The physical examination of the shoulder is a fundamental component of the assessment of patients with shoulder pathology. The accurate identification of specific pathologies, such as rotator cuff tears, labral injuries, and instability, necessitates a thorough physical examination and a knowledgeable examiner. Orthopedic surgeons, orthopedic surgery residents, students, physical therapists, and physician assistants are required to have a strong understanding of the physical examination and anatomy of the shoulder to be able to effectively diagnose and treat shoulder pathologies.

The shoulder joint is one of the most complex and mobile joints in the human body. The glenohumeral joint connects the humeral head to the glenoid fossa of the scapula.¹ The humeral head is larger than the glenoid fossa, which provides the joint with a wide range of motion but also makes it inherently unstable. The glenohumeral joint is surrounded by a joint capsule that is reinforced by ligaments and tendons, including the rotator cuff. The rotator cuff is made up of four muscles, including the supraspinatus, infraspinatus, teres minor, and subscapularis, as well as their associated tendons, which help to stabilize the humeral head in the glenoid fossa during shoulder movement.² The acromioclavicular joint is formed by the articulation of the acromion process of the scapula and the lateral clavicle.³ It is a gliding joint that allows for movement of the clavicle and scapula relative to one another. The acromioclavicular joint is stabilized by several ligaments, including the acromioclavicular ligament, coracoclavicular ligament, and coracoacromial ligament. In addition to these joints, the shoulder is also composed of various bursae and muscles, including the deltoid, pectoralis major, and latissimus dorsi. The bursae are fluid-filled sacs that help to reduce friction between structures in the shoulder, while the muscles provide the shoulder with strength and stability during movement.^1,4

Shoulder Pathology

Shoulder pathology is a common presenting complaint in orthopedic surgery clinics. Rotator cuff tears, arthritis, labral injuries, and shoulder instability are among the most common shoulder pathologies patients present with. The prevalence of rotator cuff tears increases with age, with a reported incidence of 22 percent in individuals over sixty years old.⁵ Shoulder-related injuries, such as superior labral anterior to posterior (SLAP) tears and instability, are commonly seen in athletes and can result in significant functional impairment.^6,7 Physical laborers and recreational athletes alike can suffer from rotator cuff tears and arthritis, among other injuries.

Mechanics of the Throwing Shoulder

Understanding normal throwing shoulder mechanics is crucial for identifying subtle variations from the norm that may predispose athletes to injury or limit performance. Normal throwing shoulder mechanics involve a series of complex movements that result in proper positioning and movement of the humerus and scapula. During the throwing motion, the scapula rotates and elevates while the humerus abducts and externally rotates, which creates a stable base for the arm to move.⁸

The stages of throwing can be broken down into wind-up, stride and early cocking, late arm cocking, acceleration, deceleration, and follow-through.⁸ Notably, a wide variety of shoulder and trunk musculature facilitates the process of throwing. While the pectoralis major, serratus anterior, latissimus dorsi, and subscapularis have been shown to be most involved in the acceleration phase of throwing, the rotator cuff and trunk musculature are most involved during the deceleration phase.⁸ Further, the position of the humerus and scapula at each stage of the throwing motion can affect the load and stress placed on the structures of the shoulder joint. For example, excessive external rotation during the late cocking phase has been associated with increased risk of shoulder injuries.⁹ Proper throwing mechanics depend on a combination of strength, flexibility, and coordination of the shoulder musculature. Understanding the biomechanics of the throwing motion can help clinicians identify potential mechanical deficiencies that may contribute to shoulder pathologies. A comprehensive physical examination of the throwing shoulder should include an assessment of throwing mechanics, core stability, and leg stance to identify any areas of weakness or muscle imbalances that may need to be addressed in the management plan.

Overview of the Physical Examination of the Shoulder

The physical examination of the shoulder typically includes inspection, palpation, range of motion assessment, and various special tests that are unique to the pathology being examined.^4,10,11

First, inspection of the shoulder involves visually assessing for any asymmetry, swelling, or deformity.^4,10,11 The examiner should look for any muscle atrophy, scars, or discoloration, which may indicate previous injuries or surgeries. Ideally both shoulders should be assessed for comparison. The clavicle and scapula should be compared on each side for any asymmetry or winging, which may indicate underlying pathologies such as nerve injuries or muscle weakness. It is important to closely compare the affected shoulder with the unaffected shoulder, as this may detect subtle differences and clues to narrow the differential diagnosis.

