The document outlines the clinical examination process for shoulder pain, instability, and loss of motion, emphasizing the importance of history taking, physical assessment, and various special tests. It details subjective and objective evaluations to identify conditions such as rotator cuff tears, biceps tendon issues, and different forms of shoulder instability. The evaluation strategies include observation, palpation, movement assessments, and various tests to confirm diagnoses and guide treatment for shoulder pathologies.

1. SHOULDER EXAMINATION

2. PAIN INSTABILITY LOSS OF MOTION
EXTRINSIC
OR
INTRINSIC
ACTIVE
OR
PASSIVE
EVALUATION PRINCIPLES
Get a History: Is this a new injury, old chronic
injury
Assessment: what is the primary problem ?

3. Evaluation Order
• History
• Inspection
• Palpation
• Movement : ROM & strength
• Special tests: Rotator cuff disease &impingement
Instability & Laxity, Biceps tendon & SLAP, AC
& SC joint
SEE
FEEL
MOVE

5. Subjective assessment
1. What is the patient’s age?
2. Does the patient support the upper limb in a protected position or hesitate
to move it?
3. If there was an injury, what exactly was the mechanism of injury?
4. Are there any movements or positions that cause the patient pain or
symptoms?
5. What is the extent and behaviour of the patients pain?

6. Subjective assessment
6. are there any activities that cause or increase the pain?
7. do any positions relieve the pain?
8. What is the patient unable to do functionally?
9. How long has the problem bothered the patient?
10. Is there any indication of muscle spasm, deformity, bruising, wasting,
paresthesia or numbness?

7. Subjective assessment
11. Does the patient complain of weakness and heaviness in the limb after
activity?
12. Is there any indication of nerve injury?
13. Which hand is dominant?

8. Observation

9. INSPECTION
Anterior side
Posterior side
Lateral
Overhead
Axillary
Sometimes too obvious

10. Anterior view
 Forward head posture
 Step deformity (AC joint dislocation
 Sulcus sign for shoulder instability

12. Wasting of deltoid muscles

14. Deltoid
Atrophy
Pain at insertion site-
mostly referred from
rotator cuff pathology;
rarely due to deltoid
tendinitis

15. Subacromial
region
Swelling- bursitis
Biceps tendon
Rupture- Popeye bulge

16. Posterior
side
Scapula
• Position
High – Sprengel’s Spine
• Fossae – supraspinatus &
infraspinatus atrophy
• Winging of the scapula

17. Sprengel’s deformity

18. Lennie test

19. Winging of the scapula

20. Scapular winging

21. Lateral: prominent in LD atrophy
Superior: prominent in
Supraspinatus & Trapezius
atrophy
Vertebral; prominent in serratus
ant. weakness/winging
Borders of scapula

22. PALPATION
• Tenderness
• Swelling
• Palpable gap in muscles
Acromioclavicular joint
Coracoid process
Subacromial bursa
Biceps tendon

23. MOVEMENTS
Active
Passive
Resistive

26. FLEXION- 0-
160/180°
- 0-45° 0-180°
FORWARD EXTENSION ABDUCTION-ADDUCTION
- 0-45°
CROSS
BODY
ADDUC
TION

28. EXTERNAL ROTATION- 0-45°

29. INTERNAL ROTATION- 0-55°

31. Shoulder impingement syndrome

33. Reverse scapulohumeral rhythm

35. Internal and external rotation

36. Scapulohumeral rhythm

40. Apley’s scratch test
Patient attempts to touch the opposite scapula thus testing
abduction & ER and adduction & IR
Good screening test for ROM assessment

41. Muscle strength tests
Pectoralis major
Latissimus dorsi
Deltoid

42. Trapezius Serratus anterior
Rhomboids

44. NEUROMUSCULAR EXAMINATION
 Motor examination
 Sensory examination
 Deep tendon reflexes
 Cervical spine
 Spurling test, L-Hermitte sign
Thoracic outlet syndrome
 Adson’s test, Hyperabduction test, Roos test
Brachial Plexus Injury
Brachial Neuritis
Compression Neuropathies

