Look
Expose both shoulders and the scapulae.
Inspect for:
- muscle wasting, especially supraspinatus/infraspinatus and deltoid
- scars
- asymmetry
- scapular winging or dyskinesis
- AC-joint prominence
- deformity from previous fracture or dislocation
Move
Assess active movement first:
- forward elevation
- abduction
- external rotation
- internal rotation behind the back
Then assess passive movement.
The distinction is useful:
- active limitation greater than passive limitation suggests weakness, pain inhibition or tendon failure
- similar active and passive restriction suggests capsular or arthritic stiffness
Rotator cuff
Test individual functions rather than relying on one named test:
- supraspinatus: resisted elevation in scapular plane
- infraspinatus/teres minor: external rotation strength
- subscapularis: internal rotation tests such as belly-press or lift-off when appropriate
Assess individual cuff components rather than using a single “cuff test”.
- supraspinatus: resisted elevation/scaption
- infraspinatus: resisted external rotation
- subscapularis: belly-press, lift-off or related tests depending on motion available
- teres minor: external rotation in abduction when relevant
Lag signs are useful when substantial tendon dysfunction is suspected.
Impingement/subacromial pain tests
Hawkins-Kennedy and Neer-type manoeuvres can reproduce subacromial pain but are not specific enough to diagnose a structural lesion alone.
Instability
Use apprehension/relocation testing for anterior instability and assess generalized laxity where relevant. Posterior instability requires posterior loading and symptom reproduction.
Assess:
- apprehension in a position of risk
- relocation response
- generalized laxity
- anterior/posterior translation
- sulcus sign where relevant
Distinguish pathological instability from asymptomatic laxity.
AC joint
Palpate the AC joint and use cross-body adduction when symptoms suggest AC pathology.
Complete the examination
Examine:
- cervical spine
- distal neurovascular status
- scapular control
A good summary identifies whether the dominant problem is stiffness, weakness, instability, arthritis or referred pain.
Examination framework
A shoulder examination should answer four questions:
- Is the problem arising from the shoulder rather than the neck?
- Is movement limited, painful, weak or unstable?
- Which structure is most likely involved?
- Is dysfunction primarily mechanical, neurological or pain-inhibited?
Inspect from front, side and behind. Look for scars, muscle wasting, deformity, asymmetry and scapular posture.
Cervical spine and scapula
Always screen the neck when symptoms may be radicular. Assess cervical movement, neurological findings and provocative features where appropriate.
Observe scapular motion during elevation. Dyskinesis may reflect pain, muscle imbalance, nerve injury or compensation for glenohumeral restriction.
Range of movement
Compare active and passive:
- forward elevation
- abduction
- external rotation
- internal rotation
A large active-passive discrepancy suggests weakness, pain inhibition or tendon failure. Similar restriction of active and passive movement suggests joint stiffness or adhesive capsulitis.
For external rotation, note arm position because this changes what structures are stressed.
Impingement-type pain
Provocative manoeuvres can reproduce subacromial pain but are not perfectly specific. Interpret them alongside strength, motion and history.
AC joint and biceps
Localised AC tenderness and cross-body adduction pain support AC pathology.
Anterior groove tenderness and provocative biceps manoeuvres may support long-head biceps involvement, but these tests overlap with cuff disease.
Neurology
Axillary nerve function is especially important after dislocation or proximal humeral injury. Assess deltoid contraction and sensation over the regimental-badge area, while remembering sensory testing alone can be misleading.
FRCS presentation
Present:
- dominant pathology
- range of motion pattern
- cuff power
- instability findings
- AC/biceps findings
- neurovascular status
- relevant cervical or scapular contribution
A concise mechanical summary is better than reciting every named test.