The Painful Shoulder: Part I. Clinical Evaluation - AAFP

The Painful Shoulder: Part I. Clinical Evaluation | AAFP 31/05/23 10.
54
The Painful Shoulder: Part I.

Clinical Evaluation
THOMAS W. WOODWARD, M.D., AND THOMAS M. BEST, M.D., PH.D.
! Am Fam Physician. 2000;61(10):3079-3088

" This is Part I of a two-part article on clinical evaluation of the painful shoulder. Part
II, “Acute and Chronic Injuries,”
(https://www.aafp.org/afp/2000/0601/p3291.html) will appear in the next issue
of AFP.
Family physicians need to understand diagnostic and treatment strategies

for common causes of shoulder pain. We review key elements of the
history and physical examination and describe maneuvers that can be used
to reach an appropriate diagnosis. Examination of the shoulder should
include inspection, palpation, evaluation of range of motion and
provocative testing. In addition, a thorough sensorimotor examination of
the upper extremity should be performed, and the neck and elbow should
be evaluated.
Shoulder pain is a common complaint in family practice patients. The unique anatomy
and range of motion of the glenohumeral joint can present a diagnostic challenge, but
a proper clinical evaluation usually discloses the cause of the pain.
Anatomy
The shoulder is composed of the humerus, glenoid, scapula, acromion, clavicle and
surrounding soft tissue structures. The shoulder region includes the glenohumeral
joint, the acromioclavicular joint, the sternoclavicular joint and the scapulothoracic
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The Painful Shoulder: Part I. Clinical Evaluation | AAFP 31/05/23 10.54
articulation (Figure 1a). The glenohumeral joint capsule consists of a fibrous capsule,
ligaments and the glenoid labrum. Because of its lack of bony stability, the
glenohumeral joint is the most commonly dislocated major joint in the body.
Glenohumeral stability is due to a combination of ligamentous and capsular
constraints, surrounding musculature and the glenoid labrum. Static joint stability is
provided by the joint surfaces and the capsulolabral complex, and dynamic stability by
the rotator cuff muscles and the scapular rotators (trapezius, serratus anterior,
rhomboids and levator scapulae).
FIGURE 1A.
Anatomy of the shoulder girdle.
The rotator cuff is composed of four muscles: the supraspinatus, infraspinatus, teres
minor and subscapularis (Figure 1b). The subscapularis facilitates internal rotation, and
the infraspinatus and teres minor muscles assist in external rotation. The rotator cuff
muscles depress the humeral head against the glenoid. With a poorly functioning
(torn) rotator cuff, the humeral head can migrate upward within the joint because of an
opposed action of the deltoid muscle.
FIGURE 1B.
The muscles of the rotator cuff.
Scapular stability collectively involves the trapezius, serratus anterior and rhomboid
muscles. The levator scapular and upper trapezius muscles support posture; the
trapezius and the serratus anterior muscles help rotate the scapula upward, and the
trapezius and the rhomboids aid scapular retraction.
History
A complete history begins with the patient's age, dominant hand and sport or work
activity. It is important to assess whether the injury prevents or hampers normal work
activities, hobbies and sports. The patient should be asked about shoulder pain,
instability, stiffness, locking, catching and swelling. Stiffness or loss of motion may be
the major symptom in patients with adhesive capsulitis (frozen shoulder), dislocation
or glenohumeral joint arthritis. Pain with throwing (such as pitching a baseball)
suggests anterior glenohumeral instability. Patients who complain of generalized joint
laxity often have multidirectional glenohumeral instability.
Distinguishing between an acute and a chronic problem is diagnostically helpful (Table

1). For example, a history of acute trauma to the shoulder with the arm abducted and
externally rotated strongly suggests shoulder subluxation or dislocation and possible
glenoid labral injury. In contrast, chronic pain and loss of passive range of motion
suggest frozen shoulder or tears of the rotator cuff.
TABLE 1
Key Findings in the History and Physical Examination
Finding Probable diagnosis
Serratus anterior or trapezius

Scapular winging, trauma, recent viral illness
dysfunction
Seizure and inability to passively or actively rotate

Posterior shoulder dislocation
affected arm externally
Rotator cuff tear;

Supraspinatus/infraspinatus wasting suprascapular nerve
entrapment
Pain radiating below elbow; decreased cervical

Cervical disc disease
range of motion
Shoulder pain in throwing athletes; anterior

