1Department of Orthopedics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Korea
*Corresponding author: Suk-Woong Kang,
Department of Orthopedics, Research Institute for Convergence of Biomedical
Science and Technology, Pusan National University Yangsan Hospital, School of
Medicine, Pusan National University, 20 Geumo-ro, Mulgeum-eup, Yangsan 50612,
Korea, E-mail: redmaniak@naver.com
• Received: November 16, 2024 • Revised: December 25, 2024 • Accepted: January 9, 2025
This is an Open-Access article distributed under the terms of the
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Shoulder pain is a common complaint in primary care settings. The prevalence of
shoulder pain is on the rise, especially in societies with aging populations.
Like other joint-related conditions, shoulder pain is predominantly caused by
degenerative diseases. These degenerative changes typically affect bones,
tendons, and cartilage, with common conditions including degenerative rotator
cuff tears, impingement syndrome, and osteoarthritis. Diagnosing these
degenerative diseases in older adults requires a thorough understanding of basic
anatomy, general physical examination techniques, and specific diagnostic tests.
This review aims to outline the fundamental physical examination methods for
diagnosing shoulder pain in older adult patients in primary care. The
shoulder's complex anatomy and its broad range of motion underscore the
need for a systematic approach to evaluation. Routine inspection and palpation
can identify signs such as muscle atrophy, bony protrusions, or indications of
degenerative changes. Assessing range of motion, and distinguishing between
active and passive deficits, is crucial for differentiating conditions like
frozen shoulder from rotator cuff tears. Targeted strength tests, such as the
empty can, external rotation lag, liftoff, and belly press tests, are
instrumental in isolating specific rotator cuff muscles. Additionally,
impingement tests, including Neer’s and Hawkins’ signs, are useful
for detecting subacromial impingement. A comprehensive understanding of shoulder
anatomy and a systematic physical examination are vital for accurately
diagnosing shoulder pain in older adults. When properly executed and interpreted
in the clinical context, these maneuvers help differentiate between various
conditions, ranging from degenerative changes to rotator cuff pathology.
Shoulder pain is the third most common musculoskeletal complaint, following back
and knee pain [1]. A systematic review
revealed that the prevalence of shoulder pain in the community varies widely,
with a median of 16% (ranging from 0.67% to 55.2%). In primary care settings,
prevalence estimates range from 1.01% to 4.84%, with a median of 2.36%. The
incidence of shoulder pain varies from 7.7 to 62 per 1,000 persons annually,
with a median of 37.8 per 1,000 persons per year [2]. The prevalence of shoulder pain differs across age groups, with
significant increases noted in older populations. A systematic review that
focused on occupational groups found that 16 out of 21 studies reported higher
prevalence estimates or odds ratios for shoulder pain in individuals over the
age of 50. This trend was more evident in physically demanding occupations,
where 14 out of 18 samples indicated an increased prevalence in those over 50
years old, compared to only two out of four in sedentary occupations [3].
In South Korea, data from 2011 to 2020 indicated a significant increase in
shoulder lesions among individuals aged 60–69 years, underscoring the
rising prevalence of shoulder pain within this demographic [4]. Kim et al. [5] recently carried out a study involving participants aged
40 years or older from a specific city. Their findings from a survey of 30
bilateral shoulders revealed that about 65% of individuals aged 60 years or
older reported experiencing shoulder pain. Furthermore, the incidence of
associated rotator cuff disease was significantly higher in this age group
compared to those under 60 years (P=0.006).
Age is a critical demographic factor in the context of shoulder pain. Younger
individuals exhibit a higher prevalence of traumatic dislocations and labral
injuries, whereas older adults more frequently experience degenerative wear of
the shoulder joint, along with tears in the rotator cuff tendons [6–8].
Objectives
The purpose of this review was to examine the basic approaches for diagnosing
shoulder pain in older adult patients. It assessed the physical examination
techniques used to evaluate shoulder pain.
Ethics statement
As this study is a literature review, it did not require institutional review board
approval or individual consent. Supplementary video files were provided by the
authors as examinee and examiner.
