Shoulder Examination

Shoulder pain is among the most common musculoskeletal complaints and a major reason patients seek physiotherapy and healthcare in Norway. Studies estimate that 15–20% of people experience shoulder pain during their lifetime, creating substantial burden for individuals and society. In Norway, costs related to musculoskeletal care, including shoulder pain, amount to several billion NOK annually in direct healthcare spending and indirect losses from missed work and reduced productivity¹⁹–²¹.

Shoulder Range of Motion and Anatomy

The arm’s range of motion (ROM) relative to the trunk does not depend solely on the glenohumeral joint. Motion also occurs at the acromioclavicular (AC) joint, sternoclavicular (SC) joint, and upper costosternal and costovertebral joints. Another prerequisite for normal movement is free scapular motion over the posterior thorax.

The glenohumeral joint is a multiaxial ball-and-socket synovial joint with a relatively shallow socket (cavitas glenoidalis). Joint stability and integrity depend mainly on surrounding muscles and ligaments. The labrum glenoidale, a fibrocartilage rim, encircles and deepens the socket by ~50%, enhancing stability.² ³

Rotator Cuff Function and Shoulder Biomechanics

Shoulder stability relies heavily on periarticular muscles originating from the scapula and inserting on the humeral head—the rotator cuff (supraspinatus, infraspinatus, subscapularis, teres minor). The scapular spine (spina scapulae) anchors trapezius and deltoid; laterally it widens to form the acromion, which is central to shoulder biomechanics.

The subacromial space between the acromion and humeral head contains the rotator cuff tendons and the subacromial (subdeltoid) bursa, which reduces friction. Other key landmarks include the lesser and greater tubercles separated by the intertubercular sulcus, which houses the long head of biceps tendon as it enters the joint to attach at the superior glenoid via the labrum.

Patient History

A thorough medical history helps exclude red flags and guides the physical examination.

Current condition

• Duration of symptoms.

• Onset mechanism: any triggering event or trauma?

Pain distribution and severity

• Sleep disturbance?

• Ability to lie on the affected side?

• Impact on daily activities at home and work?

Self-care and prior treatment

• What has the patient tried? Which treatments have been provided?

• Course and outcome of previous care?

Work and leisure

• Association with work demands?

• Impact on sport or recreation?

Localized symptoms

• Exact pain location and any arm radiation?

• Aggravating activities (e.g., overhead work, lifting)?

• Painful movement restrictions in specific directions?

• Sense of instability?

• Coexisting neck symptoms?

Clarifying questions (possible pathology)

• Do symptoms change with neck movement?

• Any episodes of instability during arm motion?

• Is overhead activity particularly painful?

• Is it hard to move the arm at all?

• Do the arms feel heavier during overhead tasks?

A careful history provides valuable insight to steer both examination and management.

Mechanism of Injury

Understanding mechanism is key—focus on anatomic site, arm position, and subjective experience at the time of injury.

• Anatomic site: Precise location suggests involved structures (muscle, tendon, ligament, or bone).

• Arm position: For example, abduction with external rotation during a fall raises risk of anterior shoulder dislocation. NHI

• Subjective experience: A “pop/click” may indicate fracture or ligament injury; a sensation of “out of place” suggests (sub)luxation.

Common mechanisms

• Fall on an outstretched hand (FOOSH): Common in older adults; may cause fractures, dislocations, or rotator cuff tears. Legehandboka

• Direct blow: Can injure the AC joint or cause contusions. Legehandboka

• Overuse: Repeated overhead activity (e.g., swimming, throwing) predisposes to tendinopathy or impingement. Skadefri

• Sudden yank/pull: E.g., holding onto something during a fall may cause dislocation or tendon rupture.

Why mechanism matters

• Targets the exam to likely injured structures.

• Guides imaging choice (X-ray, MRI, ultrasound).

• Shapes treatment plan (conservative vs. surgical).

• Helps forecast prognosis and rehab time.

Physical Examination

Cervical Spine Screening

The cervical spine often refers pain to the shoulder/scapular region. Screen the neck to determine whether symptoms originate from or are influenced by cervical structures.

Presentation

• Referred pain to the shoulder region.

• Radiculopathy from disc/degenerative changes causing pain/numbness down the arm.

• Myofascial pain: trigger points referring to the shoulder/upper back.

Neck screen components

• ROM: Active/passive flexion, extension, lateral flexion, rotation; note if movements provoke shoulder pain.

• Neurologic testing: Strength, sensation, reflexes; Spurling’s (extension + lateral flexion + axial load).

• Palpation: Cervical/upper thoracic muscles for tenderness/trigger points.

• Provocation/relief tests: Distraction may relieve radicular pain.

• Differential diagnosis: Consider systemic disorders involving neck and shoulder.

