Knowledge · Clinical Examination

Shoulder Examination: Look, Feel, Move and the Special Tests That Count

By Dr Richard Miller, MBChB FRCS with the MRCS Part B Questions Team · Reviewed 15 September 2026

In brief

Examine the shoulder from front, side and behind, palpate the bony landmarks, then test active, passive and resisted movement before any special test; NICE CKS puts the painful arc between 70 and 120 degrees of active abduction.

Examine the shoulder in a fixed order: look from the front, side and behind, palpate the bony landmarks, then test active, passive and resisted movement before any special test. NICE Clinical Knowledge Summaries describe a painful arc between 70 and 120 degrees of active abduction, and the British Elbow and Shoulder Society asks for a combination of provocative tests rather than one.

Key takeaways

NICE CKS asks you to compare both shoulders and inspect from the front, the side and behind.
A painful arc is pain between 70 and 120 degrees of active abduction, according to NICE CKS.
The cross-arm test is positive when raising the arm to 90 degrees and adducting it hurts over the acromioclavicular joint.
The 2025 BESS and BOA guideline recommends a combination of Hawkins-Kennedy, Neer's, Jobe's and external rotation resistance tests, not a single test.
NICE CKS states that no single shoulder test is both valid and reliable, so never call one test diagnostic.

What is the examiner marking at the shoulder station?

The Intercollegiate blueprint marks a physical examination station out of 20 across four domains: clinical and technical skill carries 8 marks, and clinical knowledge and its application, communication and professionalism carry 4 marks each. The station also gets a separate global rating of pass, borderline or fail.

More than half the marks therefore sit outside your knowledge of the condition, so a silent but technically correct examination scores poorly. You are signalled at six minutes of the nine to present your findings, so the sequence has to finish inside six.

The examiner is marking a safe, fluent sequence and your interpretation, not a list of eponyms. The MRCS Part B OSCE reports separate knowledge and skills scores, and both must be passed.

Royal College of Surgeons of England describes the applied skills stations as covering physical examination and surgical technique, so the shoulder station tests process as much as pathology.

How should you start the shoulder examination?

Introduce yourself, gain consent, expose both shoulders and ask about pain before you touch the patient. Then compare the two sides throughout.

NICE CKS suggests a quick screening test: ask the patient to place their palms at the base of the neck with elbows out, then to put the backs of the hands between the shoulder blades.

What am I looking for on inspection of the shoulder?

Inspect the shoulder from the front, the side and behind for muscle wasting, swelling, deformity or bruising, as NICE CKS directs.

Skin, for scars, sinuses and bruising
Muscle bulk, particularly deltoid and the supraspinatus and infraspinatus fossae
Bone and joint contour, including a step at the acromioclavicular joint and the position of the humeral head
Scapular position from behind, since medial winging is visible at rest or on wall press

**Medial scapular winging** is winging caused by weakness of serratus anterior, usually from long thoracic nerve injury, while lateral winging follows trapezius or rhomboid dysfunction.

What should you palpate, and in what order?

Palpate the shoulder bones and joints in a set order, looking for tenderness, warmth, swelling and crepitus. NICE CKS names the clavicle, proximal humerus and scapula, and the sternoclavicular, acromioclavicular and glenohumeral joints.

Work medially to laterally so nothing is missed: sternoclavicular joint, clavicle, acromioclavicular joint, acromion, greater tuberosity, coracoid, then the spine of the scapula from behind.

Which movements should you test at the shoulder?

Assess active, then passive, then resisted movement, as NICE CKS sets out, testing flexion, extension, abduction, adduction, and internal and external rotation.

Active movement first, so you see what the patient can do unaided
Passive movement next, which separates stiffness from weakness or pain inhibition
Resisted movement last, which points to the tendon or muscle at fault
Watch for the painful arc between 70 and 120 degrees, and check whether pain is worse with the thumb down and against resistance

Which special tests should you offer for the rotator cuff?

