Physical examination of the shoulder

INTRODUCTION — 

The evaluation of patients with shoulder dysfunction or pain can be difficult. Skillful examination of the shoulder is an integral part of this evaluation and is necessary to generate an appropriate differential diagnosis and help determine whether advanced imaging is needed. An examination checklist is provided (table 1).

The large number of shoulder examination techniques, often given eponyms named for their creators, can be confusing. In addition, although these maneuvers are often taught as if they are pathognomonic for a particular pathology, their diagnostic accuracy is often uncertain, and many studies designed to assess their test characteristics (eg, sensitivity, specificity) are difficult to interpret [1]. As an example, multiple examination maneuvers may yield positive results in a patient with an acutely injured shoulder, thereby reducing specificity.

This topic reviews the examination of the shoulder, including many special tests designed to detect particular lesions. A systematic approach to the patient with shoulder complaints and discussions of specific shoulder problems are found separately:

●Assessment of shoulder pain or dysfunction (see "Evaluation of the adult with shoulder complaints" and "Radiologic evaluation of the painful shoulder in adults" and "Evaluation of acute traumatic shoulder injury in children and adolescents")

●Rotator cuff and related conditions (see "Subacromial (shoulder) impingement syndrome" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears" and "Biceps tendinopathy and tendon rupture")

●Other shoulder-related conditions (see "Acromioclavicular joint disorders" and "Frozen shoulder (adhesive capsulitis)" and "Multidirectional instability of the shoulder" and "Pectoralis muscle and tendon injuries" and "Overview of upper extremity peripheral nerve syndromes", section on 'Proximal neuropathies' and "Clinical manifestations and diagnosis of osteoarthritis", section on 'Shoulder')

●Fractures and related injuries (see "Proximal humeral fractures in adults" and "Clavicle fractures" and "Acromioclavicular joint injuries ("separated" shoulder)")

ANATOMY AND BIOMECHANICS — 

A complex network of anatomic structures endows the human shoulder with tremendous mobility. These structures and the related biomechanics are discussed separately. (See "Evaluation of the adult with shoulder complaints", section on 'Anatomy and biomechanics'.)

TIPS FOR A PRODUCTIVE EXAMINATION — 

The following tips may be helpful for performing the shoulder examination effectively and efficiently:

●Observe the patient, noting their posture; watch how they carry and move the affected arm. (See 'Inspection' below.)

●Make the patient comfortable. This helps to ensure natural arm motion and reduces the likelihood of guarding during the examination.

●Compare shoulders.

●Perform the shoulder examination systematically. An examination checklist is provided (table 1).

●Assess scapulothoracic function.

●Use patient demographics and the history to guide the functional examination.

●Remember referred pain. Is the shoulder really causing their pain, or is it their cervical spine, gallbladder, spleen, or heart?

Help the patient to relax as much as possible during the examination. A relaxed patient is more likely to display authentic movement patterns and to allow the clinician to perform functional tests with little or no voluntary guarding. Minimize the patient's discomfort by having them take or administering appropriate analgesics prior to the examination. Although a clear view is important, the examiner needs to find a balance between exposing the shoulders and making the patient feel comfortable. When examining female patients, a tank top or sports bra often is preferred, but tucking the examination gown fabric into bra straps may be sufficient.

Shoulder mobility and strength vary widely among patients; thus, comparing shoulders is often crucial to performing an accurate examination. Inspect both shoulders from different perspectives; be certain you can see the relevant areas completely. Perform tests of strength and function on both shoulders and compare results.

Use a systematic approach to examine the shoulder. Perform the essential elements of the examination (inspection, palpation, tests of motion and strength) in the same order and manner each time. This will make you more facile with the examination and prevent you from missing things. As an example, some clinicians palpate the shoulder starting at the sternoclavicular joint and then work systematically from front to back.

It is important to assess scapulothoracic function, particularly given the multitude of patients who spend many hours using a computer and, as a result, develop weakness and dysfunction of the muscles that control the scapula. Such dysfunction is the root cause of shoulder pain in many patients. (See 'Scapulothoracic motion and strength' below.)

Keep in mind the "casualty or culprit" concept for chronic shoulder pain or overuse syndromes. Briefly stated, the site of the pain may not be the source of the problem. As an example, tests for impingement may be positive, but it does not follow that the supraspinatus and acromion are the ultimate cause of pain. The impingement may be caused by weakness of the scapular retractors, excessive tightness of the pectoralis muscles, weakness of the muscles that provide core stability, or some other abnormality that predisposes the rotator cuff to impingement. The examination findings may be accurate but incomplete, and further investigation is often necessary to clarify the primary root cause of an overuse syndrome.

When deciding what examination techniques to perform, pay attention to patient demographics and history. The patient's age, occupation, athletic activities, and history of present illness determine to a large extent the likelihood of different shoulder ailments. As an example, labral tears are relatively common among overhead athletes but unlikely in older, sedentary patients. Performing a battery of examination tests looking for a labral tear in an octogenarian with chronic shoulder weakness is unlikely to be productive.

TELEMEDICINE EXAMINATION — 

An article with extensive video clips and photographs describing in detail how to perform the musculoskeletal examination of the shoulder, spine, hip, and knee remotely using telemedicine is provided in the following reference [2].

NEUROVASCULAR ASSESSMENT — 

Among patients with acute or recent traumatic injuries, neurologic complaints (eg, weakness, paresthesias), or unusual presentations, a careful neurovascular assessment is essential; among patients without trauma or neurologic complaints, a focused neurovascular examination confirming basic motor function and sensation and adequate blood flow is sufficient.

In the patient with a history of trauma and shoulder dysfunction or pain, neurovascular considerations include:

●Cervical spine fracture and spinal cord injury

●Brachial plexus neurapraxia (ie, "stinger" or "burner")

●Axillary nerve injury (uncommon injury but most often associated with anterior glenohumeral dislocation)

A cervical fracture can present as acute shoulder pain due to radiculopathy. Cervical injury is typically associated with high-velocity or sports-related trauma. However, among older adult patients, cervical injuries can occur from minor trauma, such as a fall from standing. Assume the presence of a cervical spine injury in any older adult patient with minor trauma who complains of neck pain or radicular symptoms, including shoulder pain, and either perform the appropriate work-up or transfer the patient to a site where this work-up can be completed. The assessment and management of cervical spine injuries is discussed separately. (See "Cervical spinal column injuries in adults: Evaluation and initial management" and "Acute traumatic spinal cord injury".)

Neurapraxia of the brachial plexus (often referred to as a "burner" or "stinger") occurs frequently in American football players. Patients with a stinger usually complain of a burning pain in the upper trapezius or shoulder region that radiates into the upper arm. It is often associated with weakness and paresthesias. As the symptoms and signs associated with brachial plexus injury may mimic those caused by a cervical radiculopathy, a careful evaluation of the cervical spine should be performed. (See "Brachial plexus syndromes", section on 'Burner syndrome' and "Clinical features and diagnosis of cervical radiculopathy" and "Cervical spinal column injuries in adults: Evaluation and initial management".)