Clinical note: If shoulder area pain changes with neck testing, treat the cervical source before a shoulder-focused plan.

Objective Shoulder Examination

Observation

Compare both shoulders (symmetry principle).

• Shoulder symmetry: Height and muscle contours. Dominant shoulder may be slightly lower/larger—often normal. Marked asymmetry can indicate spasm, joint injury, or deformity.

• Scapular position & motion: Resting position and dynamic control.

  • Winging → serratus anterior weakness or long thoracic nerve injury.

  • Dyskinesis → weakness, instability, or compensations.

• Posture: Forward shoulders (tight pectorals/weak upper back). Thoracic kyphosis/lordosis influences mechanics.

• Swelling/trauma signs: Edema, ecchymosis, scars, discoloration; prominent clavicle/acromion may suggest dislocation/fracture.

• Muscle atrophy: Deltoid/rotator cuff wasting from disuse, nerve compression, or chronic injury.

• Dynamic observation: Overhead elevation and rotation—note scapulohumeral rhythm, limitations, pain, compensations.

Palpation

Palpation reveals tissue status and structural involvement.

• Swelling: Effusion, mass, nodules, bony change.

• Temperature/texture: Warm, tense tissue may indicate infection, synovitis, recent trauma, or tumor.

• Tenderness/pain: Helps localize pathology.

• Asymmetry/sensory differences: Distinguish local vs. referred pain or altered sensation.

• Crepitus with motion: May occur with OA, tendinopathy, or fracture.

Key structures

• AC joint: Pain/swelling (OA or ligament injury).

• SC joint: Tenderness, asymmetry, deformity.

• Rotator cuff insertions: Supraspinatus, infraspinatus, subscapularis tenderness → tendinopathy/tear.

• Long head of biceps tendon: Palpate along bicipital groove for pain/thickening → tendinitis/subluxation.

• Skin/soft tissue: Temperature, texture, visible/palpable changes.

Neurological Examination

Indicated when shoulder pain coexists with numbness/tingling.

Myotomes

C4: Shoulder shrug.

• C5: Shoulder abduction.

• C6: Elbow flexion, wrist extension.

• C7: Elbow extension, wrist flexion.

• C8: Thumb abduction/extension.

• T1: Finger abduction.

Dermatomes

C4: Top of shoulders.

• C5: Lateral deltoid area.

• C6: Tip of thumb.

• C7: Distal middle finger.

• C8: Distal little finger.

• T1: Medial forearm.

  
  

Pathologic reflexes

Hoffmann’s, inverted supinator → central signs.

Deep tendon reflexes

• Biceps (C5), brachioradialis (C6), triceps (C7).

Clinical relevance: Combining palpation with neuro testing localizes anatomic and neural contributors to guide diagnosis and treatment.

Movement Testing

Patients perform active movements in all functional planes: flexion, extension, abduction, adduction, internal and external rotation. ROM can be visually estimated or measured with a goniometer; compare with the contralateral side and expected normals.

Typical Active ROM (AROM) values

• Elevation via abduction: 170°–180°

• Elevation via forward flexion: 160°–180°

• Elevation in scapular plane: 170°–180°

• External rotation: 80°–90°

• Internal rotation: 60°–100°

• Extension: 50°–60°

• Adduction: 50°–75°

• Horizontal add/abd: ~130°

• Circumduction: ~200°

• Scapular protraction/retraction: not standardized

  
  

Combined/repeated movements

• Combined rotations + elevation (dynamic stability).

• Repetitions (endurance, pain/fatigue).

• Sustained positions (pain development).

Dysfunction and Restricted Movements

If movements are limited, this can provide valuable clues to the underlying pathology. The table below summarizes likely causes.

Type of limitation	Possible diagnoses
Pain	Tendinopathy, impingement, sprain/strain, labral injury
Mechanical block	Labral injury, frozen shoulder
Night pain (lying on affected side)	Rotator cuff pathology, anterior shoulder instability, AC joint injury, neoplasm
Clicking or clunking	Labral injury, shoulder instability (anterior or multidirectional)
Stiffness or instability	Frozen shoulder, anterior or multidirectional instability

Clinical significance

Comparing the patient’s active ROM with normal values and identifying which movements are painful or restricted helps the clinician isolate the problem and plan further diagnostics and treatment.

Passive Range of Motion (PROM)

PROM includes the same planes as active ROM but is performed by the clinician to assess joint mobility without muscle activation. Overpressure may be used to further stress the joint.

Movement	Normal PROM	Comment
Elevation via abduction	170°–180°	Assess end-feel and pain at end range.
Elevation via forward flexion	160°–180°	Overpressure may reveal hidden restrictions.
External rotation (lateral)	80°–90°	Often limited by capsular tightness.
Internal rotation (medial)	60°–100°	Important for hand-behind-back tasks.
Extension	50°–60°	Note any discomfort or stiffness.
Adduction	50°–75°	May be painful with AC joint pathology.

