On examination, the asymptomatic shoulder should be observed and serves as a bench-mark for comparison of the affected shoulder. The standard process of look, move, feel should be used :
The patient ought to be exposed to the waist and functional anatomy and biomechanical imbalance should be observed in the vertical position, from front and behind. Muscle wasting, swelling and improper shoulder posture are often seen.
Forward flexion and extension, abduction in the scapula plane (which is 30 degress anterior to the coronal plane) should be tested. Internal and external rotation are tested. In younger patients passive external rotation at 90 degrees abduction should be measured. Glenohumeral joint and scapulothoracic joint motion ought to be observed as one joint may compensate somewhat for the other. These movements ought to be examined passively and then actively, along with limb power, with the patient reporting any pain or discomfort.
Range of neck motion should be observed.
Tests for specific lesions can be employed; the most commonly used are outlined below:
Hawkin’s test - Flex the shoulder to 90 degrees. Then passively internally rotate the shoulder, this will exacerbate pain if impingement is present.
Neer’s sign – One hand is used to stabilise the patient’s scapula, and the patient ought to internally rotate their arm, their thumb should point downwards, the arm should then be passively abducted in the scapular plane. If impingement is present pain will be felt in the mid-range.
Copeland’s test – This is a modification of Neer’s test; if pain is felt during Neer’s test the arm is then lowered, the arm is externally rotated until the thumb is pointing upwards and the arm forward passively abducted once more. Pain should be eliminated.
Supraspinatus (Jobe's Test) – the straight arm is held at 45 degrees abduction in 30 degrees flexion under active restriction of movement.
Infraspinatus – elbow flexed to 90 degrees and external rotation attempted while the examiner actively resists this by holding the elbow to the patient’s side.
Subscapularis – the ‘Gerber lift-off’ test: The patient places their arms on their lower back with the palms facing outwards; this removes the influences of the pectoralis major, and simply lifts the arms away from the body.
Sulcus Sign – This shows inferior laxity as an indentation under the acromion is seen when the arm is pulled downwards whilst torso movement is prevented.
Draw Signs – The patient’s arm is relaxed and lying on their lap. The clinician stabilises the shoulder girdle from behind by holding the acromion and the humeral head between finger and thumb. The humeral head is then moved forwards and backwards over the glenoid. A degree of translation is normal but a movement up to or over the rim of the glenoid indicates laxity and instability.
Apprehension Test – The patient is either sitting or supine. The clinician abducts the arm to 90 degrees and passively brings it into external rotation. Anterior instability is strongly suggested if apprehension results, or if the muscles spasm prevents further external rotation.
Jobe Relocation Test – The patient is supine with the shoulder over the edge of the rotated until pain and apprehension are present. The humeral neck is then subjected to a firm downward pressure. This is maintained whilst further external rotation is brought about until pain recurs. The humeral neck pressure is then suddenly removed, a sudden increase in pain, reported as being similar to that of the symptoms usually felt by the patient in the shoulder, is positive for anterior instability. The patient ought to be very relaxed for the stress tests and realistically they are best conducted under general anaesthetic.
Anterior Stress Test – The patient is supine and the clinician fixes the patient’s scapula and elbow using both their arms. The shoulder is in 90 degrees of abduction and maximal extension and an axial load is applied to the humerus while the arm is rotating; thus attempting to sublux the head anteriorly. The arm is then moved to a flexed and adducted position across the chest. If subluxation had occurred in the first part of the manoeuvre then a palpable or audible click is felt/ heard.
Posterior Stress Test – While the patient lies in the prone position the arm is in 90 degrees flexion with the examiner stabilises the scapula by placing a hand behind it. The clinician pushes the humerus backwards; trying to sublux the joint posteriorly. Similarly to the anterior stress test the axial load is then maintained and the arm is abducted. If subluxation had occurred in the previous manoeuvre then the sudden humeral head relocation will be felt/ heard by a clunk/ click.
The active compression test has been shown to be useful in assisting diagnosis of Superior Labrum Anterior Posterior (SLAP) lesions . It has been shown that the SLAPrehension or O’Brien’s test is 87.5% effective at identifying unstable SLAP lesions. It is conducted as follows: the arm is placed in cross chest adduction with the elbow extended and shoulder internally rotated. The patient is then asked to resist a downward force on the forearm. This should be painful. The test is then repeated with the shoulder externally rotated, and a positive result is when there is no pain in this position .
Having ascertained the likely pathology based on the above tests, as well as others, palpation is then conducted. The areas that may be palpated vary depending on muscle bulk and the presence of adipose tissue. Palpable areas include the acromioclavicular joint and the clavicle, sometimes palpable are the anterior joint line and bicipital groove. The anterosuperior part of the rotator cuff can be palpated if the patient places their hand behind their back; thus extending and internally rotating the shoulder.