Assessment of the Shoulder Region

Physio assessing older womans shoulderDiagnosing shoulder pain conditions, such as rotator cuff tendinopathy or subacromial impingement syndrome, currently involves performing a structured assessment that includes taking the patient’s history in conjunction with performing clinical assessment procedures that generally involve tests used to implicate an isolated structure. Traditionally musculoskeletal assessment of the shoulder has been based around a premise that it is possible to isolate individual structures and apply a mechanical procedure that either compresses or stretches the tissue of interest or requires it to contract. Recent studies on the sensitivity, specificity and predictive accuracy of tests have concluded that, although they have a high sensitivity and reproduce symptoms, they have an associated low specificity which substantially reduces their utility in deriving a specific diagnosis (Lewis 2009).

Eric Hegedus and colleagues (Hegedus et al 2012) have produced a high quality systematic review of shoulder physical tests, in which they conclude that there is still insufficient evidence to recommend any one particular test, or combination of tests, in diagnosing the cause of shoulder pain.

A similar review in the Journal of the American Medical Association by Hermans et al (2013) concluded that the painful arc sign and pain or weakness on resisted external rotation were the best predictors of any degree of Rotator Cuff disease, while for rotator cuff tears the best indicators were a positive internal or external rotation lag sign. For a summary of this study, view the excellent summary video produced by JAMA on the multimedia tab of this link: Summary Video 

If you wish to see these orthopaedic tests being conducted, the British Journal of Sports Medicine have produced a series of online videos, showing these tests.

As part of our Shoulder Community of Practice (CoP) a core group of 16 physiotherapists are involved in a monthly journal club. The first journal club consisted of 10 articles (reviews and original studies) which investigated different aspects of shoulder assessment, e.g. shoulder instability tests, subacromial impingement tests, scapular dyskinesis and shoulder range of motion. Detailed summaries of these studies can be found here:

de Jesus, J.O., Parker, L., Frangos, A.J., Nazarian, L.N. (2009). Accuracy of MRI, MR Arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: A Meta-Analysis. American Journal of Roentgenology 192:1701-1707

Lo IKY, Nonweiler B, Woolfrey M, Litchfield R, Kirkley A (2004) An Evaluation of the Apprehension, Relocation, and Surprise Tests for Anterior Shoulder Instability. American Journal of Sports Medicine, 32(2): 301-7

Struyf F, Nijs J, Mottram S, Roussel NA, Cools AMJ, Meeusen R (2012) Clinical assessment of the scapula: a review of the literature. Br J Sports Med 0:1-8. doi:10.1136/bjsports-2012-091059

Alqunaee M, Galvin R, Fahey T. (2012). Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil. 93(2):229-36

Uhl TL, Kibler B, Gecewich B, Tripp BL (2009). Evaluation of Clinical Assessment Methods for Scapular Dyskinesis. Arthroscopy: The Journal of Arthroscopic and Related Surgery. 25(11):1240-1248

Michener LA, Walsworth MK, Doukas WC, Murphy KP (2009) Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Arch Phys Med Rehabil. 90(11):1898-903

Cadogan A, McNair P, Laslett M, Hing W (2013). Shoulder pain in primary care: diagnostic accuracy of clinical examination tests for non-traumatic acromioclavicular joint pain. BMC Musculoskeletal Disorders 14:156

Cook C, Beaty S, Kissenberth MJ, Siffri P, Pill SG, Hawkins RJ (2012) Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. J Shoulder Elbow Surg 21:13-22

Munro W, Healy R. The validity and accuracy of clinical tests used to detect labral pathology of the shoulder-a systematic review. Man Ther 2009;14:119-30

Seung Han Shin, Du Hyun Ro, O-Sung Lee, Joo Han Oh, Sae Hoon Kim 2012 Within-day reliability of shoulder range of motion measurement with a smartphone. Man Ther. 17 (4):298-304


Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. 2012 Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests.Br J Sports Med. 46(14):964-78. doi: 10.1136/bjsports-2012-091066.

Hermans J, Luime JL, Meuffels DE, et al 2013 Does This Patient With Shoulder Pain Have Rotator Cuff Disease?: The Rational Clinical Examination Systematic Review. JAMA; 310(8):837-847. doi:.05217510.1001/jama.2013.276187.

Lewis, J.S. (2009). Rotator cuff tendinopathy. Br J Sports Med 43:236-241. doi:10.1136/bjsm.2008