Look, feel, move actively then passively, then the rotator cuff tests
Expansion
Look, from front, side and behind, with both shoulders exposed: deltoid and supraspinatus wasting, scars, asymmetry, winging of the scapula, and the position of the arm.
Feel: sternoclavicular joint, clavicle, acromioclavicular joint, acromion, greater tuberosity, the bicipital groove, and the scapular spine.
Move, active first then passive, comparing sides
| Movement | Normal range |
|---|---|
| Flexion | 180 degrees |
| Extension | 60 degrees |
| Abduction | 180 degrees |
| External rotation | 70 degrees, elbows at the side |
| Internal rotation | Thumb to the level of T7 |
Scapulohumeral rhythm: the first 30 degrees of abduction is glenohumeral, then the scapula contributes one degree for every two, so hitching the shoulder suggests cuff failure.
The key discriminator
- Active limited, passive full: rotator cuff tear or painful arc
- Active and passive both limited, particularly with loss of external rotation first: adhesive capsulitis (frozen shoulder) or glenohumeral arthritis
Special tests
- Painful arc between 60 and 120 degrees: subacromial impingement. Pain at the very top of the arc, 140 to 180 degrees, suggests the acromioclavicular joint
- Empty can (Jobe): supraspinatus
- Resisted external rotation: infraspinatus and teres minor
- Gerber lift off: subscapularis
- Hawkins-Kennedy and Neer: impingement
- Apprehension and relocation: anterior instability
- Speed’s and Yergason’s: long head of biceps
- Scarf test: acromioclavicular joint
Always examine the neck, since cervical radiculopathy commonly refers pain to the shoulder, and check the axillary nerve sensation over the regimental badge area after dislocation.