Anatomy
To understand shoulder disorders, it is essential to have a basic knowledge of
shoulder anatomy. The shoulder is one of the most complex joints in the human body
and enables a wide range of movements that are crucial for everyday activities.
The shoulder comprises three bones: the clavicle, scapula, and humeral head.
Together, these bones form the glenohumeral, sternoclavicular, acromioclavicular,
and scapulothoracic joints. The primary shoulder joint, the glenohumeral joint, is a
ball-and-socket type located between the humeral head and the glenoid cavity.
However, only 25% of the humeral head articulates with the glenoid cavity [9]. This joint is inherently unstable yet allows
for a broad range of motion (ROM). Adding stability to the shoulder, the
labrum—a layer of fibrocartilage—envelops the glenoid rim [10].
The shoulder is surrounded by several key muscles that not only contribute to its
extensive ROM but also provide stability to the joints. These muscles include the
deltoid, trapezius, pectoralis major, latissimus dorsi, biceps, triceps, and rotator
cuff. They work in concert to facilitate a wide range of movements and stabilize
this highly mobile joint, thus protecting the shoulder from injury [11]. The rotator cuff muscles, comprising the
supraspinatus, infraspinatus, teres minor, and subscapularis, are crucial for normal
shoulder function. Injuries to these muscles or their tendons can severely impair
movement and cause significant pain. These muscles are interconnected by tendons
that merge to form the rotator cuff tendon. This tendon complex encircles the head
of the humerus, enabling the arm to perform a wide range of movements across various
planes while maintaining the stability of the shoulder joint [12]. The supraspinatus muscle, originating from the
supraspinatus fossa of the scapula, inserts into the greater tubercle of the
humerus. Its primary functions are to initiate arm abduction and stabilize the
humeral head within the glenoid cavity. The infraspinatus muscle arises from the
infraspinous fossa of the scapula and also attaches to the greater tubercle of the
humerus. Positioned just below the infraspinatus, the teres minor muscle originates
from the lateral border of the scapula and inserts near the infraspinatus on the
greater tubercle of the humerus. Both the infraspinatus and teres minor muscles aid
in the external rotation of the arm. The subscapularis muscle, located on the
anterior side of the scapula, occupies the subscapular fossa and attaches to the
lesser tubercle of the humerus. This muscle facilitates the internal rotation of the
arm [13].
Physical examination
The physical examination of the shoulder starts with taking the patient's
history, followed by inspection, palpation, assessment of ROM, muscle strength
testing, and provocative tests for specific conditions. It is essential to obtain a
detailed medical history to guide further testing and imaging. Typically, inquiries
should cover the patient's age, the duration and quality of the pain,
associated symptoms, and factors that aggravate or relieve the pain [14].
Shoulder pain is frequently associated with occupational factors; thus, the duration
of employment, working posture, and hours worked are significant considerations.
With the growing interest in leisure sports among older adults, it is crucial to
gather a detailed history that includes the types of sports they engage in and
whether they experience pain during these activities. Furthermore, for older
patients, it is equally important to document a treatment history for concurrent
conditions like diabetes, chronic kidney disease, and rheumatic diseases, which can
contribute to shoulder pain [15].
Inspection
Patient inspection should be conducted with both the affected and unaffected
extremities fully exposed. The examination should encompass both anterior and
posterior views to detect any muscle asymmetry or abnormal bony prominences.
Bilateral examination of the deltoid, supraspinatus, and infraspinatus fossae
for atrophy is essential [16]. If muscle
atrophy is significant, further evaluation should be undertaken, including an
assessment for shoulder pathology, to ascertain the presence of any neurological
issues [17,18].
Rupture of the long head of the biceps tendon (LHBT) can occur either
traumatically or spontaneously in older adults, often resulting in a noticeable
bulge in the upper arm, known as the Pop eye sign [19].
Degenerative arthritis commonly affects the sternoclavicular and
acromioclavicular joints in the shoulders of older adults, often resulting in
bony protrusions [20,21]. Additionally, patients with massive
rotator cuff tears may experience anterior protrusion of the humeral head into
the shoulder joints [22]. The position of
the scapula was observed from the patient's back. The differential
diagnosis should consider both the static position and the dynamic motion of the
scapula [23].