45. SPECIAL TEST
NEUROLOGICAL FUNCTION
• Upper limb neurodynamic test

46. SPECIAL TEST
THORACIC OUTLET SYNDROME
• Roos test (Elevated arm stress test)
• Adson maneuver

47. Axillary nerve injury
 Anaesthesia in the ‘Regimental badge
area’

49. 1. INSTABILITY
2. IMPINGEMENT SYNDROME
3. ROTATOR CUFF TEAR
4. BICEPS TENDON PROBLEMS
5. AC JOINT PROBLEMS
6. STIFF SHOULDER

51. Chronic Instability
Instability can be-
Unidirectional- anterior, posterior, inferior
Multidirectional (MDI) – anterior &/ or
posterior + inferior
TUBS AMBRI
•Traumatic
•Unidirectional
•Bankart’s lesion
•Surgical t/t
•Atraumatic
•Multidirectional
•Bilateral
•Rehabilitation
•Inferior capsular shift

52. CHRONIC UNIDIRECTIONAL INSTABILITY
PROVOCATIVE TESTS
to document the presence
& direction of instability
QUANTITATIVE TESTS
To quantitate the
amount of laxity
Anterior Instability
•Crank test
•Fulcrum test
•Jobe’s relocation test
Posterior Instability
•Jerk test
•Circumduction test
•Drawer tests
•Load & shift test
for both anterior and
posterior instability

53. Anterior shoulder instability
 Anterior apprehension (crank) test
 Anterior drawer test
 Crank and relocation test
 Fulcrum test
 Load and shift test

54. Anterior apprehension crank test

55. Anterior drawer test
 The patient's arm is pulled anteriorly to apply a gliding force to the
glenohumeral joint.
 If an audible click is heard/ felt apprehension during the movement, the glenoid
labrum may be torn, or the joint may be sufficiently lax to allow the humeral
head to glide over the glenoid labrum rim.

56. Anterior drawer test

57. Crank and relocation test
A. Perform the crank test
B. Add fulcrum test
C. If the examiner then applies a posterior translation
stress to the head of the humerus or the arm (relocation
test), the patient commonly loses the apprehension, any
pain that is present commonly decreases, and further
lateral rotation is possible before the apprehension or
pain returns (Fowler sign or test or the Jobe relocation
test)
D. If the arm is released, pain and forward translation
indicates positive test (SLAP /Bankart lesion,

58. Fulcrum test
By placing a hand under the GH
joint
to act as a fulcrum, apprehension
test becomes the fulcrum test

59. LOAD AND SHIFT TEST
Grasp the humeral head
and stabilize the
shoulder. Seat the
humerus on the glenoid
fossa and push
anteriorly and
posteriorly to check for
instability

60. Load and shift test in supine lying

61. POSTERIOR DISLOCATION SHOULDER
 ER restricted
 Prominence in posterior deltoid LIGHT BULB
SIGN

62. Posterior shoulder instability
 Jerk test
 Load and shift test
 Posterior apprehension test
 Push pull test

63. Jerk test
 The patient sits with the arm medially rotated and forward flexed to 90°.
 The examiner grasps the patient’s elbow and axially loads the humerus in a
proximal direction.
 While maintaining the axial loading, the examiner moves the arm horizontally
(crossflexion/horizontal adduction) across the body
 A positive test for recurrent posterior instability is the production of a sudden
jerk or clunk as the humeral head slides off (subluxes) the back of the glenoid

64. Jerk test

65. Load and shift test for posterior instability

66. Posterior apprehension test
 The patient is in a supine lying or sitting position. The examiner elevates the
patient’s shoulder in the plane of the scapula to 90° while stabilizing the
scapula with the other hand.
 The examiner then applies a posterior force on the patient’s elbow.
 While applying the axial load, the examiner horizontally adducts and medially
rotates the arm.
 A positive result is indicated by a look of apprehension or alarm on the
patient’s face

67. Circumduction test
 Pt standing, examiner standing
behind & holds the arm in
extension & abduction; performs
circumduction
 Visible subluxation/ apprehension
in position of foreward flexion 160°
& adduction (position of risk)
 = instability

68. Push pull test
• The patient lies supine.
• The examiner holds the patient’s arm at the
wrist, abducts the arm 90°, and forward flexes
it 30°.
• The examiner places the other hand over the
humerus close to the humeral head.
• The examiner then pulls up on the arm at the
wrist while pushing down on the humerus with
the other hand
• Normally, 50% posterior translation can be
accomplished.
• If more than 50% posterior translation occurs
or if the patient becomes apprehensive or pain
results, the examiner should suspect posterior

