This document provides information on evaluating shoulder pain and injuries. It discusses: 1. The most common causes of adult shoulder pain including impingement syndrome, rotator cuff problems, and athletic injuries. 2. Anatomy of the shoulder including bones, joints, muscles, and common injuries like rotator cuff tears, labral tears, and instability. 3. Physical examination techniques for the shoulder including range of motion, strength, and special tests to identify injuries. Common tests discussed are Neer's sign, Hawkins test, and relocation test. 4. Likely diagnoses suggested by specific physical examination findings. Tables summarize key examination maneuvers and what pathology a positive test may indicate

1. BY
DR MALEY DEEPAK KUMAR
SENIOR RESIDENT, AIIMS,
JODHPUR

2. • Shoulder pain: a common
complaint in primary care
• 2nd
only to knee pain for specialist
referrals
• Most common causes in adults (peak
ages 40-60)
• Subacromial impingement syndrome
• Rotator cuff problems
• Athletic injuries
• Shoulder: 8-13% of all
athletic injuries

3. • 3 Bones
• Humerus
• Scapula
• Clavicle
• 3 Joints
• Glenohumeral
• Acromioclavicular
• Sternoclavicular
• 1 “Articulation”
• Scapulothoracic

4. • Glenohumeral joint
• “Ball and socket” vs “Golf
ball and tee”
• Very mobile
• Price: instability
• 45% of all dislocations
• Joint stability depends on
multiple factors

5. • Glenohumeral joint
25% of humeral head
surface in contact with
glenoid.
• Glenoid labrum (50%)
• Joint capsule
• Ligaments

7. • Rotator Cuff Muscles
• S – Supraspinatus
• I – Infraspinatus
• t - Teres minor
• S- Supscapularis

8. Primary Elevators of ST
joint
• Upper fiber of trapezius
• Levator scapulae
• Rhomboids
Primary Depressor of ST
joint
• Lower fiber of trapezius
• Latissimus dorsi
8

9. Primary upwards rotators of
ST joint
• Upper fiber of trapezius
• Lower fiber of trapezius
• Serratus anterior
Primary downward rotators
of ST joint
• Rhomboids
• Pectoralis minor
9

10. Primary protractors of ST
joint
• Serratus anterior
Primary retractors of ST
joint
• Rhomboids
• Middle fiber of trapezius
10

11. Primary GH Joint Abductors
• Anterior fiber of deltoid
• Middle fiber of deltoid
• Supraspinatus
Primary GH Joint Adductors
• Latissimus dorsi
• Teres major
• Pectoralis major (sternal head)
11

12. Primary GH Joint Flexors
• Anterior fiber of deltoid
• Pectoralis major (clavicular head)
• Coracobrachialis
• Biceps brachii
Primary GH Joint Extensors
• Latissimus dorsi
• Teres major
• Pectoralis major (sternal head)
• Posterior deltoid
• Long head of triceps
12

13. Primary GH Joint Internal Rotators
• Anterior fiber of deltoid
• Pectoralis major
• Latissimus dorsi
• Teres major
• Subscapularis
Primary GH Joint External Rotators
• Posterior deltoid
• infraspinatus
• Teres minor
13

16. • Bursae
• Subacromial
(Subdeltoid)
• Subscapular

17. • Coordinated
shoulder motion
• Glenohumeral motion
• Acromioclavicular
motion
• Sternoclavicular
motion
• Scapulothoracic
motion Scapular-humeral rhythmScapular-humeral rhythm

19. • Impingement syndrome
• Subacromial bursitis
• Rotator cuff tendinopathy
• Rotator cuff tear
• Biceps tendinopathy
• Adhesive capsulitis
• SC joint arthritis, sprain
• AC joint arthritis, sprain
• Glenohumeral joint OA
• Instablity
• GH dislocation
• GH subluxation
• Labral tear (e.g. Bankart, SLAP,
etc.)
• Clavicle fracture
• Proximal humerus fracture
• Scapular fracture
Other arthritic diseaseOther arthritic disease
– Rheumatoid, Gout, SLERheumatoid, Gout, SLE
– Septic, Lyme, etc.Septic, Lyme, etc.
Avascular necrosisAvascular necrosis
Neoplastic diseaseNeoplastic disease
Thoracic outlet syndromeThoracic outlet syndrome
CRPSCRPS
Myofascial painMyofascial pain
Referred painReferred pain
– Cervical radiculopathyCervical radiculopathy
– CardiacCardiac
– Aortic aneurysmAortic aneurysm
– Abdominal / DiaphragmAbdominal / Diaphragm
– Other GIOther GI

