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Official reprint from UpToDate®

www.uptodate.com © 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Physical examination of the shoulder

Authors: Stephen M Simons, MD, FACSM, J Bryan Dixon, MD
Section Editor: Karl B Fields, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Feb 2023. | This topic last updated: Mar 04, 2021.

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 to help determine whether advanced imaging is
needed.

The large number of shoulder examination techniques, often named for their originators, 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. (See "Evaluation of the adult
with shoulder complaints" and "Subacromial (shoulder) impingement syndrome" and "Rotator
cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears" and
"Acromioclavicular joint disorders" and "Frozen shoulder (adhesive capsulitis)" and "Radiologic
evaluation of the painful shoulder in adults" and "Overview of upper extremity peripheral nerve
syndromes", section on 'Proximal neuropathies' and "Clinical manifestations and diagnosis of
osteoarthritis", section on 'Shoulder'.)

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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.

● 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 women, 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 and 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.
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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
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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 elder patients,
cervical injuries can occur from minor trauma, such as a fall from standing. Assume the
presence of a cervical spine injury in any elder 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 "Evaluation and initial
management of cervical spinal column injuries in adults" 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 "Evaluation and
initial management of cervical spinal column injuries in adults".)

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
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(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. (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'.)

Compression of the suprascapular nerve 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 [3-7].
Suprascapular neuropathy causes posterior shoulder pain and produces atrophy and weakness
of the supraspinatus and/or infraspinatus muscles.

Compression of the long thoracic nerve 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 [8-10]. Symptoms include acute pain in the extremity or
posterior chest wall followed by decreased shoulder range of motion, weakness with scapular
retraction and external rotation of the shoulder, and scapular winging ( picture 1).

The axillary nerve 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 [11-17]. 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
[15].

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Vascular conditions, including thoracic outlet syndrome and axillary vein thrombosis, can cause
shoulder pain. The term thoracic outlet syndrome (TOS) describes a variety of upper extremity
syndromes involving compression of the neurovascular structures that pass from the neck to
the axilla. 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 PICC lines or other central venous catheters, or from TOS [18-
21]. 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 should be noted that 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.

INSPECTION

Inspection is an important but often overlooked part of the shoulder examination.

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. In the setting of acute injury, guarding and self-imposed
immobilization of the arm suggest significant injury. The clinician may perform a limited exam
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.

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.

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) [22]. Many patients who work primarily at a desk assume this
posture due to dysfunction of the scapular stabilizing muscles. Athletes who assume this
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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).

Insight may be gained from the patient's general appearance. 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.

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, 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 4) or a clavicle fracture. 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.)

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 1). An elevated, protracted scapula is
the most common dysfunctional position and is often described as "winging" ( picture 1 and
figure 2 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.

Look for atrophy of the deltoid, supraspinatus, or infraspinatus muscles. Deltoid atrophy
renders the acromial borders more prominent. Atrophy of the supraspinatus and infraspinatus

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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.)

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. 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 (AC) joint suggests an injury of the AC
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 (AC) 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 5). Exposure of this bursa requires full
adduction of the ipsilateral arm, which is accomplished by having the patient hold their
opposite shoulder.

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.

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The subacromial structures may be indirectly examined by palpating directly below the
acromion ( picture 6). Alternatively, these structures can be moved anteriorly and better
palpated by extending the shoulder [13]. This is accomplished by gently lifting the elbow of the
adducted arm posteriorly ( picture 7). 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 8). This examination is best
done with the shoulder 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 AC joint is palpated
at the juncture of the acromion and distal clavicle, approximately 4 cm proximally from the
lateral edge of the acromion ( picture 9 and picture 10). The SC 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 AC 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 1). Although a healthy
shoulder has extensive mobility, ROM varies among patients and thus it is important to
compare shoulders ( table 2). 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. 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 motion 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
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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: flexion and extension;
adduction and abduction; and, 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 range of motion can also be assessed by having the patient perform each shoulder
motion (flexion, extension, abduction, adduction, internal, 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 [23-25]. 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 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 range of motion tests as they do not adequately assess all shoulder
movements ( picture 11) [26]. The Apley tests are performed as follows ( movie 2):

● To assess external rotation and abduction, the patient is asked 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.