69. Inferior and multidirectional shoulder
instability
 Sulcus sign
 Feagin test

70. Sulcus sign
• The patient stands with the arm by the side and
shoulder muscles relaxed.
• The examiner grasps the patient’s forearm
below the elbow and pulls the arm distally
• The presence of a sulcus sign indicate inferior
instability or glenohumeral laxity but should
only be considered positive for instability if the
patient is symptomatic (e.g., pain/ache on
activity)

71. The Feagin test
 arm abducted to 90° and the examiner pushes the humerus down
and forward
 the examiner holds the patient’s arm at the elbow (elbow straight)
abducted to 90° with one hand and arm holding the arm against the
examiner’s body.
 The other hand is placed just lateral to the acromion over the
humeral head. Ensuring the shoulder musculature is relaxed, the
examiner pushes forward and downward
 Positive signs are apprehension on the patient’s face and sulcus

73. Anterior impingement test
Hawkins kennedy test
Neer’s test
Yokum test

74. posterior impingement test
Posterior internal impingement test

75. Labral lesions
 Active compression test of O’brien

76. Hawkins-Kennedy Test
 patient sitting with arm at 90° forward
elevation and elbow flexed to 90°.
 Examiner then quickly moves the
arm into internal rotation.
 +ve = Pain located to the sub-acromial
space, Subacromial impingement, rotator
cuff tendinitis
 involves horizontally adducting the arm
across the body 10° to 20° before doing
the medial rotation (corocoid impingement
test)

77. Yocum test

78. Neer Impingement test
 Examiner performs maximal passive forward
flexion with internal rotation whilst stabilizing
the scapula.
 + = Pain located to the sub- acromial space
or anterior edge of acromion
 Subacromial impingement of supraspinatius &
anterior part of infraspinatus

79. Posterior internal impingement test
• To perform the test, the patient
is placed in the supine lying
position.
• The examiner passively abducts
the shoulder to 90° to 110°, with
15° to 20° extension and
maximum lateral rotation
• The test is considered positive if
it elicits localized pain in the
posterior shoulder.

80. LABRAL TEARS
 A Bankart lesion occurs most commonly with a traumatic anterior dislocation leading to anterior
instability
 Injury results in the labrum being detached anywhere from the 3 o’clock to the 7 o’clock position
resulting in both anterior and posterior structural injury
 the stability of the inferior glenohumeral ligament is lost.
 The SLAP lesion has the labrum detaching (pulled or peeled depending on the mechanism) from the 10
o’clock to the 2 o’clock position
 Results from a FOOSH injury, occurs during deceleration when throwing, or arises when sudden traction
is applied to the biceps
 the support of the superior glenohumeral ligament is lost.

81. Bankart lesions

82. SLAP LESIONS

83. Mechanism of injury for SLAP lesions

84. • The patient flexes the arm to 90° with the
elbow fully extended and then adducts the
arm 10-15° medial to sagittal plane.
• The arm is then maximally internally
rotated and externally rotate the patient
• resists the examiner's downward force.
• Pain on the joint line or painful clicking is
produced in the first part of the test and
decreased in the second part, the test is
positive
O’Brien test

85. CLUNK TEST
• The patient lies supine.
• The examiner places one hand on the posterior aspect of
the shoulder over the humeral head.
• The examiner’s other hand holds the humerus above the
elbow.
• The examiner fully abducts the arm over the patient’s
head.
• The examiner then pushes anteriorly with the hand over
the humeral head (a fist may be used to apply more
anterior pressure) while the other hand rotates the
humerus into lateral rotation
• A clunk or grinding sound indicates both a positive test
and a tear of the labrum.
• The test may also cause apprehension if anterior

87. • Empty can test and drop arm test - Supraspinatus
• Dropping sign, Infraspinatus test and Lateral
rotation lag sign - Infraspinatus
• Hornblower’s sign – Teres minor
• Lift off test/ abdominal compression test
/bear hug test – Subscapularis
• Speed test / Yergason’s test- Biceps
Rotator cuff tears

