Musculoskeletal
Curriculum
History &
Physical Exam
of the Shoulder
Copyright 2005
Authors
Kathleen Carr, MD
Madison Residency Program
Kathleen.Carr@fammed.wisc.edu
Dennis Breen, MD
Eau Claire Residency Program
Dennis.Breen@fammed.wisc.edu
2
Goal

Learn a standardized, evidence-based history
and physical examination of patients with
shoulder problems
WHICH WILL:

Enable family medicine resident physicians to
accurately diagnose common shoulder
problems throughout the full age spectrum of
patients seen in family medicine
3
Competency-Based Objectives

Patient care – focused history and exam

Professionalism – respect, compassion

Interpersonal and communication skills –
differential diagnosis

Medical knowledge base – anatomy, injury
mechanisms

Systems based practice – accuracy, time-efficiency
4
Shoulder Pain Key Points

Shoulder pain is a common complaint in primary
care


Most common causes in adults (peak ages 40-60)



Subacromial impingement syndrome
Rotator cuff problems
Athletic injuries


2nd only to knee pain for referral to Ortho or primary care sports
med
Shoulder accounts for 8-13% of athletic injuries
History and examination are keys to diagnosis
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Assessing shoulder pain
Components of the assessment
include

Focused history
Attentive physical examination
Thoughtfully ordered tests/studies
1.
2.
3.

for future discussion
6
Focused History
Focused History Questions

Onset of Pain


When symptoms started*
History of trauma/injury
8
Focused History Questions

Mechanism of Injury

Helps predict injured structure
Example: Fall directly onto anterior/superior
shoulderAC joint injury (shoulder separation)
Example: Arm forcefully abducted and externally
rotated  subluxation or anterior dislocation
Example: If chronic pain, note activity that triggers
pain, such as the cocking phase of throwing or the
pull-through phase of swimming
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Focused History Questions

Mechanism of Injury, continued


Can determine radiological needs
Likelihood of specific conditions varies


Setting (work, recreation, sports, traumatic,
atraumatic)
Age of the patient*
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Focused History Questions

Location of pain*
 Anterior
 Lateral
 Superior
 Posterior

Radiation of pain
 Rotator cuff problems often include pain
radiating to upper arm
 If pain starts in neck and radiates to
shoulder, consider cervical spine disease
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Focused History Questions

Consider sources of referred pain






Cervical spine – spondylolysis, arthritis, disc
disease
Cardiac - myocardial ischemia
Diaphragmatic irritation
Thoracic outlet syndrome
Gallbladder disease
Complex regional pain syndrome (a.k.a, reflex
sympathetic dystrophy)
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Focused History Questions
 Characteristics
of pain
Night pain when lying on affected Rotator cuff tear
side, muscle atrophy
< 30 yo
Biomechanical, inflammatory
> 45 yo, Hx of trauma
Rotator cuff tear - 35% of pts
Painful arc (60-120°abduction)
Pain > 120° abduction
Catching, popping, clicking
Subacromial impingement
Acromioclavicular joint
GH or AC joint arthritis, labral
tear
13
Focused History Questions

History of instability


Aggravating factors


Overhead work, repetitive movements, sports
Relieving factors/treatments tried


Glenohumeral subluxation or dislocation
Rest, immobility, medications, other treatments
History of Prior Shoulder Problems or
Surgeries
14
Differential Diagnosis
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
-
2.5
64
2
-
0.8
-
Glenohumeral Joint Arthrosis
Thoracic Outlet Syndrome
Biceps Tendonitis
15
Physical Exam
Physical Exam - General
Develop a standard routine
Alleviate the patient's fears
Adequate exposure - bilateral






Males – shirtless
Females – tank top or sports bra
Compare shoulders
17
Physical Exam – Steps*





Inspection
Palpation
Range of motion (ROM)
Strength testing
Special tests
18
Inspection



Swelling, asymmetry, muscle atrophy, scars,
ecchymosis and any venous distention
Note posture (e.g., shoulder protraction)
Deformities



