Overview of Shoulder Assessment

Original Editor - Lenie Jacobs based on the course by Shala Cunningham
Top Contributors - Lenie Jacobs, Jess Bell, Kim Jackson and Wanda van Niekerk

Introduction

A significant number of people around the world experience shoulder pain in their lifetime. It is the third most common musculoskeletal presentation in primary healthcare settings. The shoulder girdle is a complex structure consisting of four joints, many muscles, tendons, ligaments and bursae. Conducting an effective subjective and objective assessment, which considers the complexities of this region is, therefore, essential. This page provides an overview of the key features of this evaluation.

Subjective Assessment

The mnemonic L-M-N-O-P-Q-R-S-T outlines the essential areas to address in a patient's history.

L: location of symptoms and level of functional impairment

The location of symptoms can help clinicians formulate a potential diagnosis. The following list highlights pain locations and potential causes of discomfort. Please note that this list is not exhaustive:

• acromioclavicular (AC) joint pain: AC joint injury or arthritis
• superficial pain near the acromion: subacromial impingement / subacromial pain etc.
• lateral arm pain: supraspinatus insertion / frozen shoulder
• deep pain: arthritis
• deep pain with clicking: labrum
• pain radiating below the elbow: cervical spine pathology

You should also consider how a patient's pain impacts their capacity to engage in daily activities, work, school, and sports.

M: medical factors (medications) and mechanism of injury

You should screen patients for cardiac, respiratory, and upper gastrointestinal issues as potential sources of referred pain and identify the medications a patient is taking, including supplements, and any co-morbidities.

Consider the following questions to establish the mechanism of injury:

• when and how did the injury happen?
• what forces were involved?
• was there a direct blow to the shoulder?
• what position was the patient's hand in at the time of injury?
• did the patient fall on an outstretched hand?
• did the patient injure their neck?

Red flags: pain without any specific injury, symptoms linked to cardiovascular activity, and a medical history of heart disease.

N: neurological symptoms

Neurological symptoms can include numbness, tingling, paraesthesias, or sharp, burning pain radiating down the arm.

When these symptoms appear, find out if they are constant or intermittent and if they follow a dermatomal or peripheral nerve pattern. Determine if symptoms are linked to neck, shoulder, or elbow positions or movements.

O: occupation, including limitations

Are there any work-related or activity-related factors to consider? Could there be overuse? Does the patient engage in repetitive tasks? Do they perform any overhead activities?

P: palliating and provoking symptoms

Identify what triggers or exacerbates symptoms and determine how long it takes for symptoms to subside after being triggered. Are symptoms associated with overhead or throwing activities?

Red flags: persistent and relentless symptoms.

Q: quality of symptoms/pain

Determine if the symptoms are sharp, dull, stabbing, aching, or like an electric shock, and check for numbness, tingling, or weakness / clumsiness.

R: radiation of symptoms

Consider the following questions:

• where do the symptoms spread to?
• are radiating symptoms triggered by activities or position?
• how long do radiating symptoms last?

Red flag: symptoms spreading across multiple dermatomes (ensure you check peripheral nerve sensory patterns if more than one dermatome is involved).

S: severity of symptoms

Scales like the Visual Analogue Scale or the Numeric Pain Rating Scale are useful. Also, assess how symptoms impact function and activities. Does the patient need to adjust or cease activities due to symptoms?

Red flags: abrupt onset of severe pain without any incident or accident occurring.

T: timing of symptoms

Determine when symptoms appear during the day and how they relate to physical activities / movement.

Red flag: pain that interrupts sleep or is worse at night. Constant pain.

Systems review

Ask about:

• general symptoms (e.g. fatigue, breathlessness)
• cardiovascular risk factors and symptoms (chest pain)
• upper gastrointestinal symptoms (e.g. do they experience any change in symptoms with eating?)

Self-Assessment Questionnaires for Shoulder Pain

• Disabilities of the Arm, Shoulder, and Hand (DASH)
• Oxford Shoulder Score

Observation

Ensure you examine the entire upper quarter (neck, shoulder, elbow, wrist, and hand) and compare both sides. Key points at the shoulder:

• observe the position of the scapula, the dominant shoulder might be lower
• look at the acromioclavicular joint position - is there a step-off / step deformity?
• keep an eye out for any assymetry, alterations in soft tissue, redness / discolouration, swelling, bruising or muscle atrophy

Scapular Assessment

It is important to conduct a static and dynamic assessment of the scapula.

