Objective Assessment of the Shoulder

Original Editor - Carin Hunter based on the course by Ian Horsley
Top Contributors - Carin Hunter and Tarina van der Stockt

Introduction[edit | edit source]

Following a successful subjective examination, there should be at least three top differential diagnoses for the patient's problem. The focus of the objective examination is to narrow down the differential diagnosis. An accurate diagnosis will enable us to manage and treat our patients more effectively.

Causes of pain[edit | edit source]

Shoulder pain image.png
Serious conditions[edit | edit source]
  • Infection
  • Cancer/malignancy
  • Cardiopulmonary
  • Inflammatory disease
  • Neurological problems
Pathoanatomic[edit | edit source]
  • Fracture around the shoulder
  • Dislocation
  • Osteoarthrosis
  • Calcific tendinopathy
Non-specific pathoanatomic[edit | edit source]
  • Impingement syndrome
  • Instability
  • Dyskinesis
  • Adhesive capsulitis (frozen shoulder)
Neuropathic pain[edit | edit source]
  • Central sensitisation
  • Neurological dysfunction
  • Cranial nerves
  • Local nerves around the shoulder
Motor control[edit | edit source]
  • Timing issue
  • Quality of movement issue

History[edit | edit source]

Risk factors

  • Weight loss
  • Non-mechanical pain
  • There doesn't seem to be a pattern to the pain
  • Fever
  • Systemically unwell
  • Unrelenting night pain
  • Pain that waxes and wanes
  • Family history

Objective Assessment[edit | edit source]

Exclude Cx spine[edit | edit source]

STAR Assessment[edit | edit source]

in an article from 2015, McClure and Michener, proposed the STAR, Staged Approach for Rehabilitation Classification, shoulder assessment. They propose that a rehabilitation diagnosis will be made based on the findings from their assessment.

For the rehabilitation classification, 3 levels of irritability are proposed and defined, with corresponding strategies guiding intensity of treatment based on the physical stress theory.[1]

STAR shoulder Ax.png

Please read this page for further information: Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder)

SIN[edit | edit source]

It is very important to asses the severity, irritability, and the nature of the problem before conducting the objective examination. SIN gives an indication of the intensity at which the objective examination is assessed. If SIN is not understood correctly, then we may flare up our patients very early on in the examination, thus having to stop the examination and will not confirm or negate the differential diagnosis.[2][3]

1. Severity[edit | edit source]
2.Irritability[edit | edit source]

Irritability[4] can be assessed by:

  1. The vigor of activity required to provoke a patient's symptoms
  2. The severity of those symptoms
  3. The time it takes for the symptoms to subside once aggravated (i.e., pain persistence)[5]

"WHAT activity, after HOW LONG, brings on HOW MUCH pain ? And HOW LONG does is take to subside?"

3.Nature[edit | edit source]

To whether their condition is:

  • Inflammatory
  • Traumatic
  • Degenerative
  • Mechanical
Classification of SIN:[edit | edit source]
  1. High - greater than seven out of 10 (tends to disturb sleep)
  2. Moderate - four to six out of 10 (may be intermittent pain at night)
  3. Low - no pain at rest

Management options[edit | edit source]

  • Physiotherapy
  • Surgical referral
  • Pain educator

Meaningful Task Analysis[edit | edit source]

When conducting an assessment, flexion, abduction, and rotation are often standardly assessed. Linda-Joy Lee and Diane Lee, speak about a meaningful task analysis. This means we need to know what movement specifically the patient does that brings on their pain.


  • Taking off a jumper
  • Fastening the bra
  • Putting a seatbelt

Range of Motion[edit | edit source]

  • Flexion
  • Extension
  • Abduction
  • Adduction
  • Internal Rotation
  • External Rotation
  • Horizontal Flexion
  • Horizontal Extension

Active movement[edit | edit source]

  • Flexion
  • Extension
  • Abduction
  • Adduction
  • Internal Rotation
  • External Rotation
  • Horizontal Flexion
  • Horizontal Extension

Special tests[edit | edit source]

Crank Test

Hawkins-Kennedy Test

Posterior Instability

Anterior Instability

Posterior Impingement

O'Brien's test

Shoulder Symptom Modification Procedure[edit | edit source]

Described by Jeremy Lewis in 2009[6] the Shoulder Symptom Modification Procedure(SSMP) is a reliable[7] approach to the assessment of individuals with rotator cuff and subacromial pathology. SSMP is a set of four mechanical techniques used in a sequence while the patient performs a movement that reproduces their symptoms. The aim is to identify one or more methods that reduce their symptoms and/or increasing movement and function.[8] This tool offers a method to objectively assess the shoulder with the focus being to identify movements and techniques that might be contributing factors to the symptomatic movement and not to label the pathology or exact cause of pain and then utilise these movements and techniques as a means to guide treatment.

