| What to do/say to the patient on video encounter |
What to do, look for, or consider |
| Directly inspect the general area of and around exposed shoulders, front and back. |
Watch out for 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. |
| Inspect for any difference in height between the patient’s 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]. |
| Inspect for any differences in the patient’s shoulders from a posterior view. |
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]. |
| Inspect for any, sunken, swollen, bruised, and/or red areas on patient’s shoulder?” |
Sunken areas could represent atrophied areas. Swollen or bruised areas may represent contusions, fractures, or tendon ruptures. Red areas may indicate infection [17]. |
| Inspect range of motion comparing both shoulders. Evaluate for symmetry. Begin with the patient facing camera for abduction and with arms at waist, external rotation is assessed. Forward flexion is assessed with the patient turning 90⁰ to the side, along with external/internal rotation in the shoulder closest to the camera with the shoulder abducted to 90º. Posterior reach is assessed with the patient facing away from the camera. |
Range of motion (normal values) [27]: 1. Forward flexion (160–180°). 2) Extension (45°) 3. Abduction (150°) 4. External rotation (90°) 5. Internal rotation (90°) 6. Horizontal adduction (130°) 7. Posterior reach (young adults should reach tip of scapula or T7) |
| Ask patient to palpate the entire length of the clavicle. Show the patient (or screen-share diagrams) the general locations of surface anatomy and/or pain diagrams. Begin at sternal notch and have patient progress laterally to AC joint. Make sure to cover sternoclavicular joint, clavicle, and acromioclavicular joint. * |
Pain at any of these locations suggests 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]. |
| Ask patient to thoroughly palpate on the frontal aspect of shoulder. |
Pain in this region suggests tendinopathy or instability of long head of bicep, 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]. |
| Ask patient to thoroughly palpate on the lateral aspect of shoulder. |
Pain and/or weakness suggests rotator cuff tendinopathy or tear, calcific tendinitis, acromial fracture, subacromial bursitis, Salter-Harris fracture in adolescents, deltoid tear or strain (less likely) [18]. |
| Instruct patient: “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?” ** |
Pain and/or weakness suggests 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]. |
| Instruct patient: “Starting with your arms hanging down at your sides, can you reach backwards then upwards with both arms?” |
Pain and/or weakness suggests adhesive capsulitis, latissimus dorsi, subscapularis tendon, or deltoid tear or strain (less common) [17]. |
| Instruct patient: “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?” *** |
Pain and/or weakness suggests 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 commonly) [18]. |
| Instruct patient: “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?” ¤ |
Pain and/or weakness suggests glenohumeral arthritis, adhesive capsulitis, proximal humerus fracture [17]. |
| Ask patient: “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]. |
