REVIEW ARTICLE
Anatomy and Physical Examination of the Shoulder
Wajeeh Bakhsh, MD and Gregg Nicandri, MD
Abstract: The shoulder is a complex joint, with a wide range of
motion and functional demands. An understanding of the intricate
network of bony, ligamentous, muscular, and neurovascular anat-
omy is required in order to properly identify and diagnose shoulder
pathology. There exist many articulations, unique structural fea-
tures, and anatomic relationships that play a role in shoulder
function, and therefore, dysfunction and injury. Evaluation of a
patient with shoulder complaints is largely reliant upon physical
exam. As with any exam, the basic tenets of inspection, palpation,
range of motion, strength, and neurovascular integrity must be
followed. However, with the degree of complexity associated with
shoulder anatomy, specific exam maneuvers must be utilized to
isolate and help differentiate pathologies. Evaluation of rotator cuff
injury, shoulder instability, or impingement via exam guides clinical
decision-making and informs treatment options.
Key Words: shoulder, anatomy, physical exam, rotator cuff, muscle,
neurovascular, ligamentous, instability
(Sports Med Arthrosc Rev 2018;26:e10–e22)
T he shoulder is a complex joint responsible for articu-
lation of the upper extremities with the trunk or axial
skeleton. It plays a vital role in the function of the arms and
hands, the dexterity of which sets human beings apart from
many other mammals. With the demands of strength,
endurance, and flexibility that are placed on the shoulder
through everyday life, it often becomes a source of
musculoskeletal complaints and pathology. Therefore, it is a
structure that health care providers should be comfortable
evaluating, especially in athletes. An understanding of the
anatomy of this joint is necessary to comprehend both
normal and pathologic states. In addition, to aid in diag-
nosis, a thorough physical exam is invaluable in identifying
pathologies or impaired function.
ANATOMY
Skeletal
The shoulder is ultimately composed of a network of
soft tissues overlaying the skeleton.1 Bony anatomy involves
the scapula, a flat, triangular bone forming the posterior
aspect of the shoulder girdle with 17 muscular attachments,
with an anterior projection named the glenoid that forms
half of the primary shoulder joint.2,3 The clavicle, or col-
larbone, serves as a strut connecting the upper extremity
skeleton with the axial skeleton anteriorly, and articulates
with the sternum medially.4 The humerus is the long bone of
the upper arm, with a proximal head articulating within the
From the Department of Orthopaedics, University of Rochester Medical
Center, Rochester, NY.
Disclosure: The authors declare no conflict of interest.
Reprints: Gregg Nicandri, MD, University of Rochester Medical Center,
601 Elmwood Ave., P.O. Box 665, Rochester, NY 14642.
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shoulder joint5 (Figs. 1A, B). The shoulder complex is
composed of 4 smaller joints, primarily the glenohumeral
(GH) joint, and the acromioclavicular (AC), sternocla-
vicular (SC), and scapulothoracic (ST) joints.7–9 The supe-
rior shoulder suspensory complex is a bony and soft tissue
ring involving these joints that, together with many mus-
cular and ligamentous attachments, is responsible for the
articulation of the upper extremity with the axial skeleton.
The GH articulation is enveloped in the shoulder joint
capsule. The joint is covered superiorly by the bony
anterior-superior scapular projection, the acromion. The
acromion articulates with the clavicle, which serves as
the anterior connection to the axial skeleton.4,10
The GH joint is a “ball-and-socket” joint, as the ball,
or humeral head, interacts with the socket, or glenoid. Both
surfaces are covered with hyaline cartilage. Only approx-
imately 25% of the humeral head surface area actually
interfaces with the glenoid surface.11,12 The glenoid is a
shallow socket, surrounded by a labrum. The labrum, a ring
of connective tissue that surrounds the glenoid, increases the
volume of the glenoid fossa by up to 50% and serves as a
static shoulder stabilizer.13,14 The joint capsule extends from
the anatomic neck of the humerus to the border of the
glenoid fossa. A synovial membrane lining the capsule helps
produce the synovial fluid to lubricate the joint and supply
nutrients. The GH joint is cushioned superiorly by a sub-
acromial bursa to help facilitate motion. This subacromial
space is between the humeral head inferiorly and the acro-
mion superiorly.15–17
Other articulations include the AC joint, ST joint, and
SC joint. The AC joint is surrounded by an independent
joint capsule. Pain at the AC joint is often associated with or
referred to the superior shoulder. Injury to the AC joint is
colloquially known as a “shoulder separation,” aptly named
as the major function of the AC joint is to facilitate shoulder
motion in relation to the remaining axial skeleton.18–20 The
ST joint is not a true joint, as it is simply the articulation
between the scapula and thorax or rib cage. There is no
investing joint capsule. Primarily, the ST joint is responsible
for elevation and depression to change the plane of shoulder
motion, allowing the great flexibility of the shoulder. There
is some protraction, retraction, and rotation as well, the
deficiency of which can be noted on exam with certain
neurological pathologies. The ST joint contributes roughly
one third of the overall shoulder abduction range of
motion.21,22 The SC joint is a saddle joint, with only 50%
surface articulation. It is enveloped in an independent cap-
sule. This joint allows for elevation of the arm without
requiring motion of the thorax. Injury involving the SC joint
is more often concerning for possible underlying pulmonary
injury with any posterior-directed forces.23–25
Ligamentous
Ligamentous anatomy about the shoulder plays an
invaluable role in shoulder integrity and function (Fig. 2).
Static stability of the shoulder is in large part due to the GH
Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
FIGURE 1. Bony anatomy of the shoulder. Anterior (A). Posterior (B). Source: Moore et al.6
ligaments, which are essentially thickenings of the GH joint
capsule. The superior glenohumeral ligament (SGHL)
stretches from the anterior-superior labrum to the anatomic
neck of the humerus, and is responsible for restraint to
inferior translation with the arm in neutral rotation and at
the side. The SGHL also stabilizes the biceps tendon within
the groove, acting as a pulley.15,27,28 The middle gleno-
humeral ligament is slightly inferior, stretching from the
anterior labrum to the humerus. Its role is to resist anterior
and posterior translation at the midrange of shoulder rota-
tion and abduction. The inferior glenohumeral ligament
(IGHL) is a complex, with anterior, posterior, and superior
bands. The anterior band of the IGHL is responsible for
restraint to anterior and inferior translation of the humeral
head when the arm is abducted to 90 degrees and externally
rotated, or in the late-cocking phase of throwing. The IGHL
is the ligament most often associated with Bankart lesions at
its attachment along the anterior labrum. The posterior
band of the IGHL provides restraint to posterior sub-
luxation when the arm is abducted.29–31
The coracohumeral ligaments are associated with the
superior, anterior shoulder. They span from the coracoid to
the rotator cable/humerus, helping define the rotator inter-
val. The function of these structures is to limit posterior
FIGURE 2. Ligamentous anatomy of the shoulder. Source:
Cunningham.26
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Anatomy and Physical Examination of the Shoulder
translation with the shoulder flexed and internally rotated,
and inferior translation with the arm adducted to neutral
while externally rotated.32,33 The AC joint is supported
by superior, inferior, anterior, and posterior ligaments,
the most important of which are the superior and posterior.