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● To assess internal rotation and adduction, the patient is asked 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.

● To assess adduction further, the patient is asked 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 range of motion 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).

Range of Motion 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".)

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Systematic reviews of studies that assess shoulder examination tests report a wide range of
approaches and methodological quality [27-31]. 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 [32-34].

Assessment of abduction and the supraspinatus — The supraspinatus muscle and tendon
play major roles in shoulder abduction and stabilization [35,36]. 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.

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), but is involved 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
● Active painful arc and drop arm tests
● Empty can test

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 12). 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 [37]. Note that the severity of functional
impairment during testing does not correlate well with the size of a tendon tear.

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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 13). The drop arm test assesses
the ability of the patient to lower his or her 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) [38].

The "empty can" (or Jobe's) 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.
It is performed by having the patient place a straight arm in about 90 degrees of abduction and
30 degrees of forward flexion, and then internally rotating the arm completely (ie, thumb
pointing down) ( picture 14)The patient then resists the clinician's attempts to depress 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 [34].

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 he or she feels for muscle contraction [39]. 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

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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.

Isometric testing of the infraspinatus tendon in neutral position is used to assess the strength
and integrity of the tendon, as well as to elicit pain indicative of injury. This test can be
performed by having the patient attempt to externally rotate their adducted arm while the
clinician resists the movement with their hand ( picture 15 and movie 4). Preliminary data
suggests that the Hornblower sign is specific but insensitive for identifying infraspinatus injury
[40]. The maneuver is performed by having the patient abduct their shoulder to 90 degrees, flex
their elbow to 90 degrees, and then perform active external rotation against resistance
provided by the clinician. Inability to rotate suggests infraspinatus pathology.

Assessment of internal rotation and the subscapularis — The subscapularis is the rotator
cuff muscle primarily responsible for internal rotation of the shoulder. Strength of the
subscapularis can be assessed using the push-off (or Gerber's lift-off) test. This test is
performed by having the patient place one hand behind their back and push posteriorly against
resistance ( picture 16). 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).

Other tests of subscapularis integrity include the Napoleon test, internal rotation lag sign, belly
press test, belly-off sign, and bear hug test. As with supraspinatus assessment, no single test is
clearly diagnostic for subscapularis pathology. We suggest performing several tests to improve
sensitivity. In a study of 106 consecutive patients, of whom 32 had subscapularis tears
identified by arthroscopy, the bear hug test was most sensitive [41]. The authors recommend a
composite of four examination tests to help diagnose subscapularis tears: lift-off, Napoleon,
bear hug, and internal rotation lag sign [42].

The supine Napoleon test is an alternative method to assess for full-thickness and partial
subscapularis tears. This test is performed by having the supine patient place their hand on
their abdomen with the elbow flexed approximately 90 degrees. The clinician first passively
moves the patient’s elbow anteriorly (towards the ceiling) to assess for shoulder stiffness. Next,
the clinician places one hand on the patient's hand and the other hand on the patient’s
shoulder to provide stability, and then the patient is asked to move their elbow anteriorly (ie,
active movement). The test is considered positive if the patient cannot lift the elbow at least 5

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cm. In a small, observational study, the test had a sensitivity of 84 percent, using arthroscopy as
the gold standard [43].

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 13)

● Drop arm test ( movie 3)
● Weakness in external rotation ( picture 15 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'.)

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 [38,44,45]. These tests exploit the
biomechanical length-tension curve of muscle force generation and the antagonistic actions of
the rotator cuff muscles [38]. 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
[46,47]; 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 17) or full internal rotation ( picture 18). 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 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
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antagonistic muscles, decreases in passive range of motion, 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, although 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 [31,32,37,48-52]. 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 19 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 20). 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 [27,28].
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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 [53].