Acute anterior shoulder dislocation may be associated with an axillary nerve injury, but this is not common. Integrity of the axillary nerve should be assessed following acute shoulder dislocations by testing sensation over that lateral deltoid. (See "Shoulder dislocation and reduction".)

Neurovascular pathology should also be ruled out in the patient with nontraumatic shoulder pain. Examine the neck and rule out pathology of the cervical spine as the cause of referred shoulder pain. Often, cervical nerve root irritation presents predominately as arm pain, although radiation to neck may be present. Associated paresthesias, weakness, and reduced reflexes may be present. Pain can worsen with extension and rotation of the neck to the side of pain (Spurling maneuver) or by movements that increase tension on neural structures, including abduction of the shoulder and extension of the arm. This combination of shoulder pain, weakness, and aggravation by shoulder motion can lead to misdiagnosis of the problem as an intrinsic shoulder injury. The presentation and evaluation of patients with possible cervical spine disorders unrelated to trauma are discussed separately. Pain at the posterior shoulder or scapular region may also be associated with cervical nerve root irritation [3,4]. (See "Clinical features and diagnosis of cervical radiculopathy" and "Evaluation of the adult patient with neck pain".)

Compression of any of the peripheral nerves around the shoulder can cause pain, paresthesias, or weakness distal to the site of injury. Compressive neuropathies at the shoulder can involve the suprascapular, long thoracic, or axillary nerves. These compressive neuropathies are described briefly below, but a more thorough discussion is found separately. (See "Overview of upper extremity peripheral nerve syndromes", section on 'Proximal neuropathies'.)

●Suprascapular nerve injury – Compression of the suprascapular nerve (figure 1 and figure 2) is the most common neuropathy associated with shoulder pain. It can be caused by repetitive traction on the nerve at the suprascapular notch in overhead athletes or by compression at the spinoglenoid notch, most often from a paralabral cyst or an abnormally thickened transverse scapular ligament or one containing nodules [5-9]. Suprascapular neuropathy causes posterior shoulder pain and produces atrophy and weakness of the supraspinatus and/or infraspinatus muscles.

●Long thoracic nerve injury – Compression of the long thoracic nerve (figure 3) causes paralysis of the serratus anterior muscle. Classically, the syndrome is caused by prolonged compression of the nerve when a heavy load is carried over the shoulder, but injury can also occur from a direct blow or from heavy or repetitive work with the involved arm [10-12]. Symptoms include acute pain in the extremity or posterior chest wall followed by decreased shoulder range of motion (ROM), weakness with scapular retraction and external rotation of the shoulder, and scapular winging (picture 1).

●Axillary nerve injury – The axillary nerve (figure 4 and figure 5) can be injured with anterior shoulder dislocations or by direct compression. Compression can occur from the quadrilateral space syndrome, which develops when fibrous adhesions, muscle, or osteophytes compress the axillary nerve within the space; or from direct trauma to the posterior shoulder [13-19]. The quadrilateral space is bounded by the teres minor superiorly, long head of the triceps medially, teres major inferiorly, and the medial border of the humerus laterally. Quadrilateral space syndrome is characterized by posterior shoulder pain, focal tenderness, and paresthesias in a small area inferior to the acromion. Weakness of the deltoid and external rotators of the shoulder may be seen. Axillary nerve compression may be associated with compromise of the posterior humeral circumflex artery in overhead athletes [17].

Vascular conditions, including thoracic outlet syndrome and axillary vein thrombosis, can cause shoulder pain. The term "thoracic outlet syndrome" describes a variety of upper extremity syndromes involving compression of the neurovascular structures that pass from the neck to the axilla (figure 6). Symptoms can include shoulder or neck pain, weakness or easy fatigability of the arm, and paresthesias of the arm or hand. (See "Brachial plexus syndromes", section on 'Thoracic outlet syndrome'.)

Axillary vein thrombosis is most often due to heavy, prolonged use of the arm (so-called "effort thrombosis") but can occur from peripherally inserted central catheter (PICC) lines or other central venous catheters, or from thoracic outlet syndrome [20-23]. Symptoms include acute pain, swelling of the shoulder and arm, change in skin color, and temperature. (See "Primary (spontaneous) upper extremity deep vein thrombosis".)

It is common for overhead athletes to present with mild intermittent neurovascular complaints, often secondary to an underlying non-neurologic shoulder disorder, such as impingement or subtle instability. (See "Throwing injuries of the upper extremity: Clinical presentation and diagnostic approach".)

SUPPLEMENTARY ULTRASOUND EXAMINATION — 

Clinicians can incorporate diagnostic ultrasound into the physical examination to gain real-time visualization of many structures. In our experience, ultrasound can be a powerful tool for diagnosis and patient education, and it may improve patient satisfaction and compliance with the prescribed treatment plan. Performance of the ultrasound examination of the shoulder is reviewed in detail separately. (See "Musculoskeletal ultrasound of the shoulder".)

Multiple factors determine the successful integration of diagnostic ultrasound into the shoulder examination. These include access to equipment, capabilities of the ultrasound machine available, clinician proficiency, and administrative considerations such as scheduling, documentation, institutional privileging, and reimbursement.

For those clinicians who want to incorporate diagnostic ultrasound into the shoulder examination, there are two basic approaches.

●Comprehensive diagnostic evaluation – A comprehensive ultrasound examination typically involves a systematic progression using standard views of all major structures and documentation in accordance with published guidelines. The expectation is that the clinician produces a study of comparable quality to that obtained with a standalone imaging test ordered through a radiology department or other specialist. An example of when such an approach might be appropriate is a patient with a magnetic resonance imaging (MRI)-incompatible pacemaker and nonlocalizing symptoms on physical examination with possible surgical pathology.

●Focused diagnostic evaluation – A focused ultrasound examination is used to examine particular structures to address one or a small number of specific diagnostic questions. Such targeted application is a practical adjunct to the physical examination. An example of such use is a patient with possible long-head biceps tenosynovitis. Ultrasound readily reveals signs of tenosynovitis and can be used to assess tendon integrity and stability. Other examples include diagnosing an enlarged subacromial bursa or calcific tendinopathy.

INSPECTION — 

Inspection is an important but often overlooked part of the shoulder examination (table 1).

●General appearance – Before focusing on the shoulder, note the patient's posture and general appearance, which sometimes allows insight into the cause of shoulder dysfunction or underlying factors that may be contributing to their symptoms. Although the vast majority of patients seeking medical attention for shoulder symptoms have shoulder pathology, the ill-appearing patient without a distinct history of shoulder injury raises concern for referred pain from cardiac, biliary, or intra-abdominal conditions.

