shoulder pain

onset

hours days weeks months years sudden gradual

side

left right

new?

new issue previously known issue

intensity

mild mild-moderate moderate moderate-severe severe

frequency

single episode constant intermittent daily few times a week few times a month

duration

few minutes less than an hour few hours most of the day few days

status

improving unchanged resolved gradually worsening significant worsening

context

trauma/fall yes no repetitive movement yes no

location

general shoulder/deltoid trap scapula clavicle AC joint
posterior deltoid lateral deltoid anterior deltoid biceps

radiation

none neck arm biceps hand

quality

debilitating dull pressure superficial sharp throbbing stabbing

timing

daytime upon awakening night time

aggravated by

nothing flexion extension all movements abduction reaching up

relieved by

nothing flexion extension movements lying down stretching OTC meds prescription meds massage heat ice

other

+ suspected/known dislocation –

+ radicular symptoms –

+ shoulder stiffness/immobility –

inspection

normal

palpation

normal, no pain
tender: general shoulder/deltoid trap scapula clavicle
posterior deltoid lateral deltoid anterior deltoid AC joint biceps tendon subacromial bursa

ROM

muscle testing

(+) = weakness | (-) = normal

special tests

radicular testing

normal motor or abnormal motor:

deltoid (C5)

biceps (C5-6)

wrist extensors (C6)

triceps (C7)

wrist flexors (C7)

finger extensors (C7)

finger flexors (C8)

interossei (T1)

normal sensation or abnormal sensation at:

lateral arm/deltoid (C5)

lateral forearm/hand (C6)

middle finger (C7)

medial forearm/hand (C8)

medial upper arm (T1)

normal reflexes or abnormal reflexes:

biceps (C5)

brachioradialis (C6)

triceps (C7)

Hoffman

inverted radial

other

Assessment:

non-MSK rotator cuff injury AC joint osteoarthritis labral tear dislocation/subluxation

acuity

acute chronic acute on chronic

red flags

no red flags

radicular symptoms

positive negative

imaging

no indication X-Ray MRI US

details

Plan:

medication

tylenol topical NSAIDs PO NSAIDs opioids

physiotherapy

self referral MFP physio

-> private coverage?

yes no

other therapy

massage therapy

off work

yes (1-2 weeks) no

follow-up

2-4 weeks PRN only

RTC

instructions given

other

SHOULDER PAIN

S/

O/

A/

P/