CURRENT CONCEPTS

Physical Examination of the Shoulder

Joseph J. King, MD, Thomas W. Wright, MD

This article summarizes the overall assessment of the shoulder joint and seeks to help direct
clinicians to diagnose shoulder pathology using standard and specific physical examinations.
The history and standard examination can prompt the examiner to focus on specific tests to
further evaluate the shoulder and limit the differential diagnoses. An appropriate and directed
shoulder physical examination allows the clinician to focus on further diagnostic strategies
and treatment options for the patient. (J Hand Surg Am. 2014;39(10):2103e2112. Copyright
Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.)
Key words Physical examination, shoulder.

arm.1 Intra-articular glenohumeral joint pathology is

T
HE ANATOMIC AND FUNCTIONAL complexity of
the shoulder joint creates challenges for the often referred to the posterior shoulder or periscapular
clinician in diagnosing its pathologic condi- region. This can be partially explained by periscapular
tions. Physical examination of the shoulder is an muscle fatigue or strain resulting from a compensatory
important adjunct to the patient’s history, which helps increase in scapular motion with glenohumeral joint
focus the decision-making process and guides appro- pathology.1 Acromioclavicular joint pathology can
priate treatment. The patient’s history allows the cause referred pain medially often to the superomedial
physician to direct the physical examination because not scapula, base of the neck, or medial clavicle.1
every physical examination test is necessary for every
patient. Important aspects of the history include the STANDARD SHOULDER PHYSICAL
onset and timing of symptoms, inciting event, location EXAMINATION
of pain, aggravating and alleviating factors, patient’s The first step in physical examination of the shoulder is
occupation, and prior attempted treatments. After an observation. Visualization of the entire shoulder girdle
adequate history is obtained, the clinician should per- compared with the contralateral side is critical. Phys-
form a standard shoulder physical examination. Further ical examination of the shoulder should always be
specific assessment can be performed as necessary, such performed with the shirt removed (chest covered in
as testing for impingement syndrome, instability testing, females) to allow adequate visualization. Bony defor-
biceps pathology, and scapulothoracic pathology. mity, asymmetry, swelling, and muscle atrophy can be
Pain referral patterns are important to understand for noted during this portion of the examination and can
clinicians treating patients with shoulder pain to reach help direct the shoulder physical examination.
the definitive diagnosis. Pain from rotator cuff or Palpation of the entire shoulder girdle is the next
subacromial pathology is often referred to the lateral step in the physical examination. Specific anatomy that
should be palpated for tenderness include the acro-
mioclavicular joint, the entire humeral head (anterior,
From the Department of Orthopaedic Surgery and Rehabilitation, University of Florida,
Gainesville, FL. lateral, and posterior), bicipital groove, anterior acro-
Received for publication March 6, 2014; accepted in revised form April 6, 2014.
mion, periscapular region, pectoralis major tendon,
Current Concepts

trapezius muscle, and Erb point (anterior to the trape-

No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article. zius in the posterior triangle of the neck). Specific
Corresponding author: Thomas W. Wright, MD, Department of Orthopaedic Surgery consistent areas of tenderness are important to discern
and Rehabilitation, University of Florida, 3450 Hull Road, Third Floor, Room 3341, and narrow the differential diagnosis to help focus the
Gainesville, FL 32607; e-mail: [email protected]fl.edu. remainder of the shoulder examination.
0363-5023/14/3910-0041$36.00/0 Glenohumeral range of motion should be evaluated
http://dx.doi.org/10.1016/j.jhsa.2014.04.024
on every patient with shoulder complaints. Evaluation