Glenohumeral joint instability
glenohumeral joint pain and impingement
Pain or “clunking” sound with overhead motion Labral disorder
Nighttime shoulder pain Impingement
Generalized ligamentous laxity Multidirectional instability
Once the location, quality, radiation, and aggravating and relieving factors of the
shoulder pain have been established, the possibility of referred pain should be
excluded. Neck pain and pain that radiates below the elbow are often subtle signs of a
cervical spine disorder that is mistaken for a shoulder problem.
The patient should be asked about paresthesias and muscle weakness. Pneumonia,
cardiac ischemia and peptic ulcer disease can present with shoulder pain. A history of
malignancy raises the possibility of metastatic disease. The patient should be asked
about previous corticosteroid injections, particularly in the setting of osteopenia or
rotator cuff tendon atrophy.
Physical Examination
A complete physical examination includes inspection and palpation, assessment of
range of motion and strength, and provocative shoulder testing for possible
impingement syndrome and glenohumeral instability. The neck and the elbow should
also be examined to exclude the possibility that the shoulder pain is referred from a
pathologic condition in either of these regions.
INSPECTION
The physical examination includes observing the way the patient moves and carries
the shoulder. The patient should be properly disrobed to permit complete inspection of
both shoulders. Swelling, asymmetry, muscle atrophy, scars, ecchymosis and any
venous distention should be noted. Deformity, such as squaring of the shoulder that
occurs with anterior dislocation, can immediately suggest a diagnosis. Scapular
“winging,” which can be associated with shoulder instability and serratus anterior or
trapezius dysfunction, should be noted. Atrophy of the supraspinatus or infraspinatus
should prompt a further work-up for such conditions as rotator cuff tear, suprascapular
nerve entrapment or neuropathy.
PALPATION
Palpation should include examination of the acromioclavicular and sternoclavicular

joints, the cervical spine and the biceps tendon. The anterior glenohumeral joint,
coracoid process, acromion and scapula should also be palpated for any tenderness
and deformity.
RANGE-OF-MOTION TESTING
Because the complex series of articulations of the shoulder allows a wide range of
motion, the affected extremity should be compared with the unaffected side to
determine the patient's normal range. Active and passive ranges should be assessed.
For example, a patient with loss of active motion alone is more likely to have weakness
of the affected muscles than joint disease.
Shoulder abduction involves the glenohumeral joint and the scapulothoracic

articulation. Glenohumeral motion can be isolated by holding the patient's scapula with
one hand while the patient abducts the arm. The first 20 to 30 degrees of abduction
should not require scapulothoracic motion. With the arm internally rotated (palm
down), abduction continues to 120 degrees. Beyond 120 degrees, full abduction is
possible only when the humerus is externally rotated (palm up).
The Apley scratch test is another useful maneuver to assess shoulder range of motion
(Figure 2). In this test, abduction and external rotation are measured by having the
patient reach behind the head and touch the superior aspect of the opposite scapula.
Conversely, internal rotation and adduction of the shoulder are tested by having the
patient reach behind the back and touch the inferior aspect of the opposite scapula.
External rotation should be measured with the patient's arms at the side and elbows
flexed to 90 degrees.
FIGURE 2.
Apley scratch test. The patient attempts to touch the opposite scapula to test range of motion of
the shoulder. (Left) Testing abduction and external rotation. (Right) Testing adduction and internal
rotation.
EVALUATING THE ROTATOR CUFF
In evaluating the rotator cuff, the patient's affected extremity should always be
compared with the unaffected side to detect subtle differences in strength and motion.
A key finding, particularly with rotator cuff problems, is pain accompanied by
weakness. True weakness should be distinguished from weakness that is due to pain.
A patient with subacromial bursitis with a tear of the rotator cuff often has objective
rotator cuff weakness caused by pain when the arm is positioned in the arc of
impingement. Conversely, the patient will have normal strength if the arm is not tested
in abduction.1
The supraspinatus can be tested by having the patient abduct the shoulders to 90
degrees in forward flexion with the thumbs pointing downward. The patient then
attempts to elevate the arms against examiner resistance (Figure 3). This is often
referred to as the “empty can” test.
FIGURE 3.
Supraspinatus examination (“empty can” test). The patient attempts to elevate the arms against
resistance while the elbows are extended, the arms are abducted and the thumbs are pointing
downward.
Next, with the patient's arms at the sides, the patient flexes both elbows to 90 degrees
while the examiner provides resistance against external rotation (Figure 4). This
maneuver is used to evaluate the function of the infraspinatus and teres minor
muscles, which are mainly responsible for external rotation.
FIGURE 4.
Infraspinatus/teres minor examination. The patient attempts to externally rotate the arms against
resistance while the arms are at the sides and the elbows are flexed to 90 degrees.
Subscapularis function is assessed with the lift-off test. The patient rests the dorsum
of the hand on the back in the lumbar area. Inability to move the hand off the back by
further internal rotation of the arm suggests injury to the subscapularis muscle.2 In
one study, the investigators noted that only a few of the patients with confirmed
subscapularis ruptures actually demonstrated a positive result on the lift-off test; the
remainder could not complete the test because of pain.3
A modified version of the lift-off test is useful in a patient who cannot place the hand
behind the back. In this version, the patient places the hand of the affected arm on the
abdomen and resists the examiner's attempts to externally rotate the arm.
Provocative Testing
Provocative tests provide a more focused evaluation for specific problems and are
typically performed after the history and general examination have been completed
(Table 2).
TABLE 2
Tests Used in Shoulder Evaluation and Significance of