These prevent horizontal translation in the anterior-
posterior plane.34,35 Coracoclavicular ligaments include the
conoid and trapezoid ligaments, with the conoid being
relatively medial. The conoid is the stronger of the 2 ligaments,
and attaches 4.5 cm medial to the lateral end of the clavicle,
while the trapezoid attaches 2.5 cm medial to the lateral
end.36,37 The coracoacromial ligament, often released in
subacromial decompression and viewed as a pain generator, is
a triangular band of tissue connecting the coracoid process and
the anterior acromion. Its key function is to prevent superior
humeral head displacement from the GH joint.38
Muscular
Atop the skeleton is a complex network of muscular
anatomy that enables the various functions of the shoulder
(Figs. 3A, B). Superficially, the most prominent muscle is
the deltoid, responsible for the contour of the shoulder. The
anterior one third originates from the distal clavicle and the
remainder from the scapula. There is a broad insertion
about the lateral humerus.39,40 Innervation occurs via the
axillary nerve, and vascular supply is via the deltoid branch
of the thoracoacromial artery and the posterior humeral
circumflex artery. The main function of the deltoid muscle is
to abduct the arm, and it functions most efficiently at neu-
tral rotation. As there are anterior and posterior segments,
the deltoid also assists with arm flexion and extension. In
certain circumstances, such as reverse total shoulder
arthroplasty, it can function independently to achieve this
movement.41,42
Other scapulohumeral muscles include the teres major
muscle, which originates along the lateral inferior scapula,
and inserts on the medial aspect of the humeral shaft. It
assists in humerus internal rotation and adduction. Inner-
vation occurs via the lower and middle subscapular
nerves.43,44 Along with the humerus and teres minor, the
teres major forms the axillary space, a posterior anatomic
space through which the axillary nerve, posterior humeral
circumflex vessels, and scapular circumflex vessels pass.45
The coracobrachialis originates from the coracoid and
inserts along the medial aspect of the humerus. It is an
adductor and flexor of the arm, innervated by the muscu-
locutaneous nerve. Together with the short head of the
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Bakhsh and Nicandri
FIGURE 3. Shoulder muscle anatomy. Anterior (A). Posterior (B). Source: Moore et al.6
biceps brachii, the coracobrachialis forms the conjoint tendon at
its attachment to the coracoid.46,47 Pain or injury here is referred
to the anterior shoulder. Other coracoid attachments include the
pectoralis minor, which arises from ribs 3 to 5 and inserts at the
coracoid. The key function of the pectoralis minor is to depress
the shoulder, drawing the scapula inferiorly. It is innervated by
the medial pectoral nerve.48,49
Other key muscles in shoulder movement include the
pectoralis major. Innervated by both the medial and lateral
pectoral nerves, this muscle is largely responsible for chest
contour. The vascular supply is the pectoral branch of the
thoracoacromial trunk. The pectoralis major has a broad
origin with 2 heads, a clavicular head and sternal head that
spans to ribs 6 to 7. The tendon inserts along the humeral
shaft just medial to the deltoid, along the lateral lip of the
biceps groove. Major functions include flexion and adduc-
tion of the arm. In addition, it plays a significant role in
internal rotation of the arm, and is a soft tissue anchor of the
arm to the trunk.50–52 The latissimus dorsi is a broad, flat
muscle originating from the mid-lower back, spanning 4 to 8
vertebrae and posterior ribs. It crosses the inferior angle of
the scapula, often with attachments, and inserts along the
humeral shaft medial to the pectoralis major and lateral to
teres major. The latissimus dorsi is innervated by the thor-
acodorsal nerve, and supports arm extension, adduction,
and internal rotation.52,53
Other supportive muscles include the trapezius, which
is a broad flat muscle originating from the posterior upper
spine and inserting on the lateral scapula, clavicle, and
acromion. Its role is in stabilization of the scapula, and
rotation to enable movement in the scapula-thoracic
plane.54 The serratus anterior, innervated by the long
thoracic nerve, originates from the margin of the first 8 ribs.
Its function is in scapular motion, as it pulls the inferior
aspect of the scapula laterally and forward, enabling
shoulder abduction beyond 90 degrees via motion in the
ST plane.55
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Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
The triceps muscle, mainly an extensor of the elbow
joint, crosses the shoulder as the long head originates at
infraglenoid tubercle of the scapula. It has a mild role in
adduction and retroversion of the arm.56 The rhomboid
muscles, posterior muscles along the medial border of the
scapula, play a supportive role in depression of the scapula.
They are antagonists to the serratus anterior. Other muscles
include the levator scapulae, which originates from the
cervical spine and attaches at the medial scapula, and serves
to elevate the scapula and rotate it medially to allow for
motion in the scapular plane. The subclavius muscle
stretches from the first rib to the subclavian groove of the
clavicle, and depresses the shoulder while pulling the clavicle
inferiorly.57
A key shoulder muscle is the biceps brachii. Prox-
imally, the biceps has 2 heads; the short head originates
from the coracoid as part of the conjoint tendon with the
coracobrachialis muscle. The long head of the biceps most
commonly originates at the supraglenoid tubercle, often
along the superior-posterior aspect of the labrum of the GH
joint. It crosses the rotator interval and travels down the
proximal humerus in the bicipital groove. Innervation is via
the musculocutaneous nerve. The major function of this
muscle is to supinate and flex the forearm/elbow. As the
biceps crosses the shoulder joint, it also has a role in arm
flexion and adduction. The long head of the biceps tendon is
intracapsular at its origin, and is often associated with
shoulder pathology and subjective complaints.58–60
Directly overlying the shoulder capsule is the rotator
cuff. The rotator cuff is a complex structure composed of 4
muscles: anteriorly, the subscapularis, followed by the
supraspinatus, infraspinatus, and most posteriorly, the teres
minor. These muscles all originate from the scapula and
insert at the humerus. The subscapularis originates and fills
the subscapular fossa of the scapula, and inserts at the lesser
tuberosity of the humerus. It is innervated by the upper and
lower subscapular nerves, which are branches from the
Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
brachial plexus. The subscapularis courses across the ante-
rior GH joint capsule. It provides the anterior/inferior bor-
der of the rotator interval, which is a space between the
rotator cuff tendons that allows the shoulder to move as the
cuff spans across the coracoid. The interval also acts as a
sling and therefore pulley for the long head of the biceps
brachii. Other borders of the rotator interval include the
coracohumeral ligament, SGHL, and supraspinatus tendon.
The supraspinatus muscle originates from the scapula on the
posterior aspect superior to the scapular spine. It is inner-
vated by the suprascapular nerve. The infraspinatus muscle
originates from the scapula inferior to the spine, and is
innervated by the suprascapular nerve. Teres minor originates
from the axillary border of the scapula, and is innervated by
the axillary nerve. The supraspinatus, infraspinatus, and teres
minor muscles all insert across a broad footprint at the
greater tuberosity of the humerus.61–65
Functionally, the rotator cuff muscles as a unit serve
the primary purpose of force-coupling at the GH joint,
allowing for appropriate joint-reactive forces to be main-
tained for shoulder active range of motion.66 The sub-
scapularis is also responsible for humerus adduction and
internal rotation, and provides an important restraint to
anterior translation of the humeral head. The supraspinatus
works with the deltoid for shoulder abduction, especially
within the first 15 degrees. The infraspinatus participates in
external rotation of the arm, especially when at neutral
abduction, whereas the teres minor aids in external rotation
of the arm with the arm abducted. The rotator cuff also
plays a vital role in dynamic stability of the joint, main-
taining GH alignment throughout range of motion.67–69
The rotator crescent is a term applied to the aponeur-
otic portion of the distal-most aspects of the supraspinatus
and infraspinatus tendons. It is surrounded by a thick
bundle of fibers medially, the rotator cable. The cable con-
struct is thought to provide a degree of stress-shielding to the
rotator crescent tissue, and enable stress transfer to the
greater tuberosity of the humerus. Initially described by
Burkhart and colleagues, the cable serves analogous to a
suspension bridge, as it spans across the crescent tissue,
transferring stress from the anterior aspect of the tuberosity
to the posterior aspect.70–72
Neurovascular
Neurovascular anatomy about the shoulder is complex,
adding to the difficulty associated with diagnosis and sur-
gical intervention (Figs. 4A, B). The brachial plexus origi-
nates from nerve roots C5-T1, and courses anteriorly, then
laterally toward the arm. It coalesces and divides into
trunks, divisions, cords, and finally branches. During its
course, the plexus can be found beneath the clavicle near the
junction of the medial and middle one thirds. Proximally, it
gives rise to the suprascapular nerve and nerve to the sub-
clavius. The medial and lateral pectoral nerves, and upper
and lower subscapular nerves follow distally, along with the
axillary nerve and musculocutaneous nerve.73
The suprascapular nerve, responsible for innervation of
the supraspinatus and infraspinatus muscles, travels deep
to the rhomboid muscles, along the superior scapula,
through the suprascapular notch inferior to the superior
transverse scapular ligament. It then curves around the
lateral scapular spine, through the spinoglenoid notch, and
into the infraspinous fossa. Impingement or compression of
the nerve can be seen at either the suprascapular notch or
the spinoglenoid notch. For example, a paralabral cyst
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Anatomy and Physical Examination of the Shoulder
of the glenoid has been demonstrated to compress the
spinoglenoid notch, at which point denervation of the
infraspinatus muscle can occur.74,75
Further distal along the plexus, the upper and lower
subscapular nerves branch off of the posterior cord. These
innervate the superior and inferior portions of the sub-
scapularis muscle, allowing for a safe muscle-splitting
approach, typically performed at the junction of the supe-
rior two third and inferior one third of the muscle. The
axillary nerve branches further distally off of the posterior
cord. It travels anterior to the subscapularis muscle belly,
posterior to the axillary artery. The axillary nerve then
travels to the posterior aspect of the shoulder through the
quadrangular space, along with the posterior humeral cir-
cumflex artery. The quadrangular space, just medial to the
proximal humerus at the level of the anatomic neck, is
bordered by the teres major, teres minor, subscapularis, and
humerus. The triceps brachii tendon crossing this area sep-
arates it into the quadrangular and triangular spaces.76,77
The axillary nerve then innervates the teres minor muscle
and long head of the triceps brachii. It courses around the
posterior aspect of the humerus, back around the lateral
humerus to the anterior compartment as it innervates the
deltoid muscle. The nerve can be found laterally at a point
5 cm distal to the lateral edge of the acromion.78 Sensory
innervation involves the skin over the inferior deltoid as the
upper lateral cutaneous nerve of the arm. This nerve is
especially at risk in open shoulder procedures.
