Shoulder Assessment Playbook

Sports Med U | Educating Minds, Elevating Potential

Understanding the physical examination of the shoulder: a narrative review

Yang, S., Kim, T.U., Kim, D.H. and Chang, M.C., 2021. Understanding the physical examination of the shoulder: a narrative review. Annals of palliative medicine, 10(2), pp.2293303-2292303.

In today’s letter

• How to assess the shoulder

• 3 clinical tips

• A fun infographic for you to save and use in the future

• 3 resources to check out to further your knowledge about shoulders

• Meme of the week: Sloooow & controlled. Mmm, actually, not that slow 😄 

• Rapid Results =

A thorough history and physical exam should always come first in shoulder assessment, with imaging used selectively to confirm or rule out a diagnosis. Over-reliance on scans can lead to unnecessary costs and incidental findings that may not impact treatment.

• Professional takeaway =

Use a combination of tests rather than relying on just one to rule conditions in or out. No single test is perfect, so cross-referencing multiple findings with patient history leads to better decision-making.

4 Phase Tendon Rehab Framework

Aim of the study

“The aim of this study was to review the shoulder anatomy and describe the specific tests used to evaluate common shoulder conditions to facilitate accurate diagnosis and guide proper treatment of these conditions”

Did you know?

Shoulder pain is one of the most common complaints in both athletes and everyday patients, with prevalence rates ranging from 7% to 26%. Whether it’s a weekend warrior struggling with overhead lifts or a pro athlete battling rotator cuff irritation, shoulder issues can seriously impact performance and quality of life.

it’s not black & white though…

The shoulder is a complex joint with multiple moving parts. Common conditions like

• Rotator cuff disorders

• Adhesive capsulitis (frozen shoulder)

• SLAP (superior labrum anterior to posterior) lesions

• Biceps tendinopathy

• AC joint disease

• instability

Can all present with overlapping symptoms. That makes pinpointing the exact cause a challenge. But a structured approach to assessment can help cut through the confusion.

An Effective Shoulder Assessment

A well-rounded shoulder assessment should be systematic, efficient, and targeted.

Here’s a quick breakdown:

1. History Taking: Start with the basics—ask the right questions to understand the mechanism of injury, duration of symptoms, and any aggravating or relieving factors.

   A history of overhead activities? Think rotator cuff pathology. Trauma with a pop? Instability or labral involvement should be considered.

2. Observation & Palpation: Look for asymmetry, muscle wasting, or abnormal positioning. Palpation helps identify localised tenderness—pain at the AC joint might suggest AC joint disease, while tenderness at the biceps tendon could indicate tendinopathy.

3. Range of Motion (ROM) Testing: Both active and passive ROM testing can highlight mobility restrictions. A stiff shoulder with loss of external rotation? Likely adhesive capsulitis. Painful arc during abduction? Think rotator cuff pathology.

4. Strength Testing: Use resisted movements to evaluate muscle function. Weakness with external rotation? Consider rotator cuff involvement. Pain with resisted elbow flexion? Possible biceps tendon pathology.

5. Special Tests: No single test is diagnostic on its own, but a combination of tests can guide your clinical reasoning.

   A few go-to’s:

   • Hawkins-Kennedy for rotator cuff pathology

   • O’Brien’s test for SLAP tears

   • Speed’s test for biceps tendinopathy

   • Apprehension test for instability

Anatomy Of The Shoulder

Before diving into shoulder assessments, let’s start with the foundation—anatomy.

A solid understanding of shoulder structure helps distinguish between normal and pathological conditions.

Bones and Joints

The shoulder consists of three bones:

• Clavicle (collarbone)

• Scapula (shoulder blade)

• Humerus (upper arm bone)

These bones form four key joints:

1. Glenohumeral joint (GHJ) – The primary ball-and-socket joint where the humeral head meets the shallow glenoid cavity. This gives the shoulder its mobility—but also makes it inherently unstable.

2. Acromioclavicular joint (ACJ) – The junction between the acromion and clavicle, often involved in shoulder separations.

3. Sternoclavicular joint (SCJ) – The only bony connection between the shoulder girdle and the axial skeleton.

4. Scapulothoracic joint – A functional, rather than true synovial, joint allowing scapular movement over the ribcage.

Muscles and Ligaments

The shoulder’s mobility comes at the cost of stability, relying heavily on:

• The Labrum – A fibrocartilage ring deepening the glenoid cavity and aiding stability.

• The Rotator Cuff – Stabiliser consisting of:

  • Supraspinatus (abduction)

  • Infraspinatus (external rotation)

  • Teres minor (external rotation)

  • Subscapularis (internal rotation)

Other key importnat groups include the deltoid, pectoralis major and minor, biceps brachii, triceps brachii, teres major, and latissimus dorsi, which contribute to movement and support.

Nerves & Common Pathologies

The brachial plexus (C5-T1) innervates the shoulder, with branches such as:

• Suprascapular nerve – Supplies the supraspinatus and infraspinatus; compression at the spinoglenoid notch can cause infraspinatus atrophy.

