Upper Limb
Core
High Yield
Shoulder Examination
Master the comprehensive shoulder examination with systematic Look-Feel-Move approach, rotator cuff assessment, instability testing, and impingement evaluation.
Shoulder Examination
Examiner Favorite
The shoulder examination is one of the most commonly tested clinical stations. Examiners expect a fluent, systematic approach demonstrating Look-Feel-Move-Special Tests-Neurovascular assessment without rushing or causing patient discomfort.
Quick Reference One-Pager
Shoulder Examination Summary
High-Yield Exam Summary
Look
- •Anterior: deltoid wasting, scars, asymmetry
- •Lateral: squaring of shoulder
- •Posterior: supraspinatus/infraspinatus wasting, scapular winging
Feel
- •Sternoclavicular joint
- •Clavicle length
- •Acromioclavicular joint
- •Acromion and spine of scapula
- •Greater tuberosity
- •Biceps tendon in groove
Move
- •Forward flexion 0-180°
- •Abduction 0-180°
- •External rotation 0-60°
- •Internal rotation (T6-T12)
- •Extension 0-60°
Special Tests
- •Rotator cuff: Jobe's, Lift-off, Hornblower's
- •Instability: Apprehension, Relocation, Sulcus
- •Impingement: Hawkins, Neer
- •ACJ: Cross-body adduction, O'Brien's
Introduction and Setup
Before You Start
Patient Positioning: Standing initially for inspection, then seated for detailed examination
Exposure: Both shoulders exposed, patient in gown or with shirt removed. Ensure adequate exposure from neck to mid-arm bilaterally.
Consent Script: "I'd like to examine your shoulders today. I'll need to look at both sides for comparison, then feel around the joints, and finally test the movements. Please let me know if anything is painful."
Essential Equipment: None required for basic examination
Click to expand
Look (Inspection)
- Deltoid contour: Loss of rounded contour suggests wasting (axillary nerve injury, cuff tear arthropathy)
- Muscle bulk: Compare deltoid symmetry bilaterally
- Scars: Previous surgery (arthroscopy portals, open approach)
- Skin changes: Bruising (acute injury), erythema (infection)
- Shoulder position: Internally rotated (posterior dislocation), square appearance (anterior dislocation)
Must Know
Key Inspection Findings by Pathology:
- Anterior dislocation: Square shoulder, arm held in slight abduction and external rotation
- Massive cuff tear: Supraspinatus wasting, pseudoparalysis
- Long thoracic nerve palsy: Medial scapular winging on push-up
Feel (Palpation)
Systematic Palpation Sequence
Start at the sternoclavicular joint and work laterally in a logical sequence:
- Sternoclavicular joint: Swelling, tenderness, instability
- Clavicle: Full length for fracture, tenderness
- Acromioclavicular joint: Step deformity (separation), tenderness (OA, osteolysis)
- Acromion: Anterior, lateral edges
- Greater tuberosity: Rotator cuff insertion tenderness
- Bicipital groove: Biceps tendon tenderness (between tuberosities)
- Coracoid process: Deep anterior, below clavicle lateral to chest wall
- Spine of scapula: Posterior landmark
Also assess:
- Temperature with back of hand
- Effusion (rare in shoulder - deep joint)
- Crepitus during passive movement
Move (Range of Motion)
| movement | normalRange | technique | keyPoints |
|---|---|---|---|
| Forward Flexion | 0-180° | Arms straight, raise forward overhead | Watch for scapulothoracic substitution |
| Abduction | 0-180° | Arms out to side, raise overhead | Painful arc 60-120° = impingement |
| External Rotation | 0-60° | Elbows at 90°, tucked to sides, rotate out | Loss = frozen shoulder, OA |
| Internal Rotation | T6-T12 level | Hand behind back, reach up spine | Measure by vertebral level reached |
| Extension | 0-60° | Arms straight, move behind body | Often forgotten |
| Cross-body Adduction | Full | Arm across front of chest | Pain = ACJ pathology |
Key Concept
Painful Arc: Pain during mid-range abduction (60-120°) suggests subacromial impingement. Pain at end range (above 120°) suggests ACJ pathology.