The musculocutaneous nerve branches off of the bra-
chial plexus from the lateral cord, and travels anteriorly,
piercing the coracobrachialis muscle at a point between 3
and 8 cm distal to the distal to the coracoid.79,80 It then runs
down the arm between the biceps brachii and brachialis
muscles, and terminates with the lateral antebrachial cuta-
neous nerve. Injury can be seen with the deltopectoral
approach to open shoulder surgery, or manipulation of the
conjoint tendon.
The vascular anatomy about the shoulder is reliable,
and vital to understanding outcomes of injury and surgical
risks. The axillary artery, so named after the subclavian
artery passes the lateral margin of the first rib, is the main
vascular supply. Initially it travels anterior to the pectoralis
minor. It then courses posterior to it, and the thor-
acoacromial trunk branches off shortly thereafter. This
trunk pierces the coracoclavicular fascia and gives rise to
branches that supply the clavicle, acromion, pectoral mus-
cles, and deltoid muscle. The acromion and deltoid branches
lie anterior to the conjoint tendon, with the acromial branch
being relatively superior.81
As the axillary artery courses lateral to the pectoralis
minor, it gives rise to the subscapular artery, and anterior
and posterior humeral circumflex arteries. The subscapular
artery, approximately 4 cm from its origin, gives rise to the
scapular circumflex artery and thoracodorsal artery.82 The
scapular circumflex vessels travel through the triangular
space to the posterior aspect of the shoulder, while the
thoracodorsal artery supplies the latissimus dorsi. The pos-
terior humeral circumflex artery, thought to be larger than
the anterior counterpart, arises below the lower border of
the subscapularis muscle. It then travels through the quad-
rangular space with the axillary nerve, supplying the inferior
deltoid, shoulder capsule, and most importantly, the hum-
eral head. The posterior branch has recently been estab-
lished as the majority vascular supply to the humeral
head.83–85 The anterior humeral circumflex artery runs
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Bakhsh and Nicandri Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018

FIGURE 4. Shoulder neurovascular anatomy. Vascular (A). Neurological (B). Source: Moore et al.6

beneath the coracobrachialis muscle anteriorly, and wraps
around the anterior humeral neck. At the intertubercular
sulcus, it gives rise to the arcuate artery, which is responsible
for vascular supply to the humeral epiphysis. The 2 humeral
circumflex vessels then anastomose at the lateral humerus.
PHYSICAL EXAM
Owing to the incredibly complex, multifaceted role of
the shoulder in use of the upper extremities, it is a common
source of pathology, especially in athletes. With the multi-
tude of structures involved in shoulder function, isolating
a specific pathology to address relies on a thorough
physical exam.
As with any examination, an initial detailed interview
is invaluable and can help direct further parts of the exam.
To address shoulder pathology, an interview should begin
by identifying the complaint and possible sources. In the
case of trauma, the interview should localize complaints (eg,
anterior vs. posterior) and identify any functional restric-
tions to inform exam limitations. Pain complaints must be
localized and associated with any palliative or worsening
factors or activities to generate some anatomic correlation.
Patient age should be noted, both in stated age and func-
tional appearance. Certain pathologies, such as rotator cuff
injury versus impingement syndrome, follow general age
paradigms.86,87 A thorough past medical history will enable
correlations. For example, a history of previous adhesive
capsulitis increases the likelihood of this condition affecting
the contralateral shoulder.88 Cardiac or pericardial pain can
be referred as shoulder discomfort. A history of previous
trauma can raise the index of suspicion for instability, and
certain disease processes such as seizure disorders can
increase the risk of various pathologies, like posterior dis-
location. In some cases, a birth history may even be of use,
such as when evaluating brachial plexus concerns. Espe-
cially in the evaluation of an active patient, the level of
activity is important. With athletes, it is important to
understand what, if any, movements are repetitive or in high
demand in their sport. This can often provide clues in
diagnosis of clinical issues that may or may not have cor-
responding imaging findings.
Physical examination should follow a set pattern to
decrease the chance of overlooking more subtle pathologies.
Examination should begin with inspection, and proceed
with palpation, active/passive range of motion, strength, and
neurovascular exams.89 To begin, exam should be per-
formed with both shoulders exposed, without clothing cov-
ering. A preliminary skin exam should note any asymmetry
between the affected and unaffected sides. Any atrophy

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Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
should be noted, as should any gross defects such as long
head of the biceps rupture (Popeye deformity of the arm) or
pectoralis major tear (loss of inferior/medial axillary con-
tour). Swelling or edema should be compared with the
contralateral limb, and any scarring, whether indicative of
prior trauma or surgery, should be noted.
With patient consent, the next phase of the physical
exam involves palpation. Crepitus must be identified, espe-
cially in the setting of trauma, as a sign of potential fracture.
Focal tenderness can identify areas of trauma, joint degen-
eration, or any number of pathologies. Tenderness along
tendon insertions can localize specific muscle or tendon
injuries, and in conjunction with history can lead to a
diagnosis.
A key component of the shoulder physical exam is
range of motion. The “normal” range of motion of the
shoulder includes: forward flexion from 150 to 180 degrees,
extension from 40 to 60 degrees, abduction from 150 to 180
degrees, external rotation from 60 to 90 degrees, and inter-
nal rotation to the mid-thoracic level, or 50 to 70
degrees.90–92 Examination should be of both active and
passive range of motion. Limitations to range of motion can
indicate any number of etiologies. A simplification is that
loss of passive and active ranges of motion can suggest
adhesive capsulitis or GH osteoarthritis, whereas loss of
active range of motion while maintaining passive range of
motion is indicative of either rotator cuff injury or shoulder
impingement.93,94 Acute or subacute impingement tends to
present with painful range of motion, active or passive, in a
maximum arc of 90 degrees.95,96 Within the shoulder range
of motion, specifically for abduction, the scapular mechan-
ics are responsible for the last one third of motion in a so-
called “scapulohumeral rhythm.” The GH joint is limited by
bony restraints (such as the acromion) until the scapula
changes the plane of motion.8,97,98
Further evaluation of the range of motion includes the
cross-body adduction test, wherein the patient crosses their
arm, elbow extended, across the chest (Fig. 5). Anterior
shoulder pain, or pain/tenderness about the AC joint, elicited
from this maneuver indicates AC joint pathology.100,101
Limited shoulder forward flexion or abduction beyond 90
degrees may suggest scapular dyskinesia. This can be
FIGURE 5. Cross-body adduction test. Source: Park et al.99
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Anatomy and Physical Examination of the Shoulder
FIGURE 6. Speed test of biceps pathology. Source: Park et al.99
evaluated by having the patient push-up off the wall; the test is
positive for serratus anterior injury or long thoracic nerve
palsy with medial scapular winging. Lateral scapular winging
is associated with trapezius or cranial nerve XI injury.102,103
To evaluate motor function, a corresponding strength
exam is warranted. A bilateral extremity exam, when pos-
sible, is ideal for comparison to the uninvolved side. The
deltoid muscle, as previously stated, is primarily responsible
for active shoulder abduction. Active and resisted shoulder
abduction beyond 15 degrees should be evaluated and
graded. The biceps muscle should be examined via Speed
test. With the patient’s shoulder flexed, elbows extended,
and forearm supinated, a downward force is applied to the
arms by the examiner. Pain along the biceps tendon or
within the bicipital groove is a positive test result (Fig. 6).
