Shoulder Joint Assessment Essentials: ROM, End-Feel, Strength, and Functional Testing

1) Observation: Scapular Positioning and Protective Posture

Start with a quick, quiet observation before touching the patient. Your goal is to identify scapular resting position, thoracic posture, and any protective strategies that will influence ROM, strength, and functional testing.

What to look for (standing, arms relaxed)

• Scapular resting position: winging (medial border prominence), excessive protraction, downward rotation, or asymmetry in height (elevation/depression).
• Clavicle and shoulder girdle posture: guarded elevation, anterior shoulder rounding, or visible deltoid/upper trap overactivity.
• Protective posture: arm held close to body, reduced arm swing, avoidance of reaching, or supporting the involved arm with the other hand.
• Thoracic contribution: increased kyphosis or rib flare that may limit overhead motion.
• Movement quality during simple tasks: ask for a slow bilateral shoulder flexion to ~90° just to observe scapular rhythm and pain behavior (not a formal test yet).

Quick documentation cues

• Scapula: R protracted + mild winging; protective shoulder elevation with reaching.
• Posture: thoracic kyphosis; humeral IR resting posture.

2) AROM Sequence: Flexion, Abduction, External/Internal Rotation (with Substitution Cues)

Use a consistent AROM order to improve reliability. Compare sides, note pain location and timing, and watch for substitutions that can inflate apparent ROM or hide deficits.

AROM step-by-step sequence

1. Flexion (sagittal plane): patient raises arm overhead with thumb up if tolerated. Observe scapular upward rotation and trunk motion.
2. Abduction (frontal/scapular plane): raise arm out to the side (often slightly forward in the scapular plane is more comfortable). Watch for painful arc and scapular hitching.
3. External rotation (ER): elbow at side, flexed to 90°. Rotate forearm outward. Then repeat at 90° abduction only if safe and tolerated.
4. Internal rotation (IR): elbow at side, flexed to 90°. Rotate forearm inward. Then note functional IR with hand-behind-back later.

Common substitutions and how to cue them away

What to record during AROM

• Range estimate: e.g., Flexion ~140° (or goniometric value if measured).
• Pain behavior: onset angle, location, and whether pain limits motion.
• Quality: smooth vs. jerky, scapular dyskinesis, compensations.

3) PROM: Stabilization and End-Feel Notes

PROM helps differentiate mobility limitation from strength/control limitation. The shoulder complex requires stabilization to avoid measuring scapulothoracic motion instead of glenohumeral motion.

Key stabilization principles (practical)

• Control the scapula: use your hand to stabilize the lateral border/acromion region to limit excessive scapular motion when assessing glenohumeral contribution.
• Choose positions that reduce guarding: supine often decreases protective tone and allows clearer end-feel assessment.
• Move slowly into resistance: note the first point of resistance (R1) and the maximal tolerated range (R2) if relevant to your documentation style.

PROM sequence and notes

1. PROM flexion (supine): stabilize scapula as needed near end range.
   • End-feel notes: capsular/firm limitation may suggest posterior/inferior capsular tightness; empty end-feel suggests pain-limited.
2. PROM abduction (supine): monitor for superior humeral head migration signs (painful shrug, guarding).
   • End-feel notes: firm capsular end-feel with limited ER often clusters with mobility deficit patterns; painful/empty may suggest irritation.
3. PROM ER/IR at 0° abduction (supine): towel under humerus; keep elbow at 90°. Stabilize anterior shoulder/scapula to reduce anterior glide during ER and scapular protraction during IR.
   • End-feel notes: firm end-feel with clear limitation may indicate capsular restriction; sharp pain or empty end-feel suggests irritability.

Capsular pattern awareness (applied)

If you observe a consistent limitation of ER > abduction > IR with firm end-feel and relatively similar limitations across multiple planes, consider a shoulder mobility deficit pattern. If limitations are inconsistent and pain-dominant, consider irritability or protective guarding as the driver.

