Fundamentals of Shoulder Evaluation

Essential Skills for Shoulder Assessment

Intermediate · 12 chapters · 144 MCQs · 144 flashcards · Audiobook · Illustrated

This course covers foundational techniques for evaluating the shoulder joint, including history taking, observation, palpation, and special tests. Learners will develop clinical reasoning skills to differentiate common pathologies such as impingement, instability, and rotator cuff tears. Ideal for physiotherapy students and practitioners seeking a structured approach to shoulder examination.

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What you'll learn

  1. Chapter 1: Shoulder Anatomy and Functional Anatomy

    The shoulder complex is one of the most mobile and functionally versatile regions of the human body, enabling a wide range of movements essential for daily activities, sports, and occupational tasks.

  2. Chapter 2: Shoulder Biomechanics

    The shoulder complex is a highly mobile yet inherently unstable system, relying on coordinated biomechanics among four articulations: glenohumeral (GH), acromioclavicular (AC), sternoclavicular (SC), and scapulothoracic (ST).

  3. Chapter 3: Subjective Assessment and Patient History

  4. Chapter 4: Observation, Posture, and Palpation

    Observation, posture, and palpation form the foundational triad of the physical examination in physiotherapy.

  5. Chapter 5: Range of Motion and Strength Assessment

  6. Chapter 6: Rotator Cuff Special Tests

    Rotator cuff pathology is one of the most common causes of shoulder pain and dysfunction, accounting for a significant proportion of outpatient orthopaedic consultations.

  7. Chapter 7: Impingement and Instability Tests

    Impingement and instability of the shoulder joint are common clinical presentations that require precise diagnostic differentiation to guide effective treatment.

  8. Chapter 8: SLAP Lesions and Biceps Tendon Tests

    Conservative care for SLAP lesions and biceps tendinopathy includes activity modification and strengthening of the rotator cuff and scapular stabilizers.

  9. Chapter 9: AC Joint and SCJ Assessment

    The acromioclavicular (AC) and sternoclavicular (SC) joints, though often overshadowed by the glenohumeral joint, play a critical role in shoulder girdle function and upper extremity mobility.

  10. Chapter 10: Adhesive Capsulitis (Frozen Shoulder)

    Hand-behind-back test: record internal rotation by vertebral level. Normal reach is T7–T10; in frozen shoulder it may only reach L3–L5.

  11. Chapter 11: Neurological Assessment and Referred Pain

  12. Chapter 12: Imaging and Clinical Reasoning Integration

Free chapter

Chapter 1: Shoulder Anatomy and Functional Anatomy

Introduction

The shoulder complex is one of the most mobile and functionally versatile regions of the human body, enabling a wide range of movements essential for daily activities, sports, and occupational tasks. This chapter provides a comprehensive overview of shoulder anatomy and functional anatomy, integrating clinical details, measurement parameters, assessment procedures, and clinical reasoning to guide physiotherapy practice. Understanding the intricate interplay between bones, joints, muscles, and neural control is critical for accurate diagnosis, effective treatment planning, and prevention of shoulder pathologies.

Osteology

The shoulder girdle consists of three bones: the clavicle, scapula, and proximal humerus. The clavicle acts as a strut connecting the axial skeleton to the upper limb, transmitting forces and protecting underlying neurovascular structures. The scapula is a flat, triangular bone with key landmarks—the acromion, coracoid process, glenoid fossa, spine, and medial/lateral borders. The glenoid fossa is shallow and oriented slightly superiorly and anteriorly, providing minimal bony stability. The proximal humerus includes the head, anatomical neck, surgical neck, greater and lesser tuberosities, and intertubercular groove.

Clavicle fractures are common after a fall onto an outstretched hand (FOOSH); assess for shortening, deformity and neurovascular compromise.

Clavicle fractures are common after a fall onto an outstretched hand (FOOSH); assess for shortening, deformity and neurovascular compromise.

