| Inspection | Check the patient’s posture and “SEADS” (swelling, erythema, atrophy, deformity, surgical scars). |
| Palpation | Include important landmarks: acromioclavicular (AC) joint, long head of biceps tendon, coracoid, and greater tuberosity (supraspinatus insertion). |
| Range of motion testing | Check range of motion actively (patient performs) and passively (clinician performs). |
| Flexion 
| Move the arm forward as high as possible in the sagittal plane. |
| External rotation
| Check with the patient’s elbow touching their body so that external rotation occurs predominantly at the glenohumeral joint. |
| Internal rotation
| The patient is asked to reach the thumbs as high as possible behind the spine on each side. The clinician can record the highest spinous process that the individual can reach on each side (iliac crest = L4, inferior angle of scapula = T8). |
Rotator Cuff Strength Testing |
| Supraspinatus (open can) test
| Perform resisted shoulder abduction at 90 degrees with slight forward flexion to around 45 degrees to test for supraspinatus tendon strength (“open can” test), or with shoulder abduction at 30 degrees and flexion to 30 degrees (“empty can” test). |
| External rotation
| The patient resists by externally rotating the arms with elbows at his or her side. |
| Internal rotation (lift-off test)
| A positive “lift-off” test is the inability of the patient to hold his or her hand away from the body when reaching toward the small of the back. The clinician pushes the patient’s hand toward the back while the patient resists. A positive lift-off indicates subscapularis tendon insufficiency. |
| Internal rotation (belly-press test)
| A positive “belly-press” test is the inability to hold the elbow in front of the trunk while pressing down with the hand on the belly. A positive belly-press test indicates subscapularis tendon insufficiency. |
Impingement Testing |
| Neer impingement sign
| Perform by having the clinician flex the shoulder maximally in an overhead position. The test is positive when pain is reproduced with full passive shoulder flexion. Sensitivity is 79%; specificity is 53%. |
| Hawkins impingement sign
| Perform with the shoulder forward flexed 90 degrees and the elbow flexed at 90 degrees. The shoulder is then maximally internally rotated to impinge the greater tuberosity on the undersurface of the acromion. The test is considered positive when the patient’s pain is reproduced by this maneuver. Sensitivity is 79%; specificity is 59%. |
Stability testing |
| Apprehension test
| With persistent anterior instability or a recent dislocation, the patient feels pain or guards when the shoulder is abducted and externally rotated at 90 degrees. With posterior instability, the patient is apprehensive with the shoulder forward flexed and internally rotated to 90 degrees with a posteriorly directed force. |
| Load and shift test
| Perform to determine shoulder instability by manually translating the humeral head anteriorly and posteriorly in relation to the glenoid. However, this test can be difficult to perform when the patient is not relaxed. |
| O’Brien test
| Performed to rule out labral cartilage tears that often occur following a shoulder subluxation or dislocation. The test involves flexing the patient’s arm to 90 degrees, fully internally rotating the arm so the thumb is facing down (palm down), and adducting the arm to 10 degrees. Once positioned properly, the clinician applies downward force and asks the patient to resist. The test is then repeated in the same position except that the patient has his arm fully supinated (palm up). A positive O’Brien test for labral tear is pain deep in the shoulder with palm down more than the palm up. The O’Brien test can also be used to identify AC joint pathology. The patient would typically complain equally of pain directly over the AC joint with the palm down or up. |