May et al: Clinical reasoning about shoulder pain

Expert therapists use specific clinical reasoning processes

in the assessment and management of patients with
shoulder pain: a qualitative study
Stephen May1, Alison Greasley2, Sarah Reeve2 and Sarah Withers3
1
Sheffield Hallam University, 2 Sheffield Teaching Hospitals Foundation NHS Trust, 3 Sheffield Primary Care Trust
United Kingdom

Question: What are the key items in the clinical reasoning process which expert clinicians identify as being relevant to the
assessment and management of patients with shoulder pain? Design: Qualitative study using a three-round Delphi procedure.
Participants: Twenty-six experts in the UK consented to be involved and were contactable, of whom 20 contributed, with 12,
15, and 15 contributing to the different rounds. Results: Clinical reasoning was mostly about diagnostic reasoning, but also
involved narrative reasoning. Diagnostic reasoning involved both pattern recognition and hypothetico-deductive reasoning.
Diagnostic reasoning emphasised general history items, a constellation of signs and symptoms to identify specific diagnostic
categories, and standard physical examination procedures. Narrative reasoning was highlighted by the communication
involved in expert history taking, seeing patients in their functional and psychological context, and collaborative reasoning
with the patient regarding management. Conclusions: These expert clinicians demonstrated the use of diagnostic pattern
recognition, and hypothetico-deductive and narrative clinical reasoning processes. The emphasis was on the history and
basic physical examination procedures to make clinical decisions. [May S, Greasley A, Reeve S, Withers S (2008) Expert
therapists use specific clinical reasoning processes in the assessment and management of patients with shoulder
pain: a qualitative study. Australian Journal of Physiotherapy 54: 261–266]
Key words: Shoulder pain, Decision making, Problem solving, Expert opinion, Delphi technique,
Physiotherapy (modality)

Introduction model, but even in a relatively recent clinical guideline an

Patients with shoulder pain are commonly encountered in
healthcare settings (van der Windt et al 1995, May 2003) and
a number of diagnostic labels have traditionally been used,
such as capsulitis, bursitis, and subacromial impingement
syndrome (Cyriax 1982). However, the pathophysiology
underlying shoulder disorders is still controversial (Lewis
et al 2001, Tytherleigh-Strong et al 2001, Carette 2000,
Khan et al 2000, Chard et al 1994), tests used to establish
a diagnosis have limited reliability (Liesdek et al 1997, de
Winter et al 1999, Hanchard et al 2004), and the diagnostic
validity of most of the tests is moderate at best (Hegedus et
al 2008, Hughes et al 2008, Dessaur and Margarey 2008,
Calis et al 2000).
A number of synonyms or overlapping terms are used for
similar pathologies without it being clear whether these
are the same clinical entities. For instance, subacromial
impingement syndrome, impingement syndrome, rotator
cuff pathology, supraspinatus tendonitis, and supraspinatus
tendinosis are all terms that might be used for similar or
the same pathologies, but the implications of each title
are different. Impingement implies some factor external
to the tendon, the suffix ‘itis’ implies inflammation of the
tendon, and the suffix ‘osis’ implies dysfunction rather than
inflammation. These pathologies might display different
features on physical examination, warrant different
interventions, and have different prognoses. Most of this
nomenclature is developed from a pathophysiological
operational definition for impingement syndrome was not
found (Hanchard et al 2004). Furthermore, not everybody
with shoulder pain can be classified with a specific
pathoanatomical diagnosis (van der Windt et al 1995).
Non-specific classification based on symptom response to
repeated movement testing has been proposed (McKenzie
and May 2000). The potential value of this approach has
been supported by case studies, which provide clinically-
based operational definitions (Aina and May 2005,
Littlewood and May 2006).
Thus there appear to be a number of problems in linking
shoulder pathology with its classification and management.
These include the use of a range of diagnostic terms
for the same or similar anatomical problems, a lack of
standardised operational definitions for diagnostic labels
(Schellingerhout et al 2008), the limited validity of most
physical examination tests of the shoulder (Hegedus et al
2008, Hughes et al 2008, Dessaur and Margarey 2008), the
uncertain reliability of many tests (Ostor et al 2004, Hickey
et al 2007) and diagnostic labels (de Winter et al 1999,
Walker-Bone et al 2002), and the lack of a link between
diagnostic labels and specific interventions (Schellingerhout
et al 2008).
Clinical reasoning is the decision-making process used
to determine the diagnosis and management of patients’
problems (Terry and Higgs 1993, Jones et al 1994); it has
been defined as the ‘thinking and decision making associated

