Shoulder examination

LOOK

General inspection

Clinical signs
 Body habitus: increased mechanical load (e.g. osteoarthritis).
 Scars: previous upper limb surgery.
 Wasting of muscles: disuse atrophy or a lower motor neuron lesion.

Objects or equipment
 Aids and adaptations: support slings are often used to manage shoulder joint pathology.

Closer inspection of the shoulder

Anterior inspection
 Scars: previous joint trauma.
 Bruising: recent trauma or surgery.
 Asymmetry of the shoulder girdle*: scoliosis, arthritis, fractures or dislocation.
 Swelling*: unilateral swelling (e.g. effusion, inflammatory arthropathy, dislocation).
 Abnormal bony prominence: fracture (e.g. clavicular fracture) or anterior dislocation of the
glenohumeral joint
 Deltoid wasting: asymmetry in the bulk of the deltoid muscles due to disuse atrophy or axillary
nerve injury
 Pectoralis major wasting

Lateral inspection
 Scars: previous trauma or surgery.
 Deltoid wasting: disuse atrophy or axillary nerve injury.
 Bruises
 Swelling

Posterior inspection
 Scars: previous trauma or surgery.
 Trapezius muscle asymmetry: muscle wasting secondary to disuse atrophy or a spinal
accessory nerve lesion.
 Supraspinatus and infraspinatus asymmetry*: muscle wasting secondary to chronic rotator
cuff tear or a suprascapular nerve lesion.
 Scoliosis: lateral curvature of the spine that may be congenital or acquired.
 Winged scapula*: ipsilateral serratus anterior muscle weakness secondary to a long thoracic
nerve injury.
 FEEL

Temperature

Increased temperature associated with swelling and tenderness may

indicate septic arthritis or inflammatory arthritis.

Shoulder joint palpation

Palpate the various components of the shoulder girdle, noting any swelling, bony irregularities
and tenderness:

 Sternoclavicular joint: the joint between the sternum and the clavicle.

 Clavicle: extends between the sternum and the acromion of the scapula.
 Acromioclavicular joint: the joint between the acromion and the clavicle.
 Acromion: a continuation of the scapular spine and the most superolateral bony prominence of
the shoulder.
 Coracoid process of the scapula: a small hook-like bony prominence located 2cm inferior and
medial to the clavicular tip.
 Head of the humerus: located 1cm inferolateral to the coracoid process.
 Greater tubercle of the humerus: located slightly anterolateral to the head of the humerus.
 The spine of the scapula: easily palpable on the posterior aspect of the scapula, running from
the acromion towards the thoracic vertebrae.

Suggested sequence: sternoclavicular joint  clavicle  AC joint  humeral grove  coracoid

process  spine of scapula  border of scapula

MOVE

ROM

Active movement

Compound movements (screening)

External rotation and abduction of the shoulder joint: Ask the patient to put their hands
behind their head and point their elbows out to the side.

Internal rotation and adduction of the shoulder joint: Ask the patient to place each hand
behind their back and reach as far up their spine as they are able to.
Active shoulder flexion
Normal range of movement: 150°- 180°

Active shoulder extension

Normal range of movement: 40°

Active shoulder ABduction

Normal range of movement: 180°

Active shoulder ADduction

Normal range of movement: 30°- 40°

Active external rotation

Normal range of movement: 80° – 90°

Active internal rotation

Normal range of movement: the patient is able to reach to the level of T4-T8

Scapular movement
On average 50-70% of the scapula’s initial movement occurs at the glenohumeral joint.

If the glenohumeral joint’s movement is reduced due to injury or inflammation then the majority of
abduction will occur via increased scapular movement over the chest wall.

Passive movement

feel for crepitus as you move the joint (which can be associated with osteoarthritis) and observe
any discomfort or restriction in the joint’s range of movement.

