1. History & Physical Examination of the Shoulder
Garry W. K. Ho, M.D.
VCU / Fairfax Family Practice
Sports Medicine Fellow
January 2007

2. Objectives Review pertinent anatomy of the shoulder
Review differential diagnosis of shoulder complaints
Review clinical history and physical examination of the shoulder
Review common shoulder injuries & characteristic physical exam findings

3. Brief Epidemiology Athletic injuries
Shoulder pain: a common complaint in primary care
2nd only to knee pain for specialist referrals
Most common causes in adults (peak ages 40-60)
Subacromial impingement syndrome
Rotator cuff problems
Athletic injuries
Shoulder: 8-13% of all
athletic injuries

4. Anatomy 3 Bones 3 Joints 1 “Articulation” Humerus Scapula Clavicle
Glenohumeral
Acromioclavicular
Sternoclavicular
1 “Articulation”
Scapulothoracic

5. Anatomy Humerus Scapula Head * Greater tubercle* Lesser tubercle*
Intertubercular (bicipital) groove
Deltoid tuberosity
Scapula
Angles
Superior
Inferior
Lateral (Head)

6. Anatomy Scapula Glenoid Acromion Coracoid Subscapular fossa
Scapular spine
Supraspinatus fossa
Infraspinatus fossa

7. Anatomy Glenohumeral joint “Ball and socket” vs “Golf ball and tee”
Very mobile
Price: instability
45% of all dislocations
Joint stability depends on multiple factors

8. Anatomy Glenohumeral joint Passive stability Joint conformity
Glenoid labrum (50%)
Joint capsule
Ligaments
Bony restraints

9. Anatomy Muscles * Scapular stabilizers Deltoid Trapezius * Rhomboids *
Levator scapulae *
Rotator cuff
Teres major
Biceps
Pectoralis muscles *
Serratus anterior *
* Scapular stabilizers

10. Anatomy Rotator Cuff Muscles S – Supraspinatus I – Infraspinatus
t - Teres minor
S- Supscapularis

11. Anatomy
Bursae
Subacromial
(Subdeltoid)
Subscapular

12. Anatomy
Neurologic
Nerve roots
Brachial plexus
Peripheral nerves

13. Anatomy Coordinated shoulder motion Scapular-humeral rhythm
Glenohumeral motion
Acromioclavicular motion
Sternoclavicular motion
Scapulothoracic motion
Scapular-humeral rhythm

14. Differential Diagnosis
Impingement syndrome
Subacromial bursitis
Rotator cuff tendinopathy
Rotator cuff tear
Biceps tendinopathy
Adhesive capsulitis
SC joint arthritis, sprain
AC joint arthritis, sprain
Glenohumeral joint OA
Instablity
GH dislocation
GH subluxation
Labral tear (e.g. Bankart, SLAP, etc.)
Clavicle fracture
Proximal humerus fracture
Scapular fracture
Other arthritic disease
Rheumatoid, Gout, SLE
Septic, Lyme, etc.
Avascular necrosis
Neoplastic disease
Thoracic outlet syndrome
CRPS
Myofascial pain
Referred pain
Cervical radiculopathy
Cardiac
Aortic aneurysm
Abdominal / Diaphragm
Other GI

15. Clinical History Characterize pain Location of pain Night pain
Weakness
Deformity
Instability
Locking / Clicking / Clunking
Sport / Occupation
Previous treatments
Alleviating / Exacerbating
Acute vs. Chronic
Traumatic vs. Overuse
History of prior injury

16. Clinical History
Mechanism of Injury

17. Physical Exam Observation Palpation Active & passive ROM
Undress waist → up
Palpation
Active & passive ROM
Strength testing
Special tests

18. Physical Exam – Observation / Inspection
Front & Back
Height of shoulder & scapulae
Asymmetry
Obvious deformity
Ecchymosis
Muscle atrophy
Supraspinatus
Infraspinatus
Deltoid

19. Palpation
At rest & with movement
Bony structures
Joints
Soft tissues

20. Palpation Surface Anatomy (Anterior) Clavicle SC Joint
Acromion process
AC Joint
Deltoid
Coracoid process
Pectoralis major
Trapezius
Biceps (long head)
AC joint
biceps
SC joint

