Shoulder & Elbow

INTRODUCTION
&
BACKGROUND
The History is usually the
most important step to a
correct Diagnosis

HISTORY
60%

EXAMINATION
90%

INVESTIGATIONS
100%

DIAGNOSIS

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• Be Systematic:
– Pain
– Function
• Loss of Movement (stiffness/weakness)
• Instability

– Swelling
– Systemic History

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Traumatic / Non-traumatic

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 Trauma
Mechanism of Injury
The importance of understanding the mechanism
of injury can not be underestimated - it gives clues to the
personality of the fracture and the treatment required:
• When and how did the incident occur?
• What exactly happened to the limb?
• How much force was applied?
• Has the joint ever been injured before?
 Non-Trauma
Onset

• When and how did the symptoms start?

• How has it changed?
• Have you had this before?
 Introductions

1. How ya doin’? - Introduction

2. What are you doing here? - Main Complaint

3. Have you been before? – Past Medical History

4. Anything else?

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 Introduction

How ya Doin’?

Patients are People Too!!

• Shake Hands

• Introduce yourself Clearly and your Position

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 Main Complaint

Why are you here?

1. Pain

2. Function
– Loss of movement
– Instability / Locking

3. Swelling / Lump

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 PAIN

• Site – where exactly is the pain?

• Radiation – Does it go anywhere else?
• Nature – Can you describe the pain?
• Severity – How bad is the pain?
• Duration – How long have you had the pain?
• Frequency – How often do you get the pain?
• Aggravating factors – What makes the pain worse?
• Relieving Factors – What makes the pain better?
• Related Features – do you get any other symptoms?

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 PAIN

• Localised

• Referred

• Radicular

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 PAIN

• Nociceptive Pain
– Local Tissue damage
– Worse with movement
– Opiates or NSAIDs

• Neurogenic Pain
– Peripheral Nerve or Nerve Root damage
– Pain >> Tissue damage
– Often Sensory changes
– Poor response to Opiates or NSAIDs

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 Function

• Activities of Daily Living

– ADL
• Sports / Recreation
• What can’t you do that you used to be able to do?
• Why?
– Stiffness
– Weakness
– Pain

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 Function

1. Loss of Movement

2. Instability

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 Loss of Movement

• Time of Loss of Movement

• Was there a dislocation?

• Are Active and Passive movements the same?

• Stiff or Loose

• Symptoms of Neurological deficit?

• Symptoms of Tendon rupture?

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 Instability

• Does the joint ‘Give Way’?

– Has it ever given way?

• Does the joint lock?

– What does the patient mean by this?

• Does the joint click or clunk?

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 SWELLING

• Has there been swelling?

• How much?

• How soon / how long?

• Has it changed?

• Related Features
– Pain
– Function

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 Past Medical History

Have you been before?

• Musculoskeletal • Systemic
– Previous similar symptoms – Cardiac
– Other joints – Respiratory
– Arthritides – GIT
– Rheumatic Fever – GUT
– TB – Drugs
– Alcohol
– Tobacco

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 Past Medical History

Have you been before?

• Social • Family History

– Work – Musculoskeletal
– Sports / Hobbies
– Driving
– Live Alone
– Stairs
– Walking Aids
– Assistance • Anaesthetic
– Previous
– Problems

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 Mnemonic

M ust M OI/ onset

P ass P ain
F ***ing F unction
F inals F eeling / Sensation
W ith W eakness
S ome S welling
S tudying S tiffness & Stability
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20 year old male
Dislocated his left shoulder playing rugby
Ongoing Instability …
 20 year old male
Dislocated his left shoulder playing rugby
Ongoing Instability …

2. where weakness or
1. Onset: 3. Nature of pain instability)
1. Exact 4. Associated 4. ADL
Mechanism symptoms 
 4. Instability:
of Injury (clicking, 1. When
2. Able to continue locking,
instability) 2. What position(s) /
playing?
Activity
3. Management - 3. Function:
3. Disloc / Sublux /
relocated on 1. Able to play? Loose
pitch/hospital 2. Able to train 4. Clicking / Locking
4. Ease of (what
relocation training)? 5. Associated pain?
2. Pain: 3. If not, why?
1. when (pain,