Palpation of the shoulder involves assessing for any tenderness, swelling, crepitus, or deformity with manual touch. The examiner should palpate the bony landmarks, joints, and soft tissue structures, including the rotator cuff muscles and their associated tendons. Tenderness over the rotator cuff tendons may indicate related pathology, while tenderness over the bicipital groove may indicate bicipital tendonitis.^4,10,11

A range of motion assessment is used to evaluate the shoulder’s mobility and to identify any restrictions or pain associated with movement.^4,10,11 The examiner should assess active and passive range of motion of the shoulder in all planes. Active range of motion refers to the patient using their own strength or ability to move the shoulder, while passive range of motion refers to the patient getting assistance from the examiner. Specific movements of the shoulder include forward elevation, external rotation at the side, abduction, external rotation in abduction, internal rotation in abduction, and internal rotation at the side to vertebral height. Clinically normal values are 180 degrees of forward elevation and abduction, 90 degrees of external rotation, internal rotation to T4, 70 degrees of internal rotation in abduction of 90 degrees, and 90 degrees of external rotation in abduction at 90 degrees.¹² Limited range of motion or pain with certain movements may indicate underlying pathologies such as frozen shoulder, arthritis, rotator cuff pathology, or glenohumeral instability (video 1).^4,10,11

For these movements, corresponding strength testing should be performed as well. Strength is graded on a scale from 0 to 5, with 0 signifying a complete absence of muscle contraction and 5 indicating active movement against opposing resistance with full strength.¹³The examiner should ask the patient to perform forward elevation, abduction, external rotation, and internal rotation against resistance to accurately determine muscle strength. The full muscle grading scale is presented in table 1. 

Physical Examination of the Cervical Spine

Additionally, it may be necessary to perform an examination of the cervical spine, as pain can be referred to the shoulder from a cervical spine condition. This includes palpating the cervical spinous processes for any tenderness, examining full range of motion of the neck, and performing a thorough neurological examination. Normal cervical spine flexion is to approximately 80 degrees, whereas extension is to 50 degrees and rotation is to 90 degrees bilaterally.¹⁴ Spurling’s test can also be performed as a screening test for cervical radiculopathy, a condition caused by compression of the cervical nerve roots, which results in radiating pain down the arm in the distribution of the corresponding compressed nerve root. To perform this maneuver, the examiner should gently, passively extend and tilt the patient’s head to the shoulder of interest. An axial compressive force is applied to the head, and reproduction of radicular pain, or pain from the neck radiating to the shoulder and affected extremity, indicates a positive test (figure 1).

The test is considered positive when pain radiates from the neck down the ipsilateral upper extremity.¹⁵ The assessment of the cervical spine should be completed with an examination of the C5–T1 cervical and thoracic nerve roots, which form the brachial plexus. For each cervical nerve root, its respective motor function, sensory function, and reflex should be tested, as listed in table 2 and shown in figure 2.

Special Tests for the Shoulder Examination

Special tests are more targeted maneuvers that are used to further evaluate the shoulder and identify specific pathologies.^4,10,11 These tests are discussed in detail in later chapters and can include the Neer impingement test, the Hawkins impingement test, the Speed’s test, the Yergason’s test, and the apprehension, relocation, and release tests. The Neer and Hawkins impingement tests are used to evaluate for subacromial impingement, while Speed’s test and Yergason’s test are used to assess bicipital tendon pathology. Finally, the apprehension, relocation, and release tests are used to evaluate for shoulder instability.^4,10,11 When performing these special tests in practice, it is important to tailor the examination to the patient’s history and presenting symptom. For example, if a patient presents with a primary symptom of pain at the acromioclavicular joint, palpation to elicit pain of the acromioclavicular joint should be deferred until the end of the examination so as to not prematurely elicit pain, which could potentially provide false positives with respect to the remainder of the shoulder examination.

In conclusion, the physical examination of the shoulder is a critical component of the assessment of patients with shoulder pathology. Orthopedic surgeons, orthopedic surgery residents, medical students, physician assistants, and physical therapists should have a thorough understanding of these concepts.

