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Shoulder Assessment Clinical Reasoning

Original Editor - Ewa Jaraczewska based on the course by Ari Kaplan

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Assessing both active and passive range of motion is a key part of any glenohumeral joint examination.[1] [2] Active range of motion (AROM) can identify a functional limitation, but cannot determine its cause. For instance, a patient who is unable to achieve full shoulder flexion may be limited by inadequate motor control, insufficient strength, or mechanical restrictions within the capsule or surrounding musculature. Assessing passive range of motion (PROM) helps the clinician to further differentiate between these possibilities. Collectively, these findings inform whether the subsequent treatment plan should target neuromuscular control, soft tissue mobility, joint arthrokinematics, or a combination.

The PROM assessment should follow every active movement screen, regardless of the findings.[1] "Normal" active motion does not necessarily exclude passive restriction. Patients often develop compensatory strategies, such as scapular elevation, trunk lean, or contralateral shift, to mask glenohumeral limitations.[3] Conversely, AROM restrictions may completely resolve when the limb is offloaded, and the clinician moves the joint passively. Neither scenario can be fully understood without the PROM assessment.

The Relationship Between Active Motion and Passive Restriction

A core principle of the shoulder assessment is that the muscles producing a specific movement are often the same structures that resist passive motion in the opposite direction. Understanding this principle allows the clinician to generate a working hypothesis before the objective assessment begins.[4]

For example, if a patient lacks passive shoulder flexion, a clinician should check the muscles that assist with shoulder extension: latissimus dorsi, teres major, posterior deltoid, and long head of the triceps. If passive internal rotation is restricted, the external rotators—infraspinatus, teres minor, and, to a lesser degree, posterior deltoid—should be assessed.[5]

This approach encourages rapid anatomical reasoning: thinking through a movement, identifying the structures that produce it, and recognising the structures that may restrict passive motion.[4]

Capsular Restriction

The glenohumeral capsule is a common source of passive restriction. Different portions of the capsule become taut in various planes of motion;[6] identifying the implicated portion helps guide manual therapy.

Flexion and abduction are most commonly restricted by the inferior capsule (and in some cases the posterior-inferior capsule).[7] A clinical cue for inferior capsule tightness is shoulder hiking during active flexion, where the patient compensates for restricted inferior glide of the humeral head.[4]

Internal rotation is most commonly restricted by the posterior capsule, though the specific site of tightness varies by the angle of abduction.[8] When tested at 90 degrees of shoulder abduction, limited passive internal rotation is most likely caused by posterior-inferior capsule tightness. At approximately 60 degrees of shoulder abduction, the posterior capsule is the more likely source of restriction.[4][9]

The anterior capsule is the primary capsular restraint to external rotation. However, posterior capsular tightness can indirectly limit external rotation by preventing the posterior glide of the humeral head required for external rotation.[4] If a patient reports a "pinching" sensation or other signs of impingement during external rotation, clinicians should often prioritise restoring internal rotation mobility first. Clinicians should confirm this finding with additional testing, as it could be connected to a severely internally rotated scapula.

Influence of Demographics

Patient age and surgical history influence the likely source of restriction.[10] In younger patients without prior shoulder surgery, muscular tightness is the more likely cause of restriction. The likelihood of capsular involvement increases significantly in patients aged 50 and older or those who are several months postoperative.[11]

Glenohumeral Joint Assessment Technique Principles

Active Range of Motion Assessment

Active range of motion provides a valuable starting point for the assessment, revealing movement quality, compensatory strategies, and the patient's willingness and ability to move. Meaningful patterns such as shoulder hiking, trunk lean, or altered scapular rhythm can inform the clinical reasoning that follows.[4]

Passive Range of Motion Assessment

Accurate passive measurement depends on the clinician's ability to control and stabilise the scapula.[12]

Flexion

To assess passive shoulder flexion, the patient is positioned in supine. The clinician passively elevates the arm through the sagittal plane to end range. The clinician notes where in the arc movement begins to reduce and the quality of the end-feel.

Internal Rotation

The patient is positioned in supine with their arm resting on the clinician's thigh. The clinician palpates the coracoid process and acromion with the monitoring hand and guides the arm into internal rotation. Internal rotation should be measured at the point where these landmarks begin to move, indicating that glenohumeral PROM slack has been taken up and the scapula starts to advance. Care should be taken to ensure the shoulder complex does not rise off the stabilising surface, as this can give a false impression of normal range of motion.[4][13]

External Rotation

To assess passive external rotation, the patient is positioned in supine with their arm resting on the clinician's thigh. The clinician palpates the coracoid process and acromion with the monitoring hand and guides the arm into external rotation. External rotation is measured at the point where these landmarks start moving. This is the point at which true glenohumeral motion ends and scapular or trunk compensation begins.

Note: Passive external rotation range increases as the shoulder abduction angle is increased.[14]

Horizontal Adduction

The patient is positioned in supine, and the clinician passively moves the patient's arm across the body. The anterior scapula should be blocked using a broad palm contact—fingertips should be avoided, as this area is frequently tender.[4] Without adequate scapular stabilisation, passive horizontal adduction can appear full, masking true glenohumeral restriction. Restrictions in this plane are most likely related to the posterior capsule, infraspinatus, teres minor, and posterior deltoid.[15]

Abduction

The patient is positioned in supine. The clinician passively elevates the arm through the coronal plane to end range. Full abduction requires sufficient inferior capsule extensibility and adequate flexibility of latissimus dorsi, teres major, and potentially the pectoralis.[16] It also requires sufficient external rotation of the humerus to allow the greater tuberosity to clear the subacromial space. Because restrictions in external or internal rotation can also limit abduction,[17] patients often struggle to recover abduction range until restrictions across all other planes have been addressed.[4]

Clinical Priorities

Internal rotation restrictions are among the most prevalent passive deficits in shoulder dysfunction.[18] [19] Because of the interdependence of shoulder movements, resolving internal rotation restrictions early can improve other planes of motion.[20] Addressing internal rotation first does not mean ignoring other findings, but rather establishes a logical sequence that optimises treatment time.