Clinical Relevance

  • Clavicle fractures: Common in falls onto an outstretched hand (FOOSH); assess for shortening, deformity, and neurovascular compromise (brachial plexus, subclavian vessels).
  • Scapular winging: Medial winging (serratus anterior palsy, long thoracic nerve injury) or lateral winging (trapezius palsy, spinal accessory nerve injury).
  • Greater tuberosity fractures: Associated with shoulder dislocations; may cause rotator cuff dysfunction.
  • Glenoid dysplasia: Can predispose to recurrent instability.

Arthrology

The shoulder complex comprises four articulations: glenohumeral (GH), acromioclavicular (AC), sternoclavicular (SC), and scapulothoracic (ST).

Glenohumeral Joint

  • Type: Ball-and-socket synovial joint.
  • Stability: Primarily dependent on dynamic stabilizers (rotator cuff, long head of biceps) and static stabilizers (glenoid labrum, capsular ligaments—superior, middle, inferior glenohumeral ligaments). The inferior glenohumeral ligament is the primary restraint to anterior translation in abduction and external rotation.
  • Capsular pattern: Restriction of external rotation > abduction > internal rotation (typical of adhesive capsulitis).
  • Norms: GH joint range of motion—flexion 0–180°, extension 0–60°, abduction 0–180°, external rotation 0–90° (arm at side), internal rotation 0–70° (arm at side).

Acromioclavicular Joint

  • Type: Plane synovial joint.
  • Ligaments: AC ligament (horizontal stability), coracoclavicular ligaments (conoid and trapezoid—vertical stability).
  • Clinical tests: AC joint compression test, cross-body adduction test. Pain at AC joint suggests osteoarthritis, separation, or distal clavicle osteolysis.

Sternoclavicular Joint

  • Type: Saddle synovial joint (only bony articulation between upper limb and axial skeleton).
  • Ligaments: Costoclavicular, interclavicular, and sternoclavicular ligaments.
  • Clinical: Anterior dislocation is common (often from direct blow); posterior dislocation is rare but can compress trachea, esophagus, or great vessels.

Scapulothoracic Articulation

  • Type: Functional joint (not true synovial); scapula glides over thoracic cage via serratus anterior and subscapularis bursae.
  • Scapulohumeral rhythm: 2:1 ratio of GH to ST motion during abduction (e.g., 120° GH, 60° ST for full 180° abduction). Disruption indicates pathology (e.g., rotator cuff tear, frozen shoulder).

Myology

Muscles of the shoulder complex are organized into local stabilizers (rotator cuff) and global movers (deltoid, pectoralis major, latissimus dorsi, etc.).

Rotator Cuff

  • Supraspinatus: Abduction (0–30°), external rotation. Innervation: suprascapular nerve (C5–C6). Test: Empty can test (Jobe's)—patient abducts arms to 90° with internal rotation; weakness or pain indicates tear.
  • Infraspinatus: External rotation. Innervation: suprascapular nerve. Test: External rotation lag sign; drop arm test.
  • Teres minor: External rotation, adduction. Innervation: axillary nerve (C5–C6). Test: Hornblower's sign.
  • Subscapularis: Internal rotation. Innervation: upper and lower subscapular nerves (C5–C6). Test: Lift-off test, belly press test.

Scapular Stabilizers

  • Trapezius (upper, middle, lower): Elevation, retraction, depression, upward rotation. Innervation: spinal accessory nerve (CN XI). Test: Shoulder shrug, scapular retraction.
  • Serratus anterior: Protraction, upward rotation. Innervation: long thoracic nerve (C5–C7). Test: Push-up plus, wall push; winging indicates weakness.
  • Rhomboids (major and minor): Retraction, downward rotation. Innervation: dorsal scapular nerve (C4–C5). Test: Scapular retraction with resistance.
  • Levator scapulae: Elevation, downward rotation. Innervation: dorsal scapular nerve (C3–C4).

Serratus anterior (long thoracic nerve, C5–C7) is tested with a push-up plus or wall push; winging indicates weakness.