Muscle Testing

Muscle Length (Flexibility)

Assessing flexibility helps identify structures contributing to symptoms.

Muscle	Comment
Latissimus dorsi	Shortness can limit shoulder flexion and abduction.
Pectoralis major/minor	Shortness can promote forward shoulder posture.
Levator scapulae	Tightness may contribute to scapular asymmetry.
Upper trapezius	Often overactive as a compensator.
Scalenes (ant./mid./post.)	Relevant with radiating pain or neck spasm.

Muscle Strength (Resisted Testing)

Movement	Primary muscles	Comment
Shoulder flexion	Anterior deltoid, coracobrachialis	Test against resistance for weakness or pain.
Shoulder extension	Latissimus dorsi, teres major	Assesses posterior shoulder stability.
Shoulder abduction	Supraspinatus, middle deltoid	Pain common with rotator cuff pathology.
Horizontal abduction	Posterior deltoid	Tests posterior stability.
Horizontal adduction	Pectoralis major	Pain may indicate injury.
Internal rotation	Subscapularis	Important for functional strength.
External rotation	Infraspinatus, teres minor	Often weak with cuff lesions.

Scapular stabilizers to assess (resisted/functional): upper, middle, lower trapezius; serratus anterior; rhomboids; levator scapulae.

Joint Mobility (Accessory Motion)

Evaluate glides and traction to identify hypo-/hypermobility and reproduce symptoms.

Joint	Glide/traction	Comment
Glenohumeral	Anterior, posterior, inferior, distraction	Hypomobility may indicate capsular restriction.
Acromioclavicular	Anterior, posterior	Pain may indicate AC pathology.
Sternoclavicular	Anterior, posterior, superior, inferior	Important for overall shoulder mobility.
Scapulothoracic	Elevation, depression, upward/downward rotation, protraction/retraction	Essential for functional scapular role.

Clinical relevance

Combining PROM, strength, flexibility, and accessory testing clarifies drivers of shoulder pain and supports a targeted treatment plan.

Special Tests for Shoulder Pathologies

Pathology	Relevant special tests
Subacromial shoulder pain	Hawkins–Kennedy, Neer’s, Painful Arc¹⁵¹⁶¹⁷
Biceps tendinopathy	Speed’s, Yergason’s¹⁸¹⁹
Labral tears (SLAP/Bankart)	O’Brien’s, Crank, Biceps Load²⁰²¹²²
Laxity/instability	Apprehension, Relocation, Sulcus sign²³²⁴²⁵

Outcome Measures for Shoulder Assessment

Measure	Description
SPADI (Shoulder Pain and Disability Index)	Rates pain and functional limitation.
DASH / QuickDASH	Upper-limb function (shoulder/arm/hand).
Constant–Murley (CMS)	Pain, function, strength, ROM.
University of Pennsylvania Shoulder Score (U-Penn)	Pain, function, satisfaction.
VAS	Pain intensity.
PSFS (Patient-Specific Functional Scale)	Patient-prioritized activities and change over time.

Use at baseline and follow-up to quantify progress.

Screening Questions – Red & Yellow Flags

Common Red Flags (screen)

Red flag	Indicators
Systemic disease	Fever, weight loss, night sweats (infection/malignancy).
Non-dermatomal neuro symptoms	Numbness/weakness/tingling not matching shoulder dermatomes.
Constant or night pain	Cuff tendinopathy, AC injury, or serious conditions (e.g., neoplasm).
Prior cancer	New shoulder pain may suggest metastasis.
Vascular symptoms	Pulse changes, cyanosis, swelling (e.g., TOS/vascular).

Examples of Critical Red-Flag Conditions

Condition	Description
Polymyalgia rheumatica	Often bilateral shoulder pain/weakness; assess for temporal arteritis.
Acute compartment syndrome	Disproportionate pain after injury/cast—surgical emergency.
Open fractures	Require immediate care to prevent infection.
Fractures with neurovascular compromise	Risk of function loss—urgent management.
Septic arthritis	Red, hot, swollen joint—urgent evaluation.
Neoplasm	Tumors causing pain/structural change.
Cardiac ischemia	Left shoulder pain can be referred from MI (~68.7% of acute MI cases).

Yellow Flags (psychosocial)

Tool	Purpose
FABQ	Fear-avoidance beliefs.
BDI / DASS	Depression/anxiety screening.
Pain Catastrophizing Scale	Identifies catastrophizing patterns.

Fractures

Often after trauma (e.g., FOOSH).