20. • Characterize pain
• Location of pain
• Night pain
• Weakness
• Deformity
• Instability
• Locking / Clicking / Clunking
• Sport / Occupation
• Previous treatments
• Alleviating / Exacerbating
• Acute vs. Chronic
• Traumatic vs. Overuse
• History of prior injury

21. • Mechanism of Injury

22. • Observation
• Undress waist → up
• Palpation
• Active & passive ROM
• Strength testing
• Special tests

23. • Front & Back
• Height of shoulder &
scapulae
• Asymmetry
• Obvious deformity
• Ecchymosis
• Muscle atrophy
• Supraspinatus
• Infraspinatus
• Deltoid

24. • At rest & with movement
• Bony structures
• Joints
• Soft tissues

26. • Surface Anatomy
(Anterior)
• Clavicle
• SC Joint
• Acromion process
• AC Joint
• Deltoid
• Coracoid process
• Pectoralis major
• Trapezius
• Biceps (long head)
AC joint
SC joint
biceps

27. • Surface Anatomy
(Posterior)
• Scapular spine
• Acromion process
• Supraspinatus
• Infraspinatus
• Deltoid
• Trapezius
• Latissumus dorsi
• Scapula
• Inferior angle
• Medial border
Supraspinatus
Infraspinatus
Inferior angle
of scapula

29. • Forward flexion:
160 - 180°
• Extension: 40 - 60°
• Abduction: 180◦
• Adduction: 45 °
• Internal rotation:
60 - 90 °
• External rotation:
80 - 90 °
Apley Scratch TestApley Scratch Test

30. • Scapular dyskinesis
(Scapulothoracic dysfuntion)
• Compare scapular motion
through ROM on both sides
• Wall push-ups
• Symmetrical
• Smooth
• No or minimal winging

31. • Test & compare both sides
• Be specific to muscle or muscle
group
• Grade strength on 0 → 5 scale
• 0: no contraction
• 1: muscle flicker; no movement
• 2: motion, but not against gravity
• 3: motion against gravity, but not
resistance
• 4: motion against resistance
• 5: normal strength

32. • External rotation
• Tests RTC muscles that ER
the shoulder
• Infraspinatus
• Teres minor
• Arms at the sides
• Elbows flexed to 90 degrees
• Externally rotates arms
against resistance

33. • Internal rotation
• Tests RTC muscle that IR the
shoulder
• Subscapularis
• Arms at the sides
• Elbows flexed to 90 degrees
• Internally rotates arms
against resistance
• Subscapularis Lift-Off Test
• Other techniques

34. • Supraspinatus
• “Empty can" test
• Jobe’s Test
• Tests Supraspinatus
• Attempt to isolate from deltoid
• Positioned sitting
• Arms straight out
• Elbows locked straight
• Thumbs down
• Arm at 30 degrees
(in scapular plane)
• Attempts to elevate arms
against resistance

35. • Impingement Signs
• Drop-Arm Test
• Speed’s Test
• Yergason Test
• Cross-Arm Adduction
• Sulcus Sign
• Apprehension test
• Relocation test
• O’Brien’s Test
• Crank test

36. Impingement of:Impingement of:
– Subacromial bursaSubacromial bursa
– Rotator cuff muscles andRotator cuff muscles and
tendonstendons
– Biceps tendonBiceps tendon
BetweenBetween
– AcromionAcromion
– Coracoacromial ligamentCoracoacromial ligament
– AC jointAC joint
– Coracoid processCoracoid process
– Humeral headHumeral head
Rotator cuff tendonosisRotator cuff tendonosis

37. Neer’s SignNeer’s Sign
– Arm fully pronatedArm fully pronated
and placed in forcedand placed in forced
flexionflexion
– Trying to impingeTrying to impinge
subacromialsubacromial
structures withstructures with
humeral headhumeral head
– Pain is positive testPain is positive test

38. Hawkin’s SignHawkin’s Sign
– Arm is forwardArm is forward
elevated to 90elevated to 90
degrees, thendegrees, then
forcibly internallyforcibly internally
rotatedrotated
– Trying to impingeTrying to impinge
subacromialsubacromial
structures withstructures with
humeral headhumeral head
– Pain is positive testPain is positive test