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 [22,54]. However, high quality evidence about which examination
techniques are best for determining the underlying cause of shoulder dysfunction is lacking
[55]. 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 [54]. In addition, supraspinatus strength testing can be performed
with and without scapular stabilization to determine whether scapular dysfunction is
contributing to the problem [56]. (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

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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. In the scapular repositioning test
(also called the scapular retraction or stabilization test), the patient flexes his or her shoulder,
while the examiner manually compresses the patient's scapula, particularly the medial portion,
against the ribcage ( picture 21) [54,57]. 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. 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). Although there is little
high quality evidence to support these tests, we have found them to be useful.

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
[54,58]. The test is performed by assisting scapular motion during abduction and flexion of the
arm ( picture 22). 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
( movie 6). As the patient actively raises their arm into positions that typically cause
impingement, the examiner maintains 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;

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anterior and inferior laxities are most common. Several tests are used to assess this problem
[59].

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 23 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
"Clinical manifestations and diagnosis of Ehlers-Danlos syndromes".)

Apprehension, relocation, and release tests — These tests work in combination and are most
easily performed with the patient supine ( picture 24 and movie 8). To perform the
apprehension test, the patient is asked to place the symptomatic arm in the throwing position
(shoulder abducted and externally rotated). Next, the clinician braces the posterior shoulder
with one hand while using the other hand to push back on the wrist with steady, gentle
pressure, thereby increasing the abduction and external rotation of the shoulder (as if the
clinician is 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 severe glenohumeral instability.

The relocation test is begun at the end of the apprehension test and is performed by simply
reversing the forces being exerted by the examiner. Forced abduction and external rotation are
stopped, and the clinician moves the hand that was bracing the posterior shoulder to the
anterior shoulder. The examiner then pushes the humerus posteriorly (as if he or she was
attempting to relocate the shoulder). The resolution of either pain or the sensation of
impending dislocation on the part of the patient represents a positive test.

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The release test is performed at the end of the relocation test when the clinician abruptly stops
pushing the humerus posteriorly. Again, 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
[59]. 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 [27].
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 [60,61]. 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 25). 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; 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 [59].

Jerk test — The Jerk test is used to assess posteroinferior glenohumeral instability or labral tear
[62,63]. The test is performed with patient seated. Standing behind the patient, the examiner
stabilizes the patient's scapula with one hand while grasping the patients elbow with the other,
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and then placing the patients shoulder in 90 degrees abduction and internal rotation. Next, the
examiner applies an axial load to the elbow, thereby engaging the humeral head in the glenoid,
and then 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.

HERI 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 41of 50 patients with known
anterior glenohumeral instability [64]. 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 to that of the
contralateral shoulder [64].

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

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injuries, including the examination maneuvers used to help diagnose them, are described
separately. (See "Superior labrum anterior posterior (SLAP) tears".)

EXAMINATION OF THE ACROMIOCLAVICULAR JOINT

Shoulder function depends upon movement at three joints, including the acromioclavicular (AC)
joint, and one articulation. Common conditions afflicting the AC joint include acute injuries
(often referred to as "shoulder separation"), idiopathic osteoarthritis, post-traumatic arthritis,
and osteolysis. Focal pain and tenderness at the AC joint and increased pain when the patient
reaches across their body are common findings. Conditions that can mimic AC pathology
include rotator cuff disease and labral tears. Conditions affecting the AC 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 (SC) dislocations or fractures. Injuries or
deformities of the SC 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. (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

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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 (SC) and acromioclavicular (AC) joints (See 'Palpation'
above.)

● Range of motion – Range of motion (ROM) testing helps to determine the site and nature
of intrinsic shoulder pain ( table 1 and table 2). Although a healthy shoulder has
extensive mobility, ROM varies among patients and 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

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common contributor to shoulder pain. Assessment of scapulothoracic function is

described in the text ( figure 1). (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.)

