| What to say to the patient during a telephone encounter |
Possible implications |
| “Stand in front of a mirror and inspect both exposed shoulders, front, and back. Compare them. Do you see any striking differences?” |
Evaluate asymmetry from atrophy, swelling, ecchymosis or erythema, deformity, scars, or venous distension. These may have a lot of implications that should be taken into consideration with the rest of the examination. |
| “Looking at your shoulders in a mirror, do you see any difference in height between your left and right shoulders?” |
Striking differences in shoulder height may suggest paraspinal muscle spasm from cervical spine pathology, nerve injury (such as spinal accessory nerve), guarding from massive rotator cuff tear, mass, acromioclavicular separation, or degenerative changes [16]. |
| “If you can see the back of your shoulders in a mirror (perhaps with a second hand-held mirror), and trying to keep a neutral position on both sides, are you able to see a striking difference between them? Has anyone commented that your shoulders look different from each other when viewed from the back?” |
Striking differences in shoulder prominence from posterior view may suggest nerve injury (such as spinal accessory, dorsal scapular, or long thoracic nerve), muscle atrophy from chronic massive rotator cuff tear, sick scapular syndrome, nerve entrapment (suprascapular nerve due to paralabral cyst), brachial neuritis, iatrogenic injury, cervical radiculopathy [17]. |
| “Have you or anyone else noticed any sunken, swollen, bruised, and/or red areas on your shoulder?” |
Sunken areas could represent atrophied areas. Swollen or bruised areas may represent contusions, fractures, or tendon ruptures. Red areas may indicate infection [17]. |
| “Does it hurt to press anywhere along your collarbone (starting from the chest all the way to the shoulder)? Do you feel any bubbles under your skin or general deformities?” * |
Pain at any of these sites may have a lot of implications, such as sternoclavicular or acromioclavicular instability, sprain, dislocation or arthritis [15], clavicle fracture (potentially displaced if crepitus or deformity appreciated), rib fracture, supraclavicular nerve contusion, distal clavicle osteolysis [19]. |
| “Does it hurt to press on the front of your shoulder?” |
This may suggest long head of bicep tendinopathy or instability, subscapularis tendon tear, pectoralis major rupture or strain, glenohumeral arthritis, adhesive capsulitis, anteroinferior labral tear, glenoid or proximal humerus fracture, Salter-Harris fracture in adolescents [18]. |
| “Does it hurt to press on the side of your shoulder, where the bony part on top of it ends?” |
This may suggest supraspinatus tendinopathy or tear, calcific tendinitis, acromial fracture, Salter-Harris fracture in adolescents, deltoid tear or strain (less likely) [18]. |
| “Starting with your arms hanging down at your sides, can you reach out in front of you, then upwards towards the ceiling with both arms?” ** |
If pain and/or weakness is experienced, this may suggest subacromial impingement or supraspinatus pathology; cervical radiculopathy; proximal humerus or clavicle fracture; adhesive capsulitis; glenoid labrum tear; acromioclavicular joint sprain; glenohumeral arthritis; deltoid, pectoralis, or coracobrachialis tear or strain (less likely) [18]. |
| “Starting with your arms hanging down at your sides, can you reach backwards then upwards with both arms?” |
If pain and/or weakness is experienced, this may suggest adhesive capsulitis, latissimus dorsi, subscapularis tendon, or deltoid tear or strain (less common) [17]. |
| “Starting with your arms hanging down at your sides, can you reach out to your sides then upwards with both arms? Are you able to clap your hands directly above your head?” *** |
If pain and/or weakness is experienced, this may suggest supraspinatus tendon tear or tendinopathy; subacromial bursitis; cervical radiculopathy; nerve injury (such as spinal accessory, dorsal scapular, or long thoracic nerve), brachial neuritis; adhesive capsulitis; proximal humerus, acromion, or clavicle fracture; deltoid strain (less common) [18]. |
| “Starting with your arms hanging down at your sides, bend your elbows to 90⁰ with hands in front of you. Keeping your elbows touching your sides, can you swing your hands out to the sides away from each other?” ¤ |
If pain and/or weakness is experienced, this may suggest glenohumeral arthritis, adhesive capsulitis, proximal humerus fracture [17]. |
| “What tasks have you found difficult to execute due to weakness, or cause pain or range-of-motion limitation of the shoulder?” For strength testing, the clinician may also ask the patient to reproduce tasks/movements/exercises over the telephone and describe weakness and/or pain felt. |
This gives the patient an opportunity to express any specific concern they may have in mind. The responses may give clues to strength problems in the shoulder. Depending on the description of the tasks causing weakness, some common pathological culprits could be the rotator cuff, biceps, or deltoid [17]. |
| Ask patient: “Do you have any pain that runs down your arm past the elbow?” |
An affirmative response is concerning for a cervical nerve root pathology [16]. |
