• Clinical science

Orthopedic shoulder examination

Abstract

The shoulder consists of three joints: the glenohumeral joint (commonly referred to as “shoulder joint”), the sternoclavicular joint, and the acromioclavicular joint. While the glenohumeral joint possess three degrees of freedom of motion, the range of motion as a whole is further increased by the glenohumeral joint's interaction with the acromioclavicular joint and the sternoclavicular joint. Unlike in other joints, the shoulder's dynamic stability and control is provided primarily by muscles (the rotator cuff in particular) rather than ligaments. Exposure to a great deal of stress from constant movement and the fact that it is stabilized primarily by muscles with little ligament support make the shoulder susceptible to dislocation and degenerative changes. Clinical examination is the core element in orthopedic shoulder diagnostics. Besides basic anatomy and function of the shoulder, this learning card discusses the most important clinical examinations and tests of the shoulder, the shoulder girdle joints, muscles, and capsuloligamentous complex.

Basics of shoulder anatomy and function

Bones

Shoulder mobility results from the interaction of three joints:

Muscles and ligaments

For more information see shoulder dislocation.

Patient history

  • Symptoms
  • In accidents: inquire about the circumstances of the accident
  • Occupational history
  • Pre-existing conditions
  • Previous imaging
  • Previous treatment

Inspection of the shoulder region

General information

  • Be attentive to patient habitus and movement upon entering the room:
    • Uneven arm swing
    • Relieving posture
    • Unusual reactions to handshake
  • Ask the patient to undress so that both shoulders can be examined.

Procedure

  • Skin assessment: signs of injury , signs of contusion, scars, signs of inflammation
  • Muscle contour inspection
  • Shoulder symmetry inspection
    • Procedure
      • Anterior inspection should follow an imaginary line from the left to the right acromion. Alternatively, inspection is made by comparing the outline of both clavicles from the sternoclavicular joint to the acromioclavicular joint.
      • Dorsal inspection should follow an imaginary line between both scapular spines
    • Findings and assessment
      • Pathology
        • Horizontal asymmetry of the shoulder
        • Vertical asymmetry of the shoulder

Finger sign test and palm sign

  • Short description: The patient is asked to point to the painful area. The finger sign test and the palm sign can provide important information on the location of shoulder pathology in the early stages.
  • Findings and assessment
    • The patient points to the lateral clavicle with the index finger (positive finger sign) → Typical of AC joint pathologies
    • The patient points to the lateral upper arm with the palm of the hand (positive palm sign) → Typical of glenohumeral joint and subacromial region pathologies

Palpation of the shoulder region

General information on the shoulder region

The shoulder region is initially palpated for signs of inflammation (warmth, swelling). A more detailed palpation of the muscle and bone structures of the shoulder region should be performed afterwards (see table).

Procedure

Palpation of the following structures Method Findings and significance
Anterior examination
Sternoclavicular joint
  • The examiner holds the patient's clavicle between the ball of the thumb and index finger and moves the clavicle while the fingers of the other hand are firmly placed on the sternum.
  • Pain or strong movement in the joint occur as a result of trauma or in osteoarthritis or connective tissue disorders.
  • Dislocations are especially clinically relevant. Although they are very rare (only ∼ 3% of all dislocations in the shoulder region), care should be taken not to overlook them.
Clavicular, AC joint, and acromion
Coracoid process
  • The examiner palpates the coracoid process with the middle and index fingers underneath the lateral clavicle (in the infraclavicular fossa).
  • The coracoid process can be easily felt during anteflexion of the patient's arm.
Bicipital groove (Intertubercular sulcus)
  • Pain indicates a degenerative or inflammatory lesion of the long head of the biceps tendon.
  • Palpable snapping indicates a tendon dislocation.
Lesser and greater tubercle
Posterior examination
Palpation of the scapula

Shoulder mobility testing

Combined movements can be assessed in a preliminary examination, which provides a rough indication of potential pathological conditions. In subsequent detailed examinations, specific tests are used to examine individual joint components and their pathologies.

