This document provides an overview of the anatomy, differential diagnosis, clinical history, and physical examination of the shoulder. It reviews the pertinent bones, joints, muscles, nerves and bursae of the shoulder. Common shoulder injuries are discussed such as impingement syndrome, rotator cuff tears, biceps tendonitis, AC joint injuries, instability and labral tears. The physical exam section describes techniques for inspection, palpation, range of motion testing, strength testing and special tests used to evaluate the shoulder.

1. History & Physical Examination
of the Shoulder

2. Objectives
l Review pertinent anatomy of the
shoulder
l Review differential diagnosis of
shoulder complaints
l Review clinical history and physical
examination of the shoulder
l Review common shoulder injuries &
characteristic physical exam findings

3. Brief Epidemiology
l Shoulder pain: a common complaint
in primary care
– 2nd only to knee pain for specialist
referrals
– Most common causes in adults (peak
ages 40-60)
• Subacromial impingement syndrome
• Rotator cuff problems
l Athletic injuries
– Shoulder: 8-13% of all athletic injuries

4. Anatomy
l 3 Bones
– Humerus
– Scapula
– Clavicle
l 3 Joints
– Glenohumeral
– Acromioclavicular
– Sternoclavicular
l 1 “Articulation”
– Scapulothoracic

5. Anatomy
l Humerus
– Head *
– Greater tubercle*
– Lesser tubercle*
– Intertubercular (bicipital) groove
– Deltoid tuberosity
l Scapula
– Angles
• Superior
• Inferior
• Lateral (Head)

6. Anatomy
l Scapula
– Glenoid
– Acromion
– Coracoid
– Subscapular fossa
– Scapular spine
– Supraspinatus fossa
– Infraspinatus fossa

7. Anatomy
l Glenohumeral joint
– “Ball and socket” vs “Golf
ball and tee”
– Very mobile
– Price: instability
– 45% of all dislocations
– Joint stability depends on
multiple factors

8. Anatomy
l Glenohumeral joint
– Passive stability
• Joint conformity
• Glenoid labrum (50%)
• Joint capsule
• Ligaments
• Bony restraints

9. Anatomy
l Muscles
– Deltoid
– Trapezius *
– Rhomboids *
– Levator scapulae *
– Rotator cuff
– Teres major
– Biceps
– Pectoralis muscles *
– Serratus anterior *
* Scapular stabilizers

10. Anatomy
l Rotator Cuff Muscles
– S – Supraspinatus
– I – Infraspinatus
– t - Teres minor
– S- Supscapularis

11. Anatomy
l Bursae
– Subacromial
(Subdeltoid)
– Subscapular

12. Anatomy
l Neurologic
– Nerve roots
– Brachial plexus
– Peripheral nerves

13. Anatomy
l Coordinated shoulder motion
– Glenohumeral motion
– Acromioclavicular motion
– Sternoclavicular motion
– Scapulothoracic motion
Scapular-humeral rhythm

14. Differential Diagnosis
l Impingement syndrome
– Subacromial bursitis
– Rotator cuff tendinopathy
– Rotator cuff tear
– Biceps tendinopathy
l Adhesive capsulitis
l SC joint arthritis, sprain
l AC joint arthritis, sprain
l Glenohumeral joint OA
l Instablity
– GH dislocation
– GH subluxation
– Labral tear (e.g. Bankart, SLAP, etc.)
l Clavicle fracture
l Proximal humerus fracture
l Scapular fracture
l Other arthritic disease
– Rheumatoid, Gout, SLE
– Septic, Lyme, etc.
l Avascular necrosis
l Neoplastic disease
l Thoracic outlet syndrome
l CRPS
l Myofascial pain
l Referred pain
– Cervical radiculopathy
– Cardiac
– Aortic aneurysm
– Abdominal / Diaphragm
– Other GI

15. Clinical History
l Characterize pain
l Location of pain
l Night pain
l Weakness
l Deformity
l Instability
l Locking / Clicking / Clunking
l Sport / Occupation
l Previous treatments
l Alleviating / Exacerbating
l Acute vs. Chronic
l Traumatic vs. Overuse
l History of prior injury

