This document provides guidance on performing a physical examination of the shoulder, including inspection, palpation, range of motion testing, special tests, and measurements. Key steps outlined include inspecting the shoulder from multiple angles, palpating various bony landmarks and soft tissues, assessing range of motion in different planes, and performing special tests to evaluate for conditions like impingement, rotator cuff tears, labral tears, and instability. Detailed procedures are described for special tests to isolate involvement of specific shoulder structures.

1. Dr (Major) Parthasarathy S
Pg Resident,MS Orthopaedics
Stanley Medical College,Chennai
Ref :Campbell’s operative orthopaedics 13th
edn
A manual on clinical surgery,S Das 12th
edition

2. Inspection
Palpation
Range of Motion
Neurovascular status
Measurements
Special Tests

3.  Patient stripped upto waist
Female strapless dress can be used
 Patient stands/sits
 Inspection done
Front
Side
Back

4.  Position/Attitude of limb
Arm is held by chest,medially rotated/flexed-in shoulder
injury
May be supported by other hand
 Height of shoulder & scapula
 Contour
Flattened
 Wasting
 dislocation
Prominent-not very common
 Bursitis-only below deltoid
 Effusion-may extend beyond deltoid & axilla (due to synovial sac)

5.  Bony arch
Clavicle,Acromion & spine
of scapula
 Suparaspine & infraspine
area for wasting
 echymosis

6.  Deformity
Clavicle #
AC/SC joint disruption
 Axillary folds
Lowered in Ant dislocation

7.  All bones of shoulder girdle should be palpated
Humerus
Clavicle
Scapula
 Cavicle
Standing behind entire length palpated

8.  Humerus
Ascertain normal position
Greater tuberosity
 Not palpable-dislocation
 Tenderness-#/rotator cuff tear
Shaft

9.  Scapula
Acromion process
Coracoid process
 ½ inch below clavicle medial 2/3 & lateral 1/3JN
Spine
Inferior angle
Medial & lateral border

10.  3 bony point relation
Coracoid process
GT
Lateral end of clavicle

11.  Shoulder jt
Just below the coracoid process
 Codman’s method-lt hand for rt shoulder
 Thumb below spine from behind
 Index finger just ant to acromion
 Rest fingers on clavicle
 Rt hand flexes & extends shoulder

12.  Forward flexion:
160 - 180°
 Extension: 40 - 60°
 Abduction: 180◦
 Adduction: 45 °
 External rotation:
80 - 90 °
 Internal rotation:
60 - 90 °

13.  Appley’s scratch test
 Patient attempts to touch the opposite scapula thus testing
abduction & ER and adduction & IR
 Good screening testfor ROM assessment

14.  Axillary nerve
Regimental badge sign
Deltoid
 Brachial plexus
 Peripheral pulses
 Lymph nodes-axillary

15.  Winging of scapula

16.  ARM
 Angle of acromion to lateral epicondyale humerus
 Forearm
 Lateral epicondyle humerus to radius styloid
 Vertical axillary circumference
 Incresed in dislocation
 Arm circumference
 True=as above
 Apparent =from c7 spinous process

17.  Impingement
 Rotator Cuff Integrity
 Labrum and Biceps
 AC (SC) Joints
 Instability

18.  NEER impingement sign & test
 Hawkins kennedy test
 Jobe supraspinatus test
 Internal rotation resistance test
 Gerber subcoracoid impingement test

19.  1972
 Pt seated
 Passive forced forward elevation
 Stabilise scapula
 GT impinges on acromion
 Positive in
Impingement lesions
Sdhesive capsulitis
OA
Calcific tendinitis
Bony lesions

20.  10ml 1% lignocaine subacromial injection
Pain caused by impingement significantly
reduced/eliminated
Pain due to other causes not relieved(except calcific
tendinitis)

21.  1980
 Alternative to Neer test
 Forward flexing to 90degrees
 Then forcibly internally rotate
 GT further driven under the Coracoacromial lig

22.  1983
 90 degrees abduction+ 30 degrees forward flexion
 Internally rotate so that thumb faces floor
The superior portions of the rotator cuff (supraspinatus) are particularly
assessed in internal rotation (with the thumb down), and the
anterior portions in external rotation

23.  Zaslev described
 Differentiate
Internal
Classic outlet impingement
 Pt seated
 Examiner behind
 90 degrees of abd + 80degrees of ER
 Manual isometric muscle test ER & IR
 If a patient with positive impingement sign has good ER
strength & weakness in IR-positive test
 Suggests internal impingement
 Classic outlet impingement –test negative