●Guarding – In the setting of acute injury, guarding and self-imposed immobilization of the arm suggest significant injury. The clinician may perform a limited examination and then choose to proceed promptly to imaging studies. As examples, the patient with an anterior glenohumeral dislocation typically holds their arm in slight abduction with external rotation using their opposite hand, while the patient with an acute acromioclavicular sprain often has a step-off at the joint and holds their arm to their side.

●Basic movements – Watch the way the patient takes off their coat or dons an examining gown. Unilateral abnormalities in motion, such as an inability to lower the arm smoothly or use of the functional arm to help lower the injured one (possible supraspinatus tear) or use of accessory muscles to raise the arm (possible impingement syndrome or supraspinatus tear), may provide diagnostic clues.

●Posture – The patient's posture is often revealing. One posture often associated with shoulder pain involves the head and chin thrust forward with the shoulders rounded and protracted (ie, the chest is collapsed) (picture 2) [24]. Many patients who work primarily at a desk assume this posture due to dysfunction of the scapular stabilizing muscles. Athletes who assume this posture frequently have pectoralis muscles that are tight or significantly stronger than the antagonists and scapular retractors (latissimus dorsi, upper trapezius, rhomboids), which are often weak and stretched. If the scapular retractors are extremely weak or neurologically inhibited, winging of one or both scapulae may be observed (picture 1).

●Deformities and other abnormalities – After looking at the patient's posture and general appearance, inspect the shoulder region looking for any abnormality. This may include an obvious deformity, such as the classic "Popeye" deformity of the upper arm suggesting rupture of the long head biceps tendon (picture 3); a subtle asymmetry, such as a difference in shoulder height (picture 4); or a lesion, such as a surgical scar. Observe and compare the area around the patient's glenohumeral joints, looking for abnormal contours, possibly from muscle atrophy or frank dislocation. Compare the bony prominences of the scapulae, acromioclavicular joint, clavicles, and sternoclavicular joints for signs of trauma or degenerative change.

Obvious deformity is common with traumatic shoulder injuries, such as a high-grade acromioclavicular separation (picture 5) or a clavicle fracture (picture 6). However, deformities or asymmetries from nontraumatic shoulder pathology are usually more subtle. Look carefully at the elevation of the patient's shoulders and the position of their scapulae. Motion at the scapular thoracic articulation plays an important role in shoulder function, and assessing scapulothoracic function is an important part of the shoulder examination. Asymmetric positioning of the scapulae suggests problems with this articulation. (See 'Scapulothoracic motion and strength' below.)

●Appearance of scapula – The patient should be viewed from behind to assess scapular positioning. This can be done with the patient's arms at their sides or in a push-up position with their hands against a wall. Scapular position is described as elevated, depressed, retracted (rotated back on the chest wall), or protracted (rotated forward on the chest wall) (figure 7). An elevated, protracted scapula is the most common dysfunctional position and is often described as "winging" (picture 1 and figure 8 and movie 1). Although scapular winging is classically associated with dysfunction of the long thoracic nerve, muscular dysfunction (rather than true nerve injury) is usually the cause.

●Atrophy – Look for atrophy of the deltoid, supraspinatus, or infraspinatus (picture 7) muscles. Deltoid atrophy renders the acromial borders more prominent. Atrophy of the supraspinatus and infraspinatus (picture 7) in the older patient suggests the presence of a large, chronic rotator cuff tear. In the younger patient, such atrophy raises concern for suprascapular nerve injury. (See 'Neurovascular assessment' above.)

●Skin – Note the appearance of the skin, including the presence and location of ecchymosis, striae, depigmentation, or scarring. Surgical scars should prompt questions about prior shoulder injuries and surgery. An abnormal-appearing scar suggests the possibility of a collagen disorder.

PALPATION — 

Palpate the shoulders systematically, comparing each side (table 1). We suggest starting with the neck to rule out cervical pathology. Spasm of the paracervical and superior trapezius muscles is a nonspecific finding consistent with numerous cervical problems, including radiculopathy.

If referred pain from an intra-abdominal source is suspected, examine the abdomen carefully. In patients with shoulder trauma, gentle palpation can be used to identify areas of focal tenderness or deformity. As examples, a step-off in the clavicle would be consistent with a fracture, while tenderness at the acromioclavicular joint suggests an injury of the acromioclavicular ligament. Anterior glenohumeral dislocation can manifest as a palpable concavity in the subacromial space along with a bony prominence anteriorly (from the displaced humeral head).

For patients with nontraumatic intrinsic shoulder problems, at a minimum, the clinician should systematically palpate the common and important sites of pathology. Moving from proximal to distal structures, these sites include:

●Cervical spine

●Sternoclavicular joint and clavicle

●Scapular spine and adjacent musculature

●Acromion, subacromial space, and acromioclavicular joint

●Bicipital groove and greater and lesser tuberosities of the humerus

The subscapular bursa can be palpated at the junction of the superior-medial angle of the scapula and the closest underlying rib (picture 8). Exposure of this bursa requires full adduction of the ipsilateral arm, which is accomplished by having the patient hold their opposite shoulder. Anatomical studies identify six scapular bursa, two major and four minor. The minor bursa are inconsistently present. The bursa at the scapular superomedial border and inferior angle are most often associated with symptoms [25].

The acromion process of the scapula is covered by the deltoid muscle. The supraspinatus tendon attaches to the greater tubercle, located just under the anterior third of the acromion. The subacromial structures may be indirectly examined by palpating directly below the acromion (picture 9). Alternatively, these structures can be moved anteriorly and better palpated by extending the shoulder [15]. This is accomplished by gently lifting the elbow of the adducted arm posteriorly (picture 10). Tenderness is consistent with impingement syndrome, rotator cuff tendinopathy, rotator cuff tear, subacromial bursitis, muscle contusion, or a humeral lesion.

The bicipital groove can be identified by locating the greater tuberosity of the humerus and then moving the fingers slightly medially into the groove (picture 11). This examination is best done with the shoulder partially externally rotated.

Tenderness of the acromioclavicular and sternoclavicular joints is assessed as follows. The anterior, lateral, and posterior edges of the acromion are demarcated. The acromioclavicular joint is palpated at the juncture of the acromion and distal clavicle, approximately 4 cm proximally from the lateral edge of the acromion (picture 12 and picture 13). Identifying the acromioclavicular joint by this method may be challenging, particularly in individuals with robust deltoid musculature or excessive adipose. Alternatively, the examiner may begin palpation medially at the sternoclavicular joint and carefully follow the clavicle to its distal end, where the proximal aspect of the acromioclavicular joint is located.

The sternoclavicular joint is palpated at the juncture of the proximal end of the clavicle and the lateral edge of the sternum, approximately 2 to 3 cm from the midline of the body. Tenderness at the acromioclavicular joint may be the only palpable finding for those suffering chronic joint pain.

