Clinical examination is an essential element in the assessment of functional status and location of pain in the shoulder joint. The examination is always performed with the patient's shoulder region bare.
It is advisable to use a goniometer when measuring the joint mobility.
Clinical tests are fairly reliable in diagnosing e.g. rotator cuff disorders and in excluding extensive rotator cuff tears that require emergency operation Clinical Tests for Rotator Cuff Tears.
X-ray is the first-line instrumental investigation in a patient with shoulder pain.
Observe also the associated movements in the scapulae. In frozen shoulder syndrome the scapula rises earlier than in the unaffected side.
Resisted isometric tests abduction (supraspinatus test), external rotation (infraspinatus test), internal rotation + "lift off" test and biceps test
Palpation of tendons
Testing of pain in the rotator cuff and of irritation in the subacromial space; supraspinatus test: one hand of the examiner on the shoulder, the other one under the elbow raising the upper arm upwards, with the elbow joint flexed and the forearm directed forwards
Provocation tests of the acromioclavicular joint (hyperabduction and cross arms tests)
Appropriate pain history (pain radiates to the middle upper arm, around the insertion of the deltoid muscle) and
positive supraspinatus test or
positive forward elevation test: examiner passively forward flexes the shoulder overhead, and pain felt on full flexion is suggestive of supraspinatus tendon impingement against the anterior acromion
History of dislocation or recurring uncomfortable sensation of the shoulder ”giving way”
Apprehension test
The shoulder is abducted 90 degrees and externally rotated: uncomfortable sensation or pain reported by the patient suggests instability.
The test may be continued with the relocation test: the patient lies supine with the shoulder 90 degrees abducted and the elbow 90 degrees flexed. The examiner externally rotates the shoulder; the range of motion is usually restricted and the patient feels the shoulder give way. The examiner applies backward pressure from front on the shoulder to support it and repeats the test. The test is positive if the range of motion in external rotation is increased and the shoulder does not give way.
Findings in multidirectional shoulder instability
E.g. positive sulcus sign in the knee test: the patient is sitting with the shoulders relaxed and takes hold of his/her elevated knee with both hands and then lets the knee with its own weight pull the upper arm downwards: in positive test the space between the humeral head and the acromion is increased by several centimetres.
The patient often also has hyperextensible fingers and elbows, and he/she can easily twist his/her thumb to touch the forearm.
Differential diagnosis
Axial compression test is performed by pressing on the top of the patient's head with the patient sitting.