24.  Identify impingement b/w
Rotator cuff & coracoid
 90 degree forward flexion
 10-20 degrees add
 Lesser tuberosity in contact with coracoid

25.  Park et al
Evaluated impingement tests
 Hawkins kennedy test sign,painful arc sign & jobe test=positive
Means >95% chance of having impingement
Negative=<24% chance of impingement syndrome

27.  Lift off test
 Belly press test
 External rotation stress
test
 External rotation lag sign
 Patte sign
 Drop sign
 Internal rotation lag sign

28.  1991
 Gerber & Krushell
 Isolated rupture of subscapularis tendon
 Dorsum of hand placed against lower back
 Unable to lift hnd off back positive

29.  Gerber et al
 Tested in decreased IR
 Patient presses the abdomen with flat of hand in
maximal internal rotation
 If active IR is srong elbow will be anterior to
belly
 If weak
Patient feels weakness
Exerts pressure by extending shoulder
Elbow falls back
Flexes wrist

30.  ER- Infraspinatus & teres minor
 Shoulder ER from neutral position against resistance

31.  Supra & Infraspinatus
 Passively Elbow 90 degrees flexed +20degrees abduction
 Near maximal ER
 Wrist released and elbow supported
 Lag/angular drop – positive test
 >40 degrees of lag – 100% sensitive &
92% specific

32.  Teres minor
 Passively 90 abd and elbow 90 flexion
 Patient asked to externally rotate
 Weakness/pain –positive test

33.  Infraspinatus
 90 abd + 90 flex at elbow + fully externally rotated
 Examiner releases wrist and holds elbow
 Lag/drop - positive

34.  Subscapularis tendon
 Elbow 90degrees flex+ 20 degree extension+20 degrees
abduction
 Dorsum of palm elevated away from lumbar region
 Wrist released and elbow supported
 Lag-positive

35.  Dynamic labral shear test
O’Driscoll
Supine
Scapula supported by table
Elbow passively 90 degrees flexed-grasps olecranon and distal humerus
Maximum ER
Elbow dropped towards floor
Shoulder is elevated and depressed
Scapula stabilised with rt hand
Palapate for click using rt hand on acromion or left hand on distal humerus
If pain in 90-120 degrees abd arc -positive

37.  Speed test
 Yergason sign
 Popeye sign

38.  1966
 Crenshaw & Kilgore
 Shoulder 90 degrees forward flexion+elbow extended + forearm
supinated
 Flexion elbow against resistance
 Pain localised to bicipital groove-positive

39.  Supination sign
 Elbow 90 flexed+forearm pronated
 Forearm supinated against resistace
 Pain localised to bicipital groove –positive
 May be negative in partial/complete tear of
supraspinatus tendon

41.  PAINFUL ARC
 FORCED ADDUCTION TEST
 DUGA’S TEST

42. o Arm is passively and actively abducted
o Pain in the acromioclavicular joint occurs between 140°and 180°
of abduction
o In an impingement syndrome or a rotator cuff tear- between
70°and 120°.

43.  The 90°-abducted arm on the affected side is forcibly
adducted across the chest toward the normal side
 Pain=positive

44.  The patient is seated or standing and touches the contralateral
shoulder with the hand of the 90°-flexed arm of the affected
side then attempt to lower the elbow to the chest is made
 Pain=positive

45.  Acute
Hamilton ruler test
Duga’s test
Callaway’s test
 Chronic
Shift& load test
Sulcus test
Ant/post apprehension test
Ant/post drawer test
Jobe relocation test

46.  Normally ruler cant touch acromion & lateral epicondyle in
straight line

47.  Patient unable to touch
opposite shoulder with
arm by side of chest

48.  Vertical axillary circumference increased

49.  Scapula stabilised
 Humeral head grasped and compressed
 Amount of ant/post translation observed

50.  Done in 0 and 45 degrees of abd
 The limb pulled distally and sulcus is observed b/w acromion
& humeral head
 The distance is measured which cant be reduced by external
rotation
0=normal
1+=<1cm
2+=1-2cm
3+=>2cm
 Subluxation at 0 degrees-rotator interval laxity
 Subluxation at 45 degreed-inf glenohumeral lig comp laxity

52.  90 abd +elbow 90 flexed
 Progressively ER/IR to see apprehension

53.  Supine
 Using hand ant/post stress applied
to humeral head
 Ant in abd+ER
 Post in abd+IR
 GRADES
0=normal
1=head slips upto glenoid rim
2=slips over the labrum but relocates spontaneously
3=dislocation

54.  Supine + 90 abd+ER
 Ant stress applied-if pain/apprehension
Posteriorely directed force to relocate
Posteriorely directed force
released=apprehension/subluxation means ant
instability