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Shoulder red flags

What you cannot afford to miss in shoulder pain, before any special test.

Most shoulder pain is musculoskeletal. These are the conditions that are not, or that need referral before treatment, with the features that point to each. Every row carries its source, listed at the foot of the page.

Use with your local protocols. Referral pathways, and how urgently to act, differ between health services and countries: where your local protocol or current guideline differs, follow it. Never delay emergency care to check a protocol.

Can’t missWhat points to it
Cardiac referred pain1,2Features include an exertional pattern, chest symptoms, spread to the jaw or to either arm, cardiac risk factors and no mechanical trigger. The presentation should be managed as a possible cardiac event rather than a shoulder complaint: call an ambulance if symptoms are present now. If they have settled, medical assessment should still be arranged the same day, and an ambulance called if there is any doubt; the shoulder examination should not be continued.
Malignancy1,3Features include night pain not relieved by position, unexplained weight loss and a history of cancer. Apical (Pancoast) lung tumours can present as shoulder pain, sometimes spreading down the inner arm to the little finger, with wasting of the small hand muscles or a drooping eyelid and small pupil on that side, often in a smoker. Urgent medical review should be arranged (within days, not at the next routine visit) before conservative care continues.
Septic arthritis4A hot, swollen, painful shoulder with restricted movement, with or without fever or feeling unwell. Fever is often absent, so a normal temperature does not rule infection out. The risk is higher after injection or in immunocompromised patients. The patient requires same-day medical assessment.
Fracture or unreduced dislocation5,6Clavicle: point tenderness, a step or deformity after a fall or blow. Proximal humerus: an older patient, a fall onto the arm, marked bruising and inability to move the arm. Unreduced dislocation (loss of the normal shoulder contour, arm held fixed): send the patient to an emergency department now. Suspected fracture: same-day medical assessment. In both, pulses and sensation should be checked first, and strength testing deferred until fracture is excluded.
Upper-limb deep vein thrombosis (DVT)7Acute arm swelling, heaviness or dusky discolouration, after repetitive overhead exertion or in the presence of a central line, pacemaker lead or cancer. The patient requires same-day medical assessment; if there is chest pain, breathlessness or coughing up blood, call an ambulance.
Polymyalgia rheumatica8,9Age 50 or over, involvement of both shoulders (often the hips as well), morning stiffness lasting more than 45 minutes. It should not be mistaken for bilateral frozen shoulder. Refer for inflammatory markers and consider giant cell arteritis: new headache, scalp tenderness or jaw pain on chewing requires same-day medical assessment; any change in vision is an emergency: send the patient to an emergency department now.
Neck masquerading as shoulder10Features include pain spreading below the elbow, dermatomal or reflex change and symptoms with neck movement. Signs in both arms, worsening weakness, hand clumsiness or a change in gait suggest cervical myelopathy: refer for medical assessment, with the urgency set out on the neck red flags page.
Calcific tendinitis vs infection11Sudden, severe pain with little or no trauma, and guarded movement. The cause is usually calcific tendinitis, but in a hot, unwell patient infection must still be excluded.
Suprascapular nerve entrapment12Wasting of infraspinatus (with or without supraspinatus), with weakness and pain over the posterior shoulder. The weakness is out of proportion to the pain, and passive range is full. Refer for medical assessment.

A red flag raises suspicion; it does not make the diagnosis, and its absence does not rule the condition out. The table is not a complete list of every serious condition, and it is not a clinical protocol. When a red flag is present, act on the referral advice in the row, in line with your local protocols. This page is for registered health practitioners and students and is not clinical advice for patients; see the terms of use.

Last checked against the cited sources: 15 October 2026.

Then the tests: Shoulder special tests, with sensitivity, specificity and likelihood ratios.

Get the book for the shoulder questions that matter: neck or shoulder, a painful cuff or a torn one, and an unstable joint or the labrum

This table opens the chapter ‘The shoulder’ in Rule It In, Rule It Out. The book then works through the questions that matter in this region, with the published figures for each test and how to read them.

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Sources

  1. Mitchell C, Adebajo A, Hay E, Carr A. Shoulder pain: diagnosis and management in primary care. BMJ. 2005;331(7525):1124–1128. Link
  2. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. Link
  3. Panagopoulos N, Leivaditis V, Koletsis E, et al. Pancoast tumors: characteristics and preoperative assessment. J Thorac Dis. 2014;6(Suppl 1):S108–S115. Link
  4. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478–1488. Link
  5. Le MQT, Myers K, May T, Hosseinzadeh S. Clavicle Fracture. StatPearls Publishing; updated March 27, 2026. Link
  6. Pencle FJ, Varacallo MA. Proximal Humerus Fractures. StatPearls Publishing; updated August 4, 2023. Link
  7. Illig KA, Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg. 2010;51(6):1538–1547. Link
  8. Dasgupta B, Cimmino MA, Kremers HM, Schmidt WA, Schirmer M, Salvarani C, et al. 2012 Provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Arthritis Rheum. 2012;64(4):943–954. Link
  9. Mackie SL, Dejaco C, Appenzeller S, et al. British Society for Rheumatology guideline on diagnosis and treatment of giant cell arteritis. Rheumatology (Oxford). 2020;59(3):e1–e23. Link
  10. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52–62. Link
  11. Guido F, Venturin D, De Santis A, Giovannico G, Brindisino F. Clinical features in rotator cuff calcific tendinopathy: a scoping review. Shoulder Elbow. 2025;17(2):121–129. Link
  12. Cho J, Yi J, Kim H, et al. Diagnosis of suprascapular nerve entrapment syndrome based on the infraspinatus muscle cross-sectional area on shoulder MRI. Medicine (Baltimore). 2024;103(29):e39066. Link

Red flags for other regions: Neck · Elbow · Wrist and hand · Thoracic spine and chest wall · Low back and pelvis · Hip and groin · Knee · Ankle and foot

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