Australian Journal of Physiotherapy 2008 Vol. 54 – © Australian Physiotherapy Association 2008 261
Research
with clinical practice that enables therapists to take the
best-judged action for individual patients’ (Jones and Rivett
2004, p. 3). There are several models of clinical reasoning
including pattern recognition, hypothetico-deductive or
diagnostic reasoning, and narrative reasoning (Jones 1992,
Terry and Higgs 1993, Jones and Rivett 2004, Edwards
and Jones 2007). In pattern recognition, the clinician
associates problems of the current patient with previously-
seen clinical problems and adopts a previously-successful
management strategy. In hypothetico-deductive reasoning,
the clinician generates a hypothesis based on data from the
patient, which is then tested, and further hypotheses are
generated until a management pathway is defined clearly.
Narrative reasoning is a ‘process of enquiry, examination
and reflective management’ (Jones and Rivett 2004, p. 5)
by which the clinician understands the patient’s problem,
the patient’s perspective, and the context of that problem.
It demands collaborative reasoning between the patient and
the clinician, effective communication by the clinician, and
on-going reasoning until a plan of management is agreed
upon. Diagnostic and narrative reasoning are said to be
fundamentally different forms of reasoning, but intrinsically
linked in a dialectical model (Edwards and Jones 2007).
Clinical reasoning by health professionals has generally
been examined using interpretive paradigm studies, which
seek to generate practical knowledge through the description
and interpretation of phenomena explored as a whole, in
context, and to include the meanings and significant aspects
of the situation from the perspective of the people being
studied. This has been done in nursing (Benner 1984), in
occupational therapy (Fleming 1991), and in physiotherapy
(Jensen et al 1992) although clinical reasoning strategies
within physiotherapy remain largely under-researched
(Edwards et al 2004a). In physiotherapy, Jensen et al
(1992) examined the complex processes that occur during
therapeutic interaction and attempted to examine the
differences between novice and expert physiotherapists
in order to define the characteristics of the latter (Jensen
et al 1990, 1992, 2000). In an exploration of management
approaches, when ‘expert’ was defined by outcome rather
than by years of clinical experience, experts were deemed
to have a patient-centred approach to care characterised
by collaborative reasoning and encouragement of patient
empowerment (Resnik and Jensen 2003). Most of the work
on clinical reasoning has used an observational study
design, and has been of a theoretical nature rather than
exploring specific problems.
This study explored the clinical reasoning of experts
related to a complex musculoskeletal problem using a
series of questionnaires known as a Delphi process, which
is useful where clinical judgements need to be made but
empirical evidence on the topic is limited (Powell 2003).
It has been used to explore musculoskeletal topics, namely
the classification of low back pain (Binkley et al 1993),
and signs and symptoms of spinal clinical instability
(Cook et al 2005). The aim of this study was to explore
the clinical reasoning process of expert occupational and
physiotherapists in assessing and managing patients with
shoulder pain. The research question was:
What are the key items in the clinical reasoning process
which expert clinicians identify as being relevant to the
assessment and management of patients with shoulder
pain?
262 Australian Journal of Physiotherapy 2008 Vol. 54 – © Australian Physiotherapy Association 2008
Method
Design
We conducted a Delphi survey that allowed respondents to
propose and then refine and weight items until consensus
was achieved (Powell 2003, Rowe and Wright 1999). Round
1 was unstructured and allowed multiple open responses.
Clinicians were asked to share the clinical reasoning
process by which they assessed patients with shoulder pain
and arrived at a management strategy. The responses were
consolidated using qualitative thematic analysis, in which
items were grouped together through shared themes relating
to the narrative reasoning process of shoulder assessment,
classification, and management. Similar words or phrases
were reduced into a single item. In Round 2, respondents
were asked to rank the relative importance of all the items
using the scale:
1 = Essential; this item would be used in all shoulder
examinations
2 = Very important; this item would be used in most
shoulder examinations
3 = Important; this item would be used in a lot of
shoulder examinations
4 = Less important; this item would be used in a few
shoulder examinations
5 = Unimportant; this item would be used rarely in
shoulder examinations.
The items were ranked according to the responses to form a
new consolidated list with items weighted by their relative
importance, the percentage agreement for that rank, and
the composite score. In Round 3, respondents voted on
their agreement or disagreement with the ranking that
emerged from Round 2. Both the ranking of the item and
the percentage consensus for that ranking was available
to the respondents. The final list of items was generated
from the responses. All correspondence was via e-mail;
two reminders were used at each round to maximise the
response rate.
Participants
Participants were recruited by telephone from Extended
Scope or Clinical Specialist Physical Therapy or Occupa­
tional Therapy practitioners who specialised in shoulder or
upper limb problems (as defined by their job title) in the UK.
The sample was located through personal contacts, delegate
lists from conferences, ICSP (an interactive website run
by the Chartered Society of Physiotherapy), and through
the Extended Scope Practitioners Clinical Interest Group.
Demographic details and the clinical characteristics of their
patient population were collected.
Data analysis
After Round 2, items ranked as essential or very important
by ≥ 75% of respondents were ranked as primary items.
Items ranked as important by ≥ 75% of respondents were
ranked as secondary items. Items ranked as less important
or unimportant by ≥ 75% of respondents were classified
as tertiary items. Previous studies have used ≥ 75% as
indicating consensus (Binkley et al 1993, Cook et al
2005, 2006, McCarthy et al 2006). When this measure of
consensus was not reached in this study, but there was a
majority decision (50% to 74%), this majority decision was
used to rank items as above. Items where a majority decision
 May et al: Clinical reasoning for shoulder pain