Combined shoulder joint movements

Apley scratch test

  • Procedure
    • The patient is asked to make a fist with the hands and stretch out the thumbs. The hands are placed behind the neck or the back.
      • Neck: tests for external rotation and abduction of the shoulder
      • Back: tests for internal rotation, extension, and adduction of the shoulder
  • Findings and assessment

Range of motion of the shoulder

Active range of motion (the patient moves the shoulder without help from the examiner) should be performed before passive range of motion (with help from the examiner). Physiological range of motion in the shoulder (with movement of the scapula) comprises:

  • Glenohumeral joint – isolated
    • Anteversion/retroversion: 90°/0°/30°
    • Adduction/abduction: 20°/0°/90°
    • Internal/external rotation (in the neutral position): 70°/0°/60°
    • Internal/external rotation (with upper arm abducted by 90°): 70°/0°/70°
  • Glenohumeral jointshoulder girdle involvement
    • Anteversion/retroversion: 170°/0°/40°
    • Adduction/abduction: 40°/0°/180°
    • Internal/external rotation: 95°/0°/80°

References:[1]

Examination of the rotator cuff

Examination of the supraspinatus muscle: Empty can test (Jobe's 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

For more information see soft tissue lesions of the shoulder.

Examination of the subscapularis muscle: 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
    • Positive lift-off test: pain when returning the hand to the starting position or the inability to move the hand against resistance → functional disorder of the subscapularis tendon (e.g., rupture)

For more information see soft tissue lesions of the shoulder.

Examination of the subscapularis muscle: belly press test (abdominal compression test, Napoleon test)

  • Procedure (dorsal examination)
    1. The patients 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
    • Background: 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 retroverted and adducted and the wrist is flexed.
    • Negative Belly press test (physiological): pressure against the abdomen without a flexed wrist (intact subscapularis muscle)
    • Positive Belly press test: pressure against the abdomen that is associated with a flexed wrist → functional disorder of the subscapularis tendon
      • Wrist flexed < 30° → indicates a low-degree subscapular lesion < ⅓
      • Wrist flexed > 60° → indicates a high-degree subscapular lesion > ⅔

For more information see soft tissue lesions of the shoulder.

Examination of the infraspinatus muscle and teres minor muscle: infraspinatus test

  • 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

Examination of the long head of the biceps tendon

The long head of the biceps tendon traverses from the supraglenoid tubercle of the scapula through the bicipital groove of the humerus, a common site of tendon irritation. The most common pathologies, whose symptoms may be apparent upon clinical examination, include degenerative changes of the tendon with concomitant biceps tendonitis, fibromyalgia, and dislocation derived from the bicipital groove. After palpation of the biceps tendon in the bicipital groove, which should be performed with upper arm rotation, specific tests can be performed for further evaluation of a biceps tendinopathy.

Palm-up test

  • Procedure (ventrolateral examination)
    1. The examiner extends the patient's elbow and supinates the arm. The shoulder is abducted to 90° and horizontally flexed to 30°.
    2. The examiner exerts downward pressure on the palmar side of the patient's wrist.
  • Findings and significance

Speed's test

Used to diagnose pathologies of the long head of the biceps tendon as well as SLAP lesions Several sources use the term Speed's test synonymously with the palm-up test (see above). Some sources treat it is as a modification of the palm-up test, whereas others describe it as an independent test. The variant that differs most from the palm-up test is described here. The biceps muscle is not tested by abduction of the glenohumeral joint against resistance (palm-up test), but by elbow flexion.

  • 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
    • See palm-up test above
    • Speed's tests has a high level of sensitivity for lesions of the long head of the biceps tendon (∼ 90%); however, specificity is low (∼ 13%).

