Shoulder Examination in Rheumatology

A structured shoulder examination is essential for differentiating inflammatory, mechanical, and periarticular causes of shoulder pain in clinical rheumatology and musculoskeletal medicine practice. The shoulder is the third most common site of musculoskeletal consultation in Australian general practice, accounting for approximately 11% of all musculoskeletal presentations.

Shoulder complaints are responsible for significant functional impairment, lost work productivity, and reduced quality of life. In Australia, rotator cuff disease affects an estimated 20–30% of the adult population, with prevalence increasing with age — reaching 50–60% in those over 60 years. Frozen shoulder (adhesive capsulitis) has an estimated prevalence of 2–5%, with higher rates in people with diabetes mellitus, thyroid disease, and prolonged immobilisation.

The anatomical complexity of the shoulder — involving four discrete articulations and multiple periarticular structures — demands a systematic, structured examination approach. In rheumatology practice, distinguishing inflammatory arthropathy from degenerative or periarticular pathology is critical, as the investigation and management pathways diverge significantly. This guideline provides a practical framework for the clinical examination of the shoulder, with emphasis on Australian practice patterns, imaging availability, and validated scoring systems.

Articulations

The shoulder complex comprises four distinct articulations, each of which contributes to the overall range of motion and must be individually assessed during clinical examination:

Rotator Cuff — SITS Muscles

The rotator cuff muscles form a musculotendinous cuff around the GH joint, providing dynamic stabilisation and enabling glenohumeral movement. The mnemonic SITS describes the four muscles:

The Look–Feel–Move Approach

A systematic shoulder examination follows the structured Look–Feel–Move (Inspection–Palpation–Movement) framework, supplemented by special tests specific to the suspected pathology.

Normal Glenohumeral Range of Motion

Active vs Passive ROM — Diagnostic Significance

The Painful Arc

The painful arc test is performed by asking the patient to actively abduct the arm from 0° to 180°. Pain occurring specifically between 60° and 120° of abduction is characteristic of subacromial pathology (rotator cuff tendinopathy, subacromial bursitis, or calcific tendinitis). Pain at the extremes of ROM (beginning and end range) more commonly suggests capsular pathology.

Special tests are provocative manoeuvres designed to stress specific anatomical structures to reproduce symptoms and localise pathology. Each test should be interpreted in the context of the overall clinical picture, not in isolation. The table below summarises the most clinically useful shoulder special tests in rheumatology practice.

Subacromial Impingement Tests

Rotator Cuff Integrity Tests

Biceps Tendon Tests

Instability Tests

AC Joint and Labral Tests

Scapular Assessment

Scapular dyskinesis (abnormal scapular motion) contributes to shoulder pathology and should be assessed during active arm elevation:

• Observe scapulohumeral rhythm from behind during arm elevation — should be 2:1 ratio
• Lateral scapular slide test: measure distance from inferior angle to spinous process at 0°, 45° abduction, and 90° abduction; asymmetry >1.5 cm suggests scapular dyskinesis
• Winged scapula: ask patient to push against a wall; medial winging = long thoracic nerve palsy (serratus anterior); lateral winging = spinal accessory nerve palsy (trapezius)

The constellation of examination findings — rather than any single test — determines the clinical diagnosis. The following clinical patterns represent the most common diagnostic scenarios encountered in rheumatology practice.

Pattern Recognition Table

Frozen Shoulder — The Hallmark of Global Restriction

Three phases of frozen shoulder:

Rotator Cuff Pathology — The Painful Arc + Weakness Pattern

Rotator cuff disease represents a spectrum from tendinopathy to partial-thickness tears to full-thickness tears. The examination pattern is:

• Painful arc (60–120° abduction) — present in tendinopathy and tears
• Resisted weakness — specific to the involved tendon (Jobe for supraspinatus, ER for infraspinatus, IR for subscapularis)
• Passive ROM preserved — this is the critical differentiator from frozen shoulder
• Lag signs — indicate full-thickness tears (high specificity)

Bursitis vs Tendinopathy

Subacromial bursitis and rotator cuff tendinopathy frequently coexist but can be distinguished clinically:

• Bursitis alone: Painful arc, pain on Neer/Hawkins, but no weakness on resisted testing
• Tendinopathy: Painful arc plus weakness on resisted testing of the specific tendon
• Bursitis: Pain with passive internal rotation of the abducted arm (Hawkins–Kennedy positive)
• Both improve with subacromial injection of local anaesthetic ± corticosteroid (diagnostic injection)

Inflammatory Shoulder — Red Flags for Systemic Disease

Constant–Murley Shoulder Score

The Constant–Murley score is the most widely used validated outcome measure for shoulder function. It provides a composite score (0–100 points) incorporating subjective and objective components:

Interpretation: 90–100 = excellent; 80–89 = good; 70–79 = fair; <70 = poor. Age- and sex-adjusted normal values are available. The Constant–Murley score is used for monitoring treatment outcomes in rotator cuff repair, arthroplasty, and frozen shoulder management. It is less useful in acute settings where pain limits full testing.

Clinical examination guides investigation selection. Imaging should be directed by the working diagnosis derived from examination findings, not used as a screening tool for all shoulder pain.

Laboratory Investigations

Imaging

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