39. • Partial thickness tear
• Full (Complete) thickness
tear
• May be due to:
• Impingement
• Degeneration
• Overuse
• Trauma
• Partial tears
• Conservative
• Complete tears
• Surgery

40. Abducted arm slowlyAbducted arm slowly
loweredlowered
– May be able to lowerMay be able to lower
arm slowly to 90°arm slowly to 90°
(deltoid function)(deltoid function)
– Arm will then drop toArm will then drop to
side if rotator cuffside if rotator cuff
teartear
Positive testPositive test
– patient unable topatient unable to
lower arm furtherlower arm further
with controlwith control
– If able to hold at 90º,If able to hold at 90º,
pressure on wrist willpressure on wrist will
cause arm to fallcause arm to fall

41. • Injury to long head of
biceps tendon
• Typically an overuse
injury
• Repetitive (overhead)
lifting
• Impingement

42. • Forward flex shoulder to
about 90°
• Abduct shoulder to about
10°
• Arm in full supination
• Apply downward force to
distal arm
• Pain is positive test
• Weakness without pain:
muscle weakness or
rupture

43. • Elbow flexed to 90°
• Start in pronated position
• Active supination & flexion
against resistance
• Palpate biceps tendon
• Pain or painful pop is
positive test
• Tendonosis
• Subluxation

44. AC Sprain /AC Sprain /
SeparationSeparation
– Typically due toTypically due to
fall onto tip offall onto tip of
shouldershoulder
(acromion)(acromion)
– Arm tucked intoArm tucked into
sideside
– TreatmentTreatment
depends on typedepends on type

46. • Arm flexed to 90°
• Arm adducted to > 45°
• Hyperadduct shoulder
(down on elbow)
• Positive test is pain in AC
joint
• Watch out for false-
positives
• Where is the pain?

47. Failure to keep humeralFailure to keep humeral
head centered in glenoidhead centered in glenoid
DislocationDislocation
– Complete disruption ofComplete disruption of
joint congruity orjoint congruity or
alignmentalignment
SubluxationSubluxation
– Partial or incompletePartial or incomplete
dislocationdislocation
LaxityLaxity
– Slackness or looseness inSlackness or looseness in
jointjoint
– May be normal orMay be normal or
abnormalabnormal

48. • Inferior instability
• Arm relaxed in neutral
position
• Arm pulled downward
at wrist
• Positive test is a
visible sulcus at infra-
acromial area
• Compare to
contralateral side

49. • Anterior instability
• Shoulder abducted to 90°
• Slight stress to humeral
head directed in anterior
direction
• While externally rotating
shoulder
• Positive test is
apprehension due to feeling
of instability or impending
dislocation
• Beware if false positives

50. • Anterior instability
• After a positive
apprehension
• Apply posteriorly directed
force over externally
rotated humeral head
• Positive test is relief of
apprehension
• Anterior release test

51. Tear in glenoid labrumTear in glenoid labrum
Usually due to instabilityUsually due to instability
SLAP Tear (Superior LabrumSLAP Tear (Superior Labrum
Anterior to Posterior)Anterior to Posterior)
– Superior labral tearSuperior labral tear
– Fall on outstretched hand orFall on outstretched hand or
shouldershoulder
– Rotator cuff tendonosis orRotator cuff tendonosis or
tearstears
Bankart LesionBankart Lesion
– Anterior-inferior labral tearAnterior-inferior labral tear
– Anterior shoulderAnterior shoulder
dislocation / subluxationdislocation / subluxation

52. • Labral, AC, or biceps
pathology
• Arm flexed to 90°
• Arm cross-arm adducted
10-15°
• Elbow extended
• Max pronation
• Resist downward force
• Positive test if painful
• Beware location of pain
• AC
• Biceps
• Internal +/- click

53. • For labral pathology
• Repeat testing with
• Max supination
• Should be pain free

54. • Abduct arm to 90-120°
• Stabilize shoulder
• Elbow secured with one
hand
• Axially load with ER / IR
at shoulder
• Positive test: audible or
painful click / catch /
grind

55. • AC joint
• Subacromial space
• Glenohumeral joint
• Biceps tendon (long head)

56. FINDING PROBABLE DIAGNOSIS
Scapular winging, trauma, recent viral illness Serratus anterior or trapezius dysfunction
Seizure and inability to passively or actively rotate affected arm
externally
Posterior shoulder dislocation
Supraspinatus/infraspinatus wasting Rotator cuff tear; suprascapular nerve entrapment
Pain radiating below elbow; decreased cervical range of motion Cervical disc disease
Shoulder pain in throwing athletes; anterior glenohumeral joint pain
and impingement
Glenohumeral joint instability
Pain or “clunking” sound with overhead motion Labral disorder
Nighttime shoulder pain Impingement
Generalized ligamentous laxity Multidirectional instability
Key Findings in the History and Physical Examination