16. Clinical History
l Mechanism of Injury

17. Physical Exam
l Observation
– Undress waist → up
l Palpation
l Active & passive ROM
l Strength testing
l Special tests

18. Physical Exam – Observation /
Inspection
l Front & Back
l Height of shoulder &
scapulae
l Asymmetry
l Obvious deformity
l Ecchymosis
l Muscle atrophy
– Supraspinatus
– Infraspinatus
– Deltoid

19. Palpation
l At rest & with movement
l Bony structures
l Joints
l Soft tissues

20. Palpation
l Surface Anatomy (Anterior)
– Clavicle
– SC Joint
– Acromion process
– AC Joint
– Deltoid
– Coracoid process
– Pectoralis major
– Trapezius
– Biceps (long head)
AC joint
SC joint
biceps

21. Palpation
l Surface Anatomy (Posterior)
– Scapular spine
– Acromion process
– Supraspinatus
– Infraspinatus
– Deltoid
– Trapezius
– Latissumus dorsi
– Scapula
• Inferior angle
• Medial border
Supraspinatus
Infraspinatus
Inferior angle
of scapula

22. Range of Motion
l Forward flexion:
– 160 – 180°
l Extension:
– 40 - 60°
l Abduction:
– 180◦
l Adduction:
– 45 °
l Internal rotation:
– 60 - 90 °
l External rotation:
– 80 - 90 °
Apley Scratch Test

23. Range of Motion
l Scapular dyskinesis (Scapulothoracic
dysfuntion)
– Compare scapular motion through
ROM on both sides
– Wall push-ups
– Symmetrical
– Smooth
– No or minimal winging

24. Strength Testing
l Test & compare both sides
l Be specific to muscle or muscle group
l Grade strength on 0 → 5 scale
– 0: no contraction
– 1: muscle flicker; no movement
– 2: motion, but not against gravity
– 3: motion against gravity, but not resistance
– 4: motion against resistance
– 5: normal strength

25. Strength Testing
l External rotation
– Tests RTC muscles that ER the
shoulder
• Infraspinatus
• Teres minor
– Arms at the sides
– Elbows flexed to 90 degrees
– Externally rotates arms
against resistance

26. Strength Testing
l Internal rotation
– Tests RTC muscle that IR the
shoulder
• Subscapularis
– Arms at the sides
– Elbows flexed to 90 degrees
– Internally rotates arms
against resistance
– Subscapularis Lift-Off Test
– Other techniques

27. Strength Testing
l Supraspinatus
– “Empty can" test
– Jobe’s Test
– Tests Supraspinatus
– Attempt to isolate from
deltoid
– Positioned sitting
– Arms straight out
– Elbows locked straight
– Thumbs down
– Arm at 30 degrees
(in scapular plane)
– Attempts to elevate arms
against resistance

28. Special Provocative Tests
l Impingement Signs
l Drop-Arm Test
l Speed’s Test
l Yergason Test
l Cross-Arm Adduction
l Sulcus Sign
l Apprehension test
l Relocation test
l O’Brien’s Test
l Crank test

29. Subacromial Impingement Syndrome
l Impingement of:
– Subacromial bursa
– Rotator cuff muscles and
tendons
– Biceps tendon
l Between
– Acromion
– Coracoacromial ligament
– AC joint
– Coracoid process
– Humeral head
l Rotator cuff tendonosis

30. Impingement Signs
l Neer’s Sign
– Arm fully pronated and
placed in forced flexion
– Trying to impinge
subacromial structures
with humeral head
– Pain is positive test

31. Impingement Signs
l Hawkin’s Sign
– Arm is forward elevated
to 90 degrees, then
forcibly internally
rotated
– Trying to impinge
subacromial structures
with humeral head
– Pain is positive test