This can signify biceps pathology or superior labral
injury.104,105 Yergason test is performed with the patients
arm adducted, neutral rotation, with the elbow flexed to 90
degrees. Resisted supination is performed, and a positive test
presents with pain in the biceps tendon or bicipital
groove.106 Multiple studies show similar specificities
between the tests for biceps pathology.107–109
Evaluation of the pectoralis major should be part of
any routine shoulder exam as well. Beyond a visual exam
evaluating for complete tear of the tendon, the patient’s arm
and elbow should be flexed to 90 degrees, and externally
rotated. Resisted arm adduction will target the pectoralis
major. In addition, with the patient’s hands clasped or
palms opposed in front of their chest, a self-administered
exam to evaluate for tendinitis involves the patient using
both arms to apply a medially directed force. Positive exam
findings include pain or discomfort along the anterior chest
or tendon insertion along the proximal humerus.110
In pursuit of a complete exam, attention should next be
paid to the neurovascular examination. Especially in trau-
matic cases, confirming the status and function of the major
nerves and vessels is vital in informing next steps. Brachial
plexus and nerve root integrity can be examined by evalu-
ating sensory function in corresponding dermatomes and
myotomes from C4 to T1 involving the extremity, as these
can all be affected in certain pathologies about the shoulder.
Sensory nerve integrity can be evaluated with a thorough
sensory exam, identifying affected topographic areas and
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Bakhsh and Nicandri
associated innervation, such as the lateral antebrachial
cutaneous nerve versus medial brachial or antebrachial
cutaneous nerves.
The axillary nerve is responsible for motor innervation
of the deltoid and teres minor muscles. Active shoulder
abduction should be critically evaluated, as well as teres
minor activation, which will be discussed in the exam of the
rotator cuff. Axillary nerve sensory function can be eval-
uated about the lateral shoulder in the “regiment badge”
area, via the superior lateral cutaneous nerve.111 The mus-
culocutaneous nerve motor function can be evaluated by
testing biceps function, and sensory function via intact
sensation in the lateral antebrachial cutaneous nerve dis-
tribution. Distally, the radial, median, and ulnar nerves
should be evaluated for intact hand sensation in the
appropriate distributions, and motor function of the wrist
and digits. An easy screen for distal motor function is asking
the patient to demonstrate a “thumbs-up,” “peace sign,”
and “OK sign.” The radial and ulnar pulses should be
evaluated at the wrist to ensure distal flow, as well as the
brachial pulse at the antecubital fossa.
When utilizing the physical exam to guide diagnosis
and management, it is important to isolate referred sources
of pain, and establish whether the shoulder is the true source
of pathology. This includes evaluation of the cervical spine,
using Spurling maneuver.112 This is performed as the patient
turns their head toward the affected side, while the examiner
extends and applies downward pressure to the head. A
positive finding is radiating sensory symptoms down the
involved arm. It indicates cervical radiculopathy, which can
refer symptoms to the shoulder.113
The rotator cuff is clearly anatomically complex;
however, there are a series of exam maneuvers that allow for
a more targeted diagnosis of the involved structures.
Shoulder impingement, associated with subacromial bursi-
tis, can be examined with the Neer impingement test
(Fig. 7). While the examiner uses 1 hand to stabilize the
scapula and prevent motion in that plane, the other hand is
used to passively range the arm.115–117 The patient is to
remain relaxed, and the arm is then passively abducted and
FIGURE 7. Neer impingement test. Source: Powers.114
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Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
FIGURE 8. Hawkins-Kennedy impingement test. Source: Park
et al.99
internally rotated, as this minimizes the volume of the
subacromial space and elicits a response. A positive test is
pain, often about the anterior shoulder, although it can be
about the lateral shoulder and may refer down the lateral
aspect of the arm in the subdeltoid space.118,119 This test is
sensitive, up to 89%.99,120 Another impingement exam
maneuver is the Hawkins-Kennedy test, which is effective
with greater sensitivity but slightly lower specificity. It
involves passive range of motion of the arm while the
patient is relaxed, with the arm and elbow flexed to 90
degrees. The arm is then internally rotated (Fig. 8). A pos-
itive result is pain about the anterior or lateral shoulder, and
is mostly associated with shoulder impingement although it
can also signify biceps pathology.96,118,120
Internal impingement can be evaluated with exam
maneuvers designed to identify posterior GH labral lesions,
such as the relocation test, which will be discussed shortly.
In addition, internal impingement can be identified by
examining the posterior rotator cuff integrity.121,122 The
posterior impingement sign is defined as deep shoulder pain
when the patient’s arm is passively abducted to 90 degrees,
extension of 15 degrees, and maximum external rotation.
This is a highly specific test, with up to 75% sensitivity and
85% specificity.123,124
Specifically targeting rotator cuff muscles is easily
doable, reproducible, and helpful in identifying injuries. The
subscapularis muscle can be examined with Gerber test. This
involves the patient internally rotating the arm with the
elbow flexed until the dorsum of the hand is resting along
the back. Intact subscapularis function allows the patient
the ability to further internally rotate and lift the dorsum of
the hand off the back, while a positive test is the inability to
do so (Fig. 9).126 If the patient does not have the flexibility
to put the hand behind the back, a belly press-down test is a
substitute, wherein the patient internally rotates the arm and
flexes the elbow so the palm is resting on the abdomen. They
then press down, and a positive test is inability to maintain
the elbow forward, instead using shoulder extension and
wrist flexion to press down.127 Lastly the recently described
Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
FIGURE 9. Gerber test of subscapularis injury. Source: Green.125
bear-hug test involves the patient taking the affected arm
and reaching up and over to grasp the contralateral lat-
issimus dorsi, with the elbow flexed across the anterior chest.
The examiner then evaluates strength to resisted pull
off.128,129 Patient strength or function should be graded
against the contralateral limb if possible.
Supraspinatus tendon injury is more commonly eval-
uated with the Jobe, or “empty can” test130 (Fig. 10). The
supraspinatus tendon is most commonly affected in rotator
cuff injury, so this is vital to a shoulder examination. It
positions the supraspinatus tendon in a position of maximal
stress, and a positive result is pain or weakness. The arm is
flexed to 90 degrees in the scapular plane, with the forearm
FIGURE 10. Jobe test of supraspinatus injury. Source: Powers.114
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Anatomy and Physical Examination of the Shoulder
maximally pronated and shoulder internally rotated.
Downward pressure is then applied to the arm by the
examiner, most reliably above the elbow to avoid activation
of the triceps. While not incredibly sensitive, this test is up to
90% specific.131,132 A recent, more sensitive modification is
the lateral Jobe test, which involves the patient’s arm
abducted to 90 degrees in the coronal plane, with elbows
flexed to 90 degrees and internally rotated so the hand
points to the floor. A positive test is pain or weakness to a
downward force.133 The drop arm test supplements these
findings, as it can identify rotator cuff pathology, although
not as specific for supraspinatus injury alone. As the
patient’s arm is abducted to 90 degrees or beyond, a positive
sign is failure to maintain an active, slow, controlled
adduction to the side, often with abrupt collapse after 90
degrees.134
The infraspinatus tendon is evaluated with resisted
external rotation while the arm is adducted to the patient’s
side. It requires active patient participation. In addition, the
external rotation lag sign is indicative of infraspinatus or
posterior cuff pathology.135 The patient’s arm is positioned
in 20 degrees of flexion with the elbow flexed to 90 degrees.
The forearm is passively externally rotated to its maximum
extent and released. If the patient is unable to maintain this
position, it is a positive lag sign. This test is reliant on a
normal range of motion, as capsular adhesions or a global
loss of range of motion invalidates the external rotation lag
test.136
Teres minor integrity is evaluated specifically using the
hornblower sign.137 The patient’s arm passively abducted
and external rotated to 90 degrees. Inability to maintain this
position is a positive sign, suggesting posterior cuff and teres
minor pathology. Pain with resistance at this position may
indicate tendinopathy or a small tear.138,139
Especially in overhead athletes, such as baseball
pitchers, thorough evaluation of the GH labrum is essential.
As previously mentioned, Speed test can be used to identify
anterior shoulder pathology, more commonly of the biceps
although this may involve the labrum as well due to the
biceps long head tendon insertion.105 Although there is no
single test that can isolate labral pathology as well as tests
for certain rotator cuff tendon involvement, these maneu-
vers still provide valuable diagnostic information. The crank
test involves maximal abduction of the arm to 160 or so
degrees, and elbow flexion to 90 degrees.140 The examiner
then applies a compressive force directing the humeral head
into the GH joint and stresses the labrum with external and
internal rotation. Pain or clicking is a positive test, sug-
gesting labral pathology.141 A more specific and sensitive
test for labral pathology is O’Brien test.142 This involves the
patient passively flexing the arm to 90 degrees and adduct-
ing 10 degrees from neutral. The forearm/hand is then
pronated, internally rotating the arm, until the thumb points
to the ground. This position is then maintained against a
downward force, and pain or weakness is a positive finding.