Special Tests
Rotator Cuff Tests
Jobe's Test (Empty Can)
Supraspinatus integrity
Technique
- 1Patient standing with arms at 90° abduction in scapular plane (30° forward)
- 2Arms internally rotated with thumbs pointing down (empty can position)
- 3Apply downward pressure on forearms while patient resists
Positive Sign
Weakness or pain on resisted elevation
Indicates
Supraspinatus tear or impingement
Diagnostic Accuracy
Sensitivity77%
Ability to detect true positives
Specificity68%
Ability to exclude false positives
Lift-off Test (Gerber)
Subscapularis integrity
Technique
- 1Patient places hand behind back at waist level (internal rotation)
- 2Patient lifts hand off their back against resistance
- 3Compare power to contralateral side
Positive Sign
Inability to lift hand off back or maintain position
Indicates
Subscapularis tear
Diagnostic Accuracy
Sensitivity62%
Ability to detect true positives
Specificity100%
Ability to exclude false positives
Hornblower's Test
Teres minor integrity
Technique
- 1Patient places hand on opposite shoulder
- 2Elbow at 90° in scapular plane
- 3Patient attempts external rotation against resistance
Positive Sign
Weakness of external rotation with arm elevated
Indicates
Teres minor tear (posterosuperior cuff)
Diagnostic Accuracy
Sensitivity100%
Ability to detect true positives
Specificity93%
Ability to exclude false positives
External Rotation Lag Sign
Infraspinatus and posterior cuff
Technique
- 1Elbow at 90° flexion, arm by side
- 2Examiner passively externally rotates shoulder to maximum
- 3Patient asked to hold position while examiner releases
Positive Sign
Arm drops into internal rotation (lag)
Indicates
Infraspinatus tear, usually massive
Diagnostic Accuracy
Sensitivity97%
Ability to detect true positives
Specificity96%
Ability to exclude false positives
Instability Tests
Apprehension Test
Anterior instability
Technique
- 1Patient supine or standing, arm abducted 90°, elbow flexed 90°
- 2Examiner externally rotates shoulder progressively
- 3Watch patient's face for apprehension or distress
Positive Sign
Patient becomes apprehensive before subluxation, not just pain
Indicates
Anterior shoulder instability (previous dislocation)
Diagnostic Accuracy
Sensitivity72%
Ability to detect true positives
Specificity96%
Ability to exclude false positives
Relocation Test (Jobe)
Confirm anterior instability
Technique
- 1Following positive apprehension test
- 2Apply posterior-directed force to humeral head
- 3Continue external rotation
Positive Sign
Apprehension relieved, increased external rotation possible
Indicates
Confirms anterior instability
Diagnostic Accuracy
Sensitivity81%
Ability to detect true positives
Specificity92%
Ability to exclude false positives
Sulcus Sign
Inferior instability / laxity
Technique
- 1Patient sitting with arm relaxed at side
- 2Apply downward traction on arm
- 3Observe subacromial space for gap (sulcus)
Positive Sign
Visible sulcus below acromion (Grade 1: under 1cm, Grade 2: 1-2cm, Grade 3: greater than 2cm)
Indicates
Inferior instability or generalized laxity
Diagnostic Accuracy
Sensitivity28%
Ability to detect true positives
Specificity97%
Ability to exclude false positives
Impingement Tests
Hawkins-Kennedy Test
Subacromial impingement
Technique
- 1Patient standing, arm forward flexed to 90°, elbow flexed 90°
- 2Examiner internally rotates arm (lowering hand)
- 3This impinges supraspinatus under coracoacromial arch
Positive Sign
Pain with forced internal rotation
Indicates
Subacromial impingement
Diagnostic Accuracy
Sensitivity79%
Ability to detect true positives
Specificity59%
Ability to exclude false positives
Neer's Impingement Sign
Subacromial impingement
Technique
- 1Patient standing, examiner stabilizes scapula
- 2Arm passively forward flexed with elbow extended