O'Brien's test (active compression test)

  • Short description: O'Brien's test examines the integrity of the long head of the biceps tendon at the glenoid labrum (biceps anchor) in maximal internal and external rotation. It is used to assess for a SLAP lesion.
  • Procedure (ventrolateral examination)
    1. The examiner fully extends the patient's elbow. The arm to be tested is in 90° flexion and 10–15° adduction. The patient fully internally rotates the arm with the thumb pointing downwards.
    2. The examiner exerts downward pressure on the proximal lower arm while the patient resists.
    3. The patient's arm is then externally rotated. The examiner exerts downward pressure again while the patient resists.
  • Findings and significance
    • Pathological: pain (and sometimes clicking) while attempting to resist pressure exerted on the arm by the examiner
      • Pain is located deep in the shoulder and is reduced or absent with supination (compared with pronation) → positive O'Brien's test → indicates a SLAP lesion
      • Pain is experienced in another area or is not reduced with supination → negative O'Brien's test → nonspecific sign and no indication of a SLAP lesion

Yergason test

Yergason test evaluates concomitant biceps tendonitis in patient's with rotator cuff inflammation.

  • Procedure (ventrolateral examination)
    1. 90° elbow flexion. Examiner grasps patient's arm above elbow and the wrist.
    2. Patient actively attempts to supinate the forearm and to flex the elbow against resistance.
  • Findings and significance

References:[1]

Shoulder impingement tests

Painful arc test

  • Procedure
    • The examiner instructs the patient to abduct and raise the extended arm
  • Findings and significance
  • Note: Impingement syndrome can make 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

Hawkins-Kennedy test

  • Procedure (ventral examination)
    1. The examiner places the patient's arm in 90° anteversion 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.
  • Findings and significance

References:[2]

Shoulder instability tests

Anterior/posterior drawer test of the shoulder

  • Procedure (dorsal or supine examination): The examiner fixates the scapula by placing his hand firmly on the the coracoid process and the spine of the scapula. The humeral head is drawn in an anterior and posterior direction.
  • Findings and significance
    • Positive drawer test: significant translocation or difference between the two sides → hyperlaxity of the glenohumeral joint

Sulcus sign (inferior drawer test of the shoulder)

  • Procedure (dorsal examination in a sitting position)
    1. The patient's arm is relaxed and placed on the lap or on the examiner's arm.
    2. The examiner stabilizes the patient's shoulder with one hand and grasps the patient's arm just above the elbow with the other.
    3. The examiner applies a distal force to the patient's arm and inspects the patient's shoulder for the appearance of a depression between the acromion and humerus (sulcus).
  • Findings and significance

Shoulder apprehension tests

Anterior apprehension test

The anterior apprehension test is used to test for anterior shoulder instability.

  • Procedure (dorsal examination in a sitting position)
    1. The examiner stabilizes the patient's scapula with one hand.
    2. The patient's shoulder is abducted to 90° and the elbow flexed to 90°.
    3. The examiner positions the patient's arm to 90° abduction and external rotation and observes the patient's reaction upon inspection and palpation of the shoulder.
  • Findings and significance
    • Positive anterior apprehension test: palpable shoulder subluxation, sense of apprehension against external rotation or a look of concern or discomfort by the patient that the shoulder will dislocate → capsuloligamentous complex lesions

Posterior apprehension test

The posterior apprehension test can be used to test for posterior shoulder instability.

  • Procedure (optimally in a supine position)
    1. The patient's arm is passively flexed to 90° and rotated maximally internally. The elbow is flexed to 90°.
    2. The examiner places one hand on the patient's scapula and applies posterior force on the patient's elbow.
  • Findings and significance
    • Positive posterior apprehension test: analogous to the anterior apprehension test; palpable shoulder subluxation; sense of apprehension against external rotation or a look of concern or discomfort by the patient that the shoulder will dislocate → capsuloligamentous complex lesions are likely.

Relocation test

The relocation test is used to test for anterior shoulder instability.

  • Procedure
    1. The patient's arm is passively externally rotated
    2. The examiner places one hand on the patient's scapula and applies posterior force on the patient's humerus.
  • Findings and significance
    • Positive relocation test: analogous to the anterior apprehension test; palpable shoulder subluxation; sense of apprehension against external rotation or a look of concern or discomfort by the patient that the shoulder will dislocate → capsuloligamentous complex lesions are likely.

References:[1]

  • 1. Woodward TW, Best TM. The painful shoulder: part I. Clinical evaluation. Am Fam Physician. 2000; 61(10): pp. 3079–88. pmid: 10839557.
  • 2. Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. 2009; 80(5): pp. 470–6. pmid: 19725488.
last updated 11/17/2018
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