Positive Findings
Diagnosis suggested by
Test Maneuver positive result
Apley scratch Patient touches superior and inferior Loss of range of motion:
test aspects of opposite scapula rotator cuff problem
Subacromial
Neer's sign Arm in full flexion
impingement
Forward flexion of the shoulder to 90 Supraspinatus tendon

Hawkins' test
degrees and internal rotation impingement
Drop-arm
Arm lowered slowly to waist Rotator cuff tear
test
Cross-arm Forward elevation to 90 degrees and Acromioclavicular joint

test active adduction arthritis
Spurling's Spine extended with head rotated to Cervical nerve root

test affected shoulder while axially loaded disorder
Apprehension Anterior pressure on the humerus with Anterior glenohumeral

test external rotation instability
Relocation Posterior force on humerus while Anterior glenohumeral

test externally rotating the arm instability
Inferior glenohumeral
Sulcus sign Pulling downward on elbow or wrist
instability
Yergason Elbow flexed to 90 degrees with forearm Biceps tendon instability

test pronated or tendonitis
Speed's Elbow flexed 20 to 30 degrees and Biceps tendon instability

maneuver forearm supinated or tendonitis
Rotation of loaded shoulder from

“Clunk” sign Labral disorder
extension to forward flexion
NEER'S TEST
Neer's impingement sign is elicited when the patient's rotator cuff tendons are pinched
4
under the coracoacromial arch. The test4 is performed by placing the arm in forced
flexion with the arm fully pronated (Figure 5). The scapula should be stabilized during
the maneuver to prevent scapulothoracic motion. Pain with this maneuver is a sign of
subacromial impingement.
FIGURE 5.
Neer's test for impingement of the rotator cuff tendons under the coracoacromial arch. The arm is
fully pronated and placed in forced flexion.
HAWKINS' TEST
The Hawkins' test is another commonly performed assessment of impingement.5 It is

