The scapula–spine distance, elbow extension test, elbow push test, subacromial impingement tests, and manual muscle tests of shoulder abduction, external rotation, and internal rotation are assessed while the subject is sitting. Patients are supine for the combined abduction test, horizontal flexion test, capsular laxity tests, and hyper-external rotation test.

In the scapula–spine distance test, the distance from the medial edge of the scapular spine to the spinous process of the thoracic spine is measured with the arms at the sides (Fig. 9.2). The reference point on the thoracic spine is defined as the nearest spinous process. A difference of more than 1.0 cm between the left and right sides is considered abnormal. To assess the scapular stabilizers, the elbow extension test and elbow push test are performed with the shoulders in 90° of forward flexion (Figs. 9.3 and 9.4). For the elbow extension test, the subject extends the elbow joint from 90° of flexion by using maximum force, while the examiner holds the subject’s forearm to resist his extension force (Fig. 9.3). For the elbow push test, while grabbing the contralateral elbow with each hand, the subject pushes each elbow in turn anteriorly with maximum force as the examiner resists his pushing by holding the elbow (Fig. 9.4). Muscle strength is evaluated by manual muscle testing on a scale of 0–5. We assess the muscle strength of shoulder abduction with the subject’s thumb up; this is known as the “full can position” [20, 25]. We measure external rotation strength with the subject’s arm at his side [9]. To assess internal rotation strength, we record the subject’s strength in lifting his hand off his back [12]. We consider the results of the elbow extension test, elbow push test, and manual muscle tests of abduction, external rotation, and internal rotation to be abnormal when the muscle strength on the dominant side is less than that on the nondominant side. To assess the posterior tightness of the shoulder joint, subjects perform the combined abduction test and horizontal flexion test while the examiner fix the scapula and prevent it from moving by holding it. The humerus is passively abducted in the coronal plane for the combined abduction test (Fig. 9.5) and horizontally flexed for the horizontal flexion test (Fig. 9.6). If the subject’s upper arm fails to touch his head during glenohumeral abduction with a fixed scapula, the combined abduction test is graded as abnormal. The horizontal flexion test is considered abnormal when the subject is unable to reach around the other shoulder to touch the bed during horizontal flexion with a fixed scapula. Capsular laxity is evaluated by load-and-shift testing in the anterior, posterior, and inferior directions; anterior apprehension and relocation tests are also done. When the dominant side shows increased laxity or when the subject feels that the shoulder is unstable during any test, capsular laxity is considered abnormal. To evaluate subacromial impingement, we perform the Neer [31], Hawkins [14], and Yocum tests [24]. If the subject feels shoulder pain during any of these tests, subacromial impingement testing is graded as abnormal. The hyper-external rotation test (Fig. 9.7), which evaluates peel back of the superior labrum [4, 27, 28] and pathologic internal impingement [18, 26, 47], is performed in 90° of shoulder abduction with the elbow flexed at 90° in the supine position. The test is considered to be abnormal when a subject feels pain as the examiner applied external rotation torque beyond the maximum external rotation position. The number of “intact” results among the 11 physical examinations is recorded as the total Hara test score for each subject. The maximum total score (11 points) represents all “intact” results (i.e., no abnormality found) for all tests; subjects with lower scores are considered likely to have a problem in the upper-extremity kinetic chain.