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42. Fandridis E, Malahias MA, Plagou A, et al. The diagnostic value of subscapularis clinical
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58. Rabin A, Irrgang JJ, Fitzgerald GK, Eubanks A. The intertester reliability of the Scapular
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treatment of posteroinferior instability of the shoulder. Am J Sports Med 2004; 32:1849.
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GRAPHICS

Winging of the scapula

Above are two examples of winging of the scapula. (A) Winging of the right scapula
is seen from a slightly oblique perspective in the top photograph in a patient who

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had long thoracic nerve entrapment. (B) The patient in the bottom photograph,
seen from the back, also developed winging of the right scapula (arrows).

Courtesy of Stephen M Simons, MD, FACSM and Craig Young, MD.

Graphic 68399 Version 5.0

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Posture with rounded and protracted shoulders

The posture shown in the photograph, with the shoulders rounded

and protracted, is common among those who spend a great deal of
time working at a desk. In such cases, it is often associated with
dysfunction of the scapular stabilizing muscles.

Courtesy of Stephen Simons, MD.

Graphic 83224 Version 1.0

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Proximal biceps tendon rupture

This patient shows the classic "Popeye" deformity associated with a

proximal biceps tendon rupture. Note the gap between the
contracted biceps muscle and the deltoid.

Courtesy of Stephen Simons, MD, and Bryan Dixon, MD.

Graphic 80748 Version 5.0

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Deformity following Type III AC joint injury

This 65-year-old masters cyclist and professional trombone player

reports full, pain-free function after AC injury suffered when a dog
ran out in front of him while cycling. Note the intact trapezius and
anterior deltoid insertion on the clavicle, and drooped shoulder
rather than elevated clavicle in the chronic state.

AC: acromioclavicular.

Courtesy of Scott M Koehler, MD.

Graphic 82015 Version 5.0

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Scapular motion

* Boldface indicates prime or essential mover(s). Numbers refer to the figure.

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• The glenoid cavity moves superiorly, as in abduction of the arm.

Δ The glenoid cavity moves inferiorly, as in adduction of the arm.

Reproduced with permission from: Moore KL, Dalley AF. Clinically Oriented Anatomy, 5th Edition. Lippincott
Williams & Wilkins, Philadelphia 2006. Copyright © 2006 Lippincott Williams & Wilkins. www.lww.com.

Graphic 50894 Version 7.0

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Right winged scapula

Reproduced with permission from: Moore KL, Dalley AF, Agur AMR. Clinically Oriented
Anatomy, 7th Edition. Lippincott Williams & Wilkins, Philadelphia 2013. Copyright © 2013
Lippincott Williams & Wilkins. www.lww.com.

Graphic 57411 Version 9.0

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Palpation of the subscapular bursa

The subscapular bursa can be palpated at the junction of the superior-

medial angle of the scapula and the closest underlying rib.

Courtesy of Stephen Simons, MD.

Graphic 83225 Version 2.0

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Subacromial palpation

Courtesy of Stephen M Simons, MD.

Graphic 65889 Version 1.0

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Subacromial palpation with extension

Courtesy of Stephen M Simons, MD.

Graphic 77672 Version 1.0

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Biceps tendon palpation

Palpation over the proximal long head biceps tendon at the bicipital
groove should elicit tenderness if tendinopathy is present. Common
problems in examining the biceps tendon include palpating too
distally and attempting the examination with the shoulder internally
rotated.

Courtesy of Stephen Simons, MD and Bryan Dixon, MD.

Graphic 70699 Version 2.0

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AC joint local tenderness

The anterior, lateral, and posterior edges of the acromion are

marked with a pen. In this photograph, the examiner's finger is
located at the articulation between the acromion and the distal
clavicle (AC joint). The subacromial space is palpated just under the
lateral edge of the acromion.

Courtesy of Bruce C Anderson, MD.

Graphic 55667 Version 2.0

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Acromioclavicular joint palpation

Careful, systematic palpation of the clavicle, acromioclavicular joint,

and acromion can help to identify the source of pain.

Courtesy of Scott Koehler, MD.