The second part of this test is to then externally rotate the
arm, or supinate the forearm so the thumb is pointing
upwards, and again a downward force is applied and
actively resisted by the patient. Reduced discomfort in the
thumb-up position, compared with thumb-down, is sug-
gesting of labral pathology as opposed to biceps.143,144 The
posterior relocation test, more targeted in cases of shoulder
instability, also offers some value in detecting labral injury.
Although instability is often voiced as a subjective
complaint and rarely indolent, with the great range of
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Bakhsh and Nicandri
FIGURE 11. Load and shift test of glenohumeral instability.
Source: Powers.114
motion through the shoulder joint, instability is a concern.
Instability examination should first begin with a general
appraisal of overall laxity. Global joint laxity, or a high
Beighton score, must be taken into account when evaluating
shoulder joint stability.145 The exam maneuvers that follow
are often intimately associated with labral pathology, as the
labrum is responsible for increasing the depth of the GH
joint, which directly correlates with stability. To start, the
load and shift test evaluates the degree of anterior-posterior
translation of the humeral head relative to the glenoid
(Fig. 11). Initially described in 1991, the examiner stabilizes
the scapula with one hand and uses the other to first load the
humeral head into the glenoid fossa, and then test for
anterior and posterior translation.146 Excessive translation is
positive for instability in that respective direction. This test
is more sensitive for anterior than posterior instability, and
nearly 100% specific.147,148
Further instability tests include the anterior and pos-
terior drawer tests, first described in 1984.149 Posterior
drawer test involves the arm resting on a surface in the “zero
unpacked” position, at approximately 30 degrees of
abduction, and slightly flexed, with the elbow flexed at 90
degrees. While resting in this position, the humeral head is
then gripped by the examiner between the thumb and fin-
gers, and posteriorly directed force is applied. Increased
subluxation or dislocation is a positive sign of instability.
The anterior drawer test involves the patients arm abducted
to 90 degrees, slightly flexed, and externally rotated to 30
degrees. In this position, the examiner stabilizes the scapula
with one hand, and uses the other to isolate the humeral
head and apply an anterior-directed force. Translation, as
with other instability exam maneuvers, must be a relative
indication of pathology taking into account global joint
laxity and activity demands, as younger athletes may dem-
onstrate greater range of motion in their dominant
arm.148,150,151
The apprehension test can also be used to evaluate
anterior instability, as the patient lies supine and the arm is
abducted with the elbow flexed to 90 degrees, with the arm
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Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
off of the bed so the scapula is stabilized. An external
rotation force is then applied by the examiner, and a positive
finding is patient apprehension. Pain may suggest either
instability or posterior cuff pathology.152 An exam corol-
lary, the relocation test by Jobe can be used to identify
posterior cuff or internal impingement, in addition to
anterior shoulder instability.153 As the arm is externally
rotated in the above-described apprehension test maneuver,
a posterior-directed force is applied to the humeral head
once the patient reports apprehension or pain. If there is
subjective relief of either pain or apprehension, this is a
positive sign for anterior instability most commonly, or
labral or posterior cuff injury. Performing both the appre-
hension and relocation tests has demonstrated improved
sensitivity for instability.154–156
Lastly, diagnostic injection can be used to clarify
diagnoses when history and examination do not provide
sufficient clarity. Steroid injection can be used as a diag-
nostic tool, as, when injected into the appropriate space,
symptom relief after an injection indicates the source of
pathology.134,157 In the clinic setting, adding local anes-
thetic to the injection will provide a faster short-term
symptom relief to inform clinical decision-making.
For example, injection into the AC joint versus the
subacromial space can help discern the true source of
symptomology. Ultrasound guidance can be utilized for
improved accuracy.158,159
Although the shoulder is an anatomically complex
joint that enables great range of motion, function, and
dexterity of the upper extremities, it is a common source
of musculoskeletal complaints, especially in the athletic
population. Knowledge of the anatomic details sur-
rounding the shoulder helps guide both diagnosis and
intervention. Physical exam maneuvers and technique
help guide diagnosis and identification of exact etiologies.
Using just these, a well-informed clinical decision is often
possible. While imaging, which relies on an understanding
of anatomy, can supplement these findings and further
inform caretaking, the value of the exam cannot be
overstated.
REFERENCES
1. Cotter EJ, Hannon CP, Christian D, et al. Comprehensive
examination of the Athlete’s shoulder. Sports Health. 2018.
2. Kibler BW. The role of the scapula in athletic shoulder
function. Am J Sports Med. 1998;26:325–337.
3. Cools A, Dewitte V, Lanszweert F, et al. Rehabilitation of
scapular muscle balance. Am J Sports Med. 2007;35:1744.
4. Moore K, Dalley AF. Clinically Oriented Anatomy, 4th ed.
New York, NY: Lippincott Williams & Wilkins; 1999.
5. Romer A, Parsons T. The Vertebrate Body. Philadelphia, PA:
Holt-Saunders International; 1977:198–199.
6. Moore KL, Dalley AF, Agur AMR. Upper Extremity Clinically
Oriented Anatomy. Wolters Kluwer Health/Lippincott Williams &
Wilkins; 2014.
7. Marieb EN, Hoehn K. In: Marieb EN, Hoehn K, eds. Chapter 8:
Joints Anatomy and Physiology, 3rd ed. Philadelphia: Pearson
Benjamin Cummings; 2007:239–240.
8. Terry GC, Chopp TM. Functional anatomy of the shoulder.
J Athlet Train. 2000;35:248–255.
9. Martini FH. Chapter 9: Articulations Fundamentals of
Anatomy and Physiology, 4th ed. New Jersey: Prentice-Hall
International; 1998:267–268.
10. Maruvada S, Bhimji SS. Anatomy, Upper Limb, Shoulder,
Rotator Cuff [Internet]. Treasure Island, FL: StatPearls
Publishing; 2017.
Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
11. Adams CR, DeMartino AM, Rego G, et al. The rotator cuff
and the superior capsule: why we need both. Arthroscopy.
2016;32:2628–2637.
12. Turkel SJ, Panio MW, Marshall JL, et al. Stabilizing
mechanisms preventing anterior dislocation of the glenohum-
eral joint. J Bone Joint Surg Am. 1981;63:1208–1217.
13. Howell SM, Galinat BJ. The glenoid-labral socket. A
constrained articular surface. Clin Orthop Relat Res. 1989;243:
122–125.
14. Alashkham A, Alraddadi A, Felts P, et al. Blood supply and
vascularity of the glenoid labrum: its clinical implications.
J Orthop Surg (Hong Kong). 2017;25:3.
15. Ogul H, Karaca L, Can CE, et al. Anatomy, variants, and
pathologies of the superior glenohumeral ligament: magnetic
resonance imaging with three-dimensional volumetric interpo-
lated breath-hold examination sequence and conventional
magnetic resonance arthrography. Korean J Radiol. 2014;15:
508–522.
16. Petersson CJ, Redlund-Johnell I. The subacromial space in
normal shoulder radiographs. Acta Orthop Scand. 1984;55:
57–58.
17. Saladin KS. Anatomy & Physiology: The Unity of Form and
Function, 6th ed. New York, NY: McGraw-Hill; 2012.
18. Barth J, Boutsiadis A, Narbona P, et al. The anterior borders
of the clavicle and the acromion are not always aligned in the
intact acromioclavicular joint: a cadaveric study. J Shoulder
Elbow Surg. 2017;26:1121–1127.
19. Gibbs DB, Lynch TS, Nuber ED, et al. Common shoulder
injuries in american football athletes. Curr Sports Med Rep.
2015;14:413–419.
20. Spoliti M, De Cupis M, Via AG, et al. All arthroscopic
stabilization of acute acromioclavicular joint dislocation with
fiberwire and endobutton system. Muscles Ligaments Tendons
J. 2015;4:398–403.
21. Seth A, Matias R, Veloso AP, et al. A biomechanical model of
the scapulothoracic joint to accurately capture scapular
kinematics during shoulder movements. PLoS One. 2016;11:
e0141028.
22. Ludewig PM, Phadke V, Braman JP, et al. Motion of
the shoulder complex during multiplanar humeral elevation.
J Bone Joint Surg Am. 2009;91:378–389.