21. Palpation Surface Anatomy (Posterior) Scapular spine Acromion process
Supraspinatus
Infraspinatus
Deltoid
Trapezius
Latissumus dorsi
Scapula
Inferior angle
Medial border
Supraspinatus
Infraspinatus
Inferior angle of scapula

22. Range of Motion Apley Scratch Test Forward flexion: 160 - 180°
Extension: °
Abduction: 180◦
Adduction: 45 °
Internal rotation: °
External rotation: °
Apley Scratch Test

23. Range of Motion Scapular dyskinesis (Scapulothoracic dysfuntion)
Compare scapular motion through ROM on both sides
Wall push-ups
Symmetrical
Smooth
No or minimal winging

24. Strength Testing Test & compare both sides
Be specific to muscle or muscle group
Grade strength on 0 → 5 scale
0: no contraction
1: muscle flicker; no movement
2: motion, but not against gravity
3: motion against gravity, but not resistance
4: motion against resistance
5: normal strength

25. Strength Testing External rotation
Tests RTC muscles that ER the shoulder
Infraspinatus
Teres minor
Arms at the sides
Elbows flexed to 90 degrees
Externally rotates arms against resistance

26. Strength Testing Internal rotation
Tests RTC muscle that IR the shoulder
Subscapularis
Arms at the sides
Elbows flexed to 90 degrees
Internally rotates arms against resistance
Subscapularis Lift-Off Test
Other techniques

27. Strength Testing Supraspinatus “Empty can" test Jobe’s Test
Tests Supraspinatus
Attempt to isolate from deltoid
Positioned sitting
Arms straight out
Elbows locked straight
Thumbs down
Arm at 30 degrees
(in scapular plane)
Attempts to elevate arms against resistance

28. Special Provocative Tests
Impingement Signs
Drop-Arm Test
Speed’s Test
Yergason Test
Cross-Arm Adduction
Sulcus Sign
Apprehension test
Relocation test
O’Brien’s Test
Crank test

29. Subacromial Impingement Syndrome
Impingement of:
Subacromial bursa
Rotator cuff muscles and tendons
Biceps tendon
Between
Acromion
Coracoacromial ligament
AC joint
Coracoid process
Humeral head
Rotator cuff tendonosis

30. Impingement Signs Neer’s Sign
Arm fully pronated and placed in forced flexion
Trying to impinge subacromial structures with humeral head
Pain is positive test

31. Impingement Signs Hawkin’s Sign
Arm is forward elevated to 90 degrees, then forcibly internally rotated
Trying to impinge subacromial structures with humeral head
Pain is positive test

32. Rotator Cuff Tear Partial thickness tear
Full (Complete) thickness tear
May be due to:
Impingement
Degeneration
Overuse
Trauma
Partial tears
Conservative
Complete tears
Surgery

33. Rotator Cuff Tear: Drop-Arm Test
Abducted arm slowly lowered
May be able to lower arm slowly to 90° (deltoid function)
Arm will then drop to side if rotator cuff tear
Positive test
patient unable to lower arm further with control
If able to hold at 90º, pressure on wrist will cause arm to fall 

34. Biceps Tendonosis Injury to long head of biceps tendon
Typically an overuse injury
Repetitive (overhead) lifting
Impingement

35. Biceps Tendonosis: Speed’s Test
Forward flex shoulder to about 90°
Abduct shoulder to about 10°
Arm in full supination
Apply downward force to distal arm
Pain is positive test
Weakness without pain: muscle weakness or rupture

36. Biceps Tendonosis: Yergason’s Test
Elbow flexed to 90°
Start in pronated position
Active supination & flexion against resistance
Palpate biceps tendon
Pain or painful pop is positive test
Tendonosis
Subluxation

37. AC Separation AC Sprain / Separation
Typically due to fall onto tip of shoulder (acromion)
Arm tucked into side
Treatment depends on type

38. AC Arthritis / DJD

39. AC Joint: Cross-Arm Adduction Test
Arm flexed to 90°
Arm adducted to > 45°
Hyperadduct shoulder (down on elbow)
Positive test is pain in AC joint
Watch out for false-positives
Where is the pain?