Ó 2014 ASSH r Published by Elsevier, Inc. All rights reserved. r 2103

 2104 PHYSICAL EXAMINATION OF THE SHOULDER

of both active and passive range of motion of the

shoulder will help to rule out certain diagnoses and
focus the remainder of the examination. For patients
with substantial pain, it is helpful to assess the range of
motion in the supine position. Typically, forward
elevation as well as external rotation and internal
rotation with the arm at the side should be evaluated.
This should always be compared with the contralateral
side because shoulder range of motion can vary widely
in individuals.
Patients without fractures or soft tissue injury after
trauma, who have limited range of motion both actively
and passively (especially with rotation) compared with
the opposite side, have either adhesive capsulitis or
FIGURE 1: Bilateral simultaneous Jobe supraspinatus test.
glenohumeral arthritis. Adhesive capsulitis typically is
associated with excessive pain at the terminal aspects of
range of motion whereas glenohumeral arthritis has pain or atrophy with shoulder girdle pain may be the result
in midrange of motion. Radiographs can help discern of suprascapular nerve entrapment at the suprascapular
between adhesive capsulitis and glenohumeral arthritis. notch. Atrophy of the infraspinatus can be present and
Rotator cuff pathology should be considered in patients is visualized as a deep infraspinatus fossa. If nerve
with limited active range of motion but normal or near entrapments are suspected, magnetic resonance imag-
normal passive range of motion. ing to rule out a space-occupying lesion and/or elec-
It is important to evaluate motor testing of the rotator trodiagnostic studies may be helpful in confirming the
cuff in patients with shoulder pathology. Muscle diagnosis.
strength testing of internal (subscapularis) and external
rotation (infraspinatus) should be performed with the
arm at the side in neutral rotation and the elbow flexed to DIFFERENTIAL INJECTIONS
90 . Muscle strength should be compared with the The role for differential injections should be high-
contralateral side. Supraspinatus muscle strength can be lighted as a useful adjunct to the shoulder physical
tested using the Jobe test.2 The Jobe supraspinatus test is examination. In patients with multiple possible etiol-
performed with the shoulder in 90 flexion in the ogies of pain or those who have diffuse pain without a
scapular plane (scaption) with the elbow extended. A clear specific etiology, differential staged injections
downward pressure is then applied to the patient’s arm with an anesthetic with or without a corticosteroid can
against resistance (Fig. 1). This test can be performed on help elucidate the diagnosis.1 Specific areas that can be
both sides simultaneously to compare the strength of the injected include the subacromial space, glenohumeral
affected side with the contralateral side. A decrease in joint, acromioclavicular joint, and biceps tendon
strength suggests the presence of a rotator cuff tear or sheath. The use of ultrasound can help improve the
tendonitis. Pain provoked by this test without weakness accuracy of needle placement and effectiveness of
suggests tendonitis or partial rotator cuff tear. The these injections. Pain improvement or amelioration of
external rotation lag test can also be used to examine pain after an injection can help the clinician guide
infraspinatus function. This test is performed with the treatment.
patient’s shoulder placed in maximal passive external
rotation with the arm at the side and the elbow flexed 90
by the examiner. The examiner then asks the patient to SUBSCAPULARIS MUSCLE PATHOLOGY
Current Concepts

hold the arm in the externally rotated position and If there is a suspicion of subscapularis muscle pa-
removes the passive external rotation force on the pa- thology with strength or range of motion testing,
tient’s arm. If the arm drifts into internal rotation, this is a several tests can help clarify the subscapularis pa-
positive test suggestive of a complete infraspinatus tear. thology. The liftoff test3 is performed with the pa-
Rotator cuff weakness can also be caused by pe- tient’s arm fully internally rotated with the hand on
ripheral nerve problems. Isolated infraspinatus weak- the back. The patient is then asked to lift the wrist off
ness or atrophy and shoulder girdle pain suggest the back (Fig. 2). If the patient cannot lift the wrist off
compression of the suprascapular nerve at the spino- the back using the shoulder for rotation, the liftoff test
glenoid notch. Supraspinatus and infraspinatus weakness is considered positive. The liftoff test best evaluates

J Hand Surg Am. r Vol. 39, October 2014

 PHYSICAL EXAMINATION OF THE SHOULDER 2105

FIGURE 2: The liftoff test.

FIGURE 4: The bear hug test.

The patient is then asked to resist external rotation

applied to the forearm by the examiner. Weakness
compared with the contralateral shoulder is consid-
ered a positive bear hug test.

