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The Painful Shoulder: Part I. Clinical Evaluation

THOMAS W. WOODWARD, M.D., and THOMAS M. BEST, M.D., PH.D., University of Wisconsin Medical School, Madison, Wisconsin
Am Fam Physician. 2000 May 15;61(10):3079-3088.

This is Part I of a two-part article on clinical evaluation of the painful shoulder. Part II, “Acute and Chronic Injuries,” (https://www.aafp.org/afp/2000/0601/p3291.html) will
appear in the next issue of AFP.

Family physicians need to understand diagnostic and treatment strategies for common causes of shoulder pain. We review key elements of the history and
physical examination and describe maneuvers that can be used to reach an appropriate diagnosis. Examination of the shoulder should include inspection,
palpation, evaluation of range of motion and provocative testing. In addition, a thorough sensorimotor examination of the upper extremity should be
performed, and the neck and elbow should be evaluated.

Shoulder pain is a common complaint in family practice patients. The unique anatomy and range of motion of the glenohumeral joint can present a diagnostic
challenge, but a proper clinical evaluation usually discloses the cause of the pain.

Anatomy
The shoulder is composed of the humerus, glenoid, scapula, acromion, clavicle and surrounding soft tissue structures. The shoulder region includes the glenohumeral
joint, the acromioclavicular joint, the sternoclavicular joint and the scapulothoracic articulation (Figure 1a). The glenohumeral joint capsule consists of a fibrous capsule,
ligaments and the glenoid labrum. Because of its lack of bony stability, the glenohumeral joint is the most commonly dislocated major joint in the body. Glenohumeral
stability is due to a combination of ligamentous and capsular constraints, surrounding musculature and the glenoid labrum. Static joint stability is provided by the joint
surfaces and the capsulolabral complex, and dynamic stability by the rotator cuff muscles and the scapular rotators (trapezius, serratus anterior, rhomboids and levator
scapulae).

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FIGURE 1A.

Anatomy of the shoulder girdle.

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The rotator cuff is composed of four muscles: the supraspinatus, infraspinatus, teres minor and subscapularis (Figure 1b). The subscapularis facilitates internal
rotation, and the infraspinatus and teres minor muscles assist in external rotation. The rotator cuff muscles depress the humeral head against the glenoid. With a poorly
functioning (torn) rotator cuff, the humeral head can migrate upward within the joint because of an opposed action of the deltoid muscle.

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FIGURE 1B.

The muscles of the rotator cuff.

Scapular stability collectively involves the trapezius, serratus anterior and rhomboid muscles. The levator scapular and upper trapezius muscles support posture; the
trapezius and the serratus anterior muscles help rotate the scapula upward, and the trapezius and the rhomboids aid scapular retraction.

History
A complete history begins with the patient's age, dominant hand and sport or work activity. It is important to assess whether the injury prevents or hampers normal work
activities, hobbies and sports. The patient should be asked about shoulder pain, instability, stiffness, locking, catching and swelling. Stiffness or loss of motion may be
the major symptom in patients with adhesive capsulitis (frozen shoulder), dislocation or glenohumeral joint arthritis. Pain with throwing (such as pitching a baseball)
suggests anterior glenohumeral instability. Patients who complain of generalized joint laxity often have multidirectional glenohumeral instability.

Distinguishing between an acute and a chronic problem is diagnostically helpful (Table 1). For example, a history of acute trauma to the shoulder with the arm
abducted and externally rotated strongly suggests shoulder subluxation or dislocation and possible glenoid labral injury. In contrast, chronic pain and loss of passive
range of motion suggest frozen shoulder or tears of the rotator cuff.

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TABLE 1
Key Findings in the History and Physical Examination
FINDING PROBABLE DIAGNOSIS

Scapular winging, trauma, recent viral illness Serratus anterior or trapezius dysfunction

Seizure and inability to passively or actively rotate affected arm externally Posterior shoulder dislocation

Supraspinatus/infraspinatus wasting Rotator cuff tear; suprascapular nerve entrapment

Pain radiating below elbow; decreased cervical range of motion Cervical disc disease

Shoulder pain in throwing athletes; anterior glenohumeral joint pain and impingement Glenohumeral joint instability

Pain or “clunking” sound with overhead motion Labral disorder

Nighttime shoulder pain Impingement

Generalized ligamentous laxity Multidirectional instability

Once the location, quality, radiation, and aggravating and relieving factors of the shoulder pain have been established, the possibility of referred pain should be
excluded. Neck pain and pain that radiates below the elbow are often subtle signs of a cervical spine disorder that is mistaken for a shoulder problem.