RANGE OF MOTION

Approach to shoulder motion assessment — Range of motion (ROM) testing helps to determine the site and nature of intrinsic shoulder pain (table 2). Although a healthy shoulder has extensive mobility, ROM varies among patients; thus, it is important to compare shoulders (table 3). Full, painless ROM requires a normal glenohumeral joint, intact rotator cuff tendons, and functional rotator cuff muscles. (See "Evaluation of the adult with shoulder complaints", section on 'Anatomy and biomechanics'.)

The clinician should develop a routine and repeatable examination procedure (table 1). The clinician should be prepared to modify the approach to the patient as certain painful, acute injuries may preclude adhering to a rigid protocol.

Generally, active motion is assessed before passive. However, passive ROM is evaluated first when active ROM is severely limited or painful. Active motions are those motions performed by the patient independent of the examiner. Passive motions are those motions performed by the examiner without patient assistance.

The examiner should begin by watching the patient perform full flexion and elevation, full abduction and elevation, internal and external rotation with elbows at their side, internal and external rotation at 90 degrees of abduction in the neutral plane, and repeated abduction and elevation with the examiner watching scapular motion from behind the patient. If any of these are limited, the examiner repeats each of these with passive motion to assess whether the limitation is structural.

Active range of motion — The examiner should begin by observing active motions performed by the patient. These should include all the primary planes of motion (table 2 and table 3):

●Flexion and extension

●Adduction and abduction

●Internal and external rotation

Movements begin with the shoulder in a neutral (arm at side) position. Internal and external rotation are repeated from a starting position with the shoulder abducted to 90 degrees.

Active ROM can also be assessed by having the patient perform each shoulder motion (flexion, extension, abduction, adduction, internal rotation, and external rotation) unilaterally or by performing bilateral motions simultaneously, which enables the clinician to compare sides. (See "Frozen shoulder (adhesive capsulitis)" and "Clinical manifestations and diagnosis of osteoarthritis", section on 'Shoulder'.)

Although distinct, glenohumeral and scapulothoracic motion are interdependent, and they should be assessed both independently and together. In the normal shoulder, for every 30 degrees of glenohumeral abduction, there is a corresponding 12 degrees of scapulothoracic rotation [26-28]. Note that symptoms at one articulation may be caused by dysfunction at the other. As an example, rotator cuff pathology may be caused by weakness in the scapular stabilizing muscles. Conversely, the scapular stabilizers may be subjected to overuse in the setting of reduced glenohumeral mobility.

Assess internal rotation of the shoulder with the patient's arm at 90 degrees of abduction while stabilizing the scapula. This positioning isolates glenohumeral internal rotation. When examining overhead athletes, look for compensatory loss of internal rotation and increased external rotation. In the contralateral (eg, non-throwing) shoulder, full range of motion should be present.

In addition to the standard motion tests described above, Apley "scratch" tests can provide an easy and reproducible way to assess shoulder motion. However, they should be performed as an adjunct to standard ROM tests as they do not adequately assess all shoulder movements (picture 14) [29]. The Apley tests are performed as follows (movie 2):

●External rotation and abduction assessment – Ask the patient to reach behind their head and touch the superior medial tip of the opposite scapula. A patient with normal function can reach approximately the level of the T4 spinous process.

●Internal rotation and adduction assessment – Ask the patient to reach behind their back and touch the inferior tip of the opposite scapula. A patient with normal function can reach approximately the level of the T8 spinous process.

●Additional adduction assessment – Ask the patient to reach across their chest and touch the opposite shoulder. A patient with acromioclavicular pathology or impingement will have difficulty with this maneuver.

Passive range of motion — If active motion is limited, passive ROM performed by the examiner should be assessed for each major movement of the shoulder. Such testing helps the clinician to distinguish between motion limitations caused by pain and those caused by a structural constraint (eg, adhesive capsulitis or glenohumeral arthritis).

ROM limitations may be a clue to various shoulder pathologies:

●Acute injury (eg, glenohumeral dislocation, fracture)

●Significant rotator cuff tear or labral tear

●Pain from rotator cuff tendinopathy or, less commonly, acute inflammation

●Adhesive capsulitis (ie, frozen shoulder)

●Glenohumeral joint arthritis (osteoarthritis or inflammatory)

In most patients, the degree of impairment correlates with the severity of these conditions. Side-to-side comparison provides the most practical and objective assessment of motion.

EXAMINATION FOR ROTATOR CUFF PATHOLOGY

Overview and evidence — Rotator cuff injury is among the most common causes of shoulder pain. The rotator cuff tendons, particularly the supraspinatus tendon, are uniquely susceptible to subacromial impingement and dominate the conditions affecting the shoulder, especially in patients over the age of 30. Rotator cuff tendinopathy almost always represents a chronic injury of the supraspinatus and/or infraspinatus tendons. Although rotator cuff tendinopathy may occur as an isolated problem, it is often accompanied by subacromial bursitis.

Tendinopathy usually develops as a consequence of repetitive activity, generally performed at or above shoulder height, which leads to tendon degeneration and microvascular insult. Relevant shoulder anatomy and biomechanics, and the diagnosis and management of rotator cuff tendinopathy, are discussed separately. (See "Evaluation of the adult with shoulder complaints", section on 'Anatomy and biomechanics' and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears".)

Systematic reviews of studies that assess shoulder examination tests report a wide range of approaches and methodological quality [30-34]. This variation precludes meaningful meta-analysis of most tests for rotator cuff integrity. Systematic reviews of shoulder examination techniques conclude that no single maneuver can be relied upon to diagnose any particular shoulder condition or injury and emphasize the need for a comprehensive diagnostic approach guided by the history [35-37].

Assessment of abduction and the supraspinatus — The supraspinatus muscle and tendon play major roles in shoulder abduction and stabilization [38,39]. The role of the supraspinatus in abduction is synergistically coordinated with the deltoid, periscapular, and trapezius muscles. In addition, the supraspinatus dynamically stabilizes the humeral head within the glenoid fossa during abduction. Without adequate retraction and stabilization of the humeral head, upward and/or forward migration of the head occurs, which may contribute to impingement. (See 'Special tests for shoulder impingement' below.)

Inadequate supraspinatus function may occur for a variety of reasons, including tendon tears, tendon thickening, tendinitis, and pain-related neuro-inhibition. Independent of supraspinatus pathology, subacromial or subdeltoid bursitis may contribute to symptoms of pain or weakness.

Of the three abductors of the shoulder (deltoid, supraspinatus, and superior trapezius muscles), the supraspinatus plays a primary role in the initial abduction of the arm (to approximately 30 degrees), although it is active throughout abduction. Thus, isometric testing of the arm early in abduction may better assess the strength and integrity of the supraspinatus tendon.

Tests purported to isolate supraspinatus function are controversial, and studies of them are limited. Based upon this limited evidence and our clinical experience, we perform the following examination tests to assess supraspinatus function:

●Isometric strength testing – Supraspinatus isometric strength is assessed by having the patient abduct the arm to about 20 degrees in a neutral plane and having the patient resist continuous pressure for 30 seconds while the examiner attempts to adduct the arm (picture 15). Continuous pressure for a relatively prolonged period fatigues the deltoid muscle, which also contributes to the initiation of abduction.