IMPINGEMENT SYNDROME
If impingement syndrome or rotator cuff tendonitis
cannot be confirmed with palpation, strength, or range
of motion testing, the Neer6 and Hawkin7 tests can
be used to confirm anterior impingement syndrome.
Shoulder impingement syndrome encompasses a wide
spectrum of pathologies including rotator cuff tendon-
itis, partial or full-thickness cuff tears, coracoacromial
ligament tears, and subacromial bursitis. The Neer test is
performed by the examiner passively forward elevating
the patient’s arm. If the patient has anterior or lateral
shoulder pain with terminal shoulder forward elevation,
FIGURE 3: The belly press test.
the Neer test is positive. The Hawkin test is performed
by forward elevating the affected shoulder to 90 and
complete subscapularis tendon tears but it is not as then terminally internally rotating the shoulder. The
useful for partial tears. Hawkin test is positive if it provokes anterior or lateral
The belly press test4 is performed with the pa- shoulder pain with this maneuver. These 2 tests cause
tient’s hand on the abdomen and the elbow just contact between the greater tuberosity/rotator cuff and
Current Concepts

anterior to the plane of the body. The patient is then the anterolateral acromion/coracoacromial ligament,8
asked to press on the abdomen (Fig. 3). If this elicits reproducing pain in impingement syndrome. However,
anterior shoulder pain or there is weakness compared these tests have a high false-positive rate9e11 because
with the contralateral shoulder, the belly press test is they can produce pain in a wide variety of shoulder
considered positive. The bear hug test5 can also be pathologies.
performed to evaluate for subscapularis pathology
(Fig. 4). The bear hug test is performed with the SHOULDER NEUROLOGIC PATHOLOGY
patient’s affected open palm on the opposite superior Cervical nerve root and brachial plexus function
shoulder, with the affected shoulder flexed to 90 . must be assessed. Radiation of pain or paresthesias

J Hand Surg Am. r Vol. 39, October 2014

 2106 PHYSICAL EXAMINATION OF THE SHOULDER

FIGURE 7: The surprise test.

FIGURE 5: The anterior apprehension test.

can be initiated while neurologic conditions are being

investigated.
Sensibility around the shoulder girdle should also
be tested and compared with the contralateral side.
Decreased sensory function around the shoulder sug-
gests cervical nerve root or brachial plexus pathology.
Deltoid muscle palpation during deltoid activation can
be performed to assess the 3 deltoid heads and evaluate
axillary nerve function.
If all areas of the shoulder are exquisitely tender,
this should raise the suspicion of neurologic pathol-
ogy or complex regional pain syndrome. Light touch
can be used to test for allodynia about the shoulder
girdle. Patients with chronic regional pain syndrome
report pain or hypersensitivity with light touch without
obvious neurologic pathology.
FIGURE 6: Jobe relocation test. Arrow represents force by
examiner. SHOULDER INSTABILITY
When there is history of shoulder subluxation, dislo-
distal to the elbow, neck pain, prior neck surgery, cation, or subjective sense of instability, this should
limited neck range of motion, or severe shoulder pain prompt an assessment of shoulder instability. The po-
without loss of motion should prompt the physician sition of the shoulder or the activity that causes the
to perform a complete neurologic examination of perception of instability may help the examiner focus
both upper extremities. Spurling test can be per- the physical examination. Whenever instability is a
Current Concepts

formed by axially loading the neck with downward concern, axillary nerve function should be tested.
pressure from the top of the head. The neck is then Several tests have been described for anterior
extended and rotated to the affected side by the shoulder instability. The anterior apprehension test12 is
examiner. Radiating pain to the shoulder or down the performed with the patient supine and the arm abduc-
arm is a positive test suggesting cervical nerve root ted to 90 and then slowly externally rotated (Fig. 5).
compression.1 If cervical spine pathology is suspected, Anterior shoulder pain or the sense of instability at
electrodiagnostic studies or cervical spine imaging terminal external rotation is suggestive of anterior insta-
should be considered. Concomitant shoulder pathology bility. The Jobe relocation test13 is executed by a poste-
can still be present and treatment of shoulder pathology rior directed pressure applied to the anterior proximal

J Hand Surg Am. r Vol. 39, October 2014

 PHYSICAL EXAMINATION OF THE SHOULDER 2107

FIGURE 8: The posterior apprehension test. Arrow represents

force by examiner.
FIGURE 10: The Yergason test. Large arrow represents the pa-
tient’s motion. Small arrow represents resisted force by examiner.

FIGURE 9: The jerk test. Arrow represents force by examiner.