40. Shoulder Instability Failure to keep humeral head centered in glenoid
Dislocation
Complete disruption of joint congruity or alignment
Subluxation
Partial or incomplete dislocation
Laxity
Slackness or looseness in joint
May be normal or abnormal

41. Instability: Sulcus Sign
Inferior instability
Arm relaxed in neutral position
Arm pulled downward at wrist
Positive test is a visible sulcus at infra-acromial area
Compare to contralateral side

42. Instability: Apprehension Test
Anterior instability
Shoulder abducted to 90°
Slight stress to humeral head directed in anterior direction
While externally rotating shoulder
Positive test is apprehension due to feeling of instability or impending dislocation
Beware if false positives

43. Instability: Relocation Test
Anterior instability
After a positive apprehension
Apply posteriorly directed force over externally rotated humeral head
Positive test is relief of apprehension
Anterior release test

44. Glenoid Labral Tear Tear in glenoid labrum Usually due to instability
SLAP Tear (Superior Labrum Anterior to Posterior)
Superior labral tear
Fall on outstretched hand or shoulder
Rotator cuff tendonosis or tears
Bankart Lesion
Anterior-inferior labral tear
Anterior shoulder dislocation / subluxation

45. O’Brien’s Active Compression Test
Labral, AC, or biceps pathology
Arm flexed to 90°
Arm cross-arm adducted 10-15°
Elbow extended
Max pronation
Resist downward force
Positive test if painful
Beware location of pain AC
Biceps
Internal +/- click

46. O’Brien’s Active Compression Test
For labral pathology
Repeat testing with
Max supination
Should be pain free

47. Labral Tear: Crank Test
Abduct arm to °
Stabilize shoulder
Elbow secured with one hand
Axially load with ER / IR at shoulder
Positive test: audible or painful click / catch / grind

48. Diagnostic Injection AC joint Subacromial space Glenohumeral joint
Biceps tendon (long head)

49. Thanks!
Questions?

50. Rotator Cuff Tear History / Maneuver Study Qual Sens (%) Spec LR+ LR-
PV+
PV-
History of trauma 2b 36 73
1.3
0.88 72 37
Night pain 88 20
1.1
0.6 70 43
Painful arc 33 81
1.7
0.83
Empty can test 1b 84 89 50 58 2
0.22
0.28 98 22 93
Drop arm 21
100
>25
0.79 32
Evaluation of shoulder pain - Applied Evidence Journal of Family Practice,  July, 2002  by J. Herbert Stevenson,  Thomas Trojian

51. Impingement / Instability
Test
Study Qual
Sens
(%)
Spec
LR+
LR-
PV+
PV-
Impingement
Hawkin’s 1b 87 89 60
2.2
0.18 71 83
Instability
Relocation 2b 57
100
>25
0.43 73
Apprehension 68
0.32 78
Evaluation of shoulder pain - Applied Evidence Journal of Family Practice,  July, 2002  by J. Herbert Stevenson,  Thomas Trojian

52. AC Joint / SLAP Tear AC Joint SLAP Tear History / Maneuver Study Qual
Sens
(%)
Spec
LR+
LR-
PV+
PV-
AC Joint
Active
compression 1b
100 97
>25
0.01 89
SLAP Tear
Crank 2b 91 93 13
0.10 94 90 99 95
Evaluation of shoulder pain - Applied Evidence Journal of Family Practice,  July, 2002  by J. Herbert Stevenson,  Thomas Trojian

53. Differential Diagnosis
Primary Care %
Age
Subacromial Impingement Syndrome
48-72
23-62
Adhesive Capsulitis
16-22 53
Acute Bursitis 17 -
Calcific Tendonitis 6
Myofascial Pain Syndrome 5
Glenohumeral Joint Arthrosis
2.5 64
Thoracic Outlet Syndrome 2
Biceps Tendonitis
0.8
Evaluation of shoulder pain - Applied Evidence Journal of Family Practice,  July, 2002  by J. Herbert Stevenson,  Thomas Trojian