Static Assessment

Key points to check for during the static assessment are:

• scapular winging
  • winging of the medial border of the scapula is associated with serratus anterior weakness, which is often caused by long thoracic nerve palsy
• atrophy in the supraspinatus and infraspinatus fossae
• scapular protraction, retraction, elevation or depression

Remember to assess posture and shoulder position from a posterior, anterior and lateral view.

Dynamic Assessment

Scapular dyskinesia (SD) has been defined as: "alterations in scapular positioning at rest as well as during dynamic movement". Movement variations include: increased superior translation of the scapula with reduced posterior tilt of the scapula, upward rotation, and internal rotation.

The following dynamic tests can be used to assess for scapular dyskinesia:

• scapular dyskinesis test

• scapular reposition test (see video below)

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• scapular flip test (see video below)

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• scapular assist test

Please note that there is debate in the literature about how much scapular dyskinesia relates to shoulder pathology.

Functional Screen

Include the cervical and thoracic spine and shoulder in the functional screen:

• changes in symptoms with cervical range of motion might indicate cervical pathology
• pain with shoulder elevation could indicate subacromial pain / impingement, bursitis, rotator cuff related shoulder pain / tendinopathy, or a supraspinatus tear
• if a patient has difficulty reaching behind their back, consider adhesive capsulitis or rotator cuff pathology
• difficulty with horizontal adduction might indicate acriomioclavicular, sternoclavicular, or clavicular pathology

Table 1 below lists movements to include during your functional screen of the shoulder.

Table 1. Functional screening of the shoulder

Area	Movement
Cervical spine	Flexion (chin to chest) Extension Rotation (is it symmetrical?) Side bend
Shoulder – look for symmetry of movement	Hug: horizontal adduction (is this provocative) Extension with internal rotation (hand behind back reaching for opposite shoulder blade) Flexion with external rotation (hand reaching to opposite shoulder blade)
Thoracic spine	Flexion Extension Rotation

Palpation

Key palpation points for the shoulder are listed in Table 2.

Table 2. Key palpation points for the shoulder

Types of structures	Specific areas to palpate
Bony points and joints	Acromioclavicular joint Greater and lesser tuberosities Coracoid process Acromion Sternoclavicular joint Medial scapula Cervical spinous process Spine of scapula
Muscles	Long head of biceps Supraspinatus Infraspinatus Subscapularis Teres minor Teres major
Other	Axilla - look for lymph nodes/masses

Please watch the following optional video if you would like to learn more about palpation of the shoulder.

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Range of Motion

When assessing active and passive shoulder range of motion (ROM), consider both the quantity and the quality of the movement. Look out for a painful arc (i.e. pain between 60-120 degrees of shoulder elevation) or if pain is only present at the end range. Consider the following questions:

• where is the pain located?
• is the movement coordinated?
• are there any compensations?

Also, observe scapular movements with ROM (i.e. scapulohumeral rhythm). Is this movement smooth and coordinated? What thoracic movement occurs?

If you would like to learn more about scapulohumeral rhythm, please see: Scapulohumeral Rhythm.

Remeber that shoulder range of motion varies in different populations:

• males have greater mean active shoulder flexion and abduction while females have increased active external rotation
• mean ROM decreases with age
• mean ROM in all planes is reduced in individuals with diabetes
• average shoulder range of motion on the dominant side is higher than the non-dominant side, but individuals who are right-hand dominant have a lower average range of motion than people who are left-hand dominant

Table 3 shows normative values for shoulder range of motion and typical end feels. However, figures for normal range of motion vary in the literature. Where possible, use the unaffected side as a comparison for the affected side.

Table 3. Shoulder range of motion

Movement	Range of motion	Typical end feel
Flexion	180° (involves scapular movement) values given in the literature vary from 157.1-161.5°	Firm
Extension	50° (active) 60° (passive)	Firm
Abduction	30-50° (active)	Firm
Internal rotation	90° (active) 100° (passive)	Firm
External rotation	90° (active) values given in the literature range from 55-60.9°	Firm

For more information on the range of motion assessment, please see Assessing Range of Motion.

Resisted Testing

Specific points to remember for the shoulder:

• internal rotation is stronger than external rotation: 3:2 ratio
• adduction is stronger than abduction: 2:1 ratio
• extension is stronger than flexion: 5:4 ratio

For more information on the strength assessment, please see Assessing Muscle Strength.

