• 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.

Rotator cuff disorders:

• Usually affect people 35 years of age or older.
• If the person is younger than 50 years of age, consider a tendonitis of the cuff, or possible partial thickness tear. If the person is 50 years of age or older, consider a rotator cuff tear.
• Most pain occurs when performing overhead activities.
• On examination, a painful arc of movement between 60–120 degrees of abduction is found. Pain can also occur on the front and side of the shoulder, and at night.
• Active range of movement is limited, but there is a full passive range of movement.
• Massive rotator cuff tear is suggested if there is a history of trauma or dislocation, severe pain, profound weakness of abduction, or an inability to maintain the arm in 90 degrees of abduction then lower it to the side slowly (positive drop arm test).

Frozen shoulder:

• Common in people older than 40 years of age (if older than 60 years, also consider arthritis). More common in women and people with diabetes.
• May occur secondary to trauma, but the cause is often unknown.
• Frozen shoulder progresses through several stages:
• Pain:
• Gradual onset of aching upper arm pain which can become severe, can radiate down the arm (not below the elbow), and disturbs sleep at night because of the person's inability to lie on the affected side. Diagnosis can be difficult at this stage before stiffness becomes evident.
• Stiffness:
• There is global (in all directions) limitation of both active and passive range of movement, including restriction of external rotation with elbows held at 90 degrees and upper arms held at the sides, and limitation of abduction. Function is substantially limited. Pain is less severe (rest pain and night pain have usually subsided) but is still present at the end of the range of movement.
• Resolving phase:
• Gradual improvement in range of movement with less discomfort. There may be residual mild restriction of range of movement.
• Additional features:
• Can affect one, or both shoulders (but rarely together).
• The affected arm may be held in adduction and internal rotation.
• Tenderness over anterior capsule.
• No weakness.

Anterior dislocation:

• History of trauma. Typically involves a fall with the arm externally rotated and abducted.
• Pain and muscle spasm.
• Empty space below the acromion (empty socket) with the humeral head anterior.
• Limited movement.

Instability disorders:

• Usually occurs in people younger than 35 years of age.
• History of dislocation/subluxation.
• Common with overhead work or sports.
• Symptoms may be vague (e.g. athletic young males with activity-related pains in their shoulder, or an inability to perform an overhead throw due to pain). Affected people often describe 'dead arm' symptoms — tingling, weakness, numbness, shoulder fatigue, clicking, locking, or a 'popping' sensation.
• Increased laxity and pain on testing.

Acromioclavicular joint disorders:

• Injuries usually occur in people 20–50 years of age, more commonly in men, mostly in people involved in contact sports, or following a fall on to the shoulder (e.g. rugby, skiing, cycling).
• Localized joint tenderness and limitation of movement due to pain. Pain can also occur on top of the shoulder, especially when the arm is brought across the body, or during weightlifting activities.
• Deformity of the acromioclavicular joint suggests dislocation.
• Osteoarthritis of the acromioclavicular joint tends to occur in older people.

Glenohumeral joint osteoarthritis:

• Typically occurs in older people, or following traumatic injury in younger people.
• Chronic pain that is worse on movement.
• Less specific distribution of pain than other shoulder disorders.
• Decreased range of motion, both actively and passively.

[Tallia and Cardone, 2003; NZGG, 2004; Dias et al, 2005; Hazleman, 2005; Codsi, 2007; NHS Lothian, 2007a; NHS Lothian, 2007b; Burbank et al, 2008; Mitchell, 2008]