The patient should be asked about paresthesias and muscle weakness. Pneumonia, cardiac ischemia and peptic ulcer disease can present with shoulder pain. A
history of malignancy raises the possibility of metastatic disease. The patient should be asked about previous corticosteroid injections, particularly in the setting of
osteopenia or rotator cuff tendon atrophy.

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Physical Examination
A complete physical examination includes inspection and palpation, assessment of range of motion and strength, and provocative shoulder testing for possible
impingement syndrome and glenohumeral instability. The neck and the elbow should also be examined to exclude the possibility that the shoulder pain is referred from
a pathologic condition in either of these regions.

INSPECTION
The physical examination includes observing the way the patient moves and carries the shoulder. The patient should be properly disrobed to permit complete
inspection of both shoulders. Swelling, asymmetry, muscle atrophy, scars, ecchymosis and any venous distention should be noted. Deformity, such as squaring of the
shoulder that occurs with anterior dislocation, can immediately suggest a diagnosis. Scapular “winging,” which can be associated with shoulder instability and serratus
anterior or trapezius dysfunction, should be noted. Atrophy of the supraspinatus or infraspinatus should prompt a further work-up for such conditions as rotator cuff
tear, suprascapular nerve entrapment or neuropathy.

PALPATION
Palpation should include examination of the acromioclavicular and sternoclavicular joints, the cervical spine and the biceps tendon. The anterior glenohumeral joint,
coracoid process, acromion and scapula should also be palpated for any tenderness and deformity.

RANGE-OF-MOTION TESTING
Because the complex series of articulations of the shoulder allows a wide range of motion, the affected extremity should be compared with the unaffected side to
determine the patient's normal range. Active and passive ranges should be assessed. For example, a patient with loss of active motion alone is more likely to have
weakness of the affected muscles than joint disease.

Shoulder abduction involves the glenohumeral joint and the scapulothoracic articulation. Glenohumeral motion can be isolated by holding the patient's scapula with one
hand while the patient abducts the arm. The first 20 to 30 degrees of abduction should not require scapulothoracic motion. With the arm internally rotated (palm down),
abduction continues to 120 degrees. Beyond 120 degrees, full abduction is possible only when the humerus is externally rotated (palm up).

The Apley scratch test is another useful maneuver to assess shoulder range of motion (Figure 2). In this test, abduction and external rotation are measured by having
the patient reach behind the head and touch the superior aspect of the opposite scapula. Conversely, internal rotation and adduction of the shoulder are tested by
having the patient reach behind the back and touch the inferior aspect of the opposite scapula. External rotation should be measured with the patient's arms at the side
and elbows flexed to 90 degrees.

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FIGURE 2.

Apley scratch test. The patient attempts to touch the opposite scapula to test range of motion of the shoulder. (Left) Testing abduction and external rotation. (Right) Testing adduction and
internal rotation.

EVALUATING THE ROTATOR CUFF

In evaluating the rotator cuff, the patient's affected extremity should always be compared with the unaffected side to detect subtle differences in strength and motion. A
key finding, particularly with rotator cuff problems, is pain accompanied by weakness. True weakness should be distinguished from weakness that is due to pain. A
patient with subacromial bursitis with a tear of the rotator cuff often has objective rotator cuff weakness caused by pain when the arm is positioned in the arc of
impingement. Conversely, the patient will have normal strength if the arm is not tested in abduction.1

The supraspinatus can be tested by having the patient abduct the shoulders to 90 degrees in forward flexion with the thumbs pointing downward. The patient then
attempts to elevate the arms against examiner resistance (Figure 3). This is often referred to as the “empty can” test.

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FIGURE 3.

Supraspinatus examination (“empty can” test). The patient attempts to elevate the arms against resistance while the elbows are extended, the arms are abducted and the thumbs are
pointing downward.

Next, with the patient's arms at the sides, the patient flexes both elbows to 90 degrees while the examiner provides resistance against external rotation (Figure 4). This
maneuver is used to evaluate the function of the infraspinatus and teres minor muscles, which are mainly responsible for external rotation.

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FIGURE 4.

Infraspinatus/teres minor examination. The patient attempts to externally rotate the arms against resistance while the arms are at the sides and the elbows are flexed to 90 degrees.