4) Basic Strength Tests: Rotator Cuff and Scapular Control Focus

Keep strength testing simple and targeted: rotator cuff (especially ER) and scapular stabilizers (serratus anterior/lower trapezius) often determine tolerance to reaching and lifting.

Continue in our app.

• Listen to the audio with the screen off.
• Earn a certificate upon completion.
• Over 5000 courses for you to explore!

Or continue reading below...

Download the app

Rotator cuff: practical tests

• ER isometric at side: elbow at 90°, towel roll at elbow. Patient pushes into your hand outward.
  • Watch: pain vs. weakness, elbow drift, shoulder hiking.
  • Record: ER iso: 4/5 with lateral shoulder pain 3/10.
• IR isometric at side: patient pushes inward into your hand.
  • Watch: anterior shoulder pain, scapular protraction.
• Abduction/scaption isometric (light): arm ~30–45° in scapular plane, thumb up.
  • Watch: painful arc reproduction, upper trap dominance.

Scapular control: quick clinical checks

• Scapular retraction/depression hold: patient gently “sets” shoulder blade back and down, then holds while you apply light resistance to the arm in flexion or scaption.
  • Positive finding: inability to maintain scapular position, immediate shrugging, or symptom reproduction.
• Wall push-up plus (screen): hands on wall, small push-up, then add “plus” (protraction).
  • Positive finding: winging or loss of control suggests serratus anterior control deficit.

Interpretation tip

If strength appears reduced but improves noticeably when you cue scapular setting (or when symptoms decrease), this supports a scapular control contribution rather than isolated contractile weakness.

5) Simple Functional Tests: Reach Patterns and Loaded Reach Tolerance

Functional tests translate impairments into meaningful tasks. Keep them simple, repeatable, and symptom-monitored.

Hand-behind-head (HBH) reach

• How: patient places hand behind head and attempts to bring elbow out to the side.
• What it biases: combined abduction + ER; scapular upward rotation/posterior tilt.
• Watch: elbow stays forward (ER limitation), trunk side-bend, scapular hiking, pain location (lateral vs. anterior vs. posterior).
• Record example: HBH: R limited; elbow remains anterior; pain lateral 4/10.

Hand-behind-back (HBB) reach

• How: patient reaches behind back toward opposite scapula (note highest spinal level reached or relative side-to-side difference).
• What it biases: combined extension + adduction + IR; posterior shoulder mobility and scapular anterior tilt control.
• Watch: trunk flexion/rotation substitution, shoulder protraction, anterior shoulder pain.
• Record example: HBB: R to L5 vs L to T10; firm stretch posterior shoulder.

Loaded reach tolerance (simple, safe progression)

Use a light load to assess symptom behavior under demand without provoking a flare.

1. Select load: 0.5–2 kg (or a light household object). Choose the lowest load that still challenges control.
2. Task: forward reach to shoulder height (or slightly below), 5 slow reps; then optional overhead reach only if baseline symptoms are low and AROM is acceptable.
3. Rules: stop if pain escalates >2 points above baseline or if compensations dominate (shrugging, trunk lean).
4. Record: pain rating, rep tolerance, and compensation pattern. Example: Loaded reach 1 kg to 90°: 5 reps; pain 2/10; mild scapular hike reps 4–5.

6) Symptom Interpretation Patterns Suggesting Likely Impairments

Use clusters of findings rather than a single test. The goal here is not a definitive diagnosis but a working impairment hypothesis to guide next evaluation steps.

Pattern A: Mobility deficit (capsular/soft tissue restriction)

• Typical findings: AROM and PROM both limited in similar directions; firm end-feel; substitutions increase near end range; functional reaches limited with “stretch” more than sharp pain.
• Common functional impact: difficulty with overhead reach (flexion/abduction) and/or HBB reach (IR/extension).
• Next evaluation focus: quantify side-to-side PROM differences with scapular stabilization; assess thoracic mobility contribution; identify the most limiting plane (often ER or IR).