This isometric test of supraspinatus strength is highly sensitive but nonspecific for the diagnosis of supraspinatus tendon injury [40]. Note that the severity of functional impairment during testing does not correlate well with the size of a tendon tear.

●Active painful arc test – The integrity of the supraspinatus tendon can be assessed with the active painful arc test and the "drop arm" test. The active painful arc test (not to be confused with the Neer test, an impingement test performed passively and described separately) simply involves having the patient actively abduct their arm in the scapular plane from a neutral position. Pain with active abduction beyond 90 degrees marks a positive test (picture 16).

●Drop arm test – The drop arm test assesses the ability of the patient to lower their arms from a fully abducted position. A positive test occurs when the patient is unable to lower the affected arm with the same smooth, coordinated motion as the unaffected arm (movie 3) [41].

●Empty can (Jobe) test – The "empty can" (or Jobe) test is another important way of evaluating supraspinatus function. Many authors consider this the gold standard for evaluating supraspinatus function as this position makes the supraspinatus the primary muscle opposing downward motion of the arm. When pain is used to determine a positive test, the sensitivity and specificity to detect tendinopathy versus partial tendon tear is poor. However, weakness without pain is more sensitive and specific for partial or complete tendon tear [37].

The empty can test is performed as follows:

•The patient fully extends their elbow (ie, straight arm) and abducts the shoulder to about 90 degrees in the scapular plane (about 30 degrees of forward flexion).

•From this position, the patient internally rotates the shoulder completely (ie, thumb pointing down) (picture 17).

•The examiner then attempts to depress the arm while the patient resists.

When pain limits the ability to evaluate strength in abduction, the clinician can assess the integrity of the axillary nerve by having the patient fully adduct the shoulder and then abduct against some resistance while they feel for muscle contraction [42]. In addition, before attributing weakness to a supraspinatus tear, the authors note any history of neck pain or injury, limitations in motion of the cervical spine, and the presence of pain that radiates to the elbow or further distally. Such findings raise the possibility of weakness from neurologic or musculoskeletal pathology proximal to the shoulder joint. (See "Evaluation of the adult patient with neck pain" and "Clinical features and diagnosis of cervical radiculopathy".)

Assuming the absence of a neck or nerve injury (such injury is uncommon unless there is a history of trauma), weakness that manifests with any of the tests described here suggests the presence of at least a partial supraspinatus tear. However, scapular dyskinesis places additional strain on the supraspinatus and may inhibit its normal motion, and this may be the underlying cause of weakness.

To determine whether scapular dyskinesis is contributing to supraspinatus-related symptoms, repeat the tests above while ensuring the scapula is properly retracted. This is done by pressing the scapula against the patient's back while the patient performs the test. If strength improves with scapular stabilization, weakness is likely due to scapular dysfunction and not to an injury of the supraspinatus. Scapular stabilization is described in greater detail separately. (See 'Scapulothoracic motion and strength' below.)

Assessment of external rotation and the infraspinatus — The infraspinatus muscle is primarily responsible for external rotation of the shoulder, with the teres minor muscle contributing to a minor degree.

●Resisted external rotation – Resisted external rotation testing of the infraspinatus is used to assess the strength and integrity of the tendon as well as to elicit pain suggestive of injury. The starting position for this test is with the arm at 0 degrees abduction (ie, fully adducted, elbow at 90 degrees of flexion, and the shoulder in neutral rotation). The patient then attempts to externally rotate their adducted arm while the clinician resists the movement with their hand (picture 18 and movie 4).

●Drop sign – This test is performed with the examiner abducting the patient's arm to 90 degrees in the scapular plane, supporting the elbow with one hand, and then externally rotating the shoulder with the other hand. The rotation is just short of maximal. The patient is then asked to maintain this degree of external rotation for 10 seconds after the examiner removes both hands. The test is positive if the patient allows more than 5 degrees of internal rotation to occur.

In a prospective observational study of 91 patients scheduled for shoulder arthroscopy, clinicians compared six tests for infraspinatus integrity to intra-operative findings and found the drop sign and resisted external rotation test to correlate most closely with injury [43].

Preliminary data suggest that the Hornblower sign is specific but insensitive for identifying infraspinatus injury [44]. This sign is elicited by asking the patient to reach for their mouth without elevating the elbow. The test is considered positive if the patient elevates the elbow more than the hand.

Assessment of internal rotation and the subscapularis — The subscapularis is the rotator cuff muscle primarily responsible for internal rotation of the shoulder. We acknowledge the bewildering array and poor sensitivity of tests for subscapularis function. Although sensitivity may improve by performing multiple tests, as a practical matter, we suggest that non-orthopedists familiarize themselves with one or two common maneuvers and use these for assessment. The authors prefer the push-off (Gerber) test, possibly supplemented with the bear hug test.

●Push-off (Gerber lift-off) test – This test is performed by having the patient place one hand behind their back and push posteriorly against resistance (picture 19). As with other strength tests, the essential distinction is between pain with weakness (significant tendon tear) and pain without weakness (tendinopathy or minor tendon tear).

Numerous additional maneuvers for detecting subscapularis tendon tears have been described, including the internal rotation lag sign, belly press test, belly off sign, bear hug test, Napoleon test, and supine Napoleon test. In addition to the push-off test, we find the internal rotation lag sign useful. The belly press and bear hug tests are useful for patients with limited internal rotation.

●Internal rotation lag sign (IRLS) – To perform the IRLS, the patient places their hand behind their back with the elbow flexed to 90 degrees and the palm facing outward (ie, away from the body). The examiner then passively moves the patient's hand and elbow away from their body (picture 20). The clinician then releases the hand and asks the patient to maintain this position. The test is negative if the position can be maintained. A positive test, suggesting injury, occurs if the hand drifts toward the body.

●Belly press test – If the patient cannot perform the IRLS because of limited internal rotation, the belly press may be used. To do so, the examiner places their hand on the patient's belly at the level of the navel. The patient places their palm on the examiner's palm and presses against the examiner's hand. If the subscapularis is intact, the examiner will feel pressure on their palm from the patient's exertion, and the elbow will remain anterior to the body. A positive test occurs when the elbow drifts behind the patient's side, which suggests weakness and injury.

●Bear hug test – This test is performed by having the patient place the hand of the affected side on their opposite shoulder, with their fingers straight to avoid gripping the shoulder, and then raise (abduct) the affected shoulder until it is horizontal (approximately parallel with the ground). The examiner then attempts to lift the patient's hand off their shoulder while the patient resists. If the patient cannot keep their hand on the contralateral shoulder, this marks a positive test, suggesting injury. By lifting the patient's hand, the clinician exerts an external rotation force on the shoulder, which the patient must resist with internal rotation.