Subscapularis function is assessed with the lift-off test. The patient rests the dorsum of the hand on the back in the lumbar area. Inability to move the hand off the back
by further internal rotation of the arm suggests injury to the subscapularis muscle.2 In one study, the investigators noted that only a few of the patients with confirmed
subscapularis ruptures actually demonstrated a positive result on the lift-off test; the remainder could not complete the test because of pain.3

A modified version of the lift-off test is useful in a patient who cannot place the hand behind the back. In this version, the patient places the hand of the affected arm on
the abdomen and resists the examiner's attempts to externally rotate the arm.

Provocative Testing
Provocative tests provide a more focused evaluation for specific problems and are typically performed after the history and general examination have been completed
(Table 2).

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TABLE 2
Tests Used in Shoulder Evaluation and Significance of Positive Findings
TEST MANEUVER DIAGNOSIS SUGGESTED BY POSITIVE RESULT

Apley scratch test Patient touches superior and inferior aspects of opposite scapula Loss of range of motion: rotator cuff problem

Neer's sign Arm in full flexion Subacromial impingement

Hawkins' test Forward flexion of the shoulder to 90 degrees and internal rotation Supraspinatus tendon impingement

Drop-arm test Arm lowered slowly to waist Rotator cuff tear

Cross-arm test Forward elevation to 90 degrees and active adduction Acromioclavicular joint arthritis

Spurling's test Spine extended with head rotated to affected shoulder while axially loaded Cervical nerve root disorder

Apprehension test Anterior pressure on the humerus with external rotation Anterior glenohumeral instability

Relocation test Posterior force on humerus while externally rotating the arm Anterior glenohumeral instability

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TEST MANEUVER DIAGNOSIS SUGGESTED BY POSITIVE RESULT

Sulcus sign Pulling downward on elbow or wrist Inferior glenohumeral instability

Yergason test Elbow flexed to 90 degrees with forearm pronated Biceps tendon instability or tendonitis

Speed's maneuver Elbow flexed 20 to 30 degrees and forearm supinated Biceps tendon instability or tendonitis

NEER'S TEST
Neer's impingement sign is elicited when the patient's rotator cuff tendons are pinched under the coracoacromial arch. The test4 is performed by placing the arm in
forced flexion with the arm fully pronated (Figure 5). The scapula should be stabilized during the maneuver to prevent scapulothoracic motion. Pain with this maneuver
is a sign of subacromial impingement.

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FIGURE 5.

Neer's test for impingement of the rotator cuff tendons under the coracoacromial arch. The arm is fully pronated and placed in forced flexion.

HAWKINS' TEST
The Hawkins' test is another commonly performed assessment of impingement.5 It is performed by elevating the patient's arm forward to 90 degrees while forcibly
internally rotating the shoulder (Figure 6). Pain with this maneuver suggests subacromial impingement or rotator cuff tendonitis. One study6 found Hawkins' test more
sensitive for impingement than Neer's test.

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FIGURE 6.

Hawkins' test for subacromial impingement or rotator cuff tendonitis. The arm is forward elevated to 90 degrees, then forcibly internally rotated.

DROP-ARM TEST
A possible rotator cuff tear can be evaluated with the drop-arm test. This test is performed by passively abducting the patient's shoulder, then observing as the patient
slowly lowers the arm to the waist. Often, the arm will drop to the side if the patient has a rotator cuff tear or supraspinatus dysfunction. The patient may be able to
lower the arm slowly to 90 degrees (because this is a function mostly of the deltoid muscle) but will be unable to continue the maneuver as far as the waist.

CROSS-ARM TEST
Patients with acromioclavicular joint dysfunction often have shoulder pain that is mistaken for impingement syndrome. The cross-arm test isolates the acromioclavicular
joint. The patient raises the affected arm to 90 degrees. Active adduction of the arm forces the acromion into the distal end of the clavicle (Figure 7). Pain in the area of
the acromioclavicular joint suggests a disorder in this region.

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FIGURE 7.

Cross-arm test for acromioclavicular joint disorder. The patient elevates the affected arm to 90 degrees, then actively adducts it.

Instability Testing
The tests described in this section are useful in evaluating for glenohumeral joint stability. Because the shoulder is normally the most unstable joint in the body, it can
demonstrate significant glenohumeral translation (motion). Again, the uninvolved extremity should be examined for comparison with the affected side.7,8

APPREHENSION TEST
The anterior apprehension test is performed with the patient supine or seated and the shoulder in a neutral position at 90 degrees of abduction. The examiner applies
slight anterior pressure to the humerus (too much force can dislocate the humerus) and externally rotates the arm (Figure 8). Pain or apprehension about the feeling of
impending subluxation or dislocation indicates anterior glenohumeral instability.