Fracture type	Description
Humerus fractures	May involve proximal humerus; impacts function.
Clavicle fractures	~80% mid-shaft; distal 10–15%; medial 3–5%.
Management (clavicle)	Non-displaced: consider conservative; displaced: often surgical.

Diagnostic Imaging

Projection	Purpose
Supraspinatus outlet view	Assess subacromial spurs/impingement.
Scapular Y-view	Scapular position & humeral head in dislocation.
Axillary view	Glenohumeral relationship (dislocation/fracture).
AP view	Degenerative changes, calcifications.

Typical Clinical Presentations

Pathology	Typical symptoms
Glenohumeral instability	“Looseness/instability,” esp. in abduction + external rotation.
Adhesive capsulitis	Marked global pain early → progressive stiffness.
Rotator cuff / subacromial disorders	Weakness, heaviness, pain—worse with overhead activity.
Glenohumeral osteoarthritis	Progressive, activity-related deep or posterior pain.
Cardiac disease (MI)	Left shoulder pain can occur without other ischemic symptoms.

Sources:

1.     Ristori, D., Miele, S., Rossettini, G., Monaldi, E., Arceri, D., & Testa, M. (2018). Towards an integrated clinical framework for patients with shoulder pain. Archives of Physiotherapy, 8(1), 1–1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5975572/

2.     Hess, S. A. (2000). Functional stability of the glenohumeral joint. Manual Therapy, 5, 63–71.

3.     Tillman, B., & Petersen, W. (2001). Clinical anatomy. In Wulker, N., Mansat, M., & Fu, F. (Eds.), Shoulder surgery: An illustrated textbook. Martin Dunitz.

4.     Flynn, T., et al. (2008). Users’ guide to the musculoskeletal examination: Fundamentals for the evidence-based clinician. Evidence in Motion.

5.     AFP. (2012). Initial assessment of the injured shoulder. Australian Family Physician, 41(4), 217–220. https://www.racgp.org.au/afp/2012/april/initial-assessment-of-the-injured-shoulder/

6.     Hislop, H. J., & Montgomery, J. (2007). Daniels and Worthingham's muscle testing: Techniques of manual examination (8th ed.). Saunders.

7.     Magee, D. J. (2014). Orthopedic physical assessment-E-Book. Elsevier Health Sciences.

8.     Calis, M., et al. (2000). Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Annals of the Rheumatic Diseases, 59, 44–47.

9.     Murphy, D., & Hurwitz, R. (2007). A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. Archives of Physiotherapy, 8(1), 75.

10.  Song, L., Yan, H. B., Yang, J. G., Sun, Y. H., & Hu, D. Y. (2010). Impact of patients' symptom interpretation on care-seeking behaviors of patients with acute myocardial infarction. Chinese Medical Journal, 123(14), 1840–1845.

11.  Flynn, T., et al. (2008). Users’ guide to the musculoskeletal examination: Fundamentals for the evidence-based clinician. Evidence in Motion.

12.  Rutkow, I. M. (1978). Rupture of the spleen in infectious mononucleosis: A critical review. Archives of Surgery, 113(6), 718–720.

13.  Tamura, M., Hoda, M. A., & Klepetko, W. (2009). Current treatment paradigms of superior sulcus tumors. European Journal of Cardiothoracic Surgery, 36(4), 747–753.

14.  Strauss, E., Flanagin, B. A., Mitchell, M. T., Thistlethwaite, W. A., & Alverdy, J. C. (2010). Usefulness of liver biopsy in chronic hepatitis C. Annals of Hepatology, 9(Suppl), 39–42.

15.  Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery. (2010). Obesity Surgery, 20(3), 386–392.

16.  McKee, M. D. (2010). Clavicle fractures in 2010: Sling/swathe or open reduction and internal fixation? Orthopedic Clinics of North America, 41(2), 225–231.

17.  Altamimi, S. A., & McKee, M. D. (2008). Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. Journal of Bone and Joint Surgery, 90(Suppl 2 Pt 1), 1–8.

18.  Osman, A., et al. (2000). The Pain Catastrophizing Scale: Further psychometric evaluation with adult samples. Journal of Behavioral Medicine, 23(4), 351–365.

19.  Myklebust, G., & Engebretsen, L. (2009). Skulderskader: epidemiologi og behandling. Tidsskrift for Den norske legeforening, 129(3), 236–240.

20.  Helsedirektoratet. (2020). Muskel- og skjelettlidelser i Norge: Omfang og kostnader.

21.  Helsebiblioteket.no. (2021). Skuldersmerter: Veiledning for fysioterapeuter og allmennleger.

22.  Calis, M., et al. (2000). Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Annals of the Rheumatic Diseases, 59, 44–47.

23.  Murphy, D., & Hurwitz, R. (2007). A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. Archives of Physiotherapy, 8(1), 75.