Studies of these tests are typically small and vary in approach making interpretation difficult [45-48]. A systematic review and meta-analysis of 13 studies assessing four tests for subscapularis injury (lift-off, IRLS, belly press, and bear hug) found no single test to be sufficiently reliable for diagnosis [49]. While specificity was good, sensitivity was limited for each. As other authors have suggested, it is best to perform several tests to improve diagnostic accuracy for subscapularis tears.

Testing for rotator cuff tear — Although many textbooks and clinicians have long advocated using the physical examination to determine the presence of rotator cuff pathology, well-performed studies to support particular examination techniques or approaches are scarce. Based upon the best available evidence and our clinical experience, we suggest using three tests in combination to determine whether a rotator cuff tear exists:

●Active painful arc test (picture 16)

●Drop arm test (movie 3)

●Weakness in external rotation (picture 18 and movie 4)

If all three tests are positive, a significant rotator cuff tear is likely; if all three are negative, a significant tear is unlikely. The presence of a rotator cuff tear is difficult to determine in patients whose examination reveals only one or two positive tests. Diagnostic imaging is often needed to clarify the presence or absence of a full-thickness rotator cuff tear in such cases. The performance of these tests is described separately. (See 'Assessment of abduction and the supraspinatus' above and 'Assessment of external rotation and the infraspinatus' above.)

The evidence behind this approach is reviewed separately. (See "Presentation and diagnosis of rotator cuff tears", section on 'Physical examination'.)

Muscle lag testing — The concept of muscle lag provides the basis for several published tests of rotator cuff integrity, including the external rotation lag sign, internal rotation lag sign, drop or dropping sign, belly press test or Napoleon sign, and the belly off test [41,50,51]. These tests exploit the biomechanical length-tension curve of muscle force generation and the antagonistic actions of the rotator cuff muscles [41]. Although one systematic review reported that the internal and external lag tests were the most accurate for identifying full-thickness tears, this conclusion was based upon a single study involving 37 patients evaluated at a subspecialty referral center [52,53]; further study is required before muscle lag tests can be recommended to diagnose rotator cuff tear.

To assess muscle lag, the muscle is passively placed in its maximally shortened position, either full external rotation (picture 21) or full internal rotation (picture 20). When placed in this position, the ability of the muscle to exert force is minimized. The patient is then asked to maintain that position with active contraction. The difference between this passive and active range of motion (ROM) is called the lag. Lag represents an inability of the muscle to resist the antagonistic force of the opposing rotator cuff muscle and is thought to identify subtle decreases in rotator cuff strength suggestive of a tear. Loss of strength or integrity in the antagonistic muscles, decreases in passive ROM, or neurologically mediated strength deficits can confound results.

SPECIAL TESTS FOR SHOULDER IMPINGEMENT — 

The diagnosis of shoulder impingement syndrome (SIS) includes a range of clinical findings attributable to the compression of structures around the glenohumeral joint when the patient raises their arm. SIS does not refer to an injury of any specific structure, but supraspinatus injury is most common. Over time, compressed structures cause persistent pain and dysfunction. The symptoms of SIS are similar to those of rotator cuff tendinopathy, namely pain with overhead activity. The diagnosis and management of SIS is discussed separately. (See "Subacromial (shoulder) impingement syndrome".)

Although of variable quality, multiple prospective observational studies report that physical examination techniques for the shoulder are sensitive for the presence of SIS but cannot reliably distinguish among specific causes of pain and dysfunction [34,35,40,54-58]. The Neer and Hawkins-Kennedy impingement tests described below demonstrate overall sensitivities ranging from approximately 70 to 90 percent and are the primary tests we use to diagnose shoulder impingement.

Passive painful arc (Neer) test — The "passive painful arc maneuver" (passively flexing the glenohumeral joint while simultaneously preventing shoulder shrugging) is used to assess the degree of impingement (picture 22 and movie 5). Voluntary guarding by the patient while the maneuver is performed often manifests as shoulder shrugging. The severity of impingement and rotator cuff tendinopathy is determined by the angle at which the arc becomes painful.

●Pain at 90 degrees is consistent with mild impingement.

●Pain at 60 to 70 degrees is consistent with moderate impingement.

●Pain at 45 degrees or below is consistent with severe impingement.

Flexion with internal rotation (Hawkins-Kennedy) test — In this test, the clinician stabilizes the shoulder with one hand and, with the patient's elbow flexed 90 degrees, internally rotates the shoulder using the other hand (picture 23). Shoulder pain elicited by internal rotation represents a positive test.

The empty can test is also used by some clinicians to assess impingement. It is described separately. The empty can test or the infraspinatus tests can be used as confirmatory tests to increase specificity for impingement. The specificity may be as great as 90 percent [30,31].

Other tests — Although the Yocum test is used by some clinicians to assess impingement, evidence is scant, and the reliability of the maneuver has been questioned [59].

SCAPULOTHORACIC MOTION AND STRENGTH

Normal movement and approach to testing — Coordination of motion at the glenohumeral joint and the scapulothoracic articulation is important for normal shoulder function. Normally, once the shoulder is abducted more than 20 degrees, further abduction occurs at these articulations in a 2:1 ratio; for every 2 degrees of abduction at the glenohumeral joint, the scapulothoracic articulation moves 1 degree. Normal motion is smooth and symmetric. The biomechanics and anatomy of the shoulder are discussed in greater detail separately. (See "Evaluation of the adult with shoulder complaints", section on 'Anatomy and biomechanics'.)

There is abundant evidence that abnormal scapular motion is associated with glenohumeral pain and dysfunction [24,60]. However, high-quality evidence about which examination techniques are best for determining the underlying cause of shoulder dysfunction is lacking [61]. Nevertheless, we believe it is important to assess scapulothoracic motion as part of the general shoulder examination and to incorporate corrective exercises into any rehabilitation program if dysfunction is identified. According to a consensus statement from the second international conference on shoulder dyskinesis, three examination maneuvers are most useful for evaluating scapular function: direct observation, the scapular assistance test, and the scapular repositioning test [60]. In addition, supraspinatus strength testing can be performed with and without scapular stabilization to determine whether scapular dysfunction is contributing to the problem [62]. (See 'Assessment of abduction and the supraspinatus' above.)

Observation — Clinicians can assess scapulothoracic motion by observing the undressed patient from behind while simultaneous shoulder abduction and flexion is performed in the scapular plane. The patient can perform this movement while holding a light weight (2 lbs, or 1 kg). While the patient performs shoulder abduction and flexion, the clinician observes closely from behind, assessing for coordination, symmetry, and appearance. Normal motion is smooth and symmetric, and no border of the scapula should be especially prominent (as occurs with winging). Another technique is to feel the inferior tip of each scapula as the patient abducts and flexes their shoulders. The clinician can also measure the migration of the scapular tip away from the mid-thoracic line after repeated abduction to detect any progressive scapular winging and internal rotation of the shoulder.

