SHOULDER EXAMINATION

I Dewa Gede Bracika D.P.

 HISTORY
• Pain: sometimes radiates down the arm. Beware the
referred pain (e.g from neck, heart, mediastinum, and
diaphragm).
• Stiffness: may progressive and severe (e.g frozen
shoulder).
• Deformity: may consist of muscle wasting, prominence of
the AC joint or winging the scapula.
• Instability: a feeling that the shoulder might come out of
socket.
• Loss of function: inability to reach behind the back and
difficulty with combing hair or dressing.
PHYSICAL EXAMINATION
 LOOK
• Skin: scars
• Shape: asymmetry of the shoulders, winging
of the scapula, wasting of the deltoid and AC
dislocation – best seen from behind. Joint
swelling or wasting of the pectoral muscle –
more obvious from front.
• Position: if the arm is held persistently
internally rotated – posterior dislocation of
shoulder.
 LOOK
 Anterior, posterior, lateral and medial sides

 Front:
A. Prominent sternoclavicular
joint (subluxation)
B. Deformity of clavicle
(fracture)
C. Prominent
acromioclavicular joint
(subluxation/osteoarthritis)
D. Deltoid wasting
(disuse/axillary nerve
palsy)
 Sides: Swelling, deformity

 Behind: Shape and location of the scapulae

 Above: Swelling of the joints, deformity of the clavicle,

asymmetry of the supraclavicular fossae
 FEEL

Palpate the length of the clavicle

*Tenderness is found in sternoclavicular dislocations
and infections, or tumours.

Tenderness over the acromioclavicular joint is found

after recent dislocations and in osteoarthritis of the joint.
*Crepitus may be detectable when the arm is abducted

Press below the acromion and abduct the arm

*Sudden tenderness is found in tears and
inflammatory lesions involving the cuff and/or
subdeltoid bursa
 Palpate the anterior and lateral aspects of the
glenohumeral joint
*Tenderness is suggestive of infection or calcifying
supraspinatus tendinitis.

Palpate the upper humeral shaft and head via the axilla
*Exostoses of the proximal humeral are often readily
palpable by this route

Paxinos sign
To confirm OA in AC joint.
(+)  the patient experience pain
 MOVE
• Active Movements: raise both arms sideways
until the finger point the ceiling.
– Abduction may be: difficult to initiate, diminished
in range.
– Flexion and extension: raise the arms forward and
then backward
– Adduction: move the arm across the front of the
body.
– Rotation
 MOVE
(Range of Motion)

170o
165 o
 Move
(Abduction)

• Normal range: 0-170o

• Difficulty in initiating abduction is
suggestive of a major shoulder cuff
tear
• Pain during:
(A)During the arc 70-120o, suggestive of
shoulder cuff impingement in the
region of the acromion
(B)During the latter phase, suggestive of
shoulder cuff impingement in the
region of the acromioclavicular
joint/coracoacromial ligament, or
from osteoarthritis of the
acromioclavicular joint
If the patient cannot
abduct the arm Ask patient to hold
actively  passively arm in the vertical
 rotate the arm position  able 
externally  full range intact deltoid and
indicates an intact axillary nerve
glenohumeral joint

Restricted active and

Ask patient to lower the passive movements
arm to the side   fix the angle of the
sudden dropping of the scapula and abduct the
arm  major shoulder arm  absence of
cuff tears movement indicates a
fixed glenohumeral
joint
 Move
Internal rotation in
Adduction
extension
Place one hand on the
Place the hand in the
shoulder and swing the
opposite shoulder
arm, flexed at the
blade  unable 
elbow, across the
Commonly found in
chest
frozen shoulder
Normal range: 0-50o

Horizontal flexion
and adduction
The arm is moved
forward from a position External rotation at
of 90o abduction. 90o abduction pain
Normal range: 0-140o or restriction  frozen
*pain  common in shoulder
osteoarthritis or trauma
to the
acromioclavicular joint
Internal rotation in External rotation in
abduction abduct abduction abduct
the shoulder to 90o and the shoulder to 90o and
flex the elbow to a right flex the elbow to a right
angle  lower the angle  raise the
forearm from the forearm from the
horizontal plane. horizontal plane.
Normal range: 70o Normal range: 100o

External rotation in
extension place the
elbows into the sides
and flex them to 90o Cervical spine
with the hands facing Always examine in a
forward case of shoulder pain
Normal range: 70o esp. with normal
*Increase in external shoulder movements
rotation in extension
subscapularis muscle
tear
 Special Tests
(Rotator Cuff Impingement)

Neer impingement sign

Pain occurs when the shoulder is flexed to 90o and
internally rotated
Neer impingement test
Test is repeated after injection of 10-15 mL of 1%
xyocaine into the subacromial space

Hawkins-Kennedy test
90o forward flexion and
flexed elbow  stabilize
the upper arm and
internally rotate the arm
 pain  +
 Special Tests
(Anterior Glenohumeral Instability)
The apprehension test
Stand behind the patient Relocation test
 abduct the shoulder to Repeat the
90o externally rotate the apprehension test in
shoulder while pushing recumbent position.
the head of the humerus When apprehension
forwards with the thumb. appear  press down
Repeat at 45o and 135o on the upper arm 
abduction. Chronic stabilize humerus
anterior instability of head in the glenoid 
shoulder. apprehension relieve
*Apprehension  +

Drawer test of Gerber and Ganz

Support patient’s supine arm with
shoulder in 90o abduction, slight
flexion and external rotation
steadying the scapula with the
thumb on the coracoid and the
fingers behind  try to move the
humeral head anteriorly
 Special Tests
(Posterior Glenohumeral Instability)

Drawer test
Hold the relaxed, supine patient’s forearm with
the elbow flexed and the shoulder in 20o flexion
and 90o abduction place thumb lateral to the
coracoid  internally rotate the shoulder and
flex to about 80o  pressing the humeral head
backwards with the thumb
(+)  any backward displacement of the
humeral head should be detected by the thumb

Jerk test
Patient’s shoulder over the edge of the
examination couch flex both the shoulder and
elbow to 90o with one hand on the elbow,
push downwards  attempt to sublux the
humeral head posteriorly
(+)  Jerk or lump will be felt
 Special Tests
Inferior glenohumeral
instability: Sulcus sign
Grasp the arm and pull
downwards 
depression between the
humeral head and the
acromion  +
multidirectional instability
Biceps tendinitis:
Speed’s test
Extended-supinated
elbow, 90o flexed
shoulder ask patient to
resist as the examiner
tries to extend the
shoulder pain 
tendinitis
Biceps tendon
instability test
Abduct shoulder and the
elbow flexed to 90o 
locate the tendon in the
bicipital groove
internally rotate the
patient’s shoulder 
Move out of
position/click  unstable
tendon
Integrity of the long
head of biceps
Support patient’s elbow
 grasp the wrist ask
patient to pull toward the
shoulder while the
examiner resist this
movement  ruptures
long tendon of biceps 
belly of biceps appear
globular (2 sides)
THANKYOU