Key Terminology

Abduction

Motion of the glenohumeral joint upward and laterally. ↵

Acromioclavicular Joint

Articulation of the acromion process of the scapula and the lateral clavicle. ↵

Active Motion

Patient using their own strength and ability for range of motion. ↵

Crepitus

Crackling or grinding sound that occurs especially with motion. ↵

External Rotation

Motion of the glenohumeral joint, in the plane of the long axis of the humerus, away from the midline. ↵

Forward Elevation

Motion of the glenohumeral joint upward and anteriorly. ↵

Glenohumeral Joint

Highly mobile articulation between the humeral head and the glenoid fossa of the scapula. ↵

Inspection

Visually assessing for any asymmetry, swelling, or deformity. ↵

Internal Rotation

Motion of the glenohumeral joint, in the plane of the long axis of the humerus, toward the midline. ↵

Palpation

Assessing for any tenderness, swelling, or deformity with manual touch. ↵

Passive Motion

Patient getting assistance from another individual for range of motion. ↵

Range of Motion Assessment

Method of assessment of the shoulder’s mobility and to identify any restrictions or pain associated with movement. ↵

Rotator Cuff

Group of four muscles and their associated tendons including the supraspinatus, infraspinatus, teres minor, and subscapularis, which help to stabilize the humeral head in the glenoid fossa and move the humerus in several planes. ↵

Special Tests

Targeted physical exam maneuvers to further evaluate specific structures in the shoulder and to identify specific pathologies. ↵

References

1. Miniato MA, Anand P, Varacallo M. Anatomy, Shoulder and Upper Limb, Shoulder. Treasure Island, FL: StatPearls; 2022. ↵

2. Maruvada S, Madrazo-Ibarra A, Varacallo M. Anatomy, Rotator Cuff. Treasure Island, FL: StatPearls; 2022. ↵

3. Wong M, Kiel J. Anatomy, Shoulder and Upper Limb, Acromioclavicular Joint. Treasure Island, FL: StatPearls; 2022. ↵

4. Bakhsh W, Nicandri G. Anatomy and physical examination of the shoulder. Sports Med Arthrosc Rev. 2018;26(3):e10-e22. ↵

5. Yamamoto A, Takagishi K, Osawa T, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. 2010;19(1):116-120. ↵

6. Arner JW, Provencher MT, Bradley JP, Millett PJ. Evaluation and management of the contact athlete’s shoulder. J Am Acad Orthop Surg. 2022;30(6):e584-e594. ↵

7. Varacallo M, Tapscott DC, Mair SD. Superior Labrum Anterior Posterior Lesions. Treasure Island, FL: StatPearls; 2022. ↵

8. Altchek DW, Dines DM. Shoulder injuries in the throwing athlete. J Am Acad Orthop Surg. 1995;3(3):159-165. ↵

9. Wilk KE, Macrina LC, Fleisig GS, et al. Deficits in glenohumeral passive range of motion increase risk of shoulder injury in professional baseball pitchers: a prospective study. Am J Sports Med. 2015;43(10):2379-2385. ↵

10. Hippensteel KJ, Brophy R, Smith MV, Wright RW. A comprehensive review of physical examination tests of the cervical spine, scapula, and rotator cuff. J Am Acad Orthop Surg. 2019;27(11):385-394. ↵

11. King JJ, Wright TW. Physical examination of the shoulder. J Hand Surg Am. 2014;39(10):2103-2112. ↵

12. Gill TK, Shanahan EM, Tucker GR, Buchbinder R, Hill CL. Shoulder range of movement in the general population: age and gender stratified normative data using a community-based cohort. BMC Musculoskelet Disord. 2020;21(1):676. ↵

13. Naqvi U, Sherman AL. Muscle Strength Grading. Treasure Island, FL: StatPearls; 2023. ↵

14. Sukari AAA, Singh S, Bohari MH, Idris Z, Ghani ARI, Abdullah JM. Examining the range of motion of the cervical spine: utilising different bedside instruments. Malays J Med Sci. 2021;28(2):100-105. ↵

15. Jones SJ, Miller JMM. Spurling Test. Treasure Island, FL: StatPearls; 2023. ↵