• Axillary nerve – Runs through the quadrilateral space and innervates the deltoid and teres minor; vulnerable in open-shoulder procedures.

Clinical Relevance: Why This Matters

• Quadrilateral Space Syndrome – Compression of the axillary nerve, causing deltoid/teres minor weakness and shoulder pain.

• Labral Tears (SLAP lesions) – Can result from repetitive overhead movement or trauma, affecting stability.

Smarter Assessment

Assessing the shoulder is more than just poking, prodding, and hoping for the best. A well-structured shoulder exam can provide diagnostic clues, guiding you toward the right treatment path.

Let’s break it down step by step.

1. Take a Good History

Before even touching the patient, ask the right questions. A solid history can help rule out non-shoulder causes of pain and pinpoint possible injuries.

• Pain characteristics – Duration, quality, radiation, aggravating and alleviating factors.

• Trauma history – Was there a fall or direct impact? Could be a fracture or dislocation.

• Age factor – Younger patients often have traumatic injuries, while older ones are more prone to rotator cuff tears or adhesive capsulitis.

2. Look Before You Touch

Expose both shoulders and compare. Things to watch for:

• Asymmetry – Atrophy, deformity, or swelling?

• Skin changes – Ecchymosis, wounds, or scars?

• Posture – Does the humeral head sit oddly? A bulge may suggest a rotator cuff tear.

3. Find the Pain Through Palpation

Pressing on structures around the shoulder can give a few clues:

• AC joint tenderness → Possible osteoarthritis or AC irritation.

• Bicipital groove tenderness → Biceps tendon irritation.

• Lateral deltoid pain → Could indicate supraspinatus tendon or rotator cuff irritation.

• Modified Crass Position – Placing the hand behind the back in internal rotation can help better localise the supraspinatus tendon for assessment.

4. Assessing Range of Motion (ROM)

Evaluate both active (patient moves) and passive (examiner assists) movements:

• Loss of both active & passive ROM → Likely adhesive capsulitis.

• Loss of active but intact passive ROM → rotator cuff tear or overuse pathology

Normal ROM values:

• Flexion: 150°–180°

• Extension: 40°–60°

• Abduction: 150°–180°

• External rotation: 60°–90°

5. How You Test Changes Results

• Sitting Position – Useful for functional tasks and spotting compensatory movements.

• Supine Position – Eliminates gravity effects, helping assess passive ROM, especially in weak patients.

• Be Consistent – ROM should be measured in the same position each time for reliable tracking.

Rotator Cuff Disorders: Tears, Tendinopathy & SAP

Pathophysiology & Biomechanics

The rotator cuff (RC) consists of four muscles:

• Supraspinatus (most commonly injured)

• Infraspinatus

• Teres minor

• Subscapularis

They stabilise the humeral head within the glenoid while enabling smooth movement. Overuse or trauma can lead to:

• Tendinopathy (chronic overuse leads to degeneration without inflammation)

• Partial or full-thickness tears (due to trauma or wear)

Evidence-Based Tests 🔍

Subscapularis Tear (Largest Rotator Cuff Muscle, Internal Rotation Deficit)

• Lift-Off Test (Gerber Test)

  • Procedure: Hand on lower back, patient lifts hand away.

  • Evidence: Sensitivity: 62%, Specificity: 100% (Hertel et al., 1996).

  • A positive test is highly specific for subscapularis tears.

• Belly-Press Test (Alternative for elderly patients)

  • Procedure: Press hand into stomach while keeping elbow forward.

  • Evidence: Sensitivity: 40–60%, Specificity: 98% (Burkhart et al., 2006).

  • Used when limited shoulder mobility prevents the Lift-Off test.

Infraspinatus & Teres Minor (External Rotators, Weakness in ER)

• External Rotation Lag Sign

  • Procedure: Hold arm in maximum external rotation; inability to maintain position is positive.

  • Evidence: Sensitivity: 97%, Specificity: 93% (Walch et al., 1998).

  • Highly accurate for massive rotator cuff tears.

1. Subacromial Pain (SAP)

Pathophysiology & Biomechanics

Subacromial pain (SAP) refers to pain in the shoulder region, specifically beneath the acromion, which is the bony prominence at the top of the shoulder blade. The exact cause of subacromial pain is often unclear and could be related to the ligaments, tendons, or the joint capsule in the area

📊 Gold-Standard Diagnostic Method: MRI & Ultrasound
However, clinical tests can provide a strong presumptive diagnosis.

1️⃣ Neer’s Test (Passive Elevation in Internal Rotation)

• Procedure: Forced flexion with internal rotation (IR); pain indicates irritation.

• Evidence: Sensitivity: 79%, Specificity: 53% (Hegedus et al., 2012).

• A negative test helps rule it out, but positive should be confirmed with other tests.

2️⃣ Hawkins-Kennedy Test

• Procedure: 90° shoulder flexion, internal rotation; pain indicates impingement.

• Evidence: Sensitivity: 80%, Specificity: 56% (Michener et al., 2009).