23. Yi JW, Kim DH, Heo YM, et al. Bilateral sternoclavicular
joint dislocation due to sternal fracture: is it a dislocation or a
separation? Arch Orthop Trauma Surg. 2016;136:605–608.
24. Chaudhry S. Pediatric posterior sternoclavicular joint injuries.
J Am Acad Orthop Surg. 2015;23:468–475.
25. Morell DJ, Thyagarajan DS. Sternoclavicular joint dislocation
and its management: a review of the literature. World J
Orthop. 2016;7:244–250.
26. Cunningham DJ. Textbook of Anatomy. New York, NY:
William Wood and Co.; 1903.
27. Ide J, Maeda S, Takagi K. Normal variations of the
glenohumeral ligament complex: an anatomic study for
arthroscopic Bankart repair. Arthroscopy. 2004;20:164–168.
28. Boardman ND, Debski RE, Warner JJ, et al. Tensile
properties of the superior glenohumeral and coracohumeral
ligaments. J Shoulder Elbow Surg. 1996;5:249–254.
29. Passanante GJ, Skalski MR, Patel DB, et al. Inferior
glenohumeral ligament (IGHL) complex: anatomy, injuries,
imaging features, and treatment options. Emerg Radiol. 2017;
24:65–71.
30. Ticker JB, Flatow EL, Pawluk RJ, et al. The inferior
glenohumeral ligament: a correlative investigation. J Shoulder
Elbow Surg. 2006;15:665–674.
31. Debski RE, Weiss JA, Newman WJ, et al. Stress and strain in
the anterior band of the inferior glenohumeral ligament during
a simulated clinical examination. J Shoulder Elbow Surg.
2005;14(suppl S):24S–31S.
32. Kanazawa K, Hagiwara Y, Kawai N, et al. Correlations of
coracohumeral ligament and range of motion restriction in
patients with recurrent anterior glenohumeral instability
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
Anatomy and Physical Examination of the Shoulder
evaluated by magnetic resonance arthrography. J Shoulder
Elbow Surg. 2017;26:233–240.
33. Yang C, Goto A, Sahara W, et al. In vivo three-dimensional
evaluation of the functional length of glenohumeral ligaments.
Clin Biomech (Bristol, Avon). 2010;25:137–141.
34. Teece RM, Lunden JB, Lloyd AS, et al. Three-dimensional
acromioclavicular motions during elevation of the arm.
J Orthop Sports Phys Ther. 2008;38:181–190.
35. Turnbull JR. Acromioclavicular joint disorders. Med Sci
Sports Exerc. 1998;30:S26–S32.
36. Boehm TD, Kirschner S, Fischer A, et al. The relation of the
coracoclavicular ligament insertion to the acromioclavicular
joint: a cadaver study of relevance to lateral clavicle resection.
Acta Orthop Scand. 2003;74:718–721.
37. Inman VT, Saudners JB, Abbot LC. Observations of the
function of the shoulder joint. 1944. Clin Orthop Relat Res.
1996:3–12.
38. Rothenberg A, Gasbarro G, Chlebeck J, et al. The coracoa-
cromial ligament: anatomy, function, and clinical significance.
Orthop J Sports Med. 2017;5:4.
39. Rispoli DM, Athwal GS, Sperling JW, et al. The anatomy of
the deltoid insertion. J Shoulder Elbow Surg. 2009;18:386–390.
40. Potau JM, Bardina X, Ciurana N, et al. Quantitative analysis
of the deltoid and rotator cuff muscles in humans and great
apes. Int J Primatol. 2009;30:697–708.
41. Jobin CM, Brown GD, Bahu MJ, et al. Reverse total shoulder
arthroplasty for cuff tear arthropathy: the clinical effect of
deltoid lengthening and center of rotation medialization.
J Shoulder Elbow Surg. 2012;21:1269–1277.
42. Matsen FA III, Boileau P, Walch G, et al. The reverse total
shoulder arthroplasty. J Bone Joint Surg Am. 2007;89:
660–667.
43. Giessler GA, Doll S, Germann G. Macroscopic and micro-
angiographic anatomy of the teres major muscle: a new free
functional muscle flap. Plast Reconstr Surg. 2007;119:
941–949.
44. Dancker M, Lambert S, Brenner E. The neurovascular
anatomy of the teres major muscle. J Shoulder Elbow Surg.
2015;24:e57–e67.
45. Flynn LS, Wright TW, King JJ. Quadrilateral space
syndrome: a review. J Shoulder Elbow Surg. 2017.
46. Oh JW, Lee H, Lee JH. Topography of the coracobrachialis
muscle and the musculocutaneous nerve by muscular varia-
tion. Surg Radiol Anat. 2017;39:115–116.
47. Giles JW, Boons HW, Ferreira LM, et al. The effect of the
conjoined tendon of the short head of the biceps and
coracobrachialis on shoulder stability and kinematics during
in-vitro simulation. J Biomech. 2011;44:1192–1195.
48. Franz A, Klaas J, Schumann M, et al. Anatomical versus
functional motor points of selected upper body muscles.
Muscle Nerve. 2018;57:460–465.
49. Provencher MT, Kirby H, McDonald LS, et al. Surgical
release of the pectoralis minor tendon for scapular dyskinesia
and shoulder pain. Am J Sports Med. 2017;45:173–178.
50. Aarimaa V, Rantanen J, Heikkila J, et al. Rupture of the
pectoralis major muscle. Am J Sports Med. 2004;32:
1256–1262.
51. Saladin KS. Anatomy & Physiology: The Unit of Form and
Function, 5th ed. New York: McGraw-Hill; 2010. Changes
made by Kari Thomas.
52. Brown JM, Wickham JB, McAndrew DJ, et al. Muscles within
muscles: coordination of 19 muscle segments within three
shoulder muscles during isometric motor tasks. J Electromyogr
Kinesiol. 2007;17:57–73.
53. Donohue B, Lubitz M. Sports injuries to the latissimus dorsi
and teres major. Am J Sports Med. 2016.
54. Dalley AF, Moore KL, Agur AMR. Clinically Oriented
Anatomy, 6th ed. Philadelphia: Lippincott Williams &
Wilkins, Wolters Kluwer; 2010:700.
55. Brand RA. Origin and comparative anatomy of the pectoral
limb. Clin Orthop Relat Res. 2008;466:531–542.
www.sportsmedarthro.com | e19
Bakhsh and Nicandri
56. Nigel del a rosa die porte madretis. Surgical anatomy of the
triceps brachii tendon: anatomical study and clinical correla-
tion. Am J Sports Med. 2006;34:1839–1843.
57. Paine R, Voight ML. The role of the scapula. Int J Sports Phys
Ther. 2013;8:617–629.
58. Taylor SA, O’Brien SJ. Clinically relevant anatomy and
biomechanics of the proximal biceps. Clin Sports Med. 2016;
35:1–18.
59. Hussain WM, Reddy D, Atanda A, et al. The longitudinal
anatomy of the long head of the biceps tendon and implications
on tenodesis. Knee Surg Sports Traumatol Arthrosc. 2015;23:
1518–1523.
60. Nakata W, Katou S, Fujita A, et al. Biceps pulley: normal
anatomy and associated lesions at MR arthrography. Radio-
graphics. 2011;31:791–810.
61. Boon J, de Beer M, Botha D, et al. The anatomy of the
subscapularis tendon insertion as applied to rotator cuff
repair. J Shoulder Elbow Surg. 2004;13:165–169.
62. Clark JM, Harryman DT. Tendons, ligaments, and capsule of
the rotator cuff. J Bone Joint Surg. 1992;74-A:713–725.
63. Curtis A, Burbank K, Tierney J, et al. The insertional
footprint of the rotator cuff: an anatomic study. Arthrosco J
Arthrosc Relat Surg. 2006;22:603–609.
64. Aszmann OC, Dellon AL, Birely BT, et al. Innervation of the
human shoulder joint and its implications for surgery. Clin
Orthop Relat Res. 1996;330:202–207.
65. Curtis AS, Burbank KM, Tierney JJ, et al. The insertional
footprint of the rotator cuff: an anatomic study. Arthroscopy.
2006;22:609.
66. Parsons IM, Apreleva M, Fu FH, et al. The effect of rotator
cuff tears on reaction forces at the glenohumeral joint.
J Orthop Res. 2002;20:439–446.
67. Kelly BT, Kadrmas WR, Speer KP. The manual muscle
examination for rotator cuff strength. An electromyographic
investigation. Am J Sports Med. 1996;24:581–588.
