KEY POINTS• PAs should be aware of how to examine the regions of the shoulder. Not all techniques are utilized in every shoulder examination;
technique selection is based on the patient's chief complaint, age, and history of injury.
• Shoulder pain may be referred from the cervical spine; therefore, the examination should include this area as well as a neurologic examination of the upper extremity.
• All examination techniques should be performed on the unaffected side to establish a baseline.
• No test is absolutely diagnostic for any pathologic condition within the shoulder, and no clinician should rely solely on orthopedic
techniques in the diagnostic process.
The shoulder is a wonderful and complex joint, and examination and diagnoses in the shoulder can be very challenging. Its different anatomic areas each require specific examination techniques. PAs who practice in primary care, occupational health, orthopedics, and emergency/urgent care should be aware of how to examine the regions of the shoulder and determine which examination technique to use based on the patient's chief complaint, age, and history of injury.
A literature search on physical examination of the shoulder will produce multiple papers, reviews, and studies that include various modifications and descriptive titles of the same techniques. This can be very confusing for clinicians, especially when a technique is known by several names. Therefore, this article will discuss the most commonly used orthopedic examination techniques, as described by their original authors when possible.
PHYSICAL EXAMINATION
Examination of the patient who presents with shoulder pain starts with a thorough history of the injury. Table 1 lists pertinent questions to ask when taking the history. Shoulder pain may be referred from the cervical spine; therefore, the examination should include this area as well as a neurologic examination of the upper extremity. All techniques should be performed on the unaffected side to establish a baseline.
The patient's age and chief complaint are used to direct the clinician's choice of examination techniques. The patient's age will also help establish a differential diagnosis. In general, patients aged 25 years or younger typically present with acute injuries (shoulder dislocations), shoulder instability, or an acromioclavicular (AC) injury. Adult patients younger than 40 years typically present with rotator cuff impingement, adhesive capsulitis, and mild arthritic conditions of the AC joint; those older than 40 years typically present with rotator cuff pathology (impingement or tears) and arthritis of the AC and/or glenohumeral joints.
Range of motion The American Shoulder and Elbow Surgeons standardized shoulder assessment form is used to assess both active and passive range of motion1 (Table 2). A deficiency in either phase is indicative of disease process. For example, a patient with adhesive capsulitis (frozen shoulder) will have restrictions in both active and passive motions; whereas, restriction in active motion but no restriction in passive motion suggests rotator cuff pathology.
Scapular assessment The shoulder elevates from the thorax with concomitant scapular motion at a humerus-to-scapula ratio of nearly 2:1. Visual inspection of movement and position of the scapula is important. Scapulae position should demonstrate symmetry bilaterally. The distance from the thoracic spinous processes to the vertebral borders of the scapulae should be equal. The scapulae should move symmetrically during elevation of the arms. If an abnormal rhythm, called scapular dyskinesis, is noted, the patient should be treated with physical therapy. If the vertebral border of the scapula elevates away from the thorax during a wall push-up, a winging scapula is suspected, suggesting long thoracic nerve palsy.