FIGURE 11: The uppercut test. The uppercut test is performed
with the shoulder in neutral position and the forearm supinated
and with the patient making a fist. The patient is then asked to
humerus during the apprehension test. The test is rapidly bring the hand up to the chin (long arrow) as the examiner
considered positive if the patient has alleviation of pain resists the motion (short arrow) with the examiner’s hand on the
or decrease in the sense of subluxation (Fig. 6). patient’s fist. If the patient has anterior shoulder pain or a painful
Symptoms of instability have better predictive value of click over the shoulder during the maneuver, the test is consid-
anterior instability as opposed to just pain in the ered positive.
apprehension and relocation tests.14e16 The sudden
release of anterior force during the Jobe relocation test
(Fig. 7) is known as the anterior release test (surprise test should always be compared with the contralateral
Current Concepts

test).17 This test is considered positive if the patient has side. A simple clinical method to grade translation
apprehension after anterior-directed pressure is released. was described by McFarland et al.19 Grade I laxity is
Glenohumeral instability can also be tested present when the humeral head does not subluxate
manually in the supine position with the arm in slight over the glenoid rim. Grade II laxity is present when
abduction and the shoulder off the table edge using the humeral head subluxates out of the glenoid and
the anterior and posterior drawer tests.18 While the spontaneously reduced. Grade III laxity is present
table stabilizes the scapula, the examiner can apply when the humeral head stays dislocated with this
gentle anterior and posterior force to the arm while maneuver. Humeral head translation can also be esti-
visualizing movement of the proximal humerus. This mated based on distance or percentage of the humeral

J Hand Surg Am. r Vol. 39, October 2014

 2108 PHYSICAL EXAMINATION OF THE SHOULDER

FIGURE 12: A O’Brien test in internal rotation. B O’Brien test in external rotation.

head diameter; however, these methods are more

difficult to assess accurately.
Posterior glenohumeral instability can be
assessed using the load and shift test.20 The load
and shift test is performed with the patient’s
shoulder in about 20 scaption. The examiner sta-
bilizes the scapula with one hand and holds the
proximal upper arm with the other. The examiner
then applies an axial load and a posterior directed
force on the proximal humerus. Posterior shoulder
pain or painful palpable clunk is felt during this
maneuver in patients with posterior subluxation.
The posterior apprehension test is performed with
shoulder in adduction, midflexion, and internal
rotation (Fig. 8). Posterior shoulder pain or the
sense of instability at terminal internal rotation is
suggestive of posterior instability. The jerk test can
help evaluate for posteroinferior shoulder insta-
bility. The patient’s arm is abducted 90 in the
scapular plane with the elbow flexed, and then FIGURE 13: The anterior slide test. Arrows represent force by
simultaneous axial compression and adduction of examiner.
the arm is performed (Fig. 9). A palpable clunk or
painful click is considered a positive jerk test as the
humeral head subluxates posteriorly. test needs to be correlated with the patient’s symp-
The sulcus test21 should be performed bilaterally toms. If a sulcus sign is present but the maneuver
in all patients with a concern for shoulder instability does not reproduce symptoms, inferior instability is
to help differentiate unidirectional from multidirec- unlikely a cause of symptoms and is likely a normal
tional instability. The sulcus test is performed with variant.22,23 Although the sulcus test is widely accepted,
Current Concepts

the patient sitting and the arm relaxed at the side. The it has not been validated and its accuracy has not been
examiner gently grasps the patient’s forearm and adequately studied.24
pulls inferiorly. The magnitude of translation be- The normal laxity of the shoulder varies widely
tween the lateral acromion and the humeral head among individuals.25e27 Laxity of the affected shoulder
should be measured and compared with the contra- should be compared with the contralateral side and will
lateral side. Alternatively the magnitude can be be symptomatic in patients with true pathology. Isolated
graded as grade I (< 1 cm), grade II (1e2 cm), or asymmetric laxity has been documented in a high per-
grade III (> 2 cm), as originally described by Neer centage of athletes26,28; hence laxity should be corre-
and Foster.21 Inferior subluxation using the sulcus lated with symptoms.

J Hand Surg Am. r Vol. 39, October 2014

 PHYSICAL EXAMINATION OF THE SHOULDER 2109

FIGURE 14: The crank test in A external rotation and B internal rotation.