Neurovascular Testing

You should screen the upper quarter during your neurovascular assessment, including dermatomes, myotomes, and reflexes. More information on the neurological screen is available here.

Be sure to consider the peripheral nerves. If a single nerve root is affected, you may notice a slight difference in strength between sides. However, a peripheral nerve lesion usually causes significant weakness because the entire muscle loses its innervation. Please see Table 4 for a list of relevant peripheral nerve tests for the shoulder.

Table 4. Peripheral nerve tests

Nerve	Innervation	Action
Spinal accessory nerve	Sternocleidomastoid Upper trapezius	Inability to abduct the arm more than 90°
Musculocutaneous nerve	Biceps Brachialis Coracobrachilais	Weak elbow flexion with forearm supination
Long thoracic nerve	Serratus anterior	Inability to flex a fully extended arm (scapular winging)
Suprascapular nerve	Supraspinatus Infraspinatus	Pain with shoulder flexion and/or abduction
Axillary nerve	Teres minor Deltoid	Inability to abduct the arm

Accessory Movements and Joint Mobility Testing

• Open pack position of the shoulder: 55° abduction with 30° horizontal adduction and slight external rotation (scaption plane)

• Closed pack position of the shoulder: maximal abduction and external rotation
• Capsular pattern of the glenohumeral joint: external rotation is most limited, followed by abduction and internal rotation

Accessory Movements of the Shoulder

Table 7 indicates which accessory movements you can assess at the shoulder.

Table 7. Accessory movements of the shoulder

Joint	Movement
Glenohumeral joint	Lateral distraction - all motions Inferior glide - abduction Anterior glide - external rotation, horizontal abduction Posterior glide - flexion, horizontal adduction
Scapula	Distraction Upward rotation Downward rotation
Sternoclavicular joint	Posterior glide - retraction Anterior glide - protraction Inferior glide -  elevation Superior glide -  depression

Common Shoulder Conditions and Special Tests

Shoulder Instability

The glenohumeral joint is our most mobile joint. It relies on static and dynamic structures to provide stability and mobility in multiple planes.

Because of its mobility, the shoulder is more prone to dislocation and subluxation than other joints. Shoulder instability is relatively common, particularly in young athletes who play contact sports. It can be caused by trauma, repetitive microtrauma or generalised joint laxity.

Types of shoulder instability:

• anterior: most common type; typically develops from trauma in abduction and external rotation (e.g., overhead throwing, falls on outstretched arm) → predisposes to anterior dislocation
• posterior: develops from repeated trauma in flexion, adduction and internal rotation → predisposes to posterior dislocation
• multidirectional: usually insidious onset with non-specific pain on activity

Patients with shoulder instability often report: frequent dislocation, joint instability and pain during activities. They might note a sense of slipping, feeling unstable or anxious in certain positions.

Common tests for shoulder instability include the following:

• test cluster (for anterior instability):
  • apprehension test
  • relocation test
  • release (surprise) test
• load and shift test (for anterior and posterior shoulder instability)
• jerk test (posteroinferior instability)
• posterior apprehension test (for posterior glenohumeral instability)
• sulcus sign (for inferior glenohumeral instability)

If you would like to learn more, please see: Shoulder Instability.

Labral Tear

The glenoid labrum is a fibrocartilaginous structure in the shoulder joint. It helps to anchor the joint capsule and shoulder ligaments, and it deepens and increases the surface areas of the glenoid. It is frequently injured, either as a result of a single trauma or repeated trauma. Causes of labral tear include: a fall on an outstretched arm or shoulder, bracing with an outstretched arm in a motor vehicle accident, lifting heavy objects repeatedly, and engaging in overhead activities.

Sypmtoms associated with labral tears include: popping, clicking, or catching in the shoulder, pain with overhead activities or throwing a ball, a feeling of weakness or instability in the shoulder, and an aching pain of vague location.

