Courtesy: Prof Young Lae Moon, Seoul, South Korea

Comprehensive Shoulder Physical Examination

Orthopaedic Principles – Webinar Summary

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1. Introduction

• A systematic shoulder examination is essential for accurate diagnosis and treatment planning.

• A structured, stepwise approach improves diagnostic precision and reduces missed pathology.

• Key focus:

  • Cervical spine assessment

  • Rotator cuff evaluation

  • Shoulder instability assessment

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2. Core Principles of Shoulder Examination

2.1 Rule Out Cervical Spine Pathology

• Essential to differentiate:

  • Referred pain from cervical spine

  • True shoulder pathology

• Components:

  • Cervical range of motion

  • Neurological examination

  • Provocative testing

Spurling Test

• Purpose: Detect cervical radiculopathy

• Technique:

  • Neck extension + lateral bending + rotation toward symptomatic side

  • Apply axial compression (~7 kg)

• Positive Test:

  • Radicular pain radiating into the arm (not just neck pain)

• Evidence:

  • High specificity (~90–95%) for cervical radiculopathy (supported by current literature)

Neurological Correlation

• C5: Deltoid (shoulder abduction)

• C6: Biceps, wrist extension

• C7: Triceps, wrist extension

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3. Range of Motion & Capsular Patterns

Adhesive Capsulitis (Frozen Shoulder)

• Characteristic pattern:

  • Marked restriction in abduction

  • Relative preservation of forward flexion

• Clinical relevance:

  • Helps differentiate from rotator cuff pathology

• Evidence update:

  • Classical capsular pattern (ER > abduction > IR restriction) remains widely accepted

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4. Subacromial Impingement

4.1 Neer Impingement Test

• Technique:

  • Passive forward elevation with internal rotation

  • Stabilize scapula

• Positive Test:

  • Pain between 70°–130° elevation

• Indicates:

  • Subacromial impingement

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4.2 Types of Impingement

Primary Impingement

• Cause:

  • Structural narrowing (acromion, osteophytes)

• Mechanism:

  • Compression of rotator cuff and subacromial bursa

Secondary Impingement

• Cause:

  • Rotator cuff weakness

• Mechanism:

  • Superior migration of humeral head

  • Functional instability

• Clinical importance:

  • Requires different treatment approach than primary impingement

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5. Rotator Cuff Evaluation

5.1 Supraspinatus

Empty Can (Jobe) Test

• Arm at 90° abduction in scapular plane, thumb down

• Positive:

  • Pain or weakness

• Evidence:

  • High sensitivity for supraspinatus pathology

Drop Arm Test

• Passive abduction ? slow controlled lowering

• Positive:

  • Sudden drop or inability to control descent

• Indicates:

  • Full-thickness tear

• High specificity (~95%)

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5.2 Subscapularis

Belly Press Test

• Press abdomen while keeping elbow forward

• Positive:

  • Elbow drops backward / wrist flexion compensation

• High specificity (~90–98%)

Lift-Off Test

• Hand behind back ? lift away

• Positive:

  • Inability or weakness

• Best for:

  • Lower subscapularis tears

Clinical Note (Updated Evidence):

• Bear Hug Test (not demonstrated but discussed):

  • More sensitive for upper subscapularis tears

• Combining tests improves diagnostic accuracy (supported by recent literature)

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5.3 Infraspinatus & Teres Minor

External Rotation Strength Test

• Resisted external rotation

• Positive:

  • Weakness or pain

External Rotation Lag Sign

• Inability to maintain external rotation

• Suggests:

  • Significant posterior cuff tear

Hornblower’s Sign

• Arm at 90° abduction ? external rotation

• Positive:

  • Inability to externally rotate

• Indicates:

  • Teres minor involvement / massive cuff tear

• High specificity (~95%)

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6. Shoulder Instability

6.1 Anterior Instability

Apprehension Test

• Arm in 90° abduction + external rotation

• Positive:

  • Apprehension (fear of dislocation, not just pain)

Relocation Test

• Posterior pressure relieves symptoms

• Confirms:

  • Anterior instability

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6.2 Translation Tests

Anterior & Posterior Drawer Tests

• Assess humeral head translation

• Helps quantify instability

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6.3 Posterior Instability

• Posteriorly directed force

• Positive:

  • Excessive posterior translation or symptoms

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6.4 Multidirectional Instability (MDI)

Sulcus Sign

• Downward traction on arm

• Positive:

  • Visible sulcus below acromion

• Indicates:

  • Inferior capsular laxity

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7. Biceps Tendon Evaluation

7.1 Speed’s Test

• Forward flexion + supination against resistance

• Positive:

  • Pain in bicipital groove

• Indicates:

  • Long head of biceps tendinopathy

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7.2 Yergason’s Test

• Resisted supination + external rotation

• Positive:

  • Pain or snapping

• Indicates:

  • Biceps instability or subluxation

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Clinical Insight

• Biceps pathology is often associated with:

  • Subscapularis tears

  • Pulley lesions

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8. Diagnostic Injections

• Purpose: Identify pain generator

• Common targets:

  • Glenohumeral joint

  • Subacromial space

  • Biceps tendon sheath

  • Suprascapular nerve

• Interpretation:

  • Pain relief ? confirms source of pathology

• Evidence:

  • Widely supported as a diagnostic adjunct in shoulder practice

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9. Key Takeaways

• Always follow a systematic approach:

  1. Rule out cervical pathology

  2. Assess rotator cuff

  3. Evaluate instability

• Understand functional anatomy to interpret tests correctly

• Use clusters of tests rather than relying on a single test

• Consider diagnostic injections when diagnosis is unclear

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10. Expert Clinical Insight

• Belly press test preferred for subscapularis assessment in routine practice

• Imaging (MRI/Ultrasound) should be used when:

  • Clinical findings are equivocal

  • Partial tears are suspected