examination.
Myotomes
 C4 – shoulder elevation/shrug
 C5 – shoulder abduction
 C6 – elbow flexion, wrist extension
 C7 – elbow extension, wrist flexion
 C8 – thumb abduction/extension
 T1 – finger abduction

47. DERMATOMES
C4 – TOP OF SHOULDERS
C5 – LATERAL DELTOID
C6 – TIP OF THUMB
C7 – DISTAL MIDDLE
FINGER
C8 – DISTAL 5TH FINGER
T1 – MEDIAL FOREARM

48.  DEEP TENDON REFLEXES
 BICEPS BRACHII – C5 NERVE ROOT
 BRACHIORADIALIS – C6 NERVE
ROOT
 TRICEPS – C7 NERVE ROOT

49. VASCULAR ASSESSMENT
Vascular assessment
 Examining the radial and ulnar artery pulses.
Shoulder pain can be referred from neurovascular
compromise, such as in the case of thoracic outlet
syndrome.
Adson’s test
 The physiotherapist monitors the radial pulse while
placing the patient’s arm in an abducted and
externally rotated position with the elbow extended.
 The patient is instructed to extend the neck and
rotate the head to the ipsilateral side while taking a
long, deep breath. Similarly, the test considered is
positive for thoracic outlet syndrome when the
patient’s radial pulse is abolished or the patient’s
symptom is reproduced with the maneuver.

51. OUTCOME MEASURES
Shoulder pain and disability index (SPADI)
Disabilities of the arm shoulder and hand (DASH)
Constant-murley shoulder outcome score (CMS)
University of pennsylvania shoulder score (u-penn)
Visual analogue scale
Patient specific functional scale

52. FLAG SYSTEM IN PHYSIOTHERAPY

53. RED FLAGS
Red flags are sign and symptoms alerting the physiotherapist on a possible presence of
a non-musculoskeletal, life-threatening pathology, fracture, infection, tumor and inflammatory
rheumatic conditions. Examples include
Polymyalgia rheumatica. Often presents as bilateral shoulder pain and weakness. These patients
must be assessed for temporal arteritis.
Acute compartment syndrome may result from significant limb swelling following an injury or
an excessively tight bandage or cast. The pain is disproportionate to the injury. Pulse lessness of
the limb does not usually occur, or is a very late sign. This condition is a surgical emergency
Open fractures
Fractures with nerve or vascular compromise.
Neoplasia
Serious and life threatening conditions that present with symptoms mimicking shoulder pain,
such as referred ischaemic cardiac pain
Left shoulder- -MI 68.7% of patients reported shoulder pain during an acute myocardial
infarction

54. YELLOW FLAGS
To assess for yellow flags, if suspected these tools
may be used
The fear avoidance belief questionnaire (FABQ)
Depression screening tools such as the beck depression inventory
(BDI) or the depression anxiety screening scale (DASS) are
useful in screening patients for depression.
The pain catastrophizing scale, helps determine if the patient is
exaggerating their pain and symptoms and the severity of the
situations as a whole.

55. Fractures
Fractures may result from trauma such as falls onto an outstretched
hand. These are known as FOOSH injuries. Commonly fractured
within the shoulder region are:
Humeral fractures
Clavicle fractures
Clinical picture
Presentation of different shoulder pathologies
Patients with suspected glenohumeral instability or labral
pathology may have feelings of “looseness or instability”
particularly in abducted and externally rotated positions.
Patients with suspected adhesive capsulitis may report intense
global shoulder pain initially combined with a progressive loss of
range of motion.
Patients with suspected subacromial or rotator cuff related
impairment may report feelings of weakness, heaviness and/or
pain.
Shoulder osteoarthritis - progressive, activity-related pain that is
deep in the joint and often localised posteriorly. As the disease
progresses, night pain becomes more common

56.  This flow diagram provides an aid to diagnosis of shoulder conditions

57. CONCLUSION
Shoulder pain is a common musculoskeletal problem and has the
potential to profoundly impact patients’ quality of life. The shoulder
girdle is an intricate group of structures
that work together to allow for the largest ROM in the body.
This complexity makes it difficult to diagnose a patient’s condition(s)
based on history alone. A thorough and methodical physical
examination is the key to arriving at a
correct diagnosis.