32. Rotator Cuff Tear
l Partial thickness tear
l Full (Complete) thickness
tear
l May be due to:
– Impingement
– Degeneration
– Overuse
– Trauma
l Partial tears
– Conservative
l Complete tears
– Surgery

33. Rotator Cuff Tear: Drop-Arm Test
l Abducted arm slowly lowered
– May be able to lower arm slowly
to 90° (deltoid function)
– Arm will then drop to side if
rotator cuff tear
l Positive test
– patient unable to lower arm
further with control
– If able to hold at 90º, pressure on
wrist will cause arm to fall

34. Biceps Tendonosis
l Injury to long head of
biceps tendon
l Typically an overuse
injury
– Repetitive (overhead)
lifting
– Impingement

35. Biceps Tendonosis: Speed’s Test
l Forward flex shoulder to
about 90°
l Abduct shoulder to about
10°
l Arm in full supination
l Apply downward force to
distal arm
l Pain is positive test
l Weakness without pain:
muscle weakness or rupture

36. Biceps Tendonosis: Yergason’s Test
l Elbow flexed to 90°
l Start in pronated position
l Active supination & flexion
against resistance
l Palpate biceps tendon
l Pain or painful pop is
positive test
– Tendonosis
– Subluxation

37. AC Separation
AC Sprain /
Separation
– Typically due to
fall onto tip of
shoulder
(acromion)
– Arm tucked into
side
– Treatment
depends on type

38. AC Separation
l AC Sprain / Separation
– Typically due to fall
onto tip of shoulder
(acromion)
– Arm tucked into side
– Treatment depends on
type

39. AC Arthritis / DJD

40. AC Joint: Cross-Arm Adduction Test
l Arm flexed to 90°
l Arm adducted to > 45°
l Hyperadduct shoulder
(down on elbow)
l Positive test is pain in AC
joint
l Watch out for false-
positives
– Where is the pain?

41. Shoulder Instability
l Failure to keep humeral
head centered in glenoid
l Dislocation
– Complete disruption of joint
congruity or alignment
l Subluxation
– Partial or incomplete
dislocation
l Laxity
– Slackness or looseness in joint
– May be normal or abnormal

42. Instability: Sulcus Sign
l Inferior instability
l Arm relaxed in neutral
position
l Arm pulled downward
at wrist
l Positive test is a visible
sulcus at infra-acromial
area
– Compare to
contralateral side

43. Instability: Apprehension Test
l Anterior instability
l Shoulder abducted to 90°
l Slight stress to humeral
head directed in anterior
direction
l While externally rotating
shoulder
l Positive test is
apprehension due to feeling
of instability or impending
dislocation
– Beware if false positives

44. Instability: Relocation Test
l Anterior instability
l After a positive
apprehension
l Apply posteriorly directed
force over externally
rotated humeral head
l Positive test is relief of
apprehension
l Anterior release test

45. Glenoid Labral Tear
l Tear in glenoid labrum
l Usually due to instability
l SLAP Tear (Superior Labrum
Anterior to Posterior)
– Superior labral tear
– Fall on outstretched hand or
shoulder
– Rotator cuff tendonosis or
tears
l Bankart Lesion
– Anterior-inferior labral tear
– Anterior shoulder dislocation
/ subluxation

46. O’Brien’s Active Compression Test
l Labral, AC, or biceps pathology
l Arm flexed to 90°
l Arm cross-arm adducted 10-
15°
l Elbow extended
l Max pronation
l Resist downward force
l Positive test if painful
l Beware location of pain
– AC
– Biceps
– Internal +/- click

47. O’Brien’s Active Compression Test
l For labral pathology
– Repeat testing with
– Max supination
– Should be pain free

48. Labral Tear: Crank Test
l Abduct arm to 90-120°
l Stabilize shoulder
l Elbow secured with one
hand
l Axially load with ER / IR at
shoulder
l Positive test: audible or
painful click / catch /
grind

49. Diagnostic Injection
l AC joint
l Subacromial space
l Glenohumeral joint
l Biceps tendon (long head)