Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Shoulder pain - Management
How should I assess a painful shoulder?

  • Exclude referred pain from the neck, diaphragm, heart (e.g. ischaemic heart disease), lungs (e.g. apical lung cancer), and polymyalgia rheumatica (typically occurring in an elderly woman, presenting with bilateral shoulder pain associated with stiffness and loss of function and general ill health).
  • Enquire about:
    • Characteristics of the pain:
      • Onset (e.g. gradual, acute, following injury, progressive, or non-progressive), and exacerbating and relieving factors.
      • Site of maximal pain (e.g. upper lateral arm, localized over acromioclavicular joint, musculoskeletal pain elsewhere).
      • Relationship of the pain to movement or rest, and whether it is present at night.
      • Additional symptoms (e.g. instability, neurological symptoms).
    • Functional impairment:
      • Whether the dominant or non-dominant arm is affected.
      • Effects on work or sport.
      • Instability (e.g. history of dislocation).
    • Systemic features (e.g. fever, night sweats, weight loss, generalized joint pains, rash).
    • History of musculoskeletal or shoulder problems, or symptoms elsewhere.
    • Significant comorbidity (e.g. diabetes, stroke, cancer).
    • Concomitant medications and potential adverse drug reactions.
  • Perform an examination (comparing both shoulders):
    • As an initial screening test, ask the person to place the palms of their hands at the base of the neck with elbows pointing laterally and then to put their arms down and try to put the back of the hands between the shoulder blades. However, be aware that this also involves joints other than the shoulder (i.e. elbow, wrist).
    • Inspect from the front, side, and behind for muscle wasting, swelling and deformity, or bruising.
    • Palpate the shoulder bones (clavicle, proximal humerus, and scapula) and joints (sternoclavicular, acromioclavicular, glenohumeral), looking for tenderness, warmth and swelling, and crepitus.
    • Assess active, passive, and resisted movement of the shoulder joint.
    • Look for painful arc (pain between 70–120 degrees of active abduction). If this is present, specific tests can help diagnose impingement, including:
      • Hawkins' test: abduct the person's arm to 90 degrees and rotate between internal and external rotation. If there is pain with internal rotation, this is a positive Hawkins' impingement sign.
  • Investigate if appropriate:
    • Investigations should be guided by the suspected cause. Blood tests and radiography are not usually indicated as part of a primary care assessment of shoulder pain, but may be appropriate if, for example, malignancy or polymyalgia rheumatica is suspected.
    • If diabetes is suspected in a person with shoulder pain (frozen shoulder is more common in people with diabetes), consider testing to exclude this.
  • Ensure that red flag features for the following conditions have been excluded:
    • Tumour — history of cancer; symptoms and signs of cancer; unexplained deformity, mass, or swelling; lymphadenopathy. Progressive, well-localized pain, unrelated to movement, often night-predominant; not reproduced by palpation or movement during examination.
    • Infection — red skin, fever, systemically unwell.
    • Unreduced dislocation — trauma, epileptic fit, electric shock, loss of rotation, abnormal shape.
    • Acute rotator cuff tear — recent trauma, acute disabling pain and significant weakness, positive drop arm test (inability to hold the affected arm in 90 degrees of abduction then lower it slowly to the side).
    • Neurological lesion — unexplained wasting, significant sensory or motor deficit.

© NHS Institute for Innovation and Improvement