Complete Musculoskeletal Exam of the Shoulder

(English captions by Andrea Matsumoto from
the University of Michigan)

To ensure a thorough assessment it is best
to perform the musculoskeletal exam of the

shoulder in a systematic way.

The following is a suggested order of exam
that incorporates the common techniques for

diagnosing shoulder injuries.

The shoulder exam begins with inspection.

In an anterior view assess the shoulders for
asymmetry, clavicle deformity, muscular atrophy,

or skin changes.

In a posterior view assess for the same.

Next evaluate for active range of motion.

If pain or limitation exists, repeat the motion
passively.

To rule out cervical causes of referred shoulder
pain, evaluate neck range of motion: flexion,

extension, lateral flexion, and rotation.

Next evaluate active range of motion of the
shoulders: flexion, extension, abduction,

adduction, external rotation, and internal
rotation.

From the posterior view we can further assess
the combined adduction and external rotation

with Apley scratch test of external rotation.

Have the patient reach overhead and down the
spine.

Most patients can reach past C7.

Combine adduction and internal rotation with
the Apley scratch test of internal rotation.

Have the patient reach behind the back and
up the spine.

Most patients can reach to T7 or the lower
border of the scapula.

Next assess the strength of the rotator cuff
muscles.

The drop arm test evaluates for a supraspinatus
muscle tear.

Passively adduct the shoulder to 90 degrees,
flex to 30 degrees, and point thumbs down.

The test is positive if the patient is unable
to keep arms elevated after the examiner releases.

Supraspinatus muscle strength testing can
also be done using the empty can test.

In this same position provide resistance as
the patient lifts upward.

Pain suggests possible tendinopathy or tear.

Infraspinatus and teres minor muscle strength
is tested with resisted external rotation.

Pain or weakness suggests a possibly tendinopathy
or tear.

Subscapularis muscle strength can be tested
with resisted internal rotation.

Subscapularis muscle strength is also tested
with the push-off test.

Have the patient adduct the arm and internally
rotate behind their back.

Provide resistance as the patient pushes their
arm away from the body.

Pain or weakness suggests tendinopathy or
tear.

Next palpate anatomic landmarks for tenderness.

The suprasternal notch, the sternal clavicular
joint, along the clavicle, the AC joint, the

acromion, the greater tubercle of the humerus,
the lesser tubercle of the humerus, the

long head of the biceps which runs between
the greater and lesser trochanter, and as

you internally and externally rotate you can
feel that, and the coracoid.

Posteriorly look at acromion, the scapular
spine, the supraspinatus muscle above the

spine, the infraspinatus below the spine,
teres minor muscle, the trapezius muscle,

the rhomboid muscle, and look for scapular
thoracic articulation, particularly looking

for winged scapula.

Specific testing of the shoulder to evaluate
for injuries may include but is not limited

to the following tests.

Hawkin's test assesses for possible rotator
cuff impingement.

Stabilize the scapula, passively abduct the
shoulder to 90 degrees, flex the shoulder

to 30 degrees, and flex the elbow to 90 degrees,
and internally rotate the shoulder.

Pain is a positive test.

Neer's test also assesses for possible rotator
cuff impingement.

Stabilize the scapula and with the thumb pointing
down passively flex the arm.

Pain is a positive test.

The cross arm flexion test also evaluates
for acromioclavicular arthritis or subluxation.

Flex the shoulder to 90 degrees and adduct
across body.

Pain at the acromioclavicular joint is a positive
test.

There are several tests to evaluate for shoulder
instability.

To test inferior glenohumeral stability place
traction on the humerus with the arm at the

patient's side.

If a gap greater than 1cm appears between
the humoral head and the undersurface of the

acromion it is considered a positive sulcus
sign with inferior instability.

The load and shift test evaluates for anterior
and posterior glenohumeral stability.

Provide an axial load on the humerus compressing
the glenohumeral joint, then move the humeral

head anteriorly and posteriorly.

Anterior or posterior displacement is positive
for instability.

The apprehension and relocation tests also
evaluate for anterior glenohumeral stability.

With the patient supine, abduct shoulder to
90 degrees and externally rotate the arm to

place stress on the glenohumeral joint.

If the patient feels apprehensive that the arm
may dislocate it is a positive apprehension arm.

The relocation test is performed using the
examiner's hand to place a posteriorly directed

force on the glenohumeral joint.

Relief of apprehension is a positive test.

There are several tests that assess for injuries
of the biceps tendon and glenohumeral labrum.

To perform a Speed's test flex the shoulder
to 90 degrees with the arm supinated.

Provide downward resistance against the shoulder
flexion.

Pain indicates possibly bicepital tendon
or labral tear.

To perform Yergason's test flex elbow to
90 degrees, shake hands with patient and provide

resistance against supination.

Pain indicates a possible bicepital tendon
or associated labral tear.

To perform O'Brien's Test point the thumb
down and flex shoulder to 90 degrees.

Adduct the arm across midline, provide resistance
against further shoulder flexion and evaluate

for pain.

Repeat with the thumb pointing up and again
evaluate for pain.

If pain was present with the thumb down but
relieved with the thumb up, it is considered

a positive test, suspicious for labral tear.

To perform the Biceps Load Test supinate the
arm, abduct shoulder to 90 degrees, and flex

elbow to 90 degrees.

Externally rotate the arm until patient becomes
apprehensive and provide resistance against

elbow flexion.

Pain indicates possible bicepital tendonopathy
or associated labral tear.

To perform the Biceps Tension Test supinate
the arm, abduct shoulder to 90 degrees, flex

elbow to 90 degrees, and externally rotate
arm until patient becomes apprehensive and

pronate arm.

Pain indicates possible bicepital tendonopathy
or associated labral tear.

To perform the Crank Test, fully abduct the
shoulder and provide an axial load on the

humerus.

Internally and externally rotate the arm.

Pain, catching, or painful clicking is considered
a positive test suggestive of a labral tear.

There are several tests to evaluate for thoracic
outlet syndrome as a cause for the patient's

shoulder pain.

To perform the Costoclavicular Maneuver draw
the patient's shoulders inferiorly and posteriorly.

If patient has reproduction of arm pain or
numbness, consider thoracic outlet syndrome.

To perform Roos' Test abduct the shoulder
to 90 degrees, flex elbow to 90 degrees, and

rapidly open and close hands for up to 3 minutes.

If the patient has reproduction of pain or
numbness, consider thoracic outlet syndrome.

To perform Adson's Test locate the radial
pulse.

Have the patient take a deep breath and extend
neck, and rotate head towards the painful

shoulder.

If radial pulse diminishes on the affected
side, it is considered a positive test suspicious

for thoracic outlet syndrome.

Spurling's Test evaluates for cervical root
impingement.

With the head extended and rotated toward
the painful shoulder, apply an axial load

to the cervical spine.

Reproduction of pain or paresthesias with
this maneuver is a positive test.

In concluding the shoulder exam it is important
to document a neurovascular exam.

Here we demonstrate a brief exam.

Resisted wrist extension tests the radial
nerve.

Resisted opposition of the thumb tests the
median nerve.

Resisted digit abduction tests the ulnar nerve.

Radial artery pulse and capillary refill testing.

Further neurologic or vascular exam may be
indicated by history.

Acknowledgement: The Japanese translation of this video was made as part of Shizuoka-University of Michigan Advanced Residency Training, Education and Research in Family Medicine (SMARTER FM) Project supported by Shizuoka Prefecture and funded by the Community Healthcare Revival Fund.