Differentials
| Presenting Feature | What might it be? | What might I find? | |
|
Shoulder pain |
Osteoarthritis |
Older patient, history of manual work/high use of joint.
Gradual onset of pain and stiffness affecting global ROM. Global reduced ROM, stiffness & crepitus on examination. |
|
|
Impingement |
Overuse of joint e.g., patients playing tennis/swimming.
Pain worse in abduction, can be worse at night. Positive special tests e.g., painful arc, Jobe, Hawkins. |
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|
AC joint pathology |
Pain worse in extreme of shoulder abduction/arm overhead.
Positive scarf test. |
||
|
Frozen shoulder |
Middle aged patient, diabetic.
Painful joint which is worse at night and becomes stiff. Pain/stiffness on active/passive movement. External rotation is most affected movement. |
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|
Rotator cuff tear |
Acutely injured patient or older patient gradually worsening.
Pain and weakness of rotator cuff group, night pain. |
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|
Shoulder stiffness |
Osteoarthritis |
Older patient, history of manual work/high use of joint.
Gradual onset of pain and stiffness affecting global ROM. Global reduced ROM, stiffness & crepitus on examination. |
|
|
Frozen shoulder |
Middle aged patient, diabetic.
Painful joint which is worse at night and becomes stiff. Pain/stiffness on active/passive movement. External rotation is most affected movement. |
||
|
Traumatic shoulder injury |
Shoulder dislocation |
Deformity to shoulder e.g., step, arm hanging awkwardly.
Inability to move shoulder and severe pain, bruising and swelling. |
|
|
Rotator cuff tear |
Acutely injured patient or older patient gradually worsening.
Pain and weakness of rotator cuff group, night pain. |
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|
Shoulder fracture |
Deformity e.g., visible bone, step, arm hanging awkwardly.
Severe pain, swelling or bruising after an injury. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Position patient standing | ||
| Appropriate exposure of upper body | ||
| General Inspection | Systemic appearance (well/unwell) | |
| Body habitus | ||
| Pain | ||
| Joint support | ||
| Clues in bed space | ||
| Look | Examination from all aspects (anterior/lateral/posterior) | |
| Asymmetry | ||
| Skin colour | ||
| Scars | ||
| Muscle Wasting | ||
| Axilla | ||
| Winging of scapula | ||
| Feel | Check for pain | |
| Temperature | ||
| Palpation of shoulder girdle | ||
| Move | Hands behind head (functional) | |
| Hands behind back (functional) | ||
| Active abduction | ||
| Active adduction | ||
| Active flexion | ||
| Active extension | ||
| Active external rotation | ||
| Active internal rotation | ||
| Passive abduction | ||
| Passive adduction | ||
| Passive flexion | ||
| Passive extension | ||
| Move | Passive external rotation | |
| Passive internal rotation | ||
| Special Tests | Painful arc | |
| Hawkins | ||
| Apprehension | ||
| Scarf | ||
| Jobe/Empty can | ||
| Resisted external rotation | ||
| Gerber’s | ||
| Finishing | Neurovascular examination | |
| Examine joint above & below | ||
| Re-cover patient | ||
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
“I have been asked to examine your shoulder. This involves looking at, pressing on, and moving your shoulder joint. You can ask me to stop at any time. Are you happy for me to do that?”
Expose the patient’s upper body by asking them to remove clothing and position them standing. Consider offering a chaperone and if examining a female patient leave the bra on.
General Inspection
Look at the patient and around the bed space for useful signs:
- Body habitus – are they overweight or underweight?
- Pain (e.g., holding or protecting joint)
- Joint support (e.g., brace or cast)
- Clues around the bed space (e.g., medication packets)
Make sure to examine & compare both shoulders unless told otherwise by the examiner.