Offer a combination rather than one test. The 2025 BESS and BOA subacromial shoulder pain guideline states that a combination of Hawkins-Kennedy, Neer's, Jobe's and external rotation resistance tests is useful to diagnose subacromial impingement.

The same guideline reports limited utility for scapular dyskinesis and scapular reposition tests in practice, so do not lean on them.

Say the caveat out loud. NICE CKS records that there is no evidence any specific shoulder test is both valid and reliable, and that a review found no single test could be reliably recommended to make a diagnosis.

How do you test for instability and acromioclavicular pain?

Use the cross-arm test for the acromioclavicular joint: NICE CKS calls it positive when the patient raises the affected arm to 90 degrees, actively adducts the shoulder, and reports pain over that joint.

For instability, take a careful history first, including the age at first dislocation, the number of episodes and the direction, which NICE CKS asks for explicitly. Apprehension testing follows, gently.

What are the most common mistakes at the shoulder station?

Starting with special tests before look, feel and move
Testing only active movement, which hides a frozen or weak shoulder
Calling one impingement test diagnostic when NICE CKS says no single test is reliable
Forgetting the neck, which NICE CKS asks you to examine as a source of referred pain
Hurting the patient with an aggressive apprehension or cross-arm test

How should you finish the shoulder examination?

Offer to examine the joint above and below, assess neurovascular status of the limb, and say what imaging you would request.

NICE CKS supports anteroposterior and lateral shoulder radiographs after trauma, with severe pain, significantly restricted movement, red flags, suspected arthritis, or symptoms lasting more than four weeks.

The MRCS Part B Questions bank has a shoulder examination station at /Sample-Questions.

Key evidence

Shoulder pain: how should I assess someone with a painful shoulder? — NICE Clinical Knowledge Summaries (2022)
BESS/BOA Patient Care Pathway: Subacromial Shoulder Pain — British Elbow and Shoulder Society and British Orthopaedic Association (2025)
Winging of the Scapula — StatPearls, NCBI Bookshelf (2025)
Intercollegiate MRCS Part B OSCE — Royal College of Surgeons of England (2026)

FAQ

How long should a shoulder examination take in the OSCE?

Plan to complete look, feel and move inside the first few minutes so there is time for special tests and your summary. Royal College of Surgeons of England describes nine-minute stations with seventeen examined stations in the OSCE, so pace matters. Practise the sequence until it runs without pauses.

What is a painful arc and what does it mean?

NICE CKS defines the painful arc as pain between 70 and 120 degrees of active abduction. It is associated with subacromial pain, and CKS suggests checking whether the pain is worse with the thumb down and against resistance. It is a pointer, not a diagnosis.

Which shoulder special tests should I actually perform?

The 2025 BESS and BOA guideline supports combining Hawkins-Kennedy, Neer's, Jobe's and external rotation resistance tests for subacromial impingement. Performing a sensible combination and interpreting it cautiously scores better than a long list. Say why you chose them.

Do I need to examine the neck at a shoulder station?

Yes, or at least offer it. NICE CKS asks you to examine the neck, arms, axillae and chest wall for sources of referred pain and to assess cervical spine range of movement. If neck movement reproduces the pain, the problem may not be the shoulder.

What is scapular winging and how do I show it?

Medial winging comes from serratus anterior weakness, usually after long thoracic nerve injury, while lateral winging follows trapezius or rhomboid dysfunction. Look at the back from behind, then ask the patient to push against a wall with outstretched arms. Describe what you see rather than naming a lesion too quickly.

Should I ask for an ultrasound scan of the shoulder?

Not as a first move. NICE CKS records the BESS and BOA position that diagnostic ultrasound belongs in secondary care and that findings must be interpreted alongside symptoms. Partial tears are common findings and can be asymptomatic.

The MRCS Part B Questions Team

Written and maintained by doctors who have sat and scored well at this interview, and reviewed against the current published guideline in each case. Guidance changes — check the source before you rely on a threshold.

Last reviewed 15 September 2026

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