Injuries are categorised based on their position: superior, anterior and / or posterior. Injuries can be isolated to one area or combined. Combined injuries occur nearly twice as often as isolated injuries:

• superior labrum: SLAP (superior labral anterior posterior) lesions are the most frequent superior labrum injury. There are eight types of SLAP tears.
• anterior labrum: a rare injury linked with a medial glenohumeral ligament tear.
• posterior labrum: less common than anterior tears.
• anteroinferior labrum: usually occurs in shoulders where there is acute or chronic anterior instability. Injury types include: Bankart lesion; Perthes lesion; glenolabral articular disruption lesion (GLAD); anterior labroligamentous periosteal sleeve avulsion lesion (ALPSA).
• posterior and posteroinferior labrum: relatively rare and associated with posterior instability. They include reverse Bankart lesion, Kim's lesion, posterior GLAD and posterior labrocapsular periosteal sleeve avulsion lesion (POLPSA).
• circumferential labral lesion: can occur in unstable shoulders.

"The most frequent lesions are SLAP type-II in stable shoulder and Bankart lesion in unstable shoulder."

Clinical tests for labral tears include:

• compression rotation test (for SLAP lesions)
• anterior slide test (for SLAP lesions)
• crank test (for glenoid labral tears / unstable SLAP lesions)
• active compression test or O'Brien's test (for SLAP lesions)
• biceps load test I (for SLAP lesions)
• biceps load test II (for SLAP lesions)
• Kim test (for posteroinferior labral lesions)

Subacromial Impingement Syndrome / Subacromial Pain Syndrome

Charles Neer coined the term subacromial impingement syndrome in 1972. Early research on subacromial impingement syndrome tended to describe impingement as a specific pathology or diagnosis. Neer created three categories of impingement:

• stage 1: impingement from oedema, haemorrhage or both; typically associated with overuse
• stage 2: greater fibrosis and irreversible tendon changes
• stage 3: tendon rupture or tear can occur from chronic, ongoing fibrosis

However, our understanding of this condition has evolved and impingement has been labelled as "a cluster of symptoms, rather than a pathology itself."

Impingement is an "umbrella" term that "encompasses a number of pathoanatomic alterations in patients with similar clinical presentation."

Cools et al. note that two types of impingement have been described:

• subacromial (external)
  • "the mechanical encroachment of the soft tissue (bursa, rotator cuff tendons) in the subacromial space"
  • tends to occur in mid-range (painful arc)
• internal
  • "encroachment of the rotator cuff tendons between the humeral head and the glenoid rim"
  • the impingement may be anterosuperior or posterosuperior

Impingement can also be described as primary or secondary.

It can be difficult to describe subacromial impingement symptoms because the cause of the pain can vary. However, some presenting signs include pain that impacts everyday activities, pain reaching behind the back, pain with overhead activities and weakness of the shoulder muscles.

Other terminology has been suggested instead of subacromial impingement, including:

• subacromial pain syndrome: it has, however, been argued that this term is problematic as it "refers to an anatomical location that is not readily understood, and by definition excludes the acromion and the coracoacromial ligament (CAL) which may be directly related to symptoms [...] In addition, the term subacromial has no appreciable lower border and is confusing and imprecise."
• rotator cuff related shoulder pain (RCRSP): RCRSP has been proposed an "over-arching term that encompasses a spectrum of shoulder conditions including; subacromial pain (impingement) syndrome, rotator cuff tendinopathy, and symptomatic partial and full thickness rotator cuff tears." RCRSP is not a definitive diagnosis, but rather a clinical hypothesis. For more on this, see below.

Specific clinical tests used to assess for impingement include the following:

• proposed test cluster:
  • Hawkin Kennedy test: pain on testing = subacromial impingement, but will be negative in individuals with internal impingement
  • painful arc sign
  • infraspinatus muscle test
• empty can test (Jobe test): pain at the injured side = a positive test, but will be negative for posterosuperior glenoid impingement
• Neer test: interpretation depends on pain location - anterior pain tends to indicate subacromial impingement while posterior pain tends to indicate internal impingement
• modified scapular assistance test

For a more detailed discussion of our evolving understanding of "impingement", you might be interested in reading:

• Subacromial Impingement
• Lo CN, van Griensven H, Lewis J. Rotator cuff related shoulder pain: An update of potential pathoaetiological factors. New Zealand Journal of Physiotherapy, 2023;50(2):82-93.
• Lewis J. The end of an era? J Orthop Sports Phys Ther. 2018 Mar;48(3):127-129.

Rotator Cuff Related Shoulder Pain / Rotator Cuff Injury

Function of the rotator cuff muscles: the rotator cuff muscles contribute to glenohumeral joint stability. The rotator cuff consists of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles. You can review their anatomy here.

