Shoulder pain (approach)

The regional approach hub for shoulder pain. For specific conditions, see the individual Shoulder pages.

Red flags

Fever, redness/swelling, significant trauma (dislocation/fracture/cuff tear), inflammatory-arthritis or cancer history, motor/sensory loss, and sudden onset with chest or abdominal pain.

Conditions by age and structure

Problem	Structure	Age	Key exam finding
Instability	Labrum/capsule	15–30	Apprehension test positive
Impingement / cuff tendinopathy	Rotator cuff	30–60	Painful arc 60–120°
Rotator cuff tear	Supraspinatus	50+	Weak external rotation, empty-can test
Adhesive capsulitis	GH joint capsule	40–60	Global loss of ROM (esp. external rotation)
AC joint pain	AC joint	25–45	Paxinos sign
Glenohumeral OA	GH cartilage	70+	Crepitus, loss of external rotation

Frozen shoulder is predominantly a clinical diagnosis, and imaging aimed at confirming it is usually unhelpful. The key distinguishing feature on examination is that restriction is mechanical, not just pain-limited: the pathognomonic sign is an almost complete loss of active and passive external rotation, in contrast to a painful-arc restriction (which the patient can usually push through) or pain-limited restriction (which the examiner can usually overcome passively). Clinical presentation classically runs through three overlapping phases — a painful phase (2–9 months), a stiffening/freezing phase (4–12 months, pain eases but stiffness persists and external rotation is near-obliterated), and a resolution/thawing phase (12–42 months).

Examination (look, feel, move)

• Inspection: shape, wasting, deformity, compare sides.
• Palpation: AC joint, long head of biceps, supraspinatus, subacromial space/bursa.
• Active ROM: abduction 0–180° (painful arc 60–120° = subacromial impingement), internal rotation, external rotation.
• Resisted (localises tendinopathy): abduction → supraspinatus (empty-can test); internal rotation → subscapularis; external rotation → infraspinatus ± teres minor.
• Impingement special tests: the Neer impingement sign is positive if the patient reports pain with passive shoulder forward flexion beyond 90°; the Hawkins test is positive when the examiner positions the shoulder and elbow passively at 90° of flexion in front of the body and the patient reports pain on passive internal rotation. The Jobe (empty-can) test is positive for pain or weakness resisting downward pressure with the shoulder at 90° forward flexion/abduction in the scapular plane and the thumb pointing down; a positive drop-arm test (inability to slowly lower the arm from 90° abduction in a controlled manner) suggests a large cuff tear rather than simple tendinopathy.
• Biceps: Speed’s test — pain in the bicipital groove when the patient forward-elevates the shoulder against resistance with the elbow slightly flexed and forearm supinated — supports bicipital tendinopathy.
• After trauma/suspected dislocation: examine the axillary nerve specifically (most commonly injured in shoulder dislocation) — check sensation over the lateral shoulder (“patch” distribution) and deltoid motor function (abduction/extension) before and after any reduction attempt.

Rotator cuff vs adhesive capsulitis: both cause severe night pain, but the cuff gives a painful arc / movement-specific restriction whereas capsulitis gives global stiffness in all directions.

Investigations

• Bloods (selectively): ESR/CRP (PMR/infection), rheumatoid factor/anti-CCP, urate; ECG if cardiac suspected.
• Imaging: X-ray (fracture, OA, calcific tendinopathy); ultrasound for cuff tears (beware age-related false positives — asymptomatic tears are common over 60).

Children: shoulder pain is uncommon — beware septic arthritis/osteomyelitis; also consider swimmer’s shoulder.