Squaring of shoulder - anterior dislocation
Scapular "winging" - shoulder instability and
serratus anterior or trapezius dysfunction
Atrophy - supraspinatus or infraspinatus consider rotator cuff tear, suprascapular nerve
entrapment or neuropathy
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Palpation









Sternoclavicular joint
Clavicle
Acromioclavicular joint
Subacromial bursa
Coracoid process
Bicipital groove
Greater tuberosity
Lesser tuberosity
Scapula (spinatus muscles)
TIP: Start medially at
the SC joint, proceed
laterally, end posteriorly
20
Anterior Shoulder
http://www.nismat.org/orthocor/exam/shoulder.html#Functions
21
Posterior Shoulder
http://www.nismat.org/orthocor/exam/shoulder.html#Functions
22
Palpation of AC Joint


Patient's arm at his/her
side
Note swelling, pain, and
gapping.
23
Palpation of Bicipital Groove



Patient sitting,
beginning with the arm
straight
Patient actively flexes
biceps muscle while
examiner provides
supination and ER
Examiner palpates the
bicipital groove for pain
24
Range of Motion (ROM)
Evaluate active ROM




If movement limited by pain, weakness, or
tightness, assist passively
Lack of full ROM with active and passive exam
is found in adhesive capsulitis and arthropathy
Evaluate bilaterally for comparison
25
Range of Motion
Movement
Forward flexion
Extension (behind back)
Abduction
Adduction
External rotation*
Internal rotation*
Normal range
180°
40°
180° (with palms up)
0°
45° (arm at side, elbow flexed)
55° (arm at side, elbow flexed)
26
Forward Flexion


Arm straight and
brought upward
through frontal plane,
and move as far as
patient can go above
his head
0° is defined as straight
down at patient's side,
& 180° is straight up
27
Abduction



Arm straight
Hand – palm up (arm
supinated)
ROM measured in
degrees as for forward
flexion
28
External and Internal Rotation


Arm at side, elbow flexed to 90° and held at waist
Examiner externally or internally rotates arm
29
Apley scratch test for ER/IR*
External rotation and abduction
Reach for upper scapula
Compare bilaterally – note level
reached
Internal rotation and adduction
Reach for lower scapula
Compare bilaterally – note level
reached
30
Strength Tests
Flexion
Extension
31
Strength Tests*
External rotation
Infraspinatus
Teres minor
Internal rotation
Subscapularis
32
Strength tests
Empty can test*
Supraspinatus
Lift off test*
Subscapularis
33
Special Tests

Rotator cuff


Drop arm test
Labral tear



Impingement tests


Neer’s sign
Hawkin’s test

Instability tests



O’Brien’s test
Crank test
Anterior release
Relocation test
Speed’s test

Biceps tendon
34
Rotator Cuff
 Empty Can Test

Supraspinatus
 Lift off test

Subscapularis integrity
Drop Arm Test

Rotator cuff tear or supraspinatus dysfunction
35
Drop Arm Test


Purpose: tears in the rotator
cuff, primarily supraspinatus
muscle
Method: patient abducts (or
examiner passively abducts)
arm and then slowly lowers it



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
36
Video of Drop Arm Test
Click on
image for video
37
Impingement - Neer’s Sign*




Patient seated with arm
at side, palm down
(pronated)
Examiner standing
Examiner stabilizes
scapula and raises the
arm (between flexion
and abduction)
Positive test = pain
38
Video of Neer’s Sign
Click on
image for video
39
Impingement - Hawkin's Test*



Patient standing
Examiner forward
flexes shoulder to 90°,
then forcibly internally
rotates the arm
Positive test = pain in
area of superior GH
joint or AC joint
40
Video of Hawkin’s Test
Click on
image for video
41
Speed’s Test - Biceps tendon


Forward flex shoulder
against resistance
while maintaining
elbow in extension
and forearm in
supination
Positive test = tender
in bicipital groove
(bicipital tendinitis)
42
Video of Speed’s Test
Click on
image for video
43
Labral Tear (SLAP) - O'Brien's
Active Compression Test