- 3Internal rotation of arm during flexion
Positive Sign
Pain with passive forward flexion
Indicates
Subacromial impingement, rotator cuff pathology
Diagnostic Accuracy
Sensitivity79%
Ability to detect true positives
Specificity53%
Ability to exclude false positives
ACJ and Biceps Tests
Cross-body Adduction
ACJ pathology
Technique
- 1Patient flexes arm to 90°
- 2Adducts arm across chest to opposite shoulder
- 3Examiner provides overpressure
Positive Sign
Pain localized to ACJ
Indicates
ACJ osteoarthritis, osteolysis, or injury
Diagnostic Accuracy
Sensitivity77%
Ability to detect true positives
Specificity79%
Ability to exclude false positives
Speed's Test
Biceps tendinopathy / SLAP
Technique
- 1Patient forward flexes arm to 60° with elbow extended
- 2Forearm supinated (palm up)
- 3Examiner resists forward flexion
Positive Sign
Pain in bicipital groove
Indicates
Biceps tendinopathy or SLAP lesion
Diagnostic Accuracy
Sensitivity32%
Ability to detect true positives
Specificity75%
Ability to exclude false positives
Neurovascular Assessment
Neurological Examination
Key Nerves:
| Nerve | Motor | Sensory | How to Test |
|---|---|---|---|
| Axillary (C5,6) | Deltoid | Regimental badge area | Resisted abduction, sensation lateral shoulder |
| Musculocutaneous (C5,6) | Biceps | Lateral forearm | Resisted elbow flexion |
| Suprascapular (C5,6) | Supra/infraspinatus | None reliably | External rotation weakness |
| Long thoracic (C5,6,7) | Serratus anterior | None | Push against wall for winging |
Reflexes:
- Biceps (C5,6): Tap biceps tendon at antecubital fossa
- Brachioradialis (C5,6): Tap distal radius, observe elbow flexion
Vascular Assessment
- Pulses: Brachial (medial arm), radial and ulnar at wrist
- Capillary refill: Normal less than 2 seconds
- Temperature: Compare both hands
- Thoracic outlet: Consider if numbness with arm elevation
Complete the Examination
Must Know
Always state to the examiner:
"To complete my examination, I would like to:
- Examine the cervical spine for referred pain
- Examine the elbow as the joint below
- Perform a complete neurovascular assessment of the upper limb
- Examine the contralateral shoulder for comparison
- Obtain X-rays (AP, lateral, axillary views)"
Summary Presentation
VIVA SCENARIOStandard
Presenting Your Findings
EXAMINER
"55-year-old right-hand dominant male presenting with right shoulder pain and weakness for 3 months following a fall."
KEY POINTS TO SCORE
Be systematic: Look, Feel, Move, Special Tests, Neurovascular
Quantify ROM in degrees
Name specific tests and their results
Correlate findings with likely pathology
COMMON TRAPS
✗Forgetting to examine the cervical spine
✗Missing subtle wasting
✗Not comparing both sides
Common Conditions Table
| condition | look | feel | move | specialTests |
|---|---|---|---|---|
| Rotator Cuff Tear | Supraspinatus wasting | Greater tuberosity tenderness | Weakness, painful arc | Jobe's +, Lag signs + |
| Frozen Shoulder | Usually normal | Capsular tenderness | Global restriction (ER most limited) | All movements restricted |
| Anterior Instability | May appear normal | Apprehension | May be full | Apprehension +, Relocation + |
| ACJ Pathology | Step deformity, swelling | ACJ tenderness | Pain at end abduction | Cross-body adduction + |
| Impingement | Usually normal | Subacromial tenderness | Painful arc 60-120° | Hawkins +, Neer + |
Examiner Tips
Scoring High in the Shoulder Examination
High-Yield Exam Summary
Do
- •Maintain systematic approach throughout
- •Compare both sides consistently
- •Watch patient's face for pain
- •Explain findings as you go
- •Have confident summary statement
Don't
- •Rush through inspection
- •Forget cervical spine examination
- •Hurt the patient with aggressive testing
- •Miss the lag signs
- •Forget to complete the examination