Precautions

This approach does not apply to people with acute shoulder injuries or those who have had recent shoulder surgery. In these cases, pain, protective muscle guarding, and inflammatory responses are the primary factors limiting movement. The focus should be on calming the shoulder and rebuilding confidence in movement.[4]

Resources

References

  1. ↑ 1.0 1.1 van den Hoorn W, Fabre A, Nardese G, Su EY, Cutbush K, Gupta A, Kerr G. The future of clinical active shoulder range of motion assessment, best practice, and its challenges: narrative review. Sensors. 2025 Jan 23;25(3):667.
  2. ↑ Donnelly TD, Ashwin S, Macfarlane RJ, Waseem M. Clinical assessment of the shoulder. Open Orthop J. 2013 Sep 6;7:310-5.
  3. ↑ Melo ASC, Soares AL, Castro C, Matias R, Cruz EB, Vilas-Boas JP, Sousa ASP. Shoulder and Scapular Function Before and After a Scapular Therapeutic Exercise Program for Chronic Shoulder Pain and Scapular Dyskinesis: A Pre-Post Single-Group Study. J Pers Med. 2025 Jul 2;15(7):285.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 Kaplan A. Shoulder Evaluation Clinical Reasoning. Plus course 2026
  5. ↑ Latash ML. Muscle coactivation: definitions, mechanisms, and functions. J Neurophysiol. 2018 Jul 1;120(1):88-104.
  6. ↑ Moskal MJ, Harryman II DT, Romeo AA, Rhee YG, Sidles JA. Glenohumeral motion after complete capsular release. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 1999 May 1;15(4):408-16.
  7. ↑ Amako M, Hamada J, Karasuno H, Sahara R, Yamaguchi M, Yano Y, Hagiwara Y, Tamai K, Ogawa K. Evaluation of glenohumeral adduction restriction in frozen shoulder as a predictor of intra-articular lesion severity: a comparison study of the freezing and frozen phases. JSES international. 2025 Jun 2.
  8. ↑ Dashottar A, Borstad J. Posterior glenohumeral joint capsule contracture. Shoulder Elbow. 2012 Oct 1;4(4):10.1111/j.1758-5740.2012.00180.x.
  9. ↑ Lee SY, Lee KJ, Kim W, Chung SG. Relationships Between Capsular Stiffness and Clinical Features in Adhesive Capsulitis of the Shoulder. PM R. 2015 Dec;7(12):1226-1234.
  10. ↑ DePalma AF. The classic. Loss of scapulohumeral motion (frozen shoulder). Ann Surg. 1952;135:193-204. Clin Orthop Relat Res. 2008 Mar;466(3):552-60.
  11. ↑ Wang S, Zhang P, Xie J, Jiang C. Risk Factors of Postoperative Shoulder Stiffness After Rotator Cuff Repair: A Systematic Review and Meta-Analysis. JBJS reviews. 2025 Oct 1;13(10):e25.
  12. ↑ Baumgarten KM, Osborn R, Schweinle WE 3rd, Zens MJ, Helsper EA. SCAPULAR SUBSTITUTION AFTER ROTATOR CUFF REPAIR CORRELATES WITH POSTOPERATIVE PATIENT OUTCOME. Int J Sports Phys Ther. 2018 Aug;13(4):687-699.
  13. ↑ Awan R, Smith J, Boon AJ. Measuring shoulder internal rotation range of motion: a comparison of 3 techniques. Arch Phys Med Rehabil. 2002 Sep;83(9):1229-34.
  14. ↑ Leong K, Ginn KA, Halaki M. Is passive shoulder external range influenced by body posture or shoulder abduction angle? Shoulder Elbow. 2026 Feb 9:17585732261420223.
  15. ↑ Laudner KG, Stanek JM, Meister K. Assessing posterior shoulder contracture: the reliability and validity of measuring glenohumeral joint horizontal adduction. J Athl Train. 2006 Oct-Dec;41(4):375-80.
  16. ↑ Page P, Labbe A. Adhesive capsulitis: use the evidence to integrate your interventions. N Am J Sports Phys Ther. 2010 Dec;5(4):266-73.
  17. ↑ Jungwirth-Weinberger A, Gerber C, Boyce G, Jentzsch T, Roner S, Meyer DC. Restriction of Passive Glenohumeral Abduction Combined With Normal Passive External Rotation Is a Diagnostic Feature of Calcific Tendinitis. Orthop J Sports Med. 2018 Feb 6;6(2):2325967117752907.
  18. ↑ Saldiran TC, Yilmaz O. Which one is the most limited movement in restricted shoulder joint. Human Movement. 2019 Apr 24;20(2):72-8.
  19. ↑ Iida N, Velasquez Garcia A, Kuroiwa T, Hsu KL, Selim OA. Role of stretching interventions in enhancing the shoulder range of motion in overhead athletes with glenohumeral internal rotation deficit: A systematic review and meta‐analysis. PM&R. 2025 Aug 22.
  20. ↑ Minhaj S, Afridi ZK, Rubab S, Qazi Z, Siddiqui M. Glenohumeral internal rotation deficit and risk of upper extremity injury in overhead athletes: systematic review. Archives of Physical Medicine and Rehabilitation. 2025 Jan 1;106(1):91-7.
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