NPS MedicineWise
Non-traumatic shoulder pain: physical examination tests
By Dr Michael Yelland General practitioner
A targeted examination is an essential component
of the assessment of shoulder complaints.
The clinician should always consider whether the findings are consistent with the history.
If they are, diagnostic confidence is increased and imaging may not be required.
If inconsistencies are noted, other causes of pain including non-musculoskeletal causes
should be considered by revisiting the history and ordering appropriate investigations.
This video focusses on the most clinically useful examination tests for patients in
general practice presenting with non-traumatic shoulder pain.
I will demonstrate them in the conventional order of inspection, palpation and movement testing,
although doing palpation after movement testing is a reasonable alternative.
For inspection, the patient should be appropriately undressed and inspected
from the front, side and back to look for asymmetry, which may indicate
scoliosis, arthritis or trauma.
Look for scars that indicate any previous surgery/injury.
Check the shoulder for any swelling as this can indicate inflammatory joint disease,
effusion and anterior dislocation.
The presence of redness may also indicate inflammation and conditions such as early shingles.
Next move to palpation of the joints and soft tissues
to help localise the source of the pain.
Throughout palpation feel for several things concurrently.
First, the skin and subcutaneous tissues for warmth and bogginess, and for
the sensation of an effusion as signs of inflammation or infection.
Checking for tenderness over the joints and soft tissues is particularly important as
local tenderness strongly suggests the site of pathology.
Finally, assessing the relationship of bones to each other detects signs of subluxation.
An orderly system of joint palpation starts with the sternoclavicular joint,
moving out to the acromioclavicular joint and then around the glenohumeral joint.
Note that the best landmark for the glenohumeral joint line is the posterolateral corner of the acromion.
Most of the soft tissue structures of interest are at or just below this level.
At the front there are the ligaments of the joint capsule, which are tender
in inflammatory conditions such as capsulitis.
There may be a palpable effusion in inflammatory arthritis.
Also, the biceps tendon, in its groove, can be rolled under the fingers.
Anterolaterally is the subdeltoid bursa, often called the subacromial bursa.
This is tender in bursitis, but the alternative interpretation of this is tenderness of the
insertion of the supraspinatus tendon indicating tendinopathy or tendon tears.
More laterally is the attachment of the infraspinatus that may be similarly affected.
Next, move posteriorly to palpate the body of these muscles for tenderness and wasting.
Locate the spine of the scapula and palpate above it for the
supraspinatus and below it for the infraspinatus.
These are most commonly tender in their midportions.
These tender points can be a source of pain that often goes unrecognised.
Also look for wasting of supraspinatus and infraspinatus, which may occur with complete
tendon tears or neurological disorders.
Finally, anteriorly there may be some tenderness in the mid-portion of pectoralis major.
The assessment of range of movement is valuable
in establishing a baseline from which future examinations can be measured.
It begins with active movements in all functional planes for the shoulder.
The expected range of movement varies with age, gender and other factors,
so comparison of sides is very helpful in detecting abnormalities.
Assess flexion by asking the patient to raise their arms forward until they point upwards.
Assess extension by asking the patient to move them behind them.
Next assess abduction. This is done 30 degrees forward
of the coronal plane in the plane of the scapula.
Ask the patient to lift their arms away from their sides as far as possible.
You should look for a painful arc of abduction from 60 to 120 degrees suggestive of
subacromial bursitis, rotator cuff tendinopathy and tendon tears.
Assess adduction by asking the patient to bring their arms
across their trunk to the opposite sides.
Assess external rotation by asking the patient
to hold their elbows to their body flexed at 90 degrees.
Then ask them to move their forearms in an arc-like motion outwards.
This is one of the first movements affected by the contraction
of the shoulder capsule in capsulitis.
Assess internal rotation by asking the patient to place their hand behind their back and
reach as far up the spine as they are able to.
This is also often painful and restricted in subacromial bursitis,
rotator cuff tendinopathy and tears. Alternatively, external and internal rotation
may be tested with the shoulder abducted to 90 degrees, like this.
Assessment of passive movement is only necessary where active movement is limited.
It can efficiently be integrated with active movement testing
by gently assisting the patient at the end of their active range.
This can help differentiate between: weakness, secondary to a tendon tear or neurological disorder;
capsular tightness as in capsulitis; joint degeneration as in osteoarthritis;
or simply pain, as in tendinopathy or bursitis.
So, for example, with testing passive abduction in a patient whose active abduction is restricted
to 90 degrees, with a full thickness tear of supraspinatus, the passive range is greater
than the active range, but in capsulitis or osteoarthritis, passive and active ranges
should be similarly restricted.
There are many tests for testing impingement, but their common aim is to check for pain
with compression of the structures lying between the acromion and the head of the humerus,
namely the bursa and the rotator cuff tendons.
A commonly used impingement test is the Hawkins-Kennedy test, in which you face
The patient and raise their arm to 90 degrees in front of them with the elbow bent.
Put your arm on that side under their elbow, and place your hand on their shoulder to stop
it rising up as you passively internally rotate their shoulder with your other hand.
Shoulder pain occurs in a positive test.
Then test the other side for comparison.
Make sure the patient does not turn away from you in an effort to minimise any pain.
This is a test of resisted abduction used to detect rotator cuff tendon tears.
The patient is instructed to abduct both shoulders to 90 degrees in the plane of the scapula
and to hold them with the thumbs down, as if emptying a can,
while the examiner pushes firmly down on them.
A positive test is noted when there is giving way on one side, suggesting rotator cuff weakness.
When assessing patients with non-traumatic shoulder pain,
the possibility of referred pain from the cervical spine should be entertained,
particularly when the pain is in the posterior part of the shoulder, the usual site of referral
from the lower cervical spine.
A simple screening test for this is the cervical compression test.
With this the patient is seated and by directing the head, the neck is moved
into the posterior quadrant on the side of the affected shoulder by
introducing side bending, rotation and extension.
Then up to 7 kg of axial compression is applied, ceasing compression if pain is produced as
the pressure on the facet joints, discs and nerves on that side increases.
Neck or shoulder pain on the side being compressed suggests cervical discs
or facet joints as the source, whereas reproduction of arm pain or paraesthesia on that side
is positive for cervical nerve root compression, where the test is also called 'Spurling's test'.
For more information about assessing non-traumatic shoulder pain in general practice,
go to nps.org.au/news/non-traumatic-shoulder-pain
NPS MedicineWise Independent. Not-for-profit. Evidence-based.