Patients can compensate for decreased glenohumeral motion by using scapulothoracic motion, which is capable of up to 90 degrees of abduction. Such compensation manifests as shoulder shrugging. Abnormal motion most often occurs either to compensate for an injury that limits glenohumeral movement or because the stabilizing muscles of the scapula are weak, in which case there may be no asymmetry.

Special tests — Scapular instability, whether from nerve damage or muscle weakness alone, can be evaluated by either the repositioning or push-off tests. The scapular assistance test is part of the assessment of shoulder impingement. Although there is little high-quality evidence to support these tests, we have found them to be useful.

●Scapular repositioning test – To perform the scapular repositioning test (also called the scapular retraction or stabilization test), the patient flexes their shoulder while the examiner manually compresses the patient's scapula, particularly the medial portion, against the ribcage (picture 24) [60,63].

Alternatively, the patient can stabilize the scapula by standing with their back against a wall and pressing their scapula into the wall while abducting the shoulder. The elimination of pain or improved shoulder motion (shoulder flexion ≥150 degrees) and strength suggests scapular instability is contributing to the patient's symptoms.

●Scapular push-off test – In the push-off test, the patient pushes against a wall, as if performing an upright push-up. Instability manifests as scapular winging (picture 1 and movie 1).

●Scapular assistance test – The scapular assistance test is used to determine whether scapular dyskinesis is contributing to shoulder impingement, although few studies have been performed to determine its accuracy [60,64]. The test is performed by assisting scapular motion during abduction and flexion of the arm.

To perform the test, the clinician places one hand on the superior medial border of the scapula while the other hand is placed on the inferior medial scapular border (picture 25 and movie 6). As the patient actively raises their arm into positions that typically cause impingement, the examiner assists the posterior tilt, upward rotation, and external rotation of normal scapular motion. A positive test occurs when assistance relieves or reduces symptoms.

SPECIAL TESTS FOR SHOULDER INSTABILITY — 

The glenohumeral joint has a ball and socket structure. In contrast to the deep, rigid socket of the hip joint, the socket of the glenohumeral joint is shallow, like a golf ball perched on a tee. The shallowness of the joint allows for the extensive motion necessary for many sports and everyday activities but also requires that a number of dynamic (eg, rotator cuff muscles) and static (eg, labrum) structures provide stability.

Glenohumeral instability due to weakness or laxity in some of these structures may cause shoulder discomfort in young throwing athletes, people with weak shoulder musculature, and patients who have sustained a rotator cuff tear. Instability may be multi- or unidirectional; anterior and inferior laxities are most common. Several tests are used to assess this problem [65].

Sulcus sign — Downward movement of the humeral head is influenced by the tone and bulk of the deltoid, the tone and thickness of the supraspinatus muscle and tendon, and the structure and integrity of the glenohumeral capsule.

The sulcus sign maneuver evaluates the looseness of the glenohumeral joint and can help to determine a patient's tolerance for Codman pendulum exercises (picture 26 and movie 7). The following findings may be noted:

●No movement can be seen in patients with extreme guarding or muscle tension, or an overly developed deltoid muscle.

●Approximately 0.5 to 1 cm of movement is normal.

●Movement of 2 cm or more is consistent with hypermobility (glenohumeral subluxation).

Patients with benign glenohumeral hypermobility and disorders such as Ehlers Danlos can often voluntarily sublux the shoulder in multiple planes. (See "Clinical manifestations and diagnosis of hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder" and "Ehlers-Danlos syndromes: Clinical manifestations and diagnosis".)

Apprehension, relocation, and release tests — These tests work in combination and are most easily performed with the patient supine (picture 27 and movie 8).

●Apprehension test – The first of this series of three maneuvers is the apprehension test, which is performed as follows:

•The supine patient places their symptomatic arm in the throwing position (shoulder abducted and externally rotated).

•Next, with one hand, the examiner braces the patient's posterior shoulder.

•With their other hand, the examiner pushes on the patient's wrist with steady, gentle pressure, thereby increasing the abduction and external rotation forces exerted on the shoulder (as if attempting to dislocate the shoulder anteriorly).

Any sensation of impending dislocation at any time on the part of the patient constitutes a positive test. When performing the apprehension test, the clinician should apply pressure gradually and with care to avoid causing a dislocation in patients with significant glenohumeral instability.

●Relocation test – The relocation test begins at the end of the apprehension test. It is performed by simply reversing the forces being exerted by the examiner and proceeds as follows:

•The examiner stops exerting abduction and external rotation forces.

•The examiner then moves the hand that was bracing the posterior shoulder to the anterior shoulder and pushes the humerus posteriorly (as if attempting to relocate the shoulder).

Resolution of either pain or the sensation of impending dislocation on the part of the patient represents a positive test.

●Release test – The release test is performed immediately following the relocation test. The examiner abruptly stops pushing the humerus posteriorly. Any sensation of impending dislocation on the part of the patient constitutes a positive test.

A meta-analysis of these tests found both the relocation and release tests to have reasonable sensitivity (85 percent) and specificity (87 percent) for the detection of glenohumeral instability [65]. However, the authors warn that most of the studies reviewed involved patients in orthopedic clinics, and it remains uncertain whether their findings apply to more general populations. A subsequent systematic review reported that positive apprehension, relocation, and release tests are "diagnostic of anterior instability" based primarily upon the results of three high-quality trials but stated that data were insufficient to perform a meta-analysis [30]. The authors emphasized that using apprehension as the marker for a positive test, rather than pain, substantially improved test performance.

Load and shift test — The load and shift test measures anterior and posterior glenohumeral laxity [66,67]. The test is positive if there is significant translocation of the humeral head anteriorly or posteriorly in the glenoid fossa when applying a force in the respective direction.

The standard load and shift test is performed by applying an axial load to the glenohumeral joint (ie, pressing the humeral head into the glenoid) and then attempting to translocate the humeral head anteriorly and then posteriorly (picture 28). The acromion is held in a fixed position with the clinician's opposite hand while the maneuver is performed.

A modified version of the load and shift test is performed with the patient supine and their shoulder abducted 90 degrees. Again, the examiner applies an axial load by pressing the humeral head into the glenoid and then attempts to translocate the humeral head. Performing the test with the patient supine allows the scapula to be stabilized by the examining table, thereby making it easier to sublux the humeral head. The modified test may be easier to perform if the patient is larger or more muscular than the examiner.

Translocation is scored as follows: grade 1 is translation of 0 to 1 cm, grade 2 is translation of 1 to 2 cm or to the glenoid rim, grade 3 is subluxation beyond the edge of the glenoid rim, and grade 4 is a complete dislocation. The test should be performed on both shoulders to compare the affected and normal sides. While a positive load and shift test suggests instability, the apprehension, relocation, and anterior release tests are better predictors of arthroscopically evident instability [65].