88. SUPRASPINATUS TEST

89. Supraspinatus “Empty Can Test”
 Pt attempts to elevate the arms against resistance with
arms at 90° abduction in a plane 30° anterior true coronal
plane and full IR (thumb pointing downward) with elbows
extended.
 Positive = supraspinatus tear

90. Drop Arm test
 Examiner abducts patient’s shoulder to
maximum. After warning the patient,
examiner releases pt’s arm & asks him
to lower the arm back to the side
 Pt able to lower the arm part way &
then suddenly loses control- arm drops
suddenly to the side
 Indicates large rotator cuff tear Also
seen in axillary nerve palsy

91. INFRASPINATUS AND TERES MINOR
TEST

92. Dropping sign
• The patient stands with the test arm by the side.
• The examiner stands by the test side and passively places the
patient’s elbow in 90° flexion with the arm in 45° lateral
rotation.
• The patient is then asked to isometrically laterally rotate the
arm against resistance and then relax.
• If the patient is not able to maintain the laterally rotated
position and the arm drops back to the neutral position - positive
for an infraspinatus tear.

93. Lateral rotation lag sign
• The patient is seated or in standing
position with the arm by the side and
the elbow flexed to 90°
• The examiner passively abducts the
arm to 90° in the scapular plane,
laterally rotates the shoulder to end
range and asks the patient to hold it
• For a positive test, the patient cannot
hold the position and the hand springs
back anteriorly toward midline,
indicating infraspinatus and teres minor
cannot hold the position due to
weakness or pain

94. Hornblower’s sign
 The examiner elevates the patient’s arm
to 90° in the scapular plane (scaption).
 The examiner then flexes the elbow to
90°, and the patient is asked to laterally
rotate the shoulder against resistance.
 A positive test is indicated when the
patient is unable to laterally rotate the
arm and indicates a tear of teres minor.
 The patient is standing with the arms by
the side and then is asked to bring the
hands to the mouth.
 With a massive posterior rotator cuff
tear, the patient is unable to do this
without abducting the arm first
 This abduction with hands to the mouth
is called hornblower’s sign.

95. Subscapularis test

96.  1. “Lift off test/ Gerber’s test”
 Patient standing with hand behind back with the
dorsum of the hand resting on the back. The hand is
raised off the back by maintaining or increasing
internal rotation of the humerus and extension at the
shoulder.
 Full passive internal rotation is prerequisite.
 Inability = subscapularis tear/ dysfunction

97. 2. Abdominal compression test
• Patient attempts to press the hand
down against abdomen with
examiner preventing it.
• Useful when IR restricted.
• Inability = subscapularis tear/
dysfunction

98. 3. Bear hug test
• The patient stands with the hand of the test
shoulder on top of the other shoulder with the
fingers extended and the elbow in front of the
body
• The examiner stands in front of the patient and
tries to lift the hand away from the shoulder
applying a perpendicular lateral rotation force
while the patient resists the movement
• The examiner’s other hand stabilizes the patient’s
elbow
• If the patient cannot hold the hand on top of the
shoulder because of weakness, it is considered a
positive test for subscapularis strain

100. • The patient's elbow is flexed and their
forearm pronated. The examiner holds
their arm at the wrist.
• Patient actively supinates against
resistance.
• Pain located to bicipital groove = +ve
Yergasson’s test

101. Speed’s test
The patient's elbow is extended, forearm
supinated and the humerus elevated to 60°
The examiner resists humeral forward flexion
Pain located to bicipital groove = +ve

105. AC crossover
 Pt. elevates the affected arm to
90°, then actively adducts it
 If the patient feels localized pain over the AC joint, the test
is positive

107. Crank test for different ligaments

108. • Restriction of all range of motion, esp-
Abduction & ER
• Pain on attempted movements
Adhesive capsulitis

109. Note –
ER restriction occurs in 2 conditions only
1. Stiff shoulder
2.Posterior dislocation Overhead athletes may
have
restriction of IR due to posterior capsular tightness

112. Conclusion
Clinical examination of shoulder should
be guided according to patient's age,
chief complains and professional
activities.
All tests needn’t be performed to clinch
the diagnosis.
Merely knowledge of test is not enough,
good practice is essential to perform the
tests.