Table 1. Characteristics of respondents.

Experts identified and invited to participate
Characteristic n = 14 n = 36
Age (yr), mean (SD) 43 (5.3)
Time since qualifying (yr), mean (SD) 20 (2.2)
Years in present post, mean (SD) 7 (1.9)
Health care sector, n (%) Experts consent to participate
Primary care 2 (14) n = 30
Secondary care 12 (86)
Proportion of shoulder patients seen (%), 73 (5)
mean (SD)
Proportion of pathologies seen (%),
mean (SD) Experts contactable by email
Impingement/rotator cuff disease (n = 12) 44 (3.6) n = 26
Atraumatic instability (n = 12) 28 (4.1)
Adhesive capsulitis (n = 9) 12 (2.4)
Osteoarthritis (n = 5) 11 (2.3)
Round 1
n = 12

was not reached (< 50%) were discarded from the study,
but retained in the final list for information. Therefore, in
Round 2 the respondents produced a list of ranked items
where there was a majority decision about the importance
of their inclusion in a shoulder assessment.
Composite scores to determine a numerical ranking for the
different items were determined with the following formula
(Cook et al 2005):
Composite score = (n1 × 5) + (n2 × 4) + (n3 × 3) +
(n4 × 2) + (n5 × 1).
That is where the number of respondents voting an item
as: Essential (1) is multiplied by 5, Very important (2)
is multiplied by 4, Important (3) is multiplied by 3, Less
important (4) is multiplied by 2, and Unimportant (5)
is multiplied by 1; and then each separate total is added
together to gain the composite score.
In Round 3 of the Delphi study, the respondents confirmed
or denied the primary, secondary or tertiary ranking of
the item in the clinical reasoning process, and the authors
produced a percentage composite score that represented the
level of consensus about that ranking from the respondents’
responses.
Results
Flow of participants through the study
Thirty-six upper limb and shoulder experts were located
of whom 30 consented to participate in the study, but four
could not be contacted at the email addresses provided. Of
the 26 who were contactable, 20 contributed to at least one
round of the Delphi process. Twelve contributed to Round
1, 15 to Round 2, and 15 to Round 3, with 8 contributing to
all rounds (Figure 1). Demographic details and the clinical
characteristics of the patient population are provided in
Table 1.
Key items relevant to the assessment of patients
with shoulder pain
After Round 1, 887 separate items were consolidated into
238 items comprising seven themes:
1. General history
2. Diagnostic classifications
• 887 separate items
generated
• consolidated to 238
items
Round 2
n = 15
• 39 items failed to reach
consensus
Round 3
n = 15
Figure 1. Flow of participants through the study.
3. Signs and symptoms linked to specific classifications
4. General physical examination
5. Management decisions
6. Investigations
7. Intervention options.
Themes were established by the authors on a consensual
basis with complete agreement about which items belonged
with which themes. There was limited change by the
respondents in the ranking of items between Rounds 2 and
3. Composite scores from Round 2 are not reported as they
correlated closely with rank and percentage agreement.
After Round 3, items fell into one of four categories based
on participants’ responses: majority agreement about
primary importance, majority agreement about secondary
importance, majority agreement about tertiary importance,
or a wide range of responses so lack of consensus. Specific
rankings and percentage agreement with rank are presented
in Tables 2 to 5 (see eAddenda for Tables 2 to 5). The overall
rankings reported here are for groups of items rather than
for individual items.