Palpation
Palpation, combined with visual inspection, plays a crucial role in the initial
physical examination. It is essential to accurately identify the specific
location of any local tenderness. This helps in predicting the disease based on
its anatomical location and facilitates preparation for further evaluation.
In degenerative arthritis of the sternoclavicular and glenohumeral joints, it is
essential to palpate the articular processes to assess tenderness, bony
prominences, and swelling [20,21]. Rotator cuff disease is the most
prevalent condition among shoulder diseases, with the supraspinatus tendon
frequently affected, especially in cases of rotator cuff pathology. Precise
palpation is key for diagnosing issues such as tendinitis, tears, or impingement
[24]. To palpate the supraspinatus
tendon, one must identify the attachment site and the greater tuberosity area.
The patient's arm should be placed in slight extension (moving the arm
slightly behind the body) and internal rotation (turning the hand toward the
body), which moves the supraspinatus tendon anteriorly. The supraspinatus tendon
and greater tuberosity can then be palpated just anterior and slightly lateral
to the acromion [25]. The subscapularis
tendon, part of the rotator cuff, is located on the anterior aspect of the
shoulder. To palpate the subscapularis and its attachment site (the lesser
tuberosity), the patient's arm should be externally rotated with the
elbow flexed at 90°. This maneuver lengthens the subscapularis tendon and
brings it to a more superficial position [26]. The LHBT runs through the bicipital groove on the anterior
aspect of the humerus and is commonly affected by tendinitis, instability, or
rupture. The biceps groove, housing the LHBT, is situated between the greater
and lesser tubercles of the humerus. To palpate the bicep groove, place the
patient’s arm in neutral rotation with the elbow flexed to 90°.
Slightly outward rotation of the arm (turning the forearm outward) will better
expose the tendon. The bicep groove can be palpated 2–3 cm inferior to
the anterior border of the acromion [27].
Range of motion assessment
As a ball-and-socket joint, the shoulder facilitates an extensive ROM across
multiple planes [9,10]. Proper evaluation of ROM is essential for assessing
function, identifying limitations, and diagnosing various conditions. Typically,
ROM measurements include forward flexion, extension, abduction, external
rotation, and internal rotation. These measurements can be taken while the
patient is sitting, standing, or lying supine. The sitting position is
particularly convenient for simultaneously conducting other muscle tests and
provocative tests. However, it is crucial to stabilize the scapula to accurately
measure the true ROM of the glenohumeral joint. Additionally, ROM measurements
should be compared with those of the unaffected side, as the normal range varies
from person to person and with age [28].
Assessment of shoulder ROM should encompass both active (unassisted) and passive
(assisted by the examiner) movements. A loss of both may indicate a stiff
shoulder, such as frozen shoulder or secondary stiff shoulder, whereas a loss of
active ROM alone suggests shoulder weakness, potentially due to a rotator cuff
tear or neurologic dysfunction. Disease-specific tests and imaging evaluations
should be tailored to each specific symptom [29]. A video of the ROM assessment of shoulder joints is available
in Supplement 1.
Muscle strength testing and provocative tests
Shoulder strength assessment is a crucial part of physical examinations, offering
insights into muscle function that can assist in diagnosing rotator cuff
disorders [22]. It is essential to
understand the function of each tendon in the rotator cuff and to conduct muscle
strength and provocation tests accordingly. These muscle tests should be carried
out on both the affected and unaffected sides.
Supraspinatus
The supraspinatus is assessed using both the empty can test (Jobe's test)
and the full can test [30]. The empty can
test involved abducting the arm to 90°, internally rotating the forearm,
and orienting the thumb downward. A positive result, indicating pain or
weakness, is noted when the examiner exerted downward pressure on the arm.