Pattern B: Rotator cuff irritation / contractile sensitivity

• Typical findings: painful AROM (often mid-range arc), PROM near-normal or limited by pain (empty end-feel), pain with resisted ER/abduction, night pain or pain with lifting may be reported (if already known from history).
• Common functional impact: painful reaching away from body, lifting, or sustained overhead tasks; loaded reach provokes symptoms early.
• Next evaluation focus: compare isometrics (ER vs IR vs abduction) for pain/weakness; monitor symptom response to scapular setting; consider irritability level to dose further testing safely.

Pattern C: Scapular control deficit (motor control/coordination)

• Typical findings: visible dyskinesis (winging, early shrug), strength tests appear weaker with poor scapular position, symptoms improve with cueing or manual scapular assistance, PROM relatively preserved compared to AROM quality.
• Common functional impact: fatigue with repetitive reaching, discomfort with sustained postures, inconsistent pain that correlates with control demands.
• Next evaluation focus: test repeatability with cueing (set scapula, slow tempo); assess serratus anterior and lower trap endurance via low-load tasks; observe thoracic posture influence.

Sample Write-Up: Converting Findings into Prioritized Problems + Safe Next-Step Plan

Scenario (example findings)

Observation: Right scapula mildly protracted at rest; slight protective elevation during arm elevation. Thoracic kyphosis noted.

AROM: R flexion ~145° with trunk extension substitution after ~120°; pain lateral shoulder 3/10 near end range. R abduction ~120° with scapular hike and pain 4/10 between ~80–110°. ER at side limited vs L; elbow drifts away from trunk unless towel used. IR at side near-symmetric.

PROM (supine, scapular stabilization): R flexion mildly limited with firm end-feel. R ER at side limited with firm end-feel; IR relatively preserved. No clear empty end-feel.

Strength: R ER isometric 4-/5 with discomfort 3/10; IR 5/5 pain-free. Scaption isometric reproduces lateral pain 3–4/10 with upper trap dominance. Wall push-up plus shows mild winging and early fatigue on R.

Functional: HBH limited on R (elbow stays forward, compensatory neck/shoulder elevation). HBB: R reaches L5 vs L reaches T10 with firm posterior shoulder stretch. Loaded reach 1 kg to 90°: tolerates 5 reps, mild scapular hike last 2 reps; pain stays 2–3/10.

Impairment interpretation (working)

• Cluster suggests mobility deficit (notably ER and HBB limitation with firm end-feel) plus scapular control deficit (hiking/winging, fatigue), with mild contractile sensitivity of ER/scaption rather than high irritability.

Prioritized problem list (2–3 items)

1. Glenohumeral mobility restriction (ER and combined IR/extension reach) contributing to limited overhead and behind-back function.
2. Scapular upward rotation/posterior tilt control deficit evidenced by hiking/winging and improved performance with cueing.
3. Rotator cuff load intolerance (mild) with painful weakness in ER/scaption under resistance.

Safe next-step plan for further evaluation (not treatment)

• Quantify key PROM with consistent stabilization: measure ER and IR at 0° abduction (and at 90° only if tolerated) to confirm the primary mobility limiter and side-to-side difference.
• Re-test AROM with standardized cues: repeat flexion/abduction using “ribs down” and “shoulder away from ear” to determine how much limitation is control vs true mobility.
• Symptom-guided contractile testing: repeat ER and scaption isometrics at two angles (neutral and slight elevation) to see if pain is angle-dependent (helps gauge load tolerance and irritability).
• Functional tolerance progression: if loaded reach to 90° is tolerated, trial a slightly longer lever (reach farther) before increasing load; stop if pain increases >2/10 or compensations dominate.
• Document response to scapular assistance/cueing: note whether symptoms and ROM improve with scapular setting, supporting a scapular control contribution and guiding what to prioritize in subsequent assessment sessions.