Considerations: Labral tear; capsular tear; fracture;

rotator cuff tear; laxity; other joints
58 year old Female
Insidious onset shoulder pain 2 months ago
Pain extremely severe and unable to sleep
 58 year old Female
Insidious onset shoulder pain 2 months ago
Pain extremely severe and unable to sleep

1. Onset: 2. Pain: 5. Relieving

1. Gradual / 1. when factors
Sudden 2. where 3. Function:
2. Worsening / 3. Nature of pain 1. ADL
improving 4. Associated 2. Sleep
/ no symptoms 

change 3. Work
(clicking,
3. Previous 4. Recreation
locking,
similar? instability)

Considerations: Calcific tendonitis (most likely); Frozen

Shoulder; ACJ Arthritis; Degenerative cuff tear; Tumour;
Infection; Radicular origin
58 year old Female
Fell 3 months ago injuring shoulder
Normal x-rays, but still painful and
struggling with gardening & housework
 58 year old Female
Fell 3 months ago injuring shoulder
Normal x-rays, but still painful and struggling with gardening
& housework

1. Onset: 4. Associated
3. Management
symptoms
1. Exact at the time
Mechanis 3. Function:
2. Pain:
m of Injury 1. ADL
1. when
2. Able to 2. Sleep
2. where
continue 3. Recreation
with ADL? 3. Nature of pain
4. Work

Considerations: Rotator cuff tear; Greater tuberosity fracture;

Post-traumatic Frozen Shoulder
NOT Labral injury!
72 year old Farmer
Elbow pain for 2 years
Increasing in severity
 72 year old Farmer
Elbow pain for 2 years
Increasing in severity

1. Onset: 2. Pain:
1. Gradual / 1. when 5. Relieving
Sudden 2. where 
 factors
2. Worsening / (lateral/ 3. Function:
improving / medial) 1. ADL
no change 3. Nature of pain 2. Sleep
3. Previous 4. Associated 3. Work
similar? symptoms 
 4. Recreation
(clicking,
locking,
instability)

Considerations: Arthritis (most likely); Epicondylitis;

Biceps/Triceps Tendonitis
 Case 5

21 year old Rugby player

Fell onto outstretched hand
Felt a clunk
Very painful medial side of elbow
 Case 5
21 year old Rugby player
Fell onto outstretched hand
Felt a clunk
Very painful medial side of elbow

2. Pain: 3. If not, why?

1. when (pain,
1. Onset:
weakness or
1. Exact 2. where
instability)
Mechanism 3. Nature of pain
4. ADL
of Injury 4. Associated
4. Instability:
2. Able to continue symptoms 

playing? (clicking, 1. When
3. Management - ? locking, 2. What position(s) /
dislocated / instability) Activity
subluxed - ? 3. Function: 3. Disloc / Sublux /
relocated on 1. Able to play? Loose
pitch/hospital 4. Clicking / Locking
2. Able to train
4. Ease of (what 5. Associated pain?
relocation training)?

Considerations: 

Traumatic instability; fractures
Case 6

18 year old female

Right handed
Keen tennis player
Painful & clicking right scapula
No recollection of injury
 Case 6 18 year old female
Right handed
Keen tennis player
Painful & clicking right scapula
No recollection of injury

1. Onset: 2. Pain: 3. Function:

1. Gradual / 1. when 1. ADL
Sudden 2. where 2. Sleep
2. Worsening / 3. Nature of pain 3. Work
improving / 4. Associated
no change 4. Recreation
symptoms 

3. Previous 4. Other:
(clicking,
similar? locking, 1. Other joints
instability) 2. Family Hx
5. Relieving factors 3. Spinal

Considerations: Snapping Scapula; Scapula Dyskinesis;

Secondary to GHJ Instability; Hyperlaxity; Overhead Athlete
Thank You
Lennard Funk, 2015