Conversely, the full can test is conducted in a similar arm position but with
the forearm externally rotated and the thumb pointing upward, while the examiner
applied force. The tests demonstrate the highest accuracy in detecting a torn
supraspinatus tendon when muscle weakness is present, with the full can test
showing 75% accuracy and the empty can test showing 70% accuracy [30]. Both tests have proven to be highly
sensitive and specific, making them suitable for both screening and confirming
rotator cuff tears that involve the supraspinatus. A video of the empty can test
(Jobe's test), and the full can test for supraspinatus muscle strength is
available in Supplement
2.
Infraspinatus and teres minor
The infraspinatus and teres minor muscles serve as external rotators of the arm.
To assess external rotational strength, the patient holds their arm at their
side with the elbow bent at 90°. The examiner then applies inward
pressure as the patient resists by rotating the arm externally [31]. The external rotation lag sign is a
diagnostic test for the shoulder, useful in identifying tears in the
infraspinatus and supraspinatus tendons. This sign is considered positive if,
after the examiner maximally externally rotates the arm—with the shoulder
flexed at 20° and the elbow at 90°—the patient is unable to
keep the arm in this position. With a specificity of 94%, a positive external
rotation lag sign reliably indicates full-thickness tears of both the
supraspinatus and infraspinatus tendons [32]. The Hornblower test is another clinical examination that
evaluates the function and strength of the infraspinatus and teres minor
muscles. During this test, the patient's arm is passively abducted and
supported by the examiner with the elbow flexed at 90°. A positive result
occurs if the patient cannot maintain external rotation of the arm. Given that
both the infraspinatus and teres minor contribute to external rotation of the
humerus, identifying weakness in these muscles can be challenging through
physical examination alone [17]. A video
of the external rotation lag sign and Hornblower test is available in Supplement 3.
Subscapularis
The subscapularis tendon plays a crucial role in the internal rotation of the
shoulder. To assess its integrity, strength, and function, four clinical tests
are conducted. Initially, the liftoff test (Gerber test) is performed. This
involves the patient flexing their elbow, internally rotating their arm, and
placing their hand on the lumbar spine. A positive result is indicated by the
patient's inability to lift the back of their hand away from the body.
Next, the belly press test (Napoleon sign) is administered. For this test, the
patient places their hand on their abdomen with the arm internally rotated and
the elbow flexed, keeping the wrist in a neutral position. A positive result is
noted if the patient cannot maintain the elbow in a forward position or keep the
wrist neutral while pressing against the abdomen. The third test conducted is
the bear-hug test. The patient positions their elbow at shoulder height and
places their hands on the opposite shoulder. The examiner then attempts to pull
the patient's hand away from the shoulder while the patient resists. A
positive result is recorded if the patient cannot maintain their hand on the
shoulder. The fourth assessment is the internal rotation lag sign. In this test,
the examiner positions the patient’s arm behind their back in internal
rotation and lifts their hand off the back. If the patient is unable to hold the
position and the hand falls back, it suggests weakness or a tear in the
subscapularis [32–34]. Videos demonstrating the liftoff test
(Gerber test) and the internal rotation lag sign, which assess the strength of
the subscapularis tendon, are available in Supplement 4.
Additionally, a video of the belly press test (Napoleon sign) for evaluating the
strength of the subscapularis tendon can be found in Supplement 5.
Impingement test
Impingement occurs when the soft tissues—specifically the subacromial
bursa, supraspinatus tendon, and biceps tendon—within the subacromial
space become chronically trapped between the humeral head and the acromion
[35]. This condition leads to
progressive degenerative changes in the hypovascular region of the rotator cuff.
A thorough medical history and physical examination are crucial for diagnosing
shoulder impingement syndrome. Patients typically report pain or discomfort when
lifting the arm or at specific points of impingement. Special tests are integral
to the physical examination process. Initially, the Hawkins test is conducted by
passively internally rotating the patient's arm, flexing the shoulder to
90 degrees forward, and flexing the elbow. The presence of acromial pain
indicates subacromial impingement [36].
