MSK Shoulder Assessment: A Complete Guide for Physiotherapy Students
The shoulder is one of the most complex joints in the body and one of the most commonly assessed regions in MSK physiotherapy. A structured, systematic approach is essential â both for accurate diagnosis and for demonstrating clinical competence in placements and OSCEs. This guide walks through every stage of a thorough shoulder assessment.
Subjective Assessment: What to Ask and Why
The subjective assessment is where you gather the information that will guide your entire clinical reasoning. For the shoulder, key areas to cover include:
Area and nature of pain â Ask the patient to point to the area of pain. Shoulder pain can be local (subacromial, acromioclavicular, glenohumeral) or referred (cervical spine, thoracic outlet, cardiac). The distribution and nature of pain helps narrow your differential.
Onset and mechanism â Was it traumatic (fall on outstretched hand, direct blow) or insidious? Traumatic onset raises the possibility of rotator cuff tear, labral injury, or fracture. Insidious onset is more consistent with tendinopathy, frozen shoulder, or impingement.
Aggravating and easing factors â Pain with overhead activities suggests subacromial impingement. Pain at rest and at night, especially in the absence of movement-related pain, raises concern for inflammatory pathology or serious pathology.
24-hour pattern â Inflammatory conditions (rheumatoid arthritis, polymyalgia rheumatica) are typically worse in the morning. Mechanical pain is usually worse with activity.
Red flags â Always screen for: unexplained weight loss, bilateral symptoms, night sweats, history of cancer, constant severe pain unrelated to movement. These require urgent medical referral.
Objective Assessment: Observation and Active Movement
Begin your objective assessment with the patient standing or sitting, exposing both shoulders for comparison.
Observation â Look for: muscle wasting (supraspinatus, infraspinatus, deltoid), asymmetry, posture (protracted scapula, forward head posture), swelling, bruising, or deformity.
Active range of movement â Assess: flexion (normal 180°), abduction (normal 180°), external rotation (normal 60â90°), internal rotation (normal 70â90°), and horizontal adduction. Note pain, range, and quality of movement. A painful arc between 60â120° of abduction is characteristic of subacromial impingement.
Scapular movement â Observe scapular rhythm during arm elevation. Winging, dyskinesis, or premature elevation suggests serratus anterior weakness or poor neuromuscular control.
Key Special Tests for the Shoulder
Special tests should be used to confirm or refute a hypothesis formed from your subjective and active movement assessment â not as a fishing exercise. The most clinically useful tests include:
Rotator Cuff Tests: - Empty Can / Jobe's Test â Supraspinatus integrity. Sensitivity 69%, Specificity 66%. - Resisted External Rotation â Infraspinatus and teres minor. Pain or weakness suggests posterior cuff tear. - Belly Press / Lift-off Test â Subscapularis integrity.
Impingement Tests: - Neer's Sign â Passive forward flexion with internal rotation. Positive if pain reproduced. - Hawkins-Kennedy Test â Passive forward flexion to 90° then internal rotation. Sensitivity 79%, Specificity 59%.
Instability Tests: - Anterior Apprehension Test â Abduction and external rotation. Apprehension (not just pain) is a positive finding. - Sulcus Sign â Inferior instability. A visible sulcus below the acromion with downward traction.
AC Joint: - Cross-Body Adduction Test â Pain over the AC joint is a positive finding. - Paxinos Test â Thumb pressure under the posterolateral acromion with index finger on the clavicle.
Biceps: - Speed's Test â Resisted forward flexion with elbow extended and forearm supinated. - Yergason's Test â Resisted supination with elbow at 90°.
Differential Diagnosis: Common Shoulder Conditions
Using your assessment findings, consider the following common diagnoses:
| Condition | Key Features |
|---|---|
| Subacromial impingement | Painful arc 60â120°, positive Neer/Hawkins, worse overhead |
| Rotator cuff tear | Weakness on resisted testing, positive Empty Can/Lift-off |
| Frozen shoulder (adhesive capsulitis) | Global restriction (especially ER), insidious onset, night pain |
| AC joint pathology | Localised AC joint pain, positive cross-body adduction |
| Glenohumeral instability | Positive apprehension test, history of dislocation |
| Cervical referred pain | Symptoms reproduced with cervical movement, dermatomal distribution |
| Biceps tendinopathy | Anterior shoulder pain, positive Speed's/Yergason's |
Always consider the cervical spine as a source of referred shoulder pain â a cervical screen should be part of every shoulder assessment.
Clinical Reasoning: Putting It All Together
A strong shoulder assessment is not just a list of tests â it is a reasoning process. After gathering your subjective and objective findings, ask yourself:
- What is the most likely diagnosis based on the pattern of findings?
- What diagnoses have I ruled out?
- Are there any red flags that require urgent referral?
- What are the contributing factors (posture, muscle imbalance, activity demands)?
- What is the patient's main concern and goal?
Documenting your reasoning clearly â using a SOAP note or similar structure â demonstrates clinical competence and is essential for safe practice.