• Used as part of an SAP test cluster.

3️⃣ Painful Arc Test

• Procedure: Active abduction; pain between 70°–120° suggests impingement.

• Evidence: Sensitivity: 53–81%, Specificity: 55–84% (Park et al., 2005).

• Best used with Hawkins-Kennedy & Neer’s tests.

SAP Test Cluster (Park et al., 2005)
✔️ Hawkins-Kennedy + Painful Arc + Infraspinatus Weakness
✔️ 3/3 Positive = 95% Probability of SAP

2. SLAP Lesions (Superior Labrum Anterior to Posterior Tears)

Pathophysiology & Biomechanics

A SLAP lesion is a tear at the superior labrum where the biceps tendon attaches. Common in throwing athletes, weightlifters, and trauma cases (e.g., falling on an outstretched hand).

1️⃣ O’Brien’s Test

• Procedure: 90° flexion, 10–15° adduction, thumb down; pain in IR but relief in ER suggests SLAP lesion.

• Evidence: Sensitivity: 63%, Specificity: 73% (Hegedus et al., 2012).

• Good for ruling in SLAP or AC joint pathology.

2️⃣ Crank Test

• Procedure: Axial load applied while rotating humerus; clicking/grinding indicates a labral tear.

• Evidence: Sensitivity: 91%, Specificity: 93% (Kim et al., 2009).

• Best single test for labral tears.

3️⃣ Speed’s Test (Biceps Pathology & SLAP)

• Procedure: Resisted shoulder flexion with elbow extended and palm up.

• Evidence: Sensitivity: 32–56%, Specificity: 67–75% (Hegedus et al., 2012).

• Used in combination with O’Brien’s and Crank test.

3. Shoulder Instability: Anterior, Posterior, & Inferior

Pathophysiology & Biomechanics

Shoulder dislocations occur in different directions:

• Anterior Instability (most common, 95% of dislocations)

• Posterior Instability (rare, seen in seizures or contact sports)

• Multidirectional Instability (MDI) (common in hypermobile patients)

1️⃣ Apprehension Test (Anterior Instability)

• Procedure: Shoulder externally rotated at 90° abduction—apprehension indicates instability.

• Evidence: Sensitivity: 72%, Specificity: 96% (Hegedus et al., 2012).

2️⃣ Relocation Test (Confirms Anterior Instability)

• Procedure: Posterior force applied during apprehension test—relief confirms instability.

• Evidence: Sensitivity: 81%, Specificity: 99%.

3️⃣ Sulcus Sign (Inferior Instability/MDI)

• Procedure: Downward traction at elbow—gap formation is positive.

• Evidence: Sensitivity: 28%, Specificity: 91%.

Imaging: Essential OR Overused?

• X-rays: Best for bone injuries and spotting secondary signs of soft tissue damage. They’re a great first step, especially if a fracture or arthritis is suspected.

• Ultrasound (US): Perfect for real-time imaging of soft tissues like tendons and muscles. It’s quick, cost-effective, and can guide injections for more precise treatments.

• Magnetic Resonance Imaging (MRI): The gold standard for detailed views of bone marrow, cartilage, and soft tissue injuries.

The Problem: Are We Overusing Imaging?

Yes, imaging is powerful, but it’s often over-prescribed.

The reality is:

• Many shoulder issues can be diagnosed through history and physical exams alone.

• Not every patient needs expensive tests—they should be reserved for cases where imaging changes the treatment plan.

• Physical exam tests aren’t perfect—they’re subjective and can produce false positives—but when combined with history, they provide a strong diagnostic foundation.

When Should You Order Imaging?

• If you suspect a fracture, dislocation, or severe structural damage.

• If the patient isn’t improving despite treatment and you need a deeper look.

• If surgical intervention is being considered and precise visualisation is needed.

3 Clinical Tips

• Use Imaging Wisely
  MRI and ultrasound are powerful tools, but they should confirm, not replace, clinical findings. Overuse of imaging can lead to incidental findings that may not be the actual source of pain.

• Combine Tests for Better Accuracy
  No single shoulder test is perfect, so use a combination to improve diagnostic confidence. Pairing clinical exams with patient symptoms ensures a more precise assessment of rotator cuff integrity, labral injuries, and instability.

• Consider Function Over Pathology
  Not every structural abnormality seen on imaging correlates with pain or dysfunction. Focus on how the patient moves, their functional limitations, and their rehab needs rather than just the scan results.

Top 3 Resources to Check Out

And learn more about shoulders

1. Shoulder Rehab Exercises (PDF) - LINK 💪

2. Should shoulder rehab be pain free? (Article) - LINK 🏋️

3. Shoulder anatomy

Meme of The Week

When You’re Ready to Learn More

We have great resources for you to devourer

1. Killer Articles —> Literally everything you need to know about a specific injury

2. Tendinopathy 4 phase rehab frame work - My book that walks you through a step by step process of treating tendons

Thank You For Reading

Have a browse through our articles to sharpen you diagnostic skills