Serratus anterior (long thoracic nerve, C5–C7) is tested with a push-up plus or wall push; winging indicates weakness.

Force Couples

  • Scapular force couple: Upper trapezius and lower trapezius with serratus anterior produce upward rotation; levator scapulae and rhomboids produce downward rotation.
  • GH force couple: Deltoid (abduction) and rotator cuff (compression) stabilize the humeral head against the glenoid. Imbalance leads to superior migration and impingement.

Functional Anatomy

Scapulohumeral rhythm is essential for efficient overhead motion. During the first 30° of abduction, scapula may "set" (slight elevation or depression) followed by coordinated upward rotation. Kinematically, the humeral head must translate inferiorly and posteriorly to avoid impingement against the acromion. The subacromial space (between humeral head, acromion, and coracoacromial ligament) narrows with abduction, making the supraspinatus tendon vulnerable to compression.

Clinical Reasoning for Impingement

  • Neer's test: Passive flexion of the arm (with scapula stabilized) reproduces pain—indicates subacromial impingement.
  • Hawkins-Kennedy test: Flexion to 90° with internal rotation—compresses supraspinatus against coracoacromial ligament.
  • Empty can test: Assesses supraspinatus integrity; positive if pain or weakness.

Shoulder Instability

  • Anterior instability: Most common; apprehension test (abduction + external rotation) elicits fear of dislocation; relocation test (applying posterior force) reduces apprehension.
  • Posterior instability: Less common; posterior apprehension test (flexion + adduction + internal rotation).
  • Inferior instability: Sulcus sign (inferior translation with traction).

Clinical Assessment Parameters

Range of Motion (Active and Passive)

  • Flexion: 0–180° (GH contribution ~120°, ST ~60°).
  • Abduction: 0–180° (GH ~120°, ST ~60°).
  • External rotation: 0–90° (arm at side); 0–90° (arm abducted 90°).
  • Internal rotation: Reach behind back—record vertebral level (e.g., T7). Norm: up to T4–T6.
  • Cross-body adduction: 0–30° (AC joint motion).

Manual Muscle Testing (MMT)

  • Grade 0–5: Based on ability to move through full ROM against gravity and resistance.
  • Supraspinatus: Grade 5 if able to hold abduction at 90° with maximal resistance.
  • Infraspinatus: Grade 5 if able to externally rotate against resistance.
  • Subscapularis: Grade 5 if able to internally rotate against resistance.

Special Tests

  • O'Brien's test (active compression test): For labral tears (SLAP). Patient flexes shoulder to 90°, adducts 10–15°, internally rotates; pain with internal rotation and relief with external rotation suggests labral pathology.
  • Speed's test: For biceps tendinopathy; resisted forward flexion with forearm supinated—pain in bicipital groove.
  • Yergason's test: Supination with elbow flexed 90°—pain indicates biceps tendon instability.
  • Drop arm test: Patient slowly lowers abducted arm; if unable to control, indicates rotator cuff tear.

Neurological Assessment

  • Axillary nerve: Deltoid strength; sensation over lateral shoulder (regimental badge area).
  • Suprascapular nerve: Supraspinatus/infraspinatus strength.
  • Long thoracic nerve: Serratus anterior (winging with push-up).
  • Spinal accessory nerve: Trapezius strength.

Axillary nerve: check deltoid strength and sensation over the lateral shoulder, the regimental badge area.

Axillary nerve: check deltoid strength and sensation over the lateral shoulder, the regimental badge area.