performed by elevating the patient's arm forward to 90 degrees while forcibly internally
rotating the shoulder (Figure 6). Pain with this maneuver suggests subacromial
impingement or rotator cuff tendonitis. One study6 found Hawkins' test more sensitive
for impingement than Neer's test.
FIGURE 6.
Hawkins' test for subacromial impingement or rotator cuff tendonitis. The arm is forward elevated
to 90 degrees, then forcibly internally rotated.
DROP-ARM TEST
A possible rotator cuff tear can be evaluated with the drop-arm test. This test is
performed by passively abducting the patient's shoulder, then observing as the patient
slowly lowers the arm to the waist. Often, the arm will drop to the side if the patient has
a rotator cuff tear or supraspinatus dysfunction. The patient may be able to lower the
arm slowly to 90 degrees (because this is a function mostly of the deltoid muscle) but
will be unable to continue the maneuver as far as the waist.
CROSS-ARM TEST
Patients with acromioclavicular joint dysfunction often have shoulder pain that is
mistaken for impingement syndrome. The cross-arm test isolates the
acromioclavicular joint. The patient raises the affected arm to 90 degrees. Active
adduction of the arm forces the acromion into the distal end of the clavicle (Figure 7).
Pain in the area of the acromioclavicular joint suggests a disorder in this region.
FIGURE 7.
Cross-arm test for acromioclavicular joint disorder. The patient elevates the affected arm to 90
degrees, then actively adducts it.
Instability Testing
The tests described in this section are useful in evaluating for glenohumeral joint
stability. Because the shoulder is normally the most unstable joint in the body, it can
demonstrate significant glenohumeral translation (motion). Again, the uninvolved
extremity should be examined for comparison with the affected side.7,8
APPREHENSION TEST
The anterior apprehension test is performed with the patient supine or seated and the
shoulder in a neutral position at 90 degrees of abduction. The examiner applies slight
anterior pressure to the humerus (too much force can dislocate the humerus) and
externally rotates the arm (Figure 8). Pain or apprehension about the feeling of
impending subluxation or dislocation indicates anterior glenohumeral instability.
FIGURE 8.
Apprehension test for anterior instability. The patient's arm is abducted to 90 degrees while the
examiner externally rotates the arm and applies anterior pressure to the humerus.
RELOCATION TEST
The relocation test is performed immediately after a positive result on the anterior
apprehension test. With the patient supine, the examiner applies posterior force on the
proximal humerus while externally rotating the patient's arm. A decrease in pain or
apprehension suggests anterior glenohumeral instability.
YERGASON TEST
Patients with rotator cuff tendonitis frequently have concomitant inflammation of the
biceps tendon. The Yergason test is used to evaluate the biceps tendon.9 In this test,
the patient's elbow is flexed to 90 degrees with the thumb up. The examiner grasps the
wrist, resisting attempts by the patient to actively supinate the arm and flex the elbow
(Figure 9). Pain with this maneuver indicates biceps tendonitis.
FIGURE 9.
Yergason test for biceps tendon instability or tendonitis. The patient's elbow is flexed to 90 degrees,
and the examiner resists the patient's active attempts to supinate the arm and flex the elbow.
SPEED'S MANEUVER
Speed's maneuver is used to examine the proximal tendon of the long head of the
biceps. The patient's elbow is flexed 20 to 30 degrees with the forearm in supination
and the arm in about 60 degrees of flexion. The examiner resists forward flexion of the
arm while palpating the patient's biceps tendon over the anterior aspect of the
shoulder.
SULCUS SIGN
With the patient's arm in a neutral position, the examiner pulls downward on the elbow
or wrist while observing the shoulder area for a sulcus or depression lateral or inferior
to the acromion. The presence of a depression indicates inferior translation of the
humerus and suggests inferior glenohumeral instability (Figure 10). The examiner
should remember that many asymptomatic patients, especially adolescents, normally
have some degree of instability.10
FIGURE 10.
Sulcus test for glenohumeral instability. Downward traction is applied to the humerus, and the
examiner watches for a depression lateral or inferior to the acromion.
POSTERIOR APPREHENSION AND INSTABILITY
Posterior instability of the shoulder can be assessed by using a simple test.11 With the
patient supine or sitting, the examiner pushes posteriorly on the humeral head with the
patient's arm in 90 degrees of abduction and the elbow in 90 degrees of flexion.
‘CLUNK’ SIGN
Glenoid labral tears are assessed with the patient supine. The patient's arm is rotated
and loaded (force applied) from extension through to forward flexion. A “clunk” sound
or clicking sensation can indicate a labral tear even without instability.12
Cervical Disc Disease

No physical examination in a patient with shoulder pain is complete without excluding
cervical spine disease. Referred or radicular pain from disc disease should be
considered in patients who have shoulder pain that does not respond to conservative
treatment. The patient should be questioned about neck pain and previous neck injury,
and the examiner should note whether pain worsens with turning of the neck, which
suggests disc disease. Pain that originates from the neck or radiates past the elbow is
often associated with a neck disorder.
Plain film is a useful screening tool for degenerative cervical disc disease. Further
work-up and imaging studies depend on the differential diagnosis and the treatment
plan.
SPURLING'S TEST
In a patient with neck pain or pain that radiates below the elbow, a useful maneuver to
further evaluate the cervical spine is Spurling's test. The patient's cervical spine is
placed in extension and the head rotated toward the affected shoulder. An axial load is
then placed on the spine (Figure 11). Reproduction of the patient's shoulder or arm pain
indicates possible cervical nerve root compression and warrants further evaluation of
the bony and soft tissue structures of the cervical spine.
FIGURE 11.
Spurling's test for cervical root disorder. The neck is extended and rotated toward the affected
shoulder while an axial load is placed on the spine.
Author Information
THOMAS W. WOODWARD, M.D., is a clinical assistant professor of family medicine at
the University of Wisconsin Medical School, Madison. A graduate of the University of
Iowa College of Medicine, Iowa City, Dr. Woodward completed a family practice
residency at the University of Wisconsin Medical School.
THOMAS M. BEST, M.D., PH.D., is an assistant professor of family medicine and

orthopedics at the University of Wisconsin Medical School. He received his medical
degree from the University of Western Ontario Faculty of Medicine and Dentistry,
London, Ontario, and served a family practice residency in Chapel Hill, N.C. After
receiving a doctorate in biomedical engineering from Duke University, Durham, N.C., Dr.
Best completed sports medicine training at the University of Wisconsin Medical
School.
Address correspondence to Thomas M. Best, M.D., Ph.D., University of Wisconsin Hospitals