Graphic 62599 Version 2.0

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Approximate normal shoulder (glenohumeral) range of motion

Abduction 180°

Adduction 45°

Flexion 135°

Extension 45°

Internal rotation 70°

External rotation 45°

Graphic 52351 Version 3.0

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Glenohumeral joint movements

Prime
Movement mover(s)
Synergists Notes
(function) (from pendent
position)

Flexion Pectoralis major Coracobrachialis From fully extended position to its own
(clavicular head); (assisted by (coronal) plane, sternocostal head of
deltoid (clavicular biceps brachii) pectoralis major is major force
and anterior
acromial parts)

Extension Deltoid (spinal Teres major; Latissimus dorsi, sternocostal head of

part) latissimus dorsi; pectoralis major, and long head of
long head of triceps act from fully flexed position to
triceps brachii their own (coronal) planes

Abduction Deltoid (as a Supraspinatus Supraspinatus is particularly important

whole, but in initiating movement; also, upward
especiallly rotation of scapula occurs throughout
acromial part) movement, making a significant
contribution

Adduction Pectoralis major; Teres major; long In upright position and in absence of
latissimus dorsi head of triceps resistance, gravity is prime mover
brachii

Medial rotation Subscapularis Pectoralis major; With arm elevated, "synergists"

deltoid (clavicular become more important than prime
part); latissimus movers
dorsi; teres major

Lateral rotation Infraspinatus Teres minor;

deltoid (spinal
part)

Tensors of Subscapularis; Supraspinatus; Rotator cuff (SITS) muscles acting

articular capsule infraspinatus teres minor together; when "resting", their tonus
(to hold head of (simultaneously) adequately maintains integrity of joint
humerus against
glenoid cavity)

Resisting Deltoid (as a Long head of Used especially when carrying heavy
downward whole) triceps brachii; objects (suitcases, buckets)
dislocation (shunt coracobrachialis;
muscles) short head of
biceps brachii

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Reproduced with permission from: Upper Limb. In: Moore KL, Agur AMR, Dalley AF. Clinically Oriented Anatomy, 7th ed,
Lippincott Williams & Wilkins, Philadelphia 2013. Copyright © 2013 Lippincott Williams & Wilkins. www.lww.com.

Graphic 70854 Version 11.0

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Apley scratch tests

These tests provide a simple way to assess shoulder motion. To assess adduction,
the patient is asked to reach across her chest and touch the opposite shoulder
(photograph A). To assess external rotation and abduction, the patient is asked to
reach behind her head and touch the superior medial tip of the opposite scapula
(photograph B). A patient with normal function can reach approximately the level
of the T4 spinous process. To assess internal rotation and adduction, the patient
is asked to reach behind her back and touch the inferior tip of the opposite
scapula (photograph C). A patient with normal function can reach approximately
the level of the T8 spinous process.

Graphic 55077 Version 4.0

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Supraspinatus isometric strength test

Courtesy of Stephen M Simons, MD.

Graphic 56697 Version 1.0

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Painful arc sign for rotator cuff pathology

Pain with active abduction beyond 90 degrees (ie, painful arc sign)
suggests rotator cuff tendinopathy. The test is most useful when
combined with other rotator cuff tests, such as the Neer and
Hawkins-Kennedy tests.

Courtesy of Stephen Simons, MD, J Bryan Dixon, MD, and David Kruse, MD.

Graphic 70787 Version 5.0

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Jobe's test of supraspinatus strength

Jobe's test (or the "empty can" test) assesses supraspinatus function. The
patient places a straight arm in about 90 degrees of abduction and 30
degrees of forward flexion, and then internally rotates the shoulder
completely. The clinician then attempts to adduct the arm while the patient
resists. Pain without weakness suggests tendinopathy; pain with weakness
is consistent with tendon tear.

Courtesy of Stephen Simons, MD, J Bryan Dixon, MD, and David Kruse, MD.

