Patient’s Name

DOB

MRN

Date of Visit

Shoulder Pain H & P

HPI KEY: Y = Yes (positive) N = No (negative) NE= Not Examined

History elements to ask: - Onset of symptoms

- Mechanism of injury/ History of trauma or injury

- Acute traumatic, overuse, or spontaneous onset

- Pop or dislocation with injury

- Location of pain

- Neck pain

- Radiation of pain

- Provoking/alleviating factors

- Painful arc (60-120 o

abduction)

- Activities limited

PMH Prior shoulder injury or instability

Prior shoulder surgery

Other orthopedic history (surgeries, arthritis, trauma, injuries etc…)

Physical Exam Inspection

Swelling Y N NE

Erythema Y N NE

Bruising Y N NE

Atrophy Y N NE

Other deformity:________________________________

ROM (full active/passive)

Flexion Y N NE

Abduction Y N NE

Cross Body Adduction Y N NE

External rotation Y N NE

Internal rotation Y N NE

Winging of scapula Y N NE

Scapular dyskinesis Y N NE

Cervical Y N NE

Strength

Abduction Y N NE

External Rotation Y N NE

Internal rotation Y N NE

Empty can test (supraspinatus) Y N NE

Lift-off test (subscapularis) Y N NE

Drop Arm Test (supraspinatus) Y N NE

Special Tests

Impingement

Neer’s test Y N NE

Hawkin’s test Y N NE

Biceps Tendinitis

Speed’s test Y N NE

Labral Tear

O’Brien’s Test Y N NE

Crank Test Y N NE

Instability Tests

Apprehension test Y N NE

Relocation maneuver Y N NE

Palpation (pain elicited)

Sternoclavicular (SC) joint Y N NE

Clavicle Y N NE

Acromioclavicular (AC) joint Y N NE

Greater tuberosity Y N NE

Subacromial Y N NE

Biciptal Groove Y N NE

Neurovascular

Sensation Y N NE

Distal pulses Y N NE

Assessment (circle suspected diagnosis) AC joint arthritis

AC joint separation

Adhesive capsulitis (Frozen shoulder)

Biceps tendonitis

Biceps tendon rupture

Brachial plexopathy

Calcific tendonitis/bursitis

Clavicular fracture

Glenohumeral joint osteoarthritis

Greater tuberosity avulsion fracture

Multidirectional instability

Rheumatoid arthritis

Rotator cuff tear

Rotator cuff tendonopathy

Shoulder dislocation/subluxation

Subacromial bursitis

Subacromial impingement

Other:_____________________________

Plan

1) Treatment (Circle all employed)

Rest, activity modification, ice

Exercises: (specify)___________________________

Shoulder Immobilizer/Sling

Aspiration/Injection:______________________________

2) Medications

NSAIDs Y N Specify:________________________ Other:_____________________________________

3) Imaging

X-rays Y N MRI Y N If yes, specify test ordered:_____________________

4) Referral Sports Med Y N Orthopedics Y N Physical Therapy Y N

5) Follow up: ______________

© Ashwin Rao and Jonathan Drezner, 2007

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Figure 11- Apprehension Test: Abduct shoulder to

while the arm is externally rotated with concominant

anterior pressure to the humerus. A sense of

instability with this maneuver suggests anterior

instability due to a labral tear.

Figures 1 & 2: Shoulder Anatomy- Figure 1 demonstrates muscular landmarks, including rotator cuff attachments. The supraspinatus inserts most superiorly, followed

by the infraspinatus, teres minor, and subscapularis. Figure 2 more clearly identifies the 3 joints of the shoulder (SC, AC, glenohumeral) as well as other bony landmarks

Figure 6- Neer’s Impingment Test: Fully Pronate

the arm and then flex at the shoulder against

resistance. Asesseses test for impingement of the

rotator cuff tendons under the coracoacromial arch.

Figure 3- Empty Can Test: Elevate the arms

against resistance with elbows extended, the

arms abducted and the thumbs pointing downward. Assesses for supraspinatus injury

Figure 4-External Rotation Test: Externally rotate the

arms against resistance, while te arms are at the side and

the elbows are flexed to 90 degrees. Assesses for teres minor and infraspinatus injury.

Figure 7 -Hawkin’s Test: Elevate shoulder to 90o, while

keeping elbow flexed at 90 o. Support the arm and then

internally rotate the humerus. Pain with this maneuver suggests subacromial impingement of rotator cuff injury.

Figure 8-Cross-Body Adduction: Adduct

arm passively across body. Pain at AC joint indicates injury or arthritis.

Figure 9- Speed’s Test: Flex

the elbow against resistance.

Pain indicates biceps tendonitis or injury

Figure 10-Crank Test: Abduct shoulder to 90 o and

slowly internally rotate while a gentle axial load is

applied to the glenohumeral joint. Pain, catching, or

grinding in the shoulder indicates a labral tear (SLAP lesion).

Figure 5- Lift Off Test: Place 1 hand

behind the back and push out against

resistance. Assesses for subscapularis injury.