68. Lee SB, Kim KJ, O’Driscoll SW, et al. Dynamic glenohumeral
stability provided by the rotator cuff muscles in the mid-range
and end-range of motion. A study in cadavera. J Bone Joint
Surg Am. 2000;82:849–857.
69. Dark A, Ginn KA, Halaki M. Shoulder muscle recruitment
patterns during commonly used rotator cuff exercises: an
electromyographic study. Phys Ther. 2007;87:1039–1046.
70. Burkhart SS, Esch JC, Jolson RS. The rotator crescent and
rotator cable: an anatomic description of the shoulder’s
“suspension bridge”. Arthroscopy. 1993;9:611–616. Erratum
in: Arthroscopy 1994;10(2):239.
71. Denard PJ, Koo SS, Murena L, et al. Pseudoparalysis: the
importance of rotator cable integrity. Orthopedics. 2012;35:
e1353–e1357.
72. Burkhart SS. Partial repair of massive rotator cuff tears: the
evolution of a concept. Orthop Clin North Am. 1997;28:
125–132.
73. Orebaugh SL, Williams BA. Brachial plexus anatomy: normal
and variant. Scientific World J. 2009;9:300–312.
74. Leschinger T, Hackl M, Buess E, et al. The risk of
suprascapular and axillary nerve injury in reverse total
shoulder arthroplasty: an anatomic study. Injury. 2017;48:
2042–2049.
75. Westerheide KJ, Dopirak RM, Karzel RP, et al. Supra-
scapular nerve palsy secondary to spinoglenoid cysts: results of
arthroscopic treatment. Arthroscopy. 2006;22:721–727.
76. Burkhead WZ Jr, Scheinberg RR, Box G. Surgical anatomy of
the axillary nerve. J Shoulder Elbow Surg. 1992;1:31–36.
77. Tubbs RS, Tyler-Kabara EC, Aikens AC, et al. Surgical
anatomy of the axillary nerve within the quadrangular space.
J Neurosurg. 2005;102:912–914.
78. Cetik O, Uslu M, Acar HI, et al. Is there a safe area for the
axillary nerve in the deltoid muscle? A cadaveric study. J Bone
Joint Surg Am. 2006;88:2395–2399.
79. Flatow EL, Bigliani LU, April EW. An anatomic study of the
musculocutaneous nerve and its relationship to the coracoid
process. Clin Orthop Relat Res. 1989;244:166–171.
e20 | www.sportsmedarthro.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
80. Eglseder WA Jr, Goldman M. Anatomic variations of the
musculocutaneous nerve in the arm. Am J Orthop (Belle Mead
NJ). 1997;26:777–780.
81. Majumdar S, Bhattacharya S, Chatterjee A, et al. A study on
axillary artery and its branching pattern among the population
of West Bengal, India. Ital J Anat Embryol. 2013;118:159–171.
82. Mills NL, Dupin CL, Everson CT, et al. The subscapular
artery: an alternative conduit for coronary bypass. J Card
Surg. 1993;8:66–71.
83. Brooks CH, Revell WJ, Heatley FW. Vascularity of the
humeral head after proximal humeral fractures. An anatom-
ical cadaver study. J Bone Joint Surg Br. 1993;75:132–136.
84. Meyer C, Alt V, Hassanin H, et al. The arteries of the humeral
head and their relevance in fracture treatment. Surg Radiol
Anat. 2005;27:232–237.
85. Kamineni S, Ankem H, Sanghavi S. Anatomical consider-
ations for percutaneous proximal humeral fracture fixation.
Injury. 2004;35:1133–1136.
86. Milgrom C, Schaffler M, Gilbert S, et al. Rotator-cuff changes
in asymptomatic adults. The effect of age, hand dominance
and gender. J Bone Joint Surg Br. 1995;77:296–298.
87. Yamamoto A, Takagishi K, Osawa T, et al. Prevalence and
risk factors of a rotator cuff tear in the general population.
J Shoulder Elbow Surg. 2010;19:116–120.
88. Ewald A. Adhesive capsulitis: a review. Am Fam Physician.
2011;83:417–422.
89. Bates B, Hoekelman RA, Thompson JB. A Guide to Physical
Examination and History Taking. Philadelphia, PA: Lippincott
Williams & Wilkins; 1991:714pp.
90. Dutton M. Orthopaedic Examination, Evaluation, and Inter-
vention, 2nd ed. Philadelphia, PA: McGraw Hill; 2008.
91. Hoppenfeld S. Physical Examination of the Spine and
Extremities. Norwalk, CT: Prentice-Hall; 1976.
92. Norkin C, White J. Measurements of Joint Motion: A Guide to
Goniometry, 4th ed. Philadelphia, PA: F.A. Davis; 2009.
93. Mitchell C, Adebajo A, Hay E, et al. Shoulder pain: diagnosis
and management in primary care. BMJ. 2005;331:1124–1128.
94. Sharma SP, Bærheim A, Moe-Nilssen R, et al. Adhesive
capsulitis of the shoulder, treatment with corticosteroid,
corticosteroid with distension or treatment-as-usual; a rando-
mised controlled trial in primary care. BMC Musculoskelet
Disord. 2016;17:232.
95. Ludewig PM, Braman JP. Shoulder impingement: biomechan-
ical considerations in rehabilitation. Man Ther. 2011;16:33–39.
96. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes.
Am J Sports Med. 1980;8:151–158.
97. Codman EA. The Shoulder. Boston: Thomas Todd Company;
1934.
98. Veeger HE, van der Helm FC. Shoulder function: the perfect
compromise between mobility and stability. J Biomech. 2007;
40:2119–2129.
99. Park HB, Yokota A, Gill HS, et al. Diagnostic accuracy of
clinical tests for the different degrees of subacromial impinge-
ment syndrome. J Bone Joint Surg Am. 2005;87:1446–1455.
100. Zanca P. Shoulder pain: involvement of the acromioclavicular
joint. Am J Roentgenol. 1971;112:493–506.
101. Chronopoulos E, Kim TK, Park HB, et al. Diagnostic value of
physical tests for isolated chronic acromioclavicular lesions.
Am J Sports Med. 2004;32:655–661.
102. Martin RM, Fish DE. Scapular winging: anatomical review,
diagnosis, and treatments. Curr Rev Musculoskelet Med. 2008;1:
1–11.
103. Kibler WB, Ludewig PM, McClure PW, et al. Clinical
implications of scapular dyskinesis in shoulder injury: the
2013 consensus statement from the ‘Scapular Summit’. Br J
Sports Med. 2013;47:877–885.
104. Bennett WF. Specificity of the Speed’s test: arthroscopic
technique for evaluating the biceps tendon at the level of the
bicipital groove. Arthroscopy. 1998;14:789–796.
105. Van Moppes FI, Veldkamp O, Roorda J. Role of ultra-
sonography in the evaluation of the painful shoulder. Eur J
Radiol. 1995;19:142–146.
Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018
106. Hawkins RJ, Bokor DJ. Clinical evaluation of shoulder problems.
The Shoulder. Philadelphia: W.B. Saunders; 1990:149–177.
107. Hegedus EJ, Goode A, Campbell S, et al. Physical examina-
tion tests of the shoulder: a systematic review with meta-
analysis of individual tests. Br J Sports Med. 2008;42:80–92.
108. Holtby R, Razmjou H. Accuracy of the Speed’s and
Yergason’s tests in detecting biceps pathology and SLAP
lesions: comparison with arthroscopic findings. Arthroscopy.
2004;20:231–236.
109. Caliş M, Akgün K, Birtane M, et al. Diagnostic values of
clinical diagnostic tests in subacromial impingement syn-
drome. Ann Rheum Dis. 2000;59:44–47.
110. Provencher MT, Handfield K, Boniquit NT, et al. Injuries to
the pectoralis major muscle: diagnosis and management. Am J
Sports Med. 2010;38:1693–1705.
111. Choi D. Peripheral nerve lesions. Surgery. 2012;30:149–154.
112. Spurling RS, Scoville WB. Lateral rupture of the cervical
intervertebral discs: a common cause of shoulder and arm
pain. Surg Gynecol Obstet. 1944;78:350–358.
113. Caridi JM, Pumberger M, Hughes AP. Cervical radiculop-
athy: a review. HSS J. 2011;7:265–272.
114. Powers R. Shoulder examination: how to select and perform
the appropriate tests. JAAPA. 2010;23:22–26; 48.
115. Gilroy J, Meyer JS. Compression of the subclavian artery as a
cause of ischemic brachial neuropathy. Brain. 1963;86:
733–745.