57. TEST MANEUVER
DIAGNOSIS SUGGESTED BY
POSITIVE RESULT
Apley scratch test Patient touches superior and inferior
aspects of opposite scapula
Loss of range of motion: rotator cuff
problem
Neer's sign Arm in full flexion Subacromial impingement
Hawkins' test Forward flexion of the shoulder to 90
degrees and internal rotation
Supraspinatus tendon impingement
Drop-arm test Arm lowered slowly to waist Rotator cuff tear
Cross-arm test Forward elevation to 90 degrees and
active adduction
Acromioclavicular joint arthritis
Spurling's test Spine extended with head rotated to
affected shoulder while axially loaded
Cervical nerve root disorder
Tests Used in Shoulder Evaluation and Significance of Positive Findings

58. Apprehension test Anterior pressure on the
humerus with external rotation
Anterior glenohumeral
instability
Relocation test Posterior force on humerus
while externally rotating the
arm
Anterior glenohumeral
instability
Sulcus sign Pulling downward on elbow or
wrist
Inferior glenohumeral
instability
Yergason test Elbow flexed to 90 degrees
with forearm pronated
Biceps tendon instability or
tendonitis
Speed's maneuver Elbow flexed 20 to 30 degrees
and forearm supinated
Biceps tendon instability or
tendonitis
“Clunk” sign Rotation of loaded shoulder
from extension to forward
flexion
Labral disorder

60. History /History /
ManeuverManeuver
StudyStudy
QualQual
SensSens
(%)(%)
SpecSpec
(%)(%)
LR+LR+ LR-LR- PV+PV+
(%)(%)
PV-PV-
(%)(%)
History ofHistory of
traumatrauma
2b2b 3636 7373 1.31.3 0.880.88 7272 3737
Night painNight pain 2b2b 8888 2020 1.11.1 0.60.6 7070 4343
Painful arcPainful arc 2b2b 3333 8181 1.71.7 0.830.83 8181 3333
Empty canEmpty can
testtest
1b1b 8484
8989
5050
5858
1.71.7
22
0.220.22
0.280.28
3636
9898
2222
9393
Drop armDrop arm 1b1b 2121 100100 >25>25 0.790.79 100100 3232

61. TestTest StudyStudy
QualQual
SensSens
(%)(%)
SpecSpec
(%)(%)
LR+LR+ LR-LR- PV+PV+
(%)(%)
PV-PV-
(%)(%)
ImpingementImpingement
Hawkin’sHawkin’s 1b1b 8787
8989
6060 2.22.2 0.180.18 7171 8383
InstabilityInstability
RelocationRelocation 2b2b 5757 100100 >25>25 0.430.43 100100 7373
ApprehensionApprehension 2b2b 6868 100100 >25>25 0.320.32 100100 7878

62. History /History /
ManeuverManeuver
StudyStudy
QualQual
SensSens
(%)(%)
SpecSpec
(%)(%)
LR+LR+ LR-LR- PV+PV+
(%)(%)
PV-PV-
(%)(%)
AC JointAC Joint
ActiveActive
compressioncompression
1b1b 100100 9797 >25>25 0.010.01 8989 100100
SLAP TearSLAP Tear
CrankCrank 2b2b 9191 9393 1313 0.100.10 9494 9090
ActiveActive
compressioncompression
1b1b 100100 9999 >25>25 0.010.01 9595 100100

63. DiagnosisDiagnosis Primary CarePrimary Care
%%
AgeAge
Subacromial ImpingementSubacromial Impingement
SyndromeSyndrome
48-7248-72 23-6223-62
Adhesive CapsulitisAdhesive Capsulitis 16-2216-22 5353
Acute BursitisAcute Bursitis 1717 --
Calcific TendonitisCalcific Tendonitis 66 --
Myofascial Pain SyndromeMyofascial Pain Syndrome 55 --
Glenohumeral Joint ArthrosisGlenohumeral Joint Arthrosis 2.52.5 6464
Thoracic Outlet SyndromeThoracic Outlet Syndrome 22 --
Biceps TendonitisBiceps Tendonitis 0.80.8 --