BICEPS TENDON PATHOLOGY

Biceps tendon pathology in the bicipital groove should
be considered in patients with anterior shoulder pain
or with pain radiating to the anterior upper arm. The
long head of the biceps tendon can have a spectrum
of pathology including tendinosis, tenosynovitis, par-
tial tears, and tendon subluxation out of the bicipital
groove causing anterior shoulder and/or arm pain.
Patients have tenderness at the bicipital groove palpated
on the anteroinferior humeral head superior to the
pectoralis major tendon. Because of the deep location
and proximity to other structures, diagnosis of bicipital
groove pathology by physical examination can be
difficult. Anterior humeral head tenderness can also be
related to anterior supraspinatus, a subscapularis FIGURE 15: The cross shoulder adduction test. Arrow represents
tendon, or subacromial pathology. force by examiner.
Several physical examination tests are used to
evaluate for biceps pathology. The Yergason test is
performed with the shoulder in neutral and the elbow at test32 has recently been described for biceps pathology
90 flexion. The patient is then asked to actively su- (Fig. 11). Complete tear of long head of the biceps
pinate the forearm from the fully pronated position tendon presents with a “Popeye” deformity of the distal
while the examiner resists supination (Fig. 10). Ante- upper arm, which often occurs after the perception of a
Current Concepts

rior shoulder pain with this maneuver is considered a tear or pop in the shoulder.
positive test. The Speed test can also be used for
bicipital groove pathology. The patient’s arm is placed
in about 45 scaption with full forearm supination and SUPERIOR LABRAL PATHOLOGY
the patient resists downward pressure placed on the Superior labral pathology is difficult to diagnose on
forearm by the examiner. Anterior shoulder pain is physical examination for several reasons. Superior
considered a positive Speed test. A positive Speed test labral pathology is commonly associated with other
has been reported to be moderately useful for diag- shoulder pathology32,33 and overlaps with bicipital
nosing biceps tendon pathology.29e32 The upper cut groove pathology on physical examination. In addition,

J Hand Surg Am. r Vol. 39, October 2014

 2110 PHYSICAL EXAMINATION OF THE SHOULDER

TABLE 1. Shoulder Physical Examination Tests and Pathology They Assess

Test Pertinent Diagnosis Being Tested Positive Test If:

Jobe supraspinatus test Supraspinatus strength Weakness or pain, or both

External rotation lag test Infraspinatus integrity Drift back
Liftoff test Subscapularis tear Unable to perform
Belly press test Subscapularis pathology Weakness or anterior shoulder pain, or both
Bear hug test Subscapularis pathology Weakness
Neer test Impingement syndrome Pain
Hawkin test Impingement syndrome Pain
Apprehension test Anterior shoulder instability Anterior shoulder pain or instability sensation, or both
Jobe relocation test Anterior shoulder instability Reduction in pain or instability sensation, or both
Surprise test Anterior shoulder instability Pain or instability sensation, or both
Anterior drawer test Anterior shoulder instability Abnormal translation AND pain
Posterior drawer test Posterior shoulder instability Abnormal translation AND pain
Posterior apprehension test Posterior shoulder instability Posterior shoulder pain or instability sensation, or both
Load and shift test Posterior shoulder instability Posterior shoulder pain or painful clunk
Jerk test Posterior shoulder instability Palpable clunk or painful click
Sulcus test Inferior shoulder instability Abnormal motion AND pain
Yergason test Bicipital groove pathology Anterior shoulder or arm pain
Speed test Bicipital groove pathology Anterior shoulder or arm pain
Uppercut test Bicipital groove pathology Anterior shoulder or arm pain
O’Brien test Superior labral pathology Increased pain with internal rotation
Anterior slide test Superior labral pathology Deep shoulder pain or a click, or both
Crank test Superior labral pathology Deep shoulder pain or a click, or both
Cross shoulder adduction test Acromioclavicular joint pathology Pain localized to the acromioclavicular joint

clinical examination studies evaluating superior labral hip. The examiner then places an axial load on the
pathology often include patients with other concomi- elbow with one hand and an anterior directed force on
tant pathology such as other types of labral lesions.34 If the posterior humeral head with the other (Fig. 13). The
the suspicion for superior labral pathology is high, the anterior slide test is considered positive if the maneuver
physical examination can be augmented with other elicits deep shoulder pain or a click over the anterior
tests. shoulder.
The O’Brien test (active compression test)35 is The crank test40 can be performed to evaluate for
performed with the patient standing with the shoulder a superior labral tear. The arm is abducted to about 160
flexed to 90 and the elbow extended. The shoulder is in scaption. The humerus is then axially loaded and
then fully internally rotated (palm down) and the pa- terminally internally and externally rotated (Fig. 14).
tient is asked to resist inferior pressure placed on the Patients experiencing deep shoulder pain or a click are
arm by the examiner (Fig. 12A). The process is then considered to have a positive test. Although the authors
repeated with the arm fully externally rotated (palm up) reported the test to have good reliability,40 the crank test
(Fig. 12B). Greater pain in the internally rotated posi- has not been shown to be reliable in other studies.33,34,36
Current Concepts