Power (CAN BE PERFORMED AS SPECIAL TESTS)

Supraspinatus: abduction in scapular plane against resistance

Subscapularis: Gerber’s lift-off test/belly press test
Infraspinatus + teres minor: external rotation against resistance
 SPECIAL TEST

Shoulder impingement tests

Painful arc test

 Procedure: The examiner instructs the patient to abduct and raise the extended arm.
 Findings and significance
o Negative test (physiological): The patient's arm can be repeatedly raised and lowered between 0–
180°.
o Positive test: painful arc
 Pain between 60–120° indicates subacromial impingement 
 Pain from abduction/elevation at 120–170° indicates a pathology of the AC joint 
 Pain during the entire movement (0°–180°) nonspecific indication of a glenohumeral
pathology (e.g., osteoarthritis or frozen shoulder)
o Impingement syndrome can make an assessment of the actual range of motion in the shoulder
difficult due to pain. To nullify the effects of, e.g., subacromial impingement, abduction in external
rotation can be performed. As a result of this, the space between the acromion and
the supraspinatus tendon is enlarged, leading to reduced pain.

Neer test
 Procedure (dorsal examination)
1. The examiner places the patient's arm in the internal rotation position and uses the hand to
stabilize the patient's scapula.
2. Using the other hand, the examiner raises the patient's arm and moves it in a scapular range of
motion. 
 Findings and significance: Pain during flexion between 90–120° (positive Neer test)
and pain reduction in external rotation is a nonspecific indication of impingement syndrome.

Hawkins-Kennedy test
 Procedure (ventral examination)
1. The examiner places the patient's arm in 90° flexion and flexes the elbow to 90°.
2. The examiner places one hand on the patient's distal lower arm, while the other hand is placed
under the elbow.
3. The patient's lower arm is internally rotated similar to a clockhand, resulting in internal rotation of
the shoulder.   [3]

 Findings and significance: Pain during internal rotation (positive Hawkins-Kennedy test) is a

nonspecific indication of impingement syndrome
 Rotator Cuff Muscle

Examination of the supraspinatus muscle: empty can test (empty can

test/Jobe test)
 Procedure (dorsal examination)
1. The patient's upper arm should be passively abducted (∼ 90°) and flexed horizontally with
the elbow extended.
2. The arm is internally rotated (thumb pointing downwards). 
3. Check the patient's ability to maintain the arm in this position.
4. If the patient is able to maintain this position, the examiner applies pressure to the patient's arm
and the patient is asked to resist.
 Findings and significance: This test assesses for weakness and/or impingement of supraspinatus.
Weakness may represent a tear in the supraspinatus tendon or pain due to impingement.

Examination of the subscapularis muscle (Internal rotation against resistance): lift-

off test
 Procedure (dorsal examination)
1. Place the patient's hand behind the lower back with the palm facing outwards. 
2. Check the patient's ability to lift the hand away from the back.
3. If the patient is able to perform this movement, the examiner applies resistance to the patient's
palm.
4. The patient is asked to move the hand against resistance applied by the examiner.
5. Check the other arm.
 Findings and significance: Pain when returning the hand to the starting position or the inability to
move the hand against resistance (positive lift-off test) indicates a functional disorder of
the subscapularis tendon (e.g., rupture).

Examination of the subscapularis muscle: belly press

test (abdominal compression test, Napoleon test)
 Procedure (dorsal examination)
1. The patient's hand is placed flat on their abdomen with the hand, wrist, and elbow in a straight line.
2. The patient's elbow is flexed to 90°.
3. The examiner places the patient's flat hand onto the abdomen. 
4. The examiner checks that the angle between the patient's hand and forearm is 0°. 
5. The examiner asks the patient to firmly press the palm against the abdomen.
 Findings and significance
o Mechanism: Internal rotation of the shoulder is necessary to maintain pressure exerted through this
action. If the subscapularis tendon is injured, pressure against the abdomen is only possible if
 the triceps brachii muscle and posterior sections of the deltoid muscle compensate for the
injured subscapularis muscle. The upper arm is flexed and adducted and the wrist is flexed.
o Negative belly press test (physiological): pressure against the abdomen without a flexed wrist
(intact subscapularis muscle)
o Positive belly press test: Pressure against the abdomen that is associated with a flexed wrist
indicates a functional disorder of the subscapularis tendon.
 Wrist flexion < 30° indicates a low-degree subscapular lesion < ⅓.
 Wrist flexion > 60° indicates a high-degree subscapular lesion > ⅔.

