Subjective Assessment of the Shoulder

Introduction[edit | edit source]

The subjective examination of the shoulder, but the basics of it can be used as a subjective assessment for any part. The subjective examination is often undervalued in the assessment and management of patients. It's the most crucial aspect of the examination as it determines the severity, irritability, and nature of the patient's condition. Good questioning leads to the formation of a primary hypothesis, possible methods of treatment, and possible prognosis of the injury[1].

Developing Rapport[edit | edit source]

Some tools that can be applied in the subjective assessment that will assist with developing rapport are:

  • The first impression. Make sure you are prepared and ready to receive your patient.
  • Face the patient.
  • Explain that you'll be taking notes during the interview, but that you will be listening to them in between.
  • Make sure you have open body language.
  • Do not interrupt. Interrupting the flow of a patient's dialogue can interrupt them giving you important information from there. It takes patients approximately 92 seconds to explain their problem if not interrupted. Clinicians seem to be seven times more likely to interrupt.

Techniques to use[edit | edit source]

When gathering information, there are a few tools to utilise to make your task easier

  • Ask open-ended questions.
    • This gives a patient a chance to provide detailed answers. Mind the gap, leave gaps for the patients they feel they need to fill.
  • Summarising.
    • This helps to ensure that the physio has obtained the correct version of the events, facts, and the perception of the patient or the athlete. It provides the patient with an opportunity to clarify aspects of history, make amendments to the physio's understanding of the patient's condition, as well as further elaborate on an element which may have been overlooked. It helps us to understand that we're both singing off the same hymn sheet and that we know what the primary requirements of the patients are from this consultation.

Bio-psycho-social approach[edit | edit source]

The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to understand a person's medical condition it is not simply the biological factors to consider, but also the psychological and social factors[2] .

  • Bio (physiological pathology)
  • Psycho (thoughts emotions and behaviours such as psychological distress, fear/avoidance beliefs, current coping methods and attribution)
  • Social (socio-economical, socio-environmental, and cultural factors suchs as work issues, family circumstances and benefits/economics)

This model implies a patient-centered approach. Clinicians need to determine how the problem impacts on the patient's lifestyle and how the patient's lifestyle affects their problems. It's imperative that clinicians understand that is not merely a series of questions, but the process of building a relationship with the patient.

The contents of this subjective examination traditionally, focus on the biomedical, biomechanical and pathoanatomical factors. This way of questioning can limit the clinician's understanding of the patient's unique experience.

Shoulder specific considerations[edit | edit source]

When conducting the subjective interview there are a few key examples that patients will use that can give the therapist a clue as to what the possible diagnosis could be. As we conduct the examination we can rule in and rule out as we generate our hypothesis. And at the end of our subjective examination, we should have an idea of our sort of top three possible areas where we need to make our examination[3].

  • Acromioclavicular Joint
    • Putting on seatbelt
    • Getting dressed
    • Pain with cross-body movement
  • Long head biceps
    • Pain with elbow flexion
  • Subacromial pain
    • Do you get pain in all specific directions, not one specific direction
  • Rotator cuff
    • Pain tends to be more specific and with repeated movements
  • Labrum
    • Explain about catching or clicking
  • Anterior capsule
    • Feeling of anterior instability
  • Humeral head problems
    • Crepitus
  • Referred pain from cervical spine
    • Pain with cervical spine movements
  • Referred visceral pain
    • Think about the skin or eyes, general health, does their pain seem to be related to food that they eat

History[edit | edit source]

An accurate history should include the pain characteristics. Examples of some important questions and conversations relating to shoulder injuries are listed below

  • Has there been stiffness to the shoulder or instability[4]?
  • Have there been any functional impairments?
  • Has there been trauma that brought this on?
  • Do they get any aches and pains in any other joints, either in the same limb or elsewhere in their body?
  • Do they have neck pain?
  • Have they got any systemic or neurological symptoms?
  • Is it related to their occupation or sporting activities?
  • Are they on any medication and could that medication be influencing some of their pain?
  • Have they had previous musculoskeletal problems?
  • Have they had previous history of malignancy?
  • What is the patients general health like?
  • Are there other co-morbidities that could be affecting their pain ?