tion (torsion of the biceps tendon at its insertion on the Several other tests have been described to evaluate
superior labrum) compared with the externally rotated for a superior labral anterior posterior tear including the
position is suggestive of superior labral pathology. The pain provocative test,41 biceps load I test,42 biceps load
O’Brien test is the most commonly performed test for II test,43 the resisted supination external rotation test,36
superior labral pathology and shows moderate to dynamic labral shear test (O’Driscoll test) (Cheung EV
excellent sensitivity and poor to excellent specificity and O’Driscoll SW, presented at the American Asso-
with wide ranges reported.32,33e38 ciation of Orthopaedic Surgeons annual meeting, 2007),
The anterior slide test39 is performed with the pa- modified dynamic labral shear test,32 passive distraction
tient standing and the affected arm on the ipsilateral test,44 and labral tension test.38 Description of these

J Hand Surg Am. r Vol. 39, October 2014

 PHYSICAL EXAMINATION OF THE SHOULDER 2111

individual tests is beyond the scope of this article. In conclusion, a standard physical examination
Multiple studies have found that individual tests are not should be performed on all shoulder pain patients
consistently reliable in the diagnosis of superior labral after obtaining an adequate medical history. These
pathology31e33,37,38,44,45 and several studies question prompt the examiner to focus on specific tests to
the methodology of many superior labral anterior pos- better evaluate the shoulder and limit the differential
terior examination reports.46,47 Despite the multitude of diagnoses. Table 1 summarizes the specific tests that
tests described to assess for superior labral pathology, can be performed. This guided physical examination
diagnosis based on physical examination continues to technique can help facilitate accurate diagnoses in a
be a challenge. We recommend using several physical suitable time frame. An appropriate and directed
examination maneuvers followed by advanced imaging shoulder examination helps the clinician to focus on
if the suspicion of a superior labral lesion is high. further diagnostic strategies and treatment options.

REFERENCES
ACROMIOCLAVICULAR JOINT PATHOLOGY
1. Codsi M, McCarron J, Brems JJ. Clinical evaluation of shoulder
Acromioclavicular joint pathology should be considered problems. In: Rockwood CA, Matsen FA, Wirth MA, et al, eds. The
during the shoulder examination because it can easily be Shoulder. 4th ed. Philadelphia, PA: Saunders Elsevier; 2009:
overlooked as a cause of pain. Direct palpation of the 148e176.
2. Jobe F, Jobe C. Painful athletic injuries of the shoulder. Clin Orthop
acromioclavicular joint is a simple way to assess whether Relat Res 1983;(173):117e124.
the acromioclavicular joint may be a source of pain. The 3. Gerber C, Krushell RJ. Isolated rupture of the tendon of the sub-
cross shoulder adduction test can be used to further scapularis muscle: clinical features in 16 cases. J Bone Joint Surg Br.
assess the acromioclavicular joint and is performed with 1991;73(3):389e394.
4. Gerber C, Hersche O, Farron A. Isolated rupture of the subscapularis
the arm in 90 forward flexion. The examiner then gently tendon. J Bone Joint Surg Am. 1996;78(7):1015e1023.
passively adducts the shoulder (Fig. 15). If full adduction 5. Barth JRH, Burkhart SS, De Beer JF. The bear-hug test: a new and
elicits pain at the acromioclavicular joint, this is a posi- sensitive test for diagnosing a subscapularis tear. Arthroscopy.
2006;22(10):1076e1084.
tive test and is suggestive of acromioclavicular joint 6. Neer CS. Impingement lesions. Clin Orthop Relat Res. 1983;(173):70e77.
pathology. If the patient has pain with this maneuver, the 7. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J
examiner should ask the patient to identify the exact Sports Med. 1980;8(3):151e158.
8. Valadie AL, Jobe CM, Pink MM, et al. Anatomy of provocative tests
location of pain because this maneuver may cause pain for impingement syndrome of the shoulder. J Shoulder Elbow Surg.
from elsewhere. 2000;9(1):36e46.
9. MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic
accuracy of the Hawkins and Neer subacromial impingement signs.
SCAPULOTHORACIC PATHOLOGY J Shoulder Elbow Surg. 2000;9(4):299e301.
10. Park HB, Yokota A, Gill HS, et al. Diagnostic accuracy of clinical
Palpation of the medial scapular border (just medial tests for the different degrees of subacromial impingement syndrome.
to the rhomboid muscle insertion) at rest and through J Bone Joint Surg Am. 2005;87(7):1446e1455.
11. Alqunaee M, Galvin R, Fahey T. Diagnostic accuracy of clinical tests
a range of motion should be performed. Pain and/or for subacromial impingement syndrome: a systematic review and
crepitus at the medial border of the scapula are sug- meta-analysis. Arch Phys Med Rehabil. 2012;93(2):229e236.
gestive of scapulothoracic pathology. Periscapular 12. Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder.
J Bone Joint Surg Am. 1981;63(6):863e872.
muscle atrophy may be noted. 13. Jobe FW, Kvitne RS, Giangarra CE. Shoulder pain in the overhand or
Scapular winging should be evaluated with the shirt throwing athlete: the relationship of anterior instability and rotator
removed and the patient standing facing away from the cuff impingement. Orthop Rev. 1989;18(9):963e975.
examiner. The patient is asked to forward elevate the 14. Lo IKY, Nonweiler B, Woolfrey M, et al. An evaluation of the
apprehension, relocation, and surprise tests for anterior shoulder
arms slowly while the examiner’s attention is focused on instability. Am J Sports Med. 2004;32(2):301e307.
the posteromedial scapular border. Injury to the long 15. Farber AJ, Castillo RC, Clough M, et al. Clinical assessment of three
thoracic nerve causes medial winging of the poster- common tests for traumatic anterior shoulder instability. J Bone Joint
Current Concepts