As mentioned above, there is ongoing controversy around the diagnosis of rotator cuff pathology. Rotator cuff related shoulder pain (RCRSP) "was a term proposed to replace scientifically outdated and potentially flawed diagnoses such as subacromial impingement syndrome, as well as uncertain pathoanatomical diagnoses such as rotator cuff tendinitis/tendinosis, and partial thickness and full thickness rotator cuff tears."

Typically, the term rotator cuff injury or pathology refers to tendinopathy, partial tears and full thickness tears of the rotator cuff:

• rotator cuff pathology is more common in adults aged over 40 years, particularly in individuals who participate in overhead sports or occupations
• tears are more common in older populations
• macro-trauma tends to cause acute, complete tears in younger patients
• micro-trauma tends to result in degenerative tears in older patients
  • in patients with significant tendon degeneration, a small force can cause a complete tear

Individuals with rotator cuff injuries may report a deep, dull ache in their shoulder, sleep disturbances (especially when lying on the affected shoulder), difficulty reaching behind their back, and muscle weakness. These symptoms can significantly impact their ability to participate in daily activities.

A number of clinical tests have been developed to assess for rotator cuff injury, including the following:

• muscle strength testing with palpation of individual muscles, including supraspinatus and infraspinatus
• test item cluster of:
  • drop arm test
  • painful arc sign
  • infraspinatus muscle test / external rotation resistance test
• specifically for a supraspinatus tear:
  • drop arm test
  • full can
  • empty can (Jobe's test)
  • scapular retraction test
  • external rotation lag sign
  • subacromial grind test
• specifically for a infraspinatus tear:
  • infraspinatus test
• specifically for a teres minor tear:
  • hornblower's sign
• specifically for a subscapularis tear:
  • internal rotation lag sign
  • belly press test / Napoleon test
  • belly off sign
  • lift-off test
  • bear hug test

It is important to note, however, that there is: "limited evidence for any of the tests commonly used in diagnosing rotator cuff disease as being very sensitive or specific."

If you would like to review rotator cuff tears in more detail, please refer to: Rotator Cuff Tears.

Acromioclavicular Joint Injury

Acromioclavicular (AC) joint separation occurs when there is loss of articular contact between the distal end of the clavicle and the medial part of the acromion. This separation indicates that there has been injury to the stabilising ligaments (e.g. the acromioclavicular and coracoclavicular ligaments). Acromioclavicular joint separation accounts for approximately 10% of all shoulder girdle injuries.

Injury is usually caused by: (1) blunt injury to the superolateral aspect of the shoulder or (2) secondary force from a fall on the outstretched hand or elbow, resulting in a superiorly directed force - this often occurs during contact sports.

"AC Joint injury is easily missed, therefore any patient who presents with shoulder trauma and complains of pain around the AC joint, AC separation must be suspected."

Signs of an AC joint injury include: pain directly over the AC joint, a decrease in pain with cradling the arm and pain with shoulder adduction.

AC injuries are often classified using the Rockwood classification system. This is an expanded version of the earlier classification systems suggested by other authors, including Allman and Tossy et al.

Clinical tests include:

• active compression test
• Paxinos sign
• scarf test (cross-body adduction test)
• acromioclavicular joint resisted extension test

Please read Acromioclavicular Joint Disorders if you would like to learn more.

Frozen Shoulder / Adhesive Capsulitis

Frozen shoulder, also known as adhesive capsulitis, is a common shoulder condition that causes pain and reduced range of motion. It is most common in individuals aged between 40 and 70 years and affects 2-5% of the population. Women have higher rates of frozen shoulder than men.

It is considered a self-limiting condition that lasts around 2-3 years. It is typically described as having three overlapping phases:

• acute / freezing / painful phase
• adhesive / frozen / stiffening phase
• resolution / thawing phase

Risk factors include: diabetes, Dupuytren's syndrome, thyroid disease, particularly hypothyroidism, nephrolithiasis, cancer, Parkinson's, shoulder injury, smoking, heart and neck surgery and chronic regional pain syndrome.

Individuals will present with:

• shoulder pain
  • often on the lateral humerus
  • night pain, particularly when lying on the affected side
• stiffness / movement restriction (both active and passive)
  • gradual onset of stiffness / reduced range of motion in a capsular pattern (external rotation, abduction, internal rotation) - external rotation will be affected first

If you would like more information on frozen shoulder, please see: Frozen Shoulder.