Shoulder Symptom Modification Tool.png

The SSMP techniques[9] involve:

  1. Alterations to thoracic kyphosis - The first procedures of the SSMP aim to determine the influence of increasing and decreasing the thoracic kyphosis on the presenting symptoms.  If the thoracic manoeuvre reduces the symptoms by 100%, then the assessment is complete and treatment is initiated with a combination of postural awareness, exercise (including motor control during the provocative activity), and manual therapy (to ensure adequate joint and soft tissue compliance). In this scenario, the aim of treatment is to improve thoracic extension, especially during the identified provocative activity or activities
  2. Scapular positioning techniques - If the thoracic procedures do not or only partially alleviate symptoms, then symptom changes secondary to scapular procedures are assessed.
  3. Humeral head positioning procedures - If the scapular procedures do not fully alleviate symptoms, the clinician progresses to assess the effects of the humeral head procedures. The purpose of the procedures is to positively influence the patient’s symptoms by applying techniques that aim to depress, elevate, or anteriorly or posteriorly glide the humeral head.
  4. Pain and symptom neuromodulation procedure - If the first 3 stages of the SSMP do not completely alleviate or reduce symptoms, then the final stage of the SSMP (neuromodulation) involves assessing the influence of manual procedures, such as pressure-based procedures (aimed at the soft tissues and joints), that may modulate shoulder symptoms and are routinely performed throughout the cervical, thoracic, and shoulder regions.

Force Assessment[edit | edit source]

  • Definition of strength: The ability of the muscle or a muscle group to develop maximal contractile force against their resistance in a single contraction.
  • Definition of endurance: The ability for a muscle or a muscle group to repeatedly exert a submaximal force. So that's more like with our repeated movements in everyday life.
  • Definition of explosive power: The ability to produce maximum amount of force in a minimal amount of time.
  • Definition of rate of force development: It's a scientific measure of the speed of force production. From a sporting perspective, that is something we need to look at.
  • Definition of electromechanical delay: The delay between the onset of electrical activity and the measurable onset of muscle force. An electromechanical delay can give us micro instability.

Measurement of Force:

Isometrically we can standardise the measurement by using a device called the Activforce 2, it links to a cellphone and gives a value. When assessing, hold for three seconds, note if the patient experiences any pain with this because pain will  inhibit  muscle power.

  • Abduction
  • External rotation.
  • Functional position
    • External rotation with 90 degrees of abduction
    • Internal rotation with 90 degrees abduction (assessing the force of the middle trapezius and lower trapezius)
  • Long lever vs Short lever
  • Progress to assess in a functional position

Assessing serratus anterior function

In the shoulder it is important to assess the serratus anterior function as an upward rotator. The most common way of assessing the serratus is protraction.

  • Patietnt arm about 130 degrees flexion
  • Therapists hand over patients wrist
  • Other hand of the therapist over the inferior angle of the scapula sitting in the webspace between the therapists thumb and first finger
  • Apply a downward force with the hand by the wrist
  • Assess for what moves first
    • Humerus, the arm drops down followed by the scapula downwardly rotating
    • Scapula, the scapula downwardly rotates first. This indicates a deficiency of serratus anterior as a scapular upward rotator.

Proprioception[edit | edit source]

Proprioception itself can be understood as including various sub-modalities:

Proprioception (Joint Position Sense): Proprioception is our sense of joint / limb positioning. It is often measured through joint position sense - active joint position sense (AJPS) and passive joint position sense (PJPS). Joint position sense determines the ability of a person to perceive a presented joint angle and then, after the limb has been moved, to actively or passively reproduces the same joint angle[11] (Clinically measured as a joint matching task).

