Clinical Examination of the Shoulder

Joint Complex
Mike Reinold, DPT, SCS, CSCS
MikeReinold.com
Champion PT and Performance
Boston, MA

I. Introduction

A. Clinical Examination

1. Vital to successful treatment of shoulder patients

2. Must be thorough and systematic

a. Rule out & rule in

3. Main purpose is to establish underlying cause of symptoms

4. Also determines where to start with patient

a. Tolerance level aggressiveness of program

B. Components of clinical exam

1. Subjective history
2. Inspection / observation
3. Clearing the cervical spine
3. Active range of motion
4. Passive range of motion
5. Manual muscle testing
6. Accessory motion assessment
7. Laxity testing
8. Special tests
9. Palpation
10. Neurovascular assessment
11. Functional assessments
12. Imaging studies / radiographs
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Mike Reinold, DPT, SCS, CSCS
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II. Subjective Examination

A. Most important part of the clinical exam

B. Will direct the approach to the objective examination
C. History of symptoms

1. What brings you here today?

a. Pain, weakness, instability, sensations, etc.

2. When did the symptoms begin?

a. Acute traumatic incident

b. Insidious onset

3. Where, when, & how?

4. What alleviates symptoms?

5. What reproduces symptoms?

6. Chief complaint

a. Limitations in functional activities

b. Limitations in work activities
c. Limitations in recreational/athletic activities

Looking for pattern recognition of symptoms

III. Observation

A. Symmetry
B. Posture

1. Head position
2. Shoulder position
3. Pectoralis position
3. Scapular position
4. Spine position

C. Atrophy of muscle tissue

D. Visible defects

1. Ecchymosis, edema, inflammation, deformities

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Mike Reinold, DPT, SCS, CSCS
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IV. Clearing the cervical spine

A. Dermatomes, myotomes, reflexes

B. Active ROM (w/ overpressure), quadrant test, compression/distraction

V. Range of motion

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Mike Reinold, DPT, SCS, CSCS
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A. Active range of motion

1. Ability to raise arm

2. Functional ER/IR
3. Assess several factors

a. Painful arc
b. Quality of motion
c. Quantity of motion

4. Scapulohumeral rhythm

a. 0-30 = setting phase; mostly GH movement

b. 30-90 = 2.0-2.75:1 ratio of GH:ST movement
c. 90-160 = 1:1 ratio of scapulohumeral movement

5. Scapula movement & winging

B. Passive range of motion

Motion AAOS AMA Boone JBJS 79 End Feel

Flexion 180 150 166.7 Firm
Extension 60 50 62.3
IR 70 90 68.8 Firm-hard
ER 90 90 103.7 Capsular
Abduction 180 180 184.0

Motion 10-20 years 20-40 years 40-54 years 60-85 years 61-93 years
Boone JBJS 79 Boone JBJS 79 Boone JBJS 79 Walker Phys Ther 84 Downey Phys Ther 91
FLX 167.4 165 165.1 160 165
EXT 64 58 56.1 38 -
IR 70.3 66.5 68.3 59 65
ER 106.3 101 97.5 76 80.6
ABD 185.1 182.7 182.6 155 157.9

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Mike Reinold, DPT, SCS, CSCS
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C. PROM in the athletic population

Motion Baseball Players PROM Baseball Players AROM Tennis Players AROM
Wilk AJSM 02 Ellenbecker MSSE 02 Ellenbecker MSSE 02

ER 129.9 103.2 103.7

IR 62.6 42.4 45.4

D. Assess several factors during PROM

1. Quality & quantity of motion

2. Crepitus
3. End feel (overpressure)

VI. Neuromuscular system

A. Resisted manual muscle testing

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Mike Reinold, DPT, SCS, CSCS
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B. Rotator cuff integrity

1. Empty can test

Jobe: AJSM 82

2. Drop arm test

3. Lag Signs
Hertel: JSES 96
Supraspinatus Infraspintus/Supraspinatus

4. Lift-off Sign & Belly Press

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Mike Reinold, DPT, SCS, CSCS
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Gerber: JBJS 91

5. Internal impingement sign Meister: AJSM 00

C. Impingement

1. Impingement sign
Neer: Orthop Clin NA 77

2. Hawkins test
Hawkins: AJSM 80

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Mike Reinold, DPT, SCS, CSCS
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D. Biceps provocation