Surg Am. 2006;88(7):1467e1474.

omedial scapular border. Injury to cranial nerve XI cau- 16. van Kampen DA, van den Berg T, van der Woude HJ, et al. Diag-
ses lateral winging of the posteromedial scapular border. nostic value of patient characteristics, history, and six clinical tests
Scapular winging can be accentuated by performing a for traumatic anterior shoulder instability. J Shoulder Elbow Surg.
“wall pushup,” which can aid in the diagnosis of subtle 2013;22(10):1310e1319.
17. Gross ML, Distefano MC. Anterior release test: a new test for occult
winging. shoulder instability. Clin Orthop Relat Res 1997;(339):105e108.
Pseudo-winging or scapulothoracic dyskinesia can 18. Gerber C, Ganz R. Clinical assessment of instability of the shoulder:
occur as a result of concomitant shoulder pathology; with special reference to anterior and posterior drawer tests. J Bone
Joint Surg Br. 1984;66(4):551e556.
however, the winging is not as prominent as with a 19. McFarland EG, Torpey BM, Curl LA. Evaluation of shoulder laxity.
neurologic lesion. Sports Med. 1996;22(4):264e272.

J Hand Surg Am. r Vol. 39, October 2014

 2112 PHYSICAL EXAMINATION OF THE SHOULDER

20. Silliman JF, Hawkins RJ. Classification and physical diagnosis of 34. Guanche CA, Jones DC. Clinical testing for tears of the glenoid
instability of the shoulder. Clin Orthop Relat Res. 1993;(291):7e19. labrum. Arthroscopy. 2003;19(5):517e523.
21. Neer CS II, Foster CR. Inferior capsular shift for involuntary inferior 35. O’Brien SJ, Pagnani MJ, Fealy S, et al. The active compression test: a
and multidirectional instability of the shoulder: a preliminary report. new and effective test for diagnosing labral tears and acromiocla-
J Bone Joint Surg Am. 1980;62(6):897e908. vicular joint abnormality. Am J Sports Med. 1998;26(5):610e613.
22. Bahk M, Keyurapan E, Tasaki A, et al. Laxity testing of the shoulder: 36. Myers TH, Zemanovic JR, Andrews JR. The resisted supina-
a review. Am J Sports Med. 2007;35(1):131e144. tion external rotation test: a new test for the diagnosis of superior
23. Jia X, Ji JH, Petersen SA, et al. An analysis of shoulder laxity in labral anterior posterior lesions. Am J Sports Med. 2005;33(9):
patients undergoing shoulder surgery. J Bone Joint Surg Am. 1315e1320.
2009;91(9):2144e2150. 37. Oh JH, Kim JY, Kim WS, et al. The evaluation of various physical
24. McFarland EG, Garzon-Muvdi J, Jia X, et al. Clinical and diagnostic examinations for the diagnosis of type II superior labrum anterior and
tests for shoulder disorders: a critical review. Br J Sports Med. posterior lesion. Am J Sports Med. 2008;36(2):353e359.
2010;44(5):328e332. 38. Cook C, Beaty S, Kissenberth MJ, et al. Diagnostic accuracy of five
25. Lippitt SB, Harris SL, Harryman DT, et al. In vivo quantification of orthopedic clinical tests for diagnosis of superior labrum anterior
the laxity of normal and unstable glenohumeral joints. J Shoulder posterior (SLAP) lesions. J Shoulder Elbow Surg. 2012;21(1):13e22.
Elbow Surg. 1994;3(4):215e223. 39. Kibler WB. Specificity and sensitivity of the anterior slide test in