Kinaesthesia: Kinaesthesia (kinaesthesis) is the awareness of motion of the human body (motion sense)[12]. Sense of movement refers to the ability to appreciate joint movement, including the duration, direction, amplitude, speed, acceleration and timing of movements.[11]

Sense of Force: Sense of Force (SoF) is also known as sense of effort / heaviness / tension or the force matching sense. It is the ability to reproduce (or match) a desired level of force one or more times. Sense of force is thought to stem from the afferent feedback of the Golgi Tendon Organs (GTOs) embedded within our tendons, the muscle spindles within our muscles and proprioception within our skin.[13]

Sense of Change in Velocity (SoV): SoV is our ability to detect vibration, derived from oscillating objects placed against the skin.[14] It is believed to travel through the same type of large afferent nerve fibers (Aαβ) as proprioception.[15]

Proprioception is important around the shoulder because of the unstable anatomy of the ball and socket joint, sometimes referred to as the ball and saucer joint. Due to the instability the neural processing is critical  in keeping the humeral head stable. Therefore where the shoulder is in space is one of the most commonly used measures of shoulder sensory function.

References[edit | edit source]

  1. McClure PW, Michener LA. Staged Approach for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder). Phys Ther. 2015 May;95(5):791-800. doi: 10.2522/ptj.20140156. Epub 2014 Dec 11. PMID: 25504491.
  2. Petersen EJ, Thurmond SM, Jensen GM. Severity, Irritability, Nature, Stage, and Stability (SINSS): A clinical perspective. Journal of Manual & Manipulative Therapy. 2021 May 15:1-3.
  3. Koury MJ, Scarpelli E. A manual therapy approach to evaluation and treatment of a patient with a chronic lumbar nerve root irritation. Physical therapy. 1994 Jun 1;74(6):548-60.
  4. Sayres LR. Defining irritability: the measure of easily aggravated symptoms. British Journal of Therapy and Rehabilitation. 1997 Jan;4(1):18-37.
  5. Barakatt, E. T., Romano, P. S., Riddle, D. L., Beckett, L. A., & Kravitz, R. (2009). An Exploration of Maitland's Concept of Pain Irritability in Patients with Low Back Pain. The Journal of manual & manipulative therapy, 17(4), 196–205. https://doi.org/10.1179/106698109791352175
  6. Lewis, J. S. (2009) Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports Medicine, Vol 43, pp. 259-264
  7. Lewis JS, McCreesh K, Barratt E, Hegedus EJ, Sim J. Inter-rater Reliability of the Shoulder Symptom Modification Procedure in People with Shoulder Pain. BMJ Open Sport & Exercise Medicine. 2016 Nov 1;2(1):e000181
  8. Eleanor Richardson & Jeremy Lewis. The Shoulder Symptom Modification Procedure (SSMP). https://www.shoulderdoc.co.uk/article/1478
  9. Lewis J, Mccreesh K, Roy JS, Ginn K. Rotator Cuff Tendinopathy: Navigating The Diagnosis-Management Conundrum. Journal Of Orthopaedic & Sports Physical Therapy. 2015 N
  10. Lewis J, McCreesh K, Roy JS, Ginn K. Rotator cuff tendinopathy: navigating the diagnosis-management conundrum. Journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):923-37.
  11. 11.0 11.1 Riemann, B. L., & Lephart, S.M. (2002). The sensorimotor system, part 1: the physiological basis of functional joint stability. Journal of Athletic Training, 37(1),71-79.
  12. Sherrington CS. On the proprio-ceptive system, especially in its reflex aspect. Brain. 1907;29:467–482.
  13. Hung, Y. J. (2015). Neuromuscular control and rehabilitation of the unstable ankle. World Journal of Orthopedics, 6(5), page 434.
  14. Gilman, S., Joint position sense and vibration sense: anatomical organisation and assessment.Journal of neurology, neurosurgery, and psychiatry, 2002. 73(5): p. 473-7.
  15. Shakoor, N., A. Agrawal, and J.A. Block, Reduced lower extremity vibratory perception in osteoarthritis of the knee.Arthritis and rheumatism, 2008. 59(1): p. 117-21.