References

  1. Magee DJ. Orthopedic Physical Assessment. 7th ed. Elsevier; 2020.
  2. Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 3rd ed. Elsevier; 2016.
  3. Wilk KE, Reinold MM, Andrews JR. The Athlete's Shoulder. 2nd ed. Churchill Livingstone; 2009.
  4. Ludewig PM, Phadke V, Braman JP, Hassett DR, Cieminski CJ, LaPrade RF. Motion of the shoulder complex during multiplanar humeral elevation. J Bone Joint Surg Am. 2009;91(2):378-389.
  5. Michener LA, Walsworth MK, Doukas WC, Murphy KP. Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Arch Phys Med Rehabil. 2009;90(11):1898-1903.
  6. Hegedus EJ, Goode AP, Cook CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012;46(14):964-978.
  7. Kibler WB, Sciascia A. The role of the scapula in athletic shoulder function. Am J Sports Med. 2010;38(3):623-633.
  8. Terry GC, Chopp TM. Functional anatomy of the shoulder. J Athl Train. 2000;35(3):248-255.

The other 11 chapters, all 144 MCQs and the flashcards are in the PhysioAI app.

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Practice questions

5 sample MCQs from this course. Tap a question to see the answer.

  1. A 30-year-old male tennis player sustained a fall onto his outstretched right arm while playing. He experienced immediate sharp shoulder pain and has difficulty raising his arm above shoulder level. On examination, there is tenderness over the greater tuberosity and weakness in abduction and external rotation. Neer and Hawkins impingement tests are positive. No obvious deformity or apprehension is noted. The patient reports that the pain worsens with overhead activities.

    1. What is the most likely primary diagnosis for this patient?

    • A. Rotator cuff tear
    • B. Shoulder instability
    • C. Glenohumeral joint dislocation
    • D. Scapular fracture
    Show answer

    Answer: A. The clinical presentation of acute onset pain after a fall, with weakness in abduction and external rotation, positive impingement tests, and tenderness at the greater tuberosity, is classic for a rotator cuff tear. Shoulder instability would present with apprehension and subluxation, not isolated impingement signs. Dislocation would show deformity and loss of range, and scapular fracture would have different tenderness patterns.

  2. A 25-year-old female competitive swimmer presents with 3 weeks of progressive anterior shoulder pain, particularly during the overhead phase of freestyle swimming and when reaching for a jacket. Physical exam reveals tenderness over the greater tuberosity and a positive Neer impingement sign. Active abduction is painful between 60° and 120°, with mild limitation of internal rotation but normal external rotation strength. MRI shows tendinosis of the rotator cuff tendon responsible for initiating abduction.

    2. What is the most likely structure implicated in this patient's condition?

    • A. Supraspinatus muscle
    • B. Subscapularis muscle
    • C. Infraspinatus muscle
    • D. Teres minor muscle
    Show answer

    Answer: A. The supraspinatus is the primary abductor of the shoulder and its tendon inserts on the greater tuberosity. Pain during the 60-120° arc of abduction and positive Neer sign are classic for supraspinatus tendinosis, as confirmed by MRI findings.

  3. A 45-year-old patient presents with shoulder pain and difficulty reaching behind the back. The therapist plans to assess strength of the shoulder external rotators to rule out a rotator cuff pathology.

    3. During manual muscle testing of shoulder external rotation, which patient position best isolates the infraspinatus and teres minor?

    • A. Sitting with arm at 90° abduction and 90° external rotation
    • B. Supine with arm at 0° abduction and elbow flexed to 90°
    • C. Side-lying with arm at 0° abduction and elbow flexed to 90°
    • D. Prone with arm at 90° abduction and elbow flexed to 90°
    Show answer

    Answer: C. Side-lying with the arm at 0° abduction and elbow flexed to 90° minimizes the contribution of the deltoid and other muscles, allowing isolated testing of the infraspinatus and teres minor (external rotators). The

  4. A 29-year-old male baseball pitcher presents with a 3-week history of deep, diffuse shoulder pain and a sensation of catching during the late cocking phase of throwing. He reports difficulty with overhead activities and limited abduction and external rotation range of motion. Physical examination reveals a positive O'Brien's test and pain with resisted external rotation at 90 degrees of abduction, without signs of instability or impingement.