Examination of the infraspinatus muscle: infraspinatus test (External rotation

against resistance***
 Procedure
1. The test can be performed in two positions:
 Position 1: The patient's elbow is bent to 90°.
 Position 2: The patient's arm is abducted to 90° and the humerus is medially rotated to 30°. 
2. The examiner applies resistance against the back of the patient's hand. The patient is asked to
maintain his or her position.
 Findings and significance: Inability to perform external rotation against resistance may
suggest infraspinatus tendonitis. If the arm falls back to internal rotation or there is a loss of
power it may suggest a tear in the infraspinatus or teres minor tendon, muscle wasting and/or a
lower motor neurone lesion (suprascapular or axillary nerve).

Biceps tendinitis -- Examination of the long head of the biceps tendon

Speed test 
 Procedure (ventrolateral examination)
1. The examiner slightly abducts the patient's arm with the elbow at 90° flexion and the
forearm supinated.
2. The patient is asked to bend the elbow against the examiner's resistance.
 Findings and significance
o Inability to flex the elbow against resistance or the occurrence of pain (positive Speed test)
indicates pathologies of the long head of the biceps tendon and/or SLAP lesions.
 SLAP is the abbreviation for superior labrum from anterior to posterior.
 It describes an upper glenoid labrum lesion, which commonly occurs after a fall onto the
extended arm.
o The biceps muscle is not tested by abduction of the glenohumeral joint against resistance (tested
in palm-up test) but by elbow flexion.

Yergason test
 Procedure (ventrolateral examination)
1. The patient's elbow is flexed at 90°.
2. Examiner grasps the patient's arm above the elbow and the wrist.
3. The patient actively attempts to supinate the forearm and to flex the elbow against resistance.
 Findings and significance: Pain while flexing the elbow against resistance (positive Yergason test)
indicates biceps tendon inflammation (concomitant biceps tendonitis commonly occurs in patients
with rotator cuff inflammation) or instability.

EXTRA

External rotation in abduction

This clinical test assesses the function of the teres minor muscle.

1. Position the arm in 90° of abduction and bend the elbow to 90°.

2. Passively externally rotate the shoulder to its maximum degree.

Interpretation
An inability to keep the arm in this position (i.e the arm falls back to internal rotation) is
known as “Hornblower’s sign” and can be caused by teres minor pathology or an axillary
nerve lesion.

Scarf test
The scarf test assesses the function of the acromioclavicular joint.

Interpretation
If the patient experiences pain the test is considered positive and suggestive
of acromioclavicular joint pathology (e.g. osteoarthritis).
 FLOW OF EXAMINATION
 Introduction

 Wash your hands and don PPE if appropriate

 Introduce yourself to the patient including your name and role

 Confirm the patient's name and date of birth

 Briefly explain what the examination will involve using patient-friendly language

 Gain consent to proceed with the examination

 Adequately expose the upper limbs

 Position the patient standing for initial inspection of the upper limbs

 Ask if the patient has any pain before proceeding

 Gather equipment

 Look

 Perform a brief general inspection of the patient, looking for clinical signs suggestive
of underlying pathology (CAREFUL WATCH OF PATIENT UNDRESSING)

 Inspect both upper limbs with the patient standing (anterior/lateral/posterior)

 Ask the patient to push against a wall and inspect for evidence of scapular winging

 Feel

 Assess and compare shoulder joint temperature

 Palpate the various components of the shoulder girdle (tenderness and swelling)

 Move

 Assess compound movements to screen for shoulder joint pathology

 Assess active shoulder flexion

 Assess active shoulder extension

 Assess active shoulder ABduction

 Assess active shoulder ADduction

 Assess active external rotation of the shoulder joint

 Assess active internal rotation of the shoulder joint

 Assess scapular movement

 Repeat all of the above assessments passively (OPTIONAL)

 Special tests

 Supraspinatus assessment (empty can test/Jobe’s test)

 Painful arc assessment (supraspinatus impingement)

 External rotation against resistance (infraspinatus and teres minor)

 External rotation in abduction (teres minor)

 Internal rotation against resistance (Gerber’s lift-off test)

 Scarf test
 To complete the examination…

 Explain to the patient that the examination is now finished

 Thank the patient for their time

 Dispose of PPE appropriately and wash your hands

 Summarise your findings

 Suggest further assessments and investigations (e.g. neurovascular examination of

both upper limbs, examination of the joint above and below and further imaging)