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FIGURE 8.

Apprehension test for anterior instability. The patient's arm is abducted to 90 degrees while the examiner externally rotates the arm and applies anterior pressure to the humerus.

RELOCATION TEST
The relocation test is performed immediately after a positive result on the anterior apprehension test. With the patient supine, the examiner applies posterior force on
the proximal humerus while externally rotating the patient's arm. A decrease in pain or apprehension suggests anterior glenohumeral instability.

YERGASON TEST
Patients with rotator cuff tendonitis frequently have concomitant inflammation of the biceps tendon. The Yergason test is used to evaluate the biceps tendon.9 In this
test, the patient's elbow is flexed to 90 degrees with the thumb up. The examiner grasps the wrist, resisting attempts by the patient to actively supinate the arm and flex
the elbow (Figure 9). Pain with this maneuver indicates biceps tendonitis.

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FIGURE 9.

Yergason test for biceps tendon instability or tendonitis. The patient's elbow is flexed to 90 degrees, and the examiner resists the patient's active attempts to supinate the arm and flex the
elbow.

SPEED'S MANEUVER
Speed's maneuver is used to examine the proximal tendon of the long head of the biceps. The patient's elbow is flexed 20 to 30 degrees with the forearm in supination
and the arm in about 60 degrees of flexion. The examiner resists forward flexion of the arm while palpating the patient's biceps tendon over the anterior aspect of the
shoulder.

SULCUS SIGN
With the patient's arm in a neutral position, the examiner pulls downward on the elbow or wrist while observing the shoulder area for a sulcus or depression lateral or
inferior to the acromion. The presence of a depression indicates inferior translation of the humerus and suggests inferior glenohumeral instability (Figure 10). The
examiner should remember that many asymptomatic patients, especially adolescents, normally have some degree of instability.10

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FIGURE 10.

Sulcus test for glenohumeral instability. Downward traction is applied to the humerus, and the examiner watches for a depression lateral or inferior to the acromion.

POSTERIOR APPREHENSION AND INSTABILITY

Posterior instability of the shoulder can be assessed by using a simple test.11 With the patient supine or sitting, the examiner pushes posteriorly on the humeral head
with the patient's arm in 90 degrees of abduction and the elbow in 90 degrees of flexion.

‘CLUNK’ SIGN
Glenoid labral tears are assessed with the patient supine. The patient's arm is rotated and loaded (force applied) from extension through to forward flexion. A “clunk”
sound or clicking sensation can indicate a labral tear even without instability.12

Cervical Disc Disease

No physical examination in a patient with shoulder pain is complete without excluding cervical spine disease. Referred or radicular pain from disc disease should be
considered in patients who have shoulder pain that does not respond to conservative treatment. The patient should be questioned about neck pain and previous neck
injury, and the examiner should note whether pain worsens with turning of the neck, which suggests disc disease. Pain that originates from the neck or radiates past
the elbow is often associated with a neck disorder.

Plain film is a useful screening tool for degenerative cervical disc disease. Further work-up and imaging studies depend on the differential diagnosis and the treatment
plan.

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SPURLING'S TEST
In a patient with neck pain or pain that radiates below the elbow, a useful maneuver to further evaluate the cervical spine is Spurling's test. The patient's cervical spine
is placed in extension and the head rotated toward the affected shoulder. An axial load is then placed on the spine (Figure 11). Reproduction of the patient's shoulder
or arm pain indicates possible cervical nerve root compression and warrants further evaluation of the bony and soft tissue structures of the cervical spine.

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FIGURE 11.

Spurling's test for cervical root disorder. The neck is extended and rotated toward the affected shoulder while an axial load is placed on the spine.

The Authors show all author info

THOMAS W. WOODWARD, M.D., is a clinical assistant professor of family medicine at the University of Wisconsin Medical School, Madison. A graduate of the
University of Iowa College of Medicine, Iowa City, Dr. Woodward completed a family practice residency at the University of Wisconsin Medical School....

REFERENCES show all references

1. Miniaci A, Salonen D. Rotator cuff evaluation imaging and diagnosis. Orthop Clin North Am. 1997;28:43–58....

Members of various family practice departments develop articles for “Problem-Oriented Diagnosis.” This article is one in a series coordinated by the Department of
Family Medicine at the University of Wisconsin Medical School, Madison. Guest editor of the series is William E. Scheckler, M.D.

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