    4. What is the primary diagnosis based on the patient's symptoms and presentation?

    • A. Rotator cuff strain
    • B. Shoulder impingement
    • C. Glenohumeral joint instability
    • D. Labral tear
    Show answer

    Answer: D. The vignette describes an overhead athlete with mechanical symptoms (catching) and positive O'Brien's test, which is highly suggestive of a superior labral tear (SLAP lesion). Rotator cuff strain and impingement typically present with different pain patterns and special tests, while instability would involve a sense of subluxation or dislocation rather than catching.

  5. A 32-year-old female competitive swimmer presents with a 3-month history of progressive right shoulder pain. The pain is localized to the anterolateral aspect and is exacerbated during the pull-through phase of freestyle swimming. She reports difficulty with overhead activities and notes stiffness, particularly when reaching behind her back to fasten a bra. On physical examination, there is tenderness over the greater tuberosity, a positive Neer impingement sign, and painful arc between 60-120 degrees of abduction. There is no evidence of instability or neurological deficits.

    5. What is the most likely underlying cause of the patient's symptoms?

    • A. Rotator cuff tendinosis
    • B. Shoulder instability
    • C. Scapular dyskinesis
    • D. Thoracic outlet syndrome
    Show answer

    Answer: A. The patient's symptoms, including pain with internal rotation and adduction (reaching behind back), positive impingement signs, and tenderness over the greater tuberosity, are classic for rotator cuff tendinosis, particularly affecting the supraspinatus tendon. Swimmers are at high risk due to repetitive overhead motion, and the absence of instability or neurovascular findings rules out the other options.

Flashcards

  • What are the four rotator cuff muscles and their primary actions in shoulder dynamic stability?

    The rotator cuff consists of supraspinatus (initiates abduction), infraspinatus and teres minor (external rotation), and subscapularis (internal rotation). These muscles provide dynamic stability by compressing the humeral head into the glenoid fossa. Supraspinatus is most commonly torn, especially at its 'critical zone' near the insertion, and is tested clinically with the empty can test (Jobe test) for impingement.

  • What is the scapulohumeral rhythm ratio during full arm elevation, and what are the respective contributions of the glenohumeral and scapulothoracic joints?

    The scapulohumeral rhythm during full arm elevation is 2:1 (GH:ST), with 120° from glenohumeral and 60° from scapulothoracic motion, totaling 180°. This ratio is essential for normal shoulder function and is often altered in pathologies like impingement or rotator cuff tears, leading to scapular dyskinesis.

  • A patient presents with medial scapular winging that worsens when pushing against a wall. What is the most likely nerve injured, and what muscle is affected?

    Injury to the long thoracic nerve (C5-C7) causes weakness of the serratus anterior muscle. This leads to medial winging of the scapula, most pronounced during the wall push-up test (pushing against a wall with arms extended), which demonstrates the inability to stabilize the scapula against the thoracic wall. The scapula rotates such that the inferior angle moves medially and upward, and common causes include trauma, repetitive overhead activities, or iatrogenic injury during axillary surgery (e.g., mastectomy, first rib resection).

  • How is the Empty Can (Jobe) test performed and what does a positive result indicate?

    The Empty Can test is performed with the patient's arm abducted to 90° in the scapular plane (30° anterior to the coronal plane) and fully internally rotated so the thumb points downward. The examiner applies downward force while the patient resists; a positive result is pain or weakness, indicating supraspinatus tendinopathy or tear. This test has moderate sensitivity (~70%) and specificity (~60%), and is often compared with the Full Can test to improve diagnostic accuracy.

  • Describe the Hawkins-Kennedy test for subacromial impingement, including performance, interpretation, and diagnostic accuracy.

    The test is performed with the patient's shoulder flexed to 90° and elbow bent to 90°, then the examiner forcibly internally rotates the arm. Pain indicates a positive test for subacromial impingement, with a reported sensitivity of ~79% and specificity of ~59%. It is often combined with Neer's test and the painful arc sign to improve diagnostic confidence.

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