This may be used as a template or example of what you may want to include in the documentation of your shoulder exam. Click here to download a PDF version of the documentation for printing.
Inspection:
Documentation of symmetry, atrophy. (Absence/presence) of ecchymosis, swelling, deformity or defect.
Range of motion of the elbow:
Flexion to (xx degrees or full). Abduction to (xx degrees or full). Internal Rotation (to what level or comparison to opposite side). External rotation (to what level or comparison to opposite side). May also include range of motion of the neck in flexion, extension, rotation and side bending to left and right. Document motion of the scapula with abduction and adduction of the arms.
Palpation:
(Tenderness/no tenderness) to palpation (of specific areas or landmarks such as clavicle, acromioclavicular joint, acromion, scapular spine, sternoclavicular joint, biceps tendon in humeral groove, proximal humerus, scapula body, trapezius muscle body).
Specific Testing:
Rotator Cuff Testing: (Positive/Negative) Drop Arm Test, (Positive/Negative) Empty Can Test, (Positive/Negative) Push Off Test (Positive/Negative) Hawkin's Test, (Positive/Negative) Neer's Test
Stability Testing:
(Positive/Negative) Sulcus Sign, (Positive/Negative) Load and Shift Test,(Positive/Negative) Apprehension and Relocation Test
Biceps Testing:
(Positive/Negative) Speed's Test, (Positive/Negative) Yergason's Test, (Positive/Negative) Biceps Load Test, (Positive/Negative) Biceps Tension Test
Labral Testing:
(Positive/Negative) O'Brien's Test, (Positive/Negative) Crank Test
Thoracic Outlet Syndrome Testing:
(Positive/Negative) Costoclavicular Maneuver (Positive/Negative) Roos' Test, (Positive/Negative) Adson's Test
Cervical Testing:
(Positive/Negative) Spurling's Test
Neurovascular Exam:
Document radial and ulnar artery pulses and capillary refill. Sensory exam. Brief neurologic exam for motor function could include resisted wrist extension for radial nerve, resisted opposition of the thumb for the median nerve and resisted digit abduction for the ulnar nerve. Documentation of symmetry, atrophy. (Absence/presence) of ecchymosis, swelling, deformity or defect.
Range of motion of the shoulder:
Flexion to (xx degrees or full). Abduction to (xx degrees or full). Internal Rotation (to what level or comparison to opposite side). External rotation (to what level or comparison to opposite side). May also include range of motion of the neck in flexion, extension, rotation and side bending to left and right. Document motion of the scapula with abduction and adduction of the arms.