Patient standing
Arm forward flexed 90°, adducted
15° to 20° with elbow straight
Full internal rotation so thumb
pointing down
Examiner applies downward force on
arm - patient resists
Patient externally rotates arm so
thumb pointing up
Examiner applies downward force on
arm - patient resists
Positive test = Pain or painful
clicking elicited with thumb down
and decreased or eliminated with
thumb up
44
Video of O’Brien’s Test
Click on
image for video
45
Labral Tear - Crank Test



Shoulder elevated to 160°
in the scapular plane
A gentle axial load is
applied through
glenohumeral joint with
one hand, while other
hand does IR and ER
Positive test = pain,
catching, or clicking in the
shoulder
46
Video of the Crank Test
Click on
image for video
47
Glenohumeral Joint Stability

Anterior Glenohumeral Instability



Apprehension test
Relocation test
Anterior release test
48
Apprehension Test - Sitting



90° of abduction
Examiner applies slight
anterior pressure to humerus
and externally rotates arm
Positive test = patient
expresses apprehension
49
Apprehension Test



Patient in supine
position with affected
shoulder at edge of
table, arm abducted
90°
Examiner externally
rotates by pushing
forearm posteriorly.
Positive test = patient
expresses
apprehension
50
Relocation Test




Performed after positive
result on anterior
apprehension test
Patient supine
Examiner applies
posterior force on
proximal humerus while
externally rotating
patient’s arm
Positive test = patient
expresses relief
51
Video of the Apprehension &
Relocation Tests – Seated & Supine
Click on
image for video
52
Anterior Release Test



Patient in supine
position, arm abducted
90°
Examiner performs
Relocation Test, then
releases downward
pressure
Positive test = patient
expresses pain or
instability when the
humeral head is
released
53
Video of Anterior Release Test
Click on
image for video
54
The Current Evidence Base
for History Questions and
Physical Exam Tests
55
Rotator Cuff Tear
History /
Maneuver
Study Sens Spec
Qual (%)
(%)
LR+
LR- PV+ PV(%) (%)
History of
trauma
Night pain
2b
36
73
1.3
0.88
72
37
2b
88
20
1.1
0.6
70
43
Painful arc
2b
33
81
1.7
0.83
81
33
Empty can
test
1b
84
89
50
58
1.7
2
0.22
0.28
36
98
22
93
Drop arm
1b
21
100
>25
0.79
100
32
56
Impingement / Instability
Test
Study Sens Spec LR+ LR- PV+ PVQual (%) (%)
(%) (%)
Impingement
Hawkin’s
1b
87
89
60
2.2
0.18
71
83
Instability
Relocation
2b
57
100
>25 0.43
100
73
2b
68
100
>25 0.32
100
78
Apprehension
57
AC / SLAP
History /
Maneuver
Study Sens Spec LR+ LR- PV+ PVQual (%)
(%)
(%) (%)
AC
1b
100
97
>25 0.01
89
100
Crank
2b
91
93
13
0.10
94
90
Active
compression
1b
100
99
>25 0.01
95
100
Active
compression
SLAP
58
References
Luime JJ, Verhagen AP, Miedema HS, et al. Does This Patient Have an Instability of the
Shoulder or a Labrum Lesion? JAMA. 2004;292:1989-1999.
Stetson WB, Templin K. The crank test, the O’Brien test, and routine magnetic resonance
imaging scans in the diagnosis of labral tears. Am J Sports Med. 2002;30:806-809.
Stevenson JH, Trojian T. Evaluation of shoulder pain. Journal of Family Practice.
2002;51:605-11.
Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with
Shoulder Examination Part I: The Rotator Cuff Tests. Am J Sports Med. 2003;31:154160.
Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with
Shoulder Examination Part II: Laxity, Instability, and Superior Labral Anterior and
Posterior (SLAP) Lesions. Am J Sports Med. 2003;31:301-307.
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Video of Shoulder Exam
http://www.fammed.wisc.edu/our-department/media/musculoskeletal
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