Graphic 74738 Version 6.0

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External rotation test

The infraspinatus muscle is primarily responsible for external

rotation of the shoulder. The muscle can be tested by having the
patient attempt to externally rotate against resistance, as shown in
the photograph above. The shoulder is held in adduction and the
elbow bent to 90 degrees during testing.

Graphic 57983 Version 2.0

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Push off or Gerber's test

The subscapularis is the rotator cuff muscle primarily responsible

for internal rotation. Its strength can be assessed using the push-off,
or Gerber's, test. This test is performed by having the patient place
one hand behind his back and push posteriorly against resistance.

Courtesy of Stephen Simons, MD, J Bryan Dixon, MD, and David Kruse, MD

Graphic 71635 Version 2.0

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External lag test for rotator cuff tear

To perform the external lag test, the clinician places the patient's shoulder - using
passive motion - in a position of full external rotation (pictured above), and then asks
the patient to maintain this position actively. The difference between the two is the
lag.

Courtesy of Stephen Simons, MD.

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Internal lag test for rotator cuff tear

To perform the internal lag test, the clinician places the patient's
shoulder - using passive motion - in a position of full internal rotation
(pictured above), and then asks the patient to maintain this position
actively. The difference between the two is the lag.

Courtesy of Stephen Simons, MD.

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Neer test for shoulder impingement

The "passive painful arc maneuver" shown above involves passively

flexing the glenohumeral joint while simultaneously preventing
shoulder shrugging. The test is often referred to as the Neer test,
and is used to assess shoulder impingement.

Courtesy of Stephen Simons, MD, J Bryan Dixon, MD, and David Kruse, MD.

Graphic 76237 Version 5.0

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Hawkins Kennedy test for shoulder impingement

The Hawkins Kennedy test is used to assess shoulder impingement.

In this test the clinician stabilizes the shoulder with one hand and,
with the patient's elbow flexed at 90 degrees, internally rotates the
shoulder using the other hand. Shoulder pain elicited by internal
rotation represents a positive test.

Courtesy of Stephen Simons, MD, J Bryan Dixon, MD, and David Kruse, MD.

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Scapular repositioning test

The scapular repositioning test is used to help determine whether weakness of the
muscles that stabilize the scapula is contributing to the patient's shoulder dysfunction.

Courtesy of Stephen Simons, MD.

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Scapular assistance test

The scapular assistance test is used to help determine whether scapular dyskinesis is
contributing to shoulder impingement.

Courtesy of Stephen Simons, MD.

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Sulcus sign

This maneuver is used to assess glenohumoral instability. The

patient is asked to relax the shoulder. One hand is placed at the
acromion and one hand is placed near the antecubital fossa.
Downward pressure is applied to the arm to open the subacromial
space. The examiner assesses the looseness of the shoulder and the
discomfort caused by the maneuver. The sulcus sign is positive
when the humeral head (X) is readily displaced by 2 cm or more
inferiorly (arrow). Increased humoral movement in the anterior and
posterior directions demonstrates multidirectional instability.

Courtesy of Bruce C Anderson, MD.

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Anterior shoulder instability tests

These tests work in combination and are most easily performed with the
patient supine. Further details are found in the text.

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Load and shift test for glenohumeral instability

Load and shift test. The humerus is compressed into the glenoid to "load" the humeral head. Subsequently,
the examiner pushes the humeral head anteriorly or posteriorly, noting the amount of "shift" or translation.

From: Conditions of the upper extremity. In: Foundations of Athletic Training, Anderson MK (Ed), Wolters Kluwer 2016. Copyright ©
2016. Reproduced with permission from Wolters Kluwer Health.

Graphic 130469 Version 1.0

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Contributor Disclosures
Stephen M Simons, MD, FACSM No relevant financial relationship(s) with ineligible companies to
disclose. J Bryan Dixon, MD No relevant financial relationship(s) with ineligible companies to
disclose. Karl B Fields, MD No relevant financial relationship(s) with ineligible companies to
disclose. Jonathan Grayzel, MD, FAAEM No relevant financial relationship(s) with ineligible companies to
disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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