1. Static Speeds test

2. Dynamic Speeds test

3. Yer gasons test

Yergason: JBJS 31

VII. Accessory Motion Assessment

A. Assess glenohumeral joint play

1. Inferior glide
2. Posterior glide
3. Anterior glide
4. Lateral glide

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Mike Reinold, DPT, SCS, CSCS
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VIII. Laxity assessment

A. Grading of humeral head translation What is normal?

B. Seated position

1. Sulcus sign inferior laxity - Neer & Foster JBJS 80

2. Load & shift gross instability

Sillman & Hawkins CORR 93

C. Supine Position - Anterior instability

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Mike Reinold, DPT, SCS, CSCS
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1. Anterior drawer @ 45 - Wilk: JOSPT 97

2. Anterior drawer @ 90 - Wilk: JOSPT 97

3. Anterior fulcrum Andrews 95

4. Andrews Lachman of the shoulder

Andrews 95

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Mike Reinold, DPT, SCS, CSCS
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5. Relocation test
Jobe Orthop Rev 89

6. Apprehension test

D. Supine Position - Posterior instability

1. Posterior drawer @ 45 - Wilk: JOSPT 97

2. Posterior drawer @ 90 - Wilk: JOSPT 97

3. Posterior fulcrum
Norwood: AJSM 84

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Mike Reinold, DPT, SCS, CSCS
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4. Push-pull test
Matsen: 90

VIII. SLAP tests

A. Speeds tests

B. Grind test
Compression-Rotation
Snyder: Arthroscopy 90

C. Clunk test / Crank Test

Andrews: Inj. Baseball 85
Liu: AJSM 96

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Mike Reinold, DPT, SCS, CSCS
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E. Anterior slide
Kibler: Arthroscopy 95

F. Active compression test OBrien: AJSM 98

G. Biceps Load I & II Kim: AJSM 99 & Arthroscopy 01

H. Pain Provocation Mimori: AJSM 99 Increased pain in pronation

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Mike Reinold, DPT, SCS, CSCS
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IX. Acromioclavicular joint

A. Spring sign

B. Shear test
Davies: Phys Sports Med 81

C. Horizontal adduction

D. OBriens test
OBrien: AJSM 98

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Mike Reinold, DPT, SCS, CSCS
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X. Neurovascular

A. Neurological function

1. Upper limb tension test (ULTT) Magee 97

2. Tinels sign Landi 79

3. Dermatomes & Reflexes

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Mike Reinold, DPT, SCS, CSCS
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C. Thoracic outlet

1. Roos (EAST) test

Generalized compression
Roos: J Surg 76

2. Adson maneuver Compression between anterior & middle scalenes

or between cervical rib and scalenes. Adson: Ann Surg 27

3. Costoclavicular (Military) test Compression between 1st rib & clavicle

in costoclavicular space. Magee 97

4. Allen test Compression between pectoralis minor and ribs. Allen: AJ

Med Sci 29

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Mike Reinold, DPT, SCS, CSCS
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XI. Palpation
A. Specific structures
1. Greater tuberosity rotator cuff insertion
2. Biceps brachii (proximal)
3. Coracoid process
4. Subacromial bursa
5. Anterior deltoid
6. Infraspinatus internal impingement location
7. Quadralateral space
8. 1st rib
9. Acromioclavicular joint
10. Scapular mobility (crepitus, etc) during AROM
XII. Functional Assessment
A. Specific shoulder assessment forms
1. American Shoulder Elbow Surgeon Form
2. UCLA Shoulder Form
3. Jobe-Tobonie Athletic Shoulder Form
4. Modified Athletic Shoulder Form Reinold, Wilk, Andrews
5. Mimori Scoring System
XIII. Summary
A. Key Points
1. Systemic approach to shoulder exam
2. Logical progression
3. Knowledge of anatomy & biomechanics
4. Establish chief complaints
5. Correlate clinical findings to history

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 Clinical Examination of the Shoulder
Mike Reinold, DPT, SCS, CSCS
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Mike Reinold, DPT, SCS, CSCS
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Mike Reinold, DPT, SCS, CSCS
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