Next, the Neer sign test involves fixing the scapula in a depressed position and
having the examiner maximally flex the patient’s arm forward (passive ROM
testing). Pain localized to the anterior aspect of the shoulder suggests
impingement syndrome [36]. Additionally,
the Painful arc sign is identified by pain occurring as the elbow is fully
extended and abducted between 60° and 120° in the scapular plane,
which indicates a pathology in the subacromial space [37]. Lastly, the Jobe test, also known as the empty-can
test, is positive for impingement syndrome and supraspinatus lesions [37]. Although these tests individually have
low sensitivity and specificity, when used collectively, they can provide a more
comprehensive assessment of shoulder impingement syndrome. A video file of the
Neer sign test and Hawkins test for checking impingement of the shoulder joint
is available in Supplement
6.
Osteoarthritis of the glenohumeral joint
Osteoarthritis is a degenerative disease whose prevalence increases with age. It
is a significant cause of physical disability and often severely impairs the
quality of life in older adults [38]. In
a study of a Korean population, Cho [39]
reported that approximately 5% of patients over 65 years of age had shoulder
arthritis of Kellgren-Lawrence grade 2 or higher. In addition, Oh [8] reported prevalence rates of 11.3% for
Samilson-Prieto grade 1, 3.4% for grade 2, and 1.3% for grade 3. In general,
patients with glenohumeral joint osteoarthritis present with decreased ROM
accompanied by crepitus as their main symptom. Osteoarthritis often manifests as
a secondary stiff shoulder, characterized by reduced passive and active ranges
of motion. Assessment of tenderness is conducted along the joint line, and
palpation is used to check for swelling and effusion along the joint surface
[40].
Acromioclavicular joint disease
Acromioclavicular (AC) joint disease encompasses a range of conditions affecting
the joint between the clavicle and the acromion of the scapula. These conditions
include degenerative changes such as osteoarthritis and traumatic injuries like
dislocation or separation. AC joint arthritis is the predominant cause of
shoulder pain in middle-aged individuals, primarily due to the degeneration of
cartilage and the intraarticular disc [41]. Primary osteoarthritis of the AC joint appears to be associated
with normal age-related damage and subsequent loss of protective cartilage,
causing painful bone-on-bone contact [42]. Although most patients do not exhibit symptoms, some may experience
pain around the AC joint during daily activities, particularly during overhead
or crossbody movements [43]. The physical
examination for AC joint disease starts with observing any joint asymmetry
through palpation and assessing the area for tenderness. The cross-body
adduction test is highly effective for diagnosing AC joint pathology. During
this test, the examiner stands in front of the patient, lifts the
patient's arm to 90 degrees forward, holds the elbow, and adducts the
shoulder across the body. This maneuver typically provokes pain around the AC
joint, indicating potential pathology [42]. Another diagnostic tool is the O’Brien active compression
test, where the examiner stands behind the patient. The patient flexes their arm
forward to 90 degrees with the elbow fully extended, then adducts the arm
10° to 15° with internal rotation, thumb pointing downward. The
examiner applies a downward force against the patient’s resistance. The
test is repeated with the palms fully supinated. A positive result—pain
during the first maneuver that disappears in the second—confirms the
diagnosis if the pain is localized to the AC joint [44]. Tenderness on palpation of the AC joint, which seems
to be the easiest and most effective method, has been recommended as a screening
test for AC joint disease due to its high sensitivity (96%) [45,46].
Conclusion
The shoulder is a crucial joint that facilitates a broad spectrum of activities due
to its extensive ROM. Shoulder pain can originate from various anatomical
structures, including cartilage, ligaments, tendons, and bones. A deep understanding
of these structures is essential for conducting precise physical examinations of the
shoulder. By performing a comprehensive physical examination and utilizing
appropriate imaging studies, the underlying causes of shoulder pain can be
effectively analyzed.
Authors' contributions
Project administration: Kang SW
Conceptualization: Kang S, Kang SW
Methodology & data curation: Kang S, Kang SW
Funding acquisition: Kang SW
Writing – original draft: Kang S, Kang SW
Writing – review & editing: Kang S, Kang SW
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Funding
This research was supported by a 2024 Research Grant from Pusan National
University Yangsan Hospital.
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