Look
Inspect the shoulders from anterior, lateral and posterior aspects, making sure to note the following: asymmetry (i.e. obvious deformity to one shoulder, compare the height of the patient’s shoulders), evidence of trauma, skin colour (e.g., erythema), swelling, scars (evidence of previous surgery or trauma to shoulder), muscle wasting, axillary swelling/skin changes.
Check for scapula winging – examine with patient facing wall, pressing into the wall with both arms at shoulder height and shoulder-width apart looking for any asymmetry or bulge to either scapula (indicating a long thoracic nerve palsy).
Feel
Check for pain prior to palpation of joint. Ask if the patient is in any discomfort when palpating and look at their face – are they visibly in pain?
Feel for changes in skin temperature.
Palpate the shoulder from the anterior aspect, feeling from medial to lateral along anterior shoulder girdle: sternum – clavicle – acromion – coracoid – humeral head. Then palpate from the posterior aspect, feeling the glenohumeral joint and the scapula.
Move
Firstly, check for gross pathology by observing quick functional screening movements prior to examining full range of movement of the shoulder joint. Ask the patient to put their hands behind their head (external rotation and their hands behind their back to level of scapula (internal rotation). If there is pain when carrying out either of these movements there is likely an issue within the shoulder joint which you will examine further to specify.
Examine active individual shoulder movements, comparing both sides looking for discomfort and range of movement (normal range):
Adduction – straight arm moves medially across the anterior body to contralateral side (40°)
Abduction – straight arm moves laterally and upwards until arms above head (180°)
Flexion – straight arm moves forwards and upwards until arms above head (180°)
Extension – straight arm moves backwards and upwards to furthest point possible (60°)
External rotation – keeping elbows tucked into the lateral torso and the elbow joint flexed to 90°, the forearm rotates laterally (90°)
Internal rotation – with arms behind back, hands meet in midline and reach up back as far as possible (90°)
Examine passive movements by repeating the above with doctor moving the patient’s arm with one hand and the other hand placed on patient’s shoulder. Throughout all joint movement the doctor is checking for discomfort, crepitus and any difference in range of movement compared with active movement.
Special Tests
Painful arc: this requires slow abduction and then adduction of the straight arm. The test is positive if the patient experiences pain at around 60-120° of abduction and indicates impingement syndrome.
Hawkin’s test: with the patient’s shoulder and elbow flexed to 90° and shoulder internally rotated, the doctor passively internally rotates the shoulder further. The test is positive if the patient experiences pain and indicates impingement syndrome.
Apprehension test: with the patient’s shoulder abducted 90° with elbow flexed 90° and shoulder externally rotated (high-five position), the doctor passively externally rotates the shoulder further. The test is positive if the patient feels apprehension and indicates shoulder joint instability.
Scarf test: with the patient’s shoulder adducted with elbow flexed and their hand placed on their contralateral shoulder, the doctor passively adducts the shoulder further. The test is positive if the patient experiences pain and indicates acromioclavicular joint pathology.
Jobe/Empty Can test: this tests the supraspinatus muscle – with the patient’s shoulder abducted 90° and internally rotated (thumbs down), the doctor adducts the patient’s shoulder against resistance. The test is positive if the patient experiences pain/weakness and indicates impingement/tear of supraspinatus.
Resisted external rotation: this tests the infraspinatus & teres minor muscles – keeping the patient’s elbows tucked into the lateral chest wall with the elbow joint flexed to 90°, the doctor opposes lateral movement. The test is positive if the patient experiences pain/weakness and indicates impingement or tear of infraspinatus and/or teres minor.
Gerber’s lift-off test: this tests the subscapularis muscle – with the patient’s shoulder internally rotated with the dorsum of their hand on their back, the doctor opposes posterior movement. The test is positive if the patient experiences pain/weakness and indicates impingement/tear of subscapularis.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the examination findings you may wish to carry out a full neurovascular assessment, examine the joint above and below as well as arrange further investigations including X-ray, ultrasound or MRI scanning.
Last updated Dec 2024
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