26. Lintner SA, Levy A, Kenter K, et al. Glenohumeral translation in the throwing athletes with superior glenoid labral tears. Arthroscopy.
asymptomatic athlete’s shoulder and its relationship to other clini- 1995;11(3):296e300.
cally measurable anthropometric variables. Am J Sports Med. 40. Liu SH, Henry MH, Nuccion SL. A prospective evaluation of a new
1996;24(6):716e720. physical examination in predicting glenoid labral tears. Am J Sports
27. Sauers EL, Borsa PA, Herling DE, et al. Instrumented measurement Med. 1996;24(6):721e725.
of glenohumeral joint laxity: reliability and normative data. Knee 41. Mimori K, Muneta T, Nakagawa T, et al. A new pain provocation test
Surg Sports Traumatol Arthrosc. 2001;9(1):34e41. for superior labral tears of the shoulder. Am J Sports Med.
28. McFarland EG, Campbell G, McDowell J. Posterior shoulder laxity 1999;27(2):137e142.
in asymptomatic athletes. Am J Sports Med. 1996;24(4):468e471. 42. Kim SH, Ha KI, Han KY. Biceps load test: a clinical test for superior
29. Bennett WF. Specificity of the Speed’s test: arthroscopic technique labrum anterior and posterior lesions in shoulders with recurrent
for evaluating the biceps tendon at the level of the bicipital groove. anterior dislocations. Am J Sports Med. 1999;27(3):300e303.
Arthroscopy. 1998;14(8):789e796. 43. Kim SH, Ha KL, Ahn JH, et al. Biceps load test II: a clinical test for
30. Holtby R, Razmjou H. Accuracy of the Speed’s and Yergason’s SLAP lesions of the shoulder. Arthroscopy. 2001;17(2):160e164.
tests in detecting biceps pathology and SLAP lesions: com- 44. Schlechter JA, Summa S, Rubin BD. The passive distraction test: a
parison with arthroscopic findings. Arthroscopy. 2004;20(3): new diagnostic aid for clinically significant superior labral pathology.
231e236. Arthroscopy. 2009;25(12):1374e1379.
31. Jia X, Petersen SA, Khosravi AH, et al. Examination of the shoulder: 45. Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests
the past, the present, and the future. J Bone Joint Surg Am. of the shoulder: a systematic review with meta-analysis of individual
2009;91(suppl 6):10e18. tests. Br J Sports Med. 2008;42(2):80e92.
32. Kibler WB, Sciascia AD, Hester P, et al. Clinical utility of traditional 46. Walton DM, Sadi J. Identifying SLAP lesions: a meta-analysis of
and new tests in the diagnosis of biceps tendon injuries and superior clinical tests and exercise in clinical reasoning. Phys Ther Sport.
labrum anterior and posterior lesions in the shoulder. Am J Sports 2008;9(4):167e176.
Med. 2009;37(9):1840e1847. 47. Calvert E, Chambers GK, Regan W, et al. Special physical exami-
33. Parentis MA, Glousman RE, Mohr KS, et al. An evaluation of the nation tests for superior labrum anterior posterior shoulder tears are
provocative tests for superior labral anterior posterior lesions. Am J clinically limited and invalid: a diagnostic systematic review. J Clin
Sports Med. 2006;34(2):265e268. Epidemiol. 2009;62(5):558e563.
Current Concepts

J Hand Surg Am. r Vol. 39, October 2014