116. Neer CS II. Anterior acromioplasty for the chronic impinge-
ment syndrome in the shoulder: a preliminary report. J Bone
Joint Surg Am. 1972;54:41–50.
117. Neer CS. Impingement lesions. Clin Orthop Rel Res. 1983;173:
70–77.
118. Valadie AL, Jobe CM, Pink MM, et al. Anatomy of
provocative tests for impingement syndrome of the shoulder.
J Shoulder Elbow Surg. 2000;9:36–46.
119. Koester MC, George MS, Kuhn JE. Shoulder impingement
syndrome. Am J Med. 2005;118:452–455.
120. MacDonald PB, Clark P, Sutherland K. An analysis of the
diagnostic accuracy of the Hawkins and Neer subacromial
impingement signs. J Shoulder Elbow Surg. 2000;9:299–301.
121. McFarland EG, Hsu CY, Neira C, et al. Internal impingement
of the shoulder: a clinical and arthroscopic analysis. J Shoulder
Elbow Surg. 1999;8:458–460.
122. Myers JB, Laudner KG, Pasquale MR, et al. Glenohumeral
range of motion deficits and posterior shoulder tightness in
throwers with pathologic internal impingement. Am J Sports
Med. 2006;34:385–391.
123. Meister K, Buckley B, Batts J. The posterior impingement
sign: diagnosis of rotator cuff and posterior labral tears
secondary to internal impingement in overhand athletes. Am J
Orthop (Belle Mead NJ). 2004;33:412–415.
124. Tyler TF, Nicholas SJ, Roy T, et al. Quantification of
posterior capsule tightness and motion loss in patients with
shoulder impingement. Am J Sports Med. 2000;28:668–673.
125. Green A. Chronic massive rotator cuff tears: evaluation and
management. J Am Acad Orthop. 2003;11:321–331.
126. Gerber C, Krushell RJ. Isolated rupture of the tendon of the
subscapularis muscle. Clinical features in 16 cases. J Bone
Joint Surg Br. 1991;73:389–394.
127. Rigsby R, Sitler M, Kelly JD. Subscapularis tendon integrity:
an examination of shoulder index tests. J Athl Train. 2010;
45:404–406.
128. Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new
and sensitive test for diagnosing a subscapularis tear.
Arthroscopy. 2006;22:1076–1084.
129. Pennock AT, Pennington WW, Torry MR, et al. The influence
of arm and shoulder position on the bear-hug, belly-press, and
lift-off tests: an electromyographic study. Am J Sports Med.
2011;39:2338–2346.
130. Jobe FW, Moynes DR. Delineation of diagnostic criteria and
a rehabilitation program for rotator cuff injuries. Am J Sports
Med. 1982;10:336–339.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.
Anatomy and Physical Examination of the Shoulder
131. Holtby R, Razmjou H. Validity of the supraspinatus test
as a single clinical test in diagnosing patients with rotator
cuff pathology. J Orthop Sports Phys Ther. 2004;34:
194–200.
132. Leroux JL, Thomas E, Bonnel F, et al. Diagnostic value of
clinical tests for shoulder impingement syndrome. Rev Rhum
Engl Ed. 1995;62:423–428.
133. Gillooly JJ, Chidambaram R, Mok D. The lateral Jobe test: a
more reliable method of diagnosing rotator cuff tears. Int J
Shoulder Surg. 2010;4:41–43.
134. Bak K, Sørensen AK, Jørgensen U, et al. The value of
clinical tests in acute full-thickness tears of the supraspinatus
tendon: does a subacromial lidocaine injection help in the
clinical diagnosis? A prospective study. Arthroscopy. 2010;26:
734–742.
135. Hertel R, Ballmer FT, Lombert SM, et al. Lag signs in the
diagnosis of rotator cuff rupture. J Shoulder Elbow Surg.
1996;5:307–313.
136. Hurschler C, Wülker N, Windhagen H, et al. Evaluation of
the lag sign tests for external rotator function of the shoulder.
J Shoulder Elbow Surg. 2004;13:298–304.
137. Arthuis M. Obstetrical paralysis of the brachial plexus I.
diagnosis: clinical study of the initial period. Rev Chir Orthop
Reparatrice Appar Mot. 1972;58(suppl I):124–136.
138. Neer CS. Anatomy of shoulder reconstruction. In: Neer CS,
ed. Shoulder Reconstruction. Philadelphia: W.B. Saunders
Company; 1990:1–39.
139. Walch G, Boulahia A, Calderone S, et al. The ‘dropping’ and
‘hornblower’s’ signs in evaluation of rotator-cuff tears. J Bone
Joint Surg Br. 1998;80:624–628.
140. Liu SH, Henry MH, Nuccion SL. A prospective evaluation of
a new physical examination in predicting glenoid labral tears.
Am J Sports Med. 1996;24:721–725.
141. Stetson WB, Templin K. The crank test, the O’Brien test, and
routine magnetic resonance imaging scans in the diagnosis of
labral tears. Am J Sports Med. 2002;30:806–809.
142. O’Brien SJ, Pagnani MJ, Fealy S, et al. The active
compression test: a new and effective test for diagnosing
labral tears and acromioclavicular joint abnormality. Am J
Sports Med. 1998;26:610–613.
143. Kemp K, Sheps DM. Clinical tests to identify SLAP lesions: a
meta-analysis. Clin J Sport Med. 2009;19:339–340.
144. Walton DM, Sadi J. Identifying SLAP lesions: a meta-analysis
of clinical tests and exercise in clinical reasoning. Phys Ther
Sport. 2008;9:167–176.
145. Smits-Engelsman B, Klerks M, Kirby A. Beighton score:
a valid measure for generalized hypermobility in children.
J Pediatr. 2011;158:119–123.
146. Abrams JS. Special shoulder problems in the throwing athlete
(pathology, diagnosis, and nonoperative management). Clin
Sports Med. 1991;10:839–861.
147. Tzannes A, Paxinos A, Callanan M, et al. An assessment of
the interexaminer reliability of tests for shoulder instability.
J Shoulder Elbow Surg. 2004;13:18–23.
148. Tzannes A, Murrell GA. Clinical examination of the unstable
shoulder. Sports Med. 2002;32:447–457.
149. Gerber C, Ganz R. Clinical assessment of instability of the
shoulder. With special reference to anterior and posterior
drawer tests. J Bone Joint Surg Br. 1984;66:551–556.
150. Saha AK. The classic. Mechanism of shoulder movements and
a plea for the recognition of zero position of glenohumeral
joint. Clin Orthop Relat Res. 1983;173:3–10.
151. Díaz Heredia J, Ruiz Iban MA, et al. The posterior unstable
shoulder: natural history, clinical evaluation and imaging.
Open Orthop J. 2017;11:972–978.
152. Rowe CR, Zarins B. Recurrent transient subluxation of the
shoulder. J Bone Joint Surg Am. 1981;63:863–872.
153. Jobe FW, Kvitne RS, Giangarra CE. Shoulder pain in the
overhand or throwing athlete. The relationship of anterior
instability and rotator cuff impingement. Orthop Rev. 1989;
18:963–975. Erratum in: Orthop Rev. 1989;18:1268.
www.sportsmedarthro.com | e21
Bakhsh and Nicandri Sports Med Arthrosc Rev  Volume 26, Number 3, September 2018

154. Kumar K, Makandura M, Leong NJ, et al. Is the
apprehension test sufficient for the diagnosis of anterior
shoulder instability in young patients without magnetic
resonance imaging (MRI)? Ann Acad Med Singapore. 2015;
44:178–184.
155. Lizzio VA, Meta F, Fidai M, et al. Clinical evaluation and
physical exam findings in patients with ant shoulder insta-
bility. Curr Rev Musculoskelet Med. 2017;10:434–441.
156. Hegedus EJ, Cook C, Lewis J, et al. Combining orthopedic
special tests to improve diagnosis of shoulder pathology. Phys
Ther Sport. 2015;16:87–92.
157. Tallia AF, Cardone DA. Diagnostic and therapeutic injection
of the shoulder region. Am Fam Physician. 2003;67:
1271–1278.
158. Lee SW, Tiu T, Roberts J, et al. Point-of-care ultrasonography
findings and care use among patients undergoing ultrasound-
guided shoulder injections. Am J Phys Med Rehabil. 2018;
97:56–61.
159. Daley EL, Bajaj S, Bisson LJ, et al. Improving injection
accuracy of the elbow, knee, and shoulder: does injection site
and imaging make a difference? A systematic review. Am J
Sports Med. 2011;39:656–662.

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