and Clinics, 621 Science Dr., Madison, WI 53711. Reprints are not available from the authors.
Reference(s)
1. Miniaci A, Salonen D. Rotator cuff evaluation imaging and diagnosis. Orthop Clin
North Am. 1997;28:43-58.
2. Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle:
clinical features in 16 cases. J Bone Joint Surg [Br]. 1991;73B:389-94.
3. Deutsch A, Altchek DW, Veltri DM, Potter HG, Warren RF. Traumatic tears of the
subscapularis tendon: clinical diagnosis, magnetic resonance imaging findings, and
operative treatment. Am J Sports Med. 1997;25:13-22.
4. Neer CS. Impingement lesions. Clin Orthop. 1983;173:70-77.
5. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med.

1980;8:151-7.
6. Bak K, Fauno P. Clinical findings in competitive swimmers with shoulder pain. Am J

Sports Med. 1997;25:254-60.
7. Harryman DT, Sidles JA, Clark JM, McQuade KJ, Gibb TD, Matsen FA. Translation of
the humeral head on the glenoid with passive glenohumeral motion. J Bone Joint Surg
[Am]. 1990;72:1334-43.
8. Harryman DT, Sidles JA, Harris SL, Matsen FA. Laxity at the normal glenohumeral
joint: a quantitative in-vivo assessment. J Shoulder Elbow Surg. 1992;1:66-76.
9. Yergason RM. Supination sign. J Bone Joint Surg [Am]. 1931;13:160.
10. Emery RH, Mullaji AB. Glenohumeral joint instability in normal adolescents. J Bone
Joint Surg [Br]. 1991;73B:406-8.
11. O'Driscoll SW. A reliable and simple test for posterior instability of the shoulder. J
Bone Joint Surg [Br]. 1991;73B(suppl 1):50.
12. Glasgow SG, Bruce RA, Yacobucci GN, Torg JS. Arthroscopic resection of glenoid
labral tears in the athlete: a report of 29 cases. Arthroscopy. 1992;8:48-54.
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The Painful Shoulder: Part I. Clinical Evaluation | AAFP 31/05/23 10.

The Painful Shoulder: Part I.

! Am Fam Physician. 2000;61(10):3079-3088

Family physicians need to understand diagnostic and treatment strategies

Anatomy of the shoulder girdle.

The muscles of the rotator cuff.

Distinguishing between an acute and a chronic problem is diagnostically helpful (Table

suggest frozen shoulder or tears of the rotator cuff.

Key Findings in the History and Physical Examination

Finding Probable diagnosis

Serratus anterior or trapezius

Seizure and inability to passively or actively rotate

Rotator cuff tear;

Pain radiating below elbow; decreased cervical

Shoulder pain in throwing athletes; anterior

Pain or “clunking” sound with overhead motion Labral disorder

Nighttime shoulder pain Impingement

Generalized ligamentous laxity Multidirectional instability

Palpation should include examination of the acromioclavicular and sternoclavicular

Shoulder abduction involves the glenohumeral joint and the scapulothoracic

EVALUATING THE ROTATOR CUFF

Tests Used in Shoulder Evaluation and Significance of

Test Maneuver positive result

Forward flexion of the shoulder to 90 Supraspinatus tendon

Cross-arm Forward elevation to 90 degrees and Acromioclavicular joint

Spurling's Spine extended with head rotated to Cervical nerve root

Apprehension Anterior pressure on the humerus with Anterior glenohumeral

Relocation Posterior force on humerus while Anterior glenohumeral

Yergason Elbow flexed to 90 degrees with forearm Biceps tendon instability

Speed's Elbow flexed 20 to 30 degrees and Biceps tendon instability

Rotation of loaded shoulder from

The Hawkins' test is another commonly performed assessment of impingement.5 It is

POSTERIOR APPREHENSION AND INSTABILITY

Cervical Disc Disease

THOMAS M. BEST, M.D., PH.D., is an assistant professor of family medicine and

Address correspondence to Thomas M. Best, M.D., Ph.D., University of Wisconsin Hospitals

4. Neer CS. Impingement lesions. Clin Orthop. 1983;173:70-77.

5. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med.

6. Bak K, Fauno P. Clinical findings in competitive swimmers with shoulder pain. Am J

9. Yergason RM. Supination sign. J Bone Joint Surg [Am]. 1931;13:160.

Copyright © 2000 by the American Academy of Family Physicians.

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