Examine the shoulders visually for asymmetry, atrophy, edema, masses, scars or other deformities.
It is important to assess the scapula for medial or lateral winging and protraction.
Feel for tenderness, trigger points, crepitus, clicks or spasms. In particular, the acromioclavicular joints, sternoclavicular joints and biceps tendons should be palpated.
Ranges of Motion
Normal ranges of motion of the shoulder include forward flexion (sagittal plane) from 0 to 180 degrees,
extension from 0 to 45-60 degrees, abduction (coronal plane) from 0 to 170-180 degrees, adduction from 0 to 45 degrees, external rotation from 0 to 90 degrees,
and internal rotation from 0 to 90 degrees. The range of internal rotation is also described by the vertebral level the patient can touch, as if scratching their back,
and with this method T4-T8 is normal.
Empty Can Test
The shoulder is internally rotated with the thumb pointing down and a forward angulation of 30 degrees.
The examiner provides resistance to shoulder abduction in this position. A positive test is ipsilateral shoulder pain and suggestive of supraspinatus tendinopathy.
Drop Arm Test
The examiner passively abducts the shoulder to 90 degrees and the patient is asked to lower the arm slowly back to their slide.
A positive test is when the arm does not return slowly but “drops”, and suggestive of a rotator cuff tear or significant tendinopathy.
The arm is internally rotated with the dorsum of the hand on the patient’s back. Resistance is provided as the patient attempts to “lift” the hand “off” their back.
A positive test is an inability to lift-off, or relative weakness, and suggestive of subscapularis pathology.
With the elbow flexed and forearm pronated, the examiner provides resistance to supination.
A positive test is pain in the bicipital groove and suggestive of biceps tendinopathy.
Special Tests Continued
With the elbow fully extended, the forearm supinated, and the shoulder externally rotated, the examiner provides resistance to forward flexion.
Similar to Yergason’s test, a positive test is pain in the bicipital groove and indicative of biceps tendinopathy.
Neer’s Sign Test
The examiner provides passive forward flexion of the shoulder while the arm is either in full internal or external rotation. A positive test is pain near the acromion and suggestive of impingement of the rotator cuff against the undersurface of the acromion or the coracoacromial ligament.
The examiner passively abducts the shoulder to 90 degrees, flexes the elbow, and internally rotates the arm.
A positive test is pain near the acromion and suggestive of impingement of the rotator cuff.
Apley Scarf Test
The examiner passively adducts the arms to near the contralateral shoulder, as when donning a scarf.
A positive test is pain near the ipsilateral acromioclavicular joint and suggestive of acromioclavicular arthritis.