Shoulder Examination: History Taking and Clinical Examination

A systematic shoulder examination begins with a detailed history, followed by careful inspection, palpation, and assessment of shoulder movements. A structured approach helps identify common conditions such as rotator cuff tears, shoulder instability, adhesive capsulitis, arthritis, fractures, infections, and nerve injuries.

History Taking

Pain

Pain is the most common presenting complaint in patients with shoulder disorders. Important points to assess include:

• Onset
  • Acute onset: trauma, fractures, dislocations, septic arthritis
  • Insidious onset: inflammatory disorders, degenerative disease, adhesive capsulitis, tuberculosis
• Duration
  • Long-standing pain is common in inflammatory arthritis, frozen shoulder, and chronic infections.
• Radiation
  • Pain may radiate to:
    • Posterior shoulder
    • Axilla
    • Lateral aspect of the upper arm
• Aggravating factors
  • Most painful shoulder conditions worsen with movement.
• Character of pain
  • Throbbing, severe pain often suggests:
    • Pyogenic infection
    • Acute traumatic injury
• Relieving factors
  • Determine whether symptoms improve with:
    • Rest
    • Massage
    • Analgesics
  • Ask whether relief is complete or partial and how long it lasts.
• Relationship to trauma
  • Previous shoulder dislocations
  • Fractures
  • Fracture-dislocations
  Also ask about:
  • Previous treatment
  • Duration of immobilization
  • Postoperative or post-injury physiotherapy
  • Episodes of recurrent instability
• Pain during specific movements
  • Early abduction: suggests supraspinatus tear
  • Painful arc: suggests supraspinatus impingement
  • Forward flexion: may indicate biceps tendon pathology
  • Internal rotation (reaching behind the back): may indicate subscapularis injury
• Associated fever
  • Fever raises suspicion for septic arthritis or other infective conditions.

Swelling

Determine whether swelling developed:

• Spontaneously
  • Infection
  • Pigmented villonodular synovitis (PVNS)
  • Reactive effusion
  • Inflammatory arthritis
  • Hemophilia
  • Degenerative disease
• Following trauma
  • Hemarthrosis
  • Soft tissue injury

Limitation of Movement

Ask about:

• Gradual onset
  • Adhesive capsulitis
  • Chronic infection
• Following treatment
  • Post-traumatic stiffness
  • Postoperative stiffness

Weakness (Loss of Power)

Weakness may be associated with:

• Recurrent shoulder subluxation
• Recurrent dislocation
• Dead arm syndrome

Shoulder Instability

Assess:

• Voluntary or involuntary instability
• Direction of instability
• Triggering movements
• Frequency of episodes
• Duration of symptoms
• Associated neurological symptoms or weakness

Referred Pain and Systemic Symptoms

Shoulder pain may originate outside the shoulder. Always ask about conditions involving:

• Gastric or duodenal disease
• Diaphragmatic irritation
• Cardiopulmonary disorders
• Mediastinal pathology
• Polyarthralgia suggesting systemic inflammatory disease

Inspection

Inspection should be performed from the front, back, top, and medial aspect while comparing both shoulders.

Shoulder Attitude (Posture)

Characteristic postures may indicate specific conditions:

Inspection from the Front

Compare both shoulders and examine:

• Sternal notch
• Sternoclavicular joint
• Clavicle and its contour
• Supraclavicular and infraclavicular fossae
• Acromioclavicular (AC) joint
• Preglenoid fossa
• Anterior axillary fold
• Coracoid prominence
• Deltoid muscle bulk
• Shoulder contour
• Pectoralis muscle
• Sternocleidomastoid muscle
• Alignment of the chin with the suprasternal notch

Inspection from Behind

Assess:

• Midline alignment
• Symmetry of the shoulders
• Trapezius muscle
• Medial border of the scapula
• Scapular winging (commonly due to serratus anterior weakness)
• Spine of the scapula
• Inferior angle of the scapula
• Supraspinous fossa
• Infraspinous fossa
• Posterior axillary fold
• Soft spot (approximately 1 cm medial and 2 cm inferior to the acromion) for swelling

Inspection from Above

Observe:

• Acromioclavicular joint
• Overall shoulder contour

Inspection from the Medial Aspect

Look for:

• Enlarged lymph nodes
• Sebaceous cysts or skin infections

Evaluate the skin using the SEADS approach:

• Swelling
• Erythema
• Atrophy
• Discoloration
• Suppuration (including scars and sinuses)

Palpation

Begin by assessing:

• Local temperature
• Superficial tenderness

Proceed to deep regional palpation.

Anterior Structures

Palpate:

• Sternoclavicular joint
• Clavicle
• Acromioclavicular joint
• Acromion (including os acromiale)
• Subacromial bursa
• Long head of the biceps tendon
  • Best palpated 1–4 cm anterior to the acromion with approximately 10° of internal rotation
• Myositis masses
• Pectoralis major tendon
• Supraclavicular fossa for brachial plexus tenderness or “burners” and “stingers”

Lateral Aspect

Assess for:

• Deltoid muscle bulk
• Step deformity suggesting inferior shoulder subluxation

Posterior Aspect

Palpate the soft spot for:

• Effusion
• Swelling
• Local tenderness

Medial Aspect

Assess:

• Axillary artery pulsations

Assessment of Shoulder Movements

Both active and passive range of motion should be examined and compared with the opposite side.

Forward Flexion

• Normal range: 160–180°

Abduction

Observe:

• Scapulohumeral rhythm
• External rotation after approximately 90° of abduction
• Shoulder shrugging, which may indicate chronic rotator cuff insufficiency

Look for a painful arc, characterized by:

• Minimal pain during early abduction
• Pain during the mid-range
• Improvement near terminal abduction

This finding commonly suggests:

• Supraspinatus impingement
• Partial supraspinatus tear

Additional findings:

• Inability to initiate abduction suggests supraspinatus weakness.
• Inability to maintain abduction suggests deltoid weakness.

Adduction

Ask the patient to:

• Bring the arm across the chest
• Compare cross-body adduction with the opposite side

Internal Rotation

Assess with:

• Arm at the side (0° abduction)
• Arm abducted to 90°

Normal internal rotation at 90° abduction is approximately 45°.

The Apley Scratch Test provides a functional assessment by asking the patient to reach behind the back.

Normal findings:

• Women: thumb reaches approximately T7
• Men: thumb reaches approximately T9

External Rotation

Evaluate with:

• Arm at the side
• Shoulder abducted to 90°

Normal external rotation is approximately 90°.

Total Active Elevation

Ask the patient to elevate the arm in the plane of the scapula, approximately 20–30° anterior to the coronal plane.

Scapular Protraction

Ask the patient to:

• Round the shoulders forward
• Assume a “hunched” posture

This evaluates serratus anterior function.

Scapular Retraction

Ask the patient to:

• Pull both shoulders backward into an “attention” position

Alternating between protraction and retraction may reproduce symptoms of snapping scapula syndrome.

Clinical Pearls

• Always compare findings with the opposite shoulder.
• Observe the patient before touching the shoulder, as posture often provides important diagnostic clues.
• A painful arc strongly suggests rotator cuff pathology, particularly supraspinatus impingement.
• Fever with shoulder pain should prompt evaluation for septic arthritis or osteomyelitis.
• Shoulder pain may be referred from the neck, diaphragm, heart, lungs, or upper gastrointestinal tract, so a complete history is essential.
• Both active and passive range of motion should be documented, as preserved passive motion with restricted active motion often indicates rotator cuff pathology, whereas restriction of both suggests adhesive capsulitis or arthritis.