Jerk test — The jerk test is used to assess posteroinferior glenohumeral instability or labral tear [68,69]. The test is usually performed with patient seated and proceeds as follows:

●Standing behind the patient, the examiner stabilizes the patient's scapula with one hand while grasping the patient's elbow with the other.

●The examiner then passively moves the patient's shoulder into 90 degrees of abduction and internal rotation.

●The examiner then applies an axial load to the elbow, thereby engaging the humeral head in the glenoid, and gradually adducts the patient's arm across their body.

In the presence of a posteroinferior labral tear, the humeral head will suddenly shift (or "jerk") posteriorly.

Hyperextension internal rotation test — The hyperextension internal rotation (HERI) test has been proposed as an alternative method to evaluate anterior shoulder instability. In a small observational study, the test identified significant differences in motion (>10 degrees) in 41 of 50 patients with known anterior glenohumeral instability [70]. One appeal of this test is that patients need not be placed in a position of instability, thereby eliminating the possibility of accidental dislocation and reducing any pain or apprehension the patient may experience.

The test is performed by an examiner standing behind the patient. If examining the right shoulder, the clinician holds the left wrist of the patient and passively flexes their arm above their head while simultaneously placing their left elbow atop the patient's left scapula. This bracing position is used to help prevent movement of the torso and scapula when assessing the opposite shoulder. The right shoulder is then brought into maximal extension passively. The angle formed by the arm relative to a vertical line to the ground is compared with that of the contralateral shoulder [70].

SPECIAL TESTS FOR BICEPS TENDON PATHOLOGY — 

Assessment of the biceps tendon includes evaluation for a spectrum of disorders ranging from mild tendinopathy to complete tendon rupture. Biceps tendon injuries occur more often in patients who engage in frequent pulling, lifting, reaching, or throwing for work or recreation. Degenerative tendinosis and biceps tendon rupture are usually seen in older patients, while isolated tendinopathy usually presents in young or middle-aged patients. The examination techniques used to diagnose biceps tendon pathology, in addition to the relevant anatomy, presentation, diagnosis, and management of biceps tendon injuries, are discussed separately. (See "Biceps tendinopathy and tendon rupture".)

SPECIAL TESTS FOR LABRAL (SLAP) PATHOLOGY — 

Superior labrum anterior posterior (SLAP) tear refers to a specific injury of the superior portion of the glenoid labrum that extends from anterior to posterior in a curved fashion. These tears are common in overhead throwing athletes and laborers involved in overhead activities. SLAP injuries, including the examination maneuvers used to help diagnose them, are described separately. (See "Superior labrum anterior to posterior (SLAP) tears".)

EXAMINATION OF THE ACROMIOCLAVICULAR JOINT — 

Shoulder function depends upon movement at three joints, including the acromioclavicular joint, and one articulation. Common conditions afflicting the acromioclavicular joint include acute injuries (often referred to as "shoulder separation"), idiopathic osteoarthritis, post-traumatic arthritis, and osteolysis. Focal pain and tenderness at the acromioclavicular joint and increased pain when the patient reaches across their body are common findings. Conditions that can mimic acromioclavicular pathology include rotator cuff disease and labral tears. Conditions affecting the acromioclavicular joint and examination of this joint are reviewed separately. (See "Acromioclavicular joint disorders", section on 'Examination' and "Acromioclavicular joint injuries ("separated" shoulder)".)

EXAMINATION OF THE STERNOCLAVICULAR JOINT — 

Trauma, such as a fall onto the shoulder or a direct blow to the area around the superior sternum and medial clavicle, can cause sternoclavicular dislocations or fractures. Injuries or deformities of the sternoclavicular joint are typically identified by palpation. Most dislocations are anterior and are easily recognized as an anterior prominence adjacent to the manubrium. Posterior dislocations are more difficult to diagnose and potentially more dangerous, as vascular structures traveling behind the clavicle may be injured. Localized joint swelling may obscure the posterior position of the clavicle. (See "Initial evaluation and management of chest wall trauma in adults", section on 'Sternoclavicular dislocation'.)

SUMMARY AND RECOMMENDATIONS

●Limitations of the shoulder examination – Many maneuvers are used to assess shoulder function and are often taught as if they are pathognomonic for a particular pathology. However, the diagnostic accuracy of these tests is often limited. Tips for performing a focused and productive shoulder examination are provided in the text. An examination checklist is provided (table 1). (See 'Tips for a productive examination' above.)

●Neurovascular assessment – Among patients with recent trauma, neurologic complaints (eg, weakness, paresthesias), or unusual presentations, a careful neurovascular assessment is essential; among patients without such complaints, a focused neurovascular examination confirming basic motor function and sensation and adequate blood flow is sufficient. Neurovascular injuries associated with shoulder complaints include cervical spine fracture and spinal cord injury, brachial plexus neurapraxia, and axillary nerve injury (often associated with anterior glenohumeral dislocation). (See 'Neurovascular assessment' above.)

●Inspection – Inspection is an important but often overlooked part of the shoulder examination. Make note of the patient's posture (including how they hold the affected arm), the appearance of the entire shoulder (including the posterior glenohumeral and scapulothoracic regions), and any deformity, asymmetry, or skin abnormality. (See 'Inspection' above.)

●Palpation – Palpate the shoulders systematically, comparing each side. We suggest starting with the neck to rule out cervical pathology. At a minimum, the clinician should palpate the following sites:

•Cervical spine

•Scapular spine and adjacent musculature

•Acromion and the subacromial space

•Bicipital groove

•Greater and lesser tuberosities of the humerus

•Clavicle, including sternoclavicular and acromioclavicular joints (see 'Palpation' above)

●Range of motion – Range of motion (ROM) testing helps to determine the site and nature of intrinsic shoulder pain (table 2 and table 3). Although a healthy shoulder has extensive mobility, ROM varies among patients; thus, it is important to compare shoulders. Full, painless active ROM requires a normal glenohumeral joint, intact rotator cuff tendons, and functional rotator cuff muscles. (See 'Range of motion' above.)

●Rotator cuff – Rotator cuff injury is among the most common causes of shoulder pain, especially in patients over the age of 30. Examination maneuvers to assess the rotator cuff and shoulder impingement, an important risk factor for rotator cuff injury, are described in the text. (See 'Examination for rotator cuff pathology' above and 'Special tests for shoulder impingement' above.)

●Coordination and scapulothoracic function – Coordination of motion at the glenohumeral joint and the scapulothoracic articulation is important for normal shoulder function. Among patients who work primarily at a desk, scapulothoracic dysfunction is a common contributor to shoulder pain. Assessment of scapulothoracic function is described in the text (figure 7). (See 'Scapulothoracic motion and strength' above.)

●Instability – Glenohumeral instability due to weakness or laxity in some of the structures that stabilize the joint may cause shoulder discomfort in young throwing athletes, people with weak shoulder musculature, and patients who have sustained a rotator cuff tear. (See 'Special tests for shoulder instability' above.)