Red Flags[edit | edit source]

Some red flags to consider are:

  • arthritis
  • pain and weakness
  • sudden loss of ability to actively raise their arm
  • muscle swelling
  • red skin,
  • painful joint[5]
  • fever
  • systemically unwell
  • trauma leading to loss of rotation
  • abnormal shape
  • possible shoulder dislocation, which could sometimes be missed around there
  • new symptoms of inflammation in several joints then we should suspect inflammatory arthritis
  • malignancy
  • referred pain from the neck, heart or lungs
  • polymyalgia rheumatica
  • hemiplegic shoulder[6]

Other tests to consider[edit | edit source]

An x-ray should be considered if

  • There is a history of trauma
  • There is little improvement with conservative treatment
  • Symptoms last greater than four weeks
  • There is severe pain or restriction of movement

Blood tests should be performed if any of the following are suspected

  • malignancy,
  • polymyalgia rheumatica
  • inflammatory arthritis is suspected
  • Patients ought to be tested for diabetes if they present with a frozen shoulder.

Social determinants of health[edit | edit source]

An important factor when assessing the shoulder is to consider the social determinants of health. Social determinants of health[7] are an underlying cause of today’s major societal health dilemmas including obesity, heart disease, diabetes, and depression. Moreover, complex interactions and feedback loops exist among the social determinants of health.

Examples of social determinants of health include:

  • Income level
  • Educational opportunities
  • Occupation, employment status, and workplace safety
  • Gender inequity
  • Racial segregation
  • Food insecurity and inaccessibility of nutritious food choices
  • Access to housing and utility services
  • Early childhood experiences and development
  • Social support and community inclusivity
  • Crime rates and exposure to violent behavior
  • Availability of transportation
  • Neighborhood conditions and physical environment
  • Access to safe drinking water, clean air, and toxin-free environments
  • Recreational and leisure opportunities

We have health screening, which leads for the clinician to act upon the outcomes of the above. Once the problem has been identified, we can refer our patients onto a suitable place where . We need to look and see what the social system is around us and our patients so that we can help identify these problems and help get some solution to these problems.

Other considerations[edit | edit source]

The two other important aspects to consider are smoking, and waist circumference and waist to hip ratio. All three of these have been shown to have an effect on the prevalence of shoulder pain. Smoking is associated with rotator cuff tears, shoulder dysfunction, and shoulder symptoms. It may also accelerate rotator cuff degeneration and increase the prevalence of larger tears. It may increase the risk of symptomatic rotator cuff tears, and which could then consequently need for greater surgical intervention.

Shoulder Physical Examination[edit | edit source]

The shoulder physical examination should include inspection, palpation, active, passive movements, checking their neck, arms, axilla, chest for referred cause and a neurological exam if appropriate. A further presentation or more detailed assessment of the objective assessment is to follow.

References[edit | edit source]

  1. Maxwell C, Robinson K, McCreesh K. Managing shoulder pain: a meta-ethnography exploring healthcare providers’ experiences. Disability and Rehabilitation. 2021 Mar 2:1-3.
  2. Gatchel, Robert J., Peng, Yuan Bo, Peters, Madelon, L.; Fuchs, Perry, N.; Turk, Dennis C. 2007 The biopsychosocial approach to chronic pain: Scientific advances and future directionsfckLR Psychological Bulletin, Vol 133(4), 581-624
  3. Matsen III FA, Tang A, Russ SM, Hsu JE. Relationship between patient-reported assessment of shoulder function and objective range-of-motion measurements. JBJS. 2017 Mar 1;99(5):417-26.
  4. Philp F, Faux-Nightingale A, Woolley S, de Quincey E, Pandyan A. Implications for the design of a Diagnostic Decision Support System (DDSS) to reduce time and cost to diagnosis in paediatric shoulder instability. BMC medical informatics and decision making. 2021 Dec;21(1):1-3.
  5. Barrett E, Larkin L, Caulfield S, De Burca N, Flanagan A, Gilsenan C, Kelleher M, McCarthy E, Murtagh R, McCreesh K. Physical therapy management of nontraumatic shoulder problems lacks high-quality clinical practice guidelines: a systematic review with quality assessment using the AGREE II checklist. journal of orthopaedic & sports physical therapy. 2021 Feb;51(2):63-71.
  6. Nadler M, Pauls M, Cluckie G, Moynihan B, Pereira AC. Shoulder pain after recent stroke (SPARS): hemiplegic shoulder pain incidence within 72 hours post-stroke and 8–10 week follow-up (NCT 02574000). Physiotherapy. 2020 Jun 1;107:142-9.
  7. Briggs AM, Cross MJ, Hoy DG, Sanchez-Riera L, Blyth FM, Woolf AD, March L. Musculoskeletal health conditions represent a global threat to healthy aging: a report for the 2015 World Health Organization world report on ageing and health. The Gerontologist. 2016 Apr 1;56(suppl_2):S243-55.