Australian Journal of Physiotherapy 2008 Vol. 54 – © Australian Physiotherapy Association 2008 263
Research
Majority agreement about primary importance occurred
with the following issues:
• General history items
• Two most frequently considered diagnostic categories
(rotator cuff disease, neck pain)
• Use of a constellation of signs and symptoms in clinical
recognition of diagnostic categories (frozen shoulder,
instability, impingement, rotator cuff problems,
glenohumeral osteoarthritis, and acromioclavicular
joint problems)
• General physical examination items, mostly of a ‘non-
specialist’ nature (such as active and passive range of
movement and resisted tests)
• Management decisions based on a range of
considerations (such as stage of disorder, diagnosis,
and response to intervention)
• Use of investigations
• Certain intervention options (mostly advice and
exercise based).
Majority agreement about secondary importance occurred
with the following items:
• Next most frequently considered diagnostic categories
(frozen shoulder, acromioclavicular joint)
• Some specific physical examination tests.
Majority agreement about tertiary importance occurred
with the following items:
• Specific diagnostic categories (non-specific shoulder
pain, avascular necrosis, long-head of biceps
dysfunction, Ehlos Danlos syndrome, Marfan’s
disease, serious pathology, nerve palsy, Pancoast
tumour, visceral disease)
• Some specific physical examination tests
• Therapist-conducted intervention options (such
as TENS, acupuncture or upper limb tension test
mobilisations).
There was a wide range of responses about the relative
importance of a number of items; therefore, there was lack
of consensus in these areas:
• Specific diagnostic categories (including instability
and labral tears)
• Physical examination items, especially specific
diagnostic tests (such as Burkhead’s, Hawkins-
Kennedy, and Neer tests)
• Intervention options (such as manual therapy, injection,
and taping).
Discussion
Both diagnostic and narrative clinical reasoning processes
were used by this group of expert clinicians, however much
weight was given to diagnostic reasoning (Jones et al 2008).
Hypothetico-deductive reasoning was used in the history-
taking to inform the use of specific tests, differentiation
and management decisions; and diagnostic reasoning was
under-pinned by pattern recognition, which is commonly
used by more experienced clinicians (Jones 1992, Terry
and Higgs 1993). This was done through a constellation of
signs and symptoms, was heavily dependent on the history
taking, and relied not simply on diagnostic classifications,
but also on patterns of impairment. This reflects the lack
of standardised operational definitions for diagnostic
labels (Schellingerhout et al 2008), the limited validity and
reliability of most physical examination tests of the shoulder
(Hegedus et al 2007, Hughes et al 2008, Dessaur and
Margarey 2008, Ostor et al 2004, Hickey et al 2007), and
the fact that not everyone can be given a structural diagnosis.
264 Australian Journal of Physiotherapy 2008 Vol. 54 – © Australian Physiotherapy Association 2008
That impairment as well as pathology featured strongly in
the reasoning process is confirmed by the importance of
the standard parts of the physical examination compared to
specialist orthopaedic tests. Several of the experts indeed
identified responses to movement as a key feature of the
diagnostic reasoning process (Edwards et al 2006). This is
consistent with low back pain impairments, in which pattern
recognition based on clinical features is a key feature of
a number of classification systems (McKenzie and May
2003, Van Dillen et al 2003, O’Sullivan 2006, Brennan
et al 2006). In a similar way management decisions were
not based on recipes related to pathology but also involved
hypothetico-deductive reasoning and took into account
diagnostic classification, stage of the disorder, functional
requirements, and response to intervention.
Where diagnostic reasoning was used by these clinicians
there were also elements of narrative or patient-centred
reasoning. This was highlighted in the importance of
the history in the clinical reasoning process, awareness
of patients’ psychosocial context, taking the functional
requirements of the patients into account, the emphasis on
collaborative reasoning with the patient, and the provision
of advice and exercises as part of the management plan. The
primacy given to history items emphasised the importance
of clinician-patient communication and probably highlights
the advanced skill levels of this group in their history taking
and interpretation.
Diagnostic and narrative reasoning are meant to be
underpinned by different research paradigms: diagnostic
reasoning reflecting a positive or quantitative approach, and
narrative reasoning an interpretative or qualitative approach
(Jones et al 2008). Narrative reasoning is context-dependent
and socially constructed and leads to what has been termed
‘communicative’ decision-making and management
(Edwards et al 2004b). The use of both types of clinical
reasoning by these clinicians confirms the dialectical model
of the two (Edward and Jones 2007).
Some elements appear to be contradictory, especially
regarding specific diagnostic tests. For instance, Neer and
Hawkins-Kennedy tests were considered items of primary
importance in the diagnostic constellation of signs and
symptoms for establishing the diagnostic category of
impingement. But the same tests were excluded from the
general physical examination items as there was lack of
consensus about their importance. We interpreted this as
follows: a single test used in isolation has limited diagnostic
accuracy, but combined with other tests and information
from the history it can be useful.
A number of limitations need to be recognised with this
study. Not everybody who consented to participate in the
study responded, but it is impossible for us to know why
this occurred. About 77% of consenting and contactable
respondents contributed to data collection overall, but
at each round response rates ranged from 46% to 58%.
However, in the first round of data collection, the last two
respondents contributed few new items to those already
raised, suggesting that we had achieved saturation point of
new items. In addition, we cannot know if respondents were
actually able to make the diagnostic classifications from
history and physical examinations items that they suggested
they were capable of doing. However, the combination of
an uncertain scientific background and plenty of diverse
opinion makes this an excellent topic for expert opinion
consensus.

The study has a number of clinical, research, and
educational implications. It has emphasised movement
impairments, based on the patient’s history and standard
examination procedures, rather than specific structural
diagnoses based on specific tests. This has both clinical and
educational implications regarding diagnostic reasoning.
It is in accord with a recent review, which concluded that,
because of a lack of standardised operational definitions for
diagnostic labels and the lack of a link between diagnostic
labels and specific interventions, it is time for a different
approach to the management of shoulder problems based
on other than specific structural pathology (Schellingerhout
et al 2008). Whether the constellation of signs and
symptoms that our respondents suggested is actually of
useful diagnostic accuracy should be validated by further
research. Furthermore, it would be of interest to compare
the clinical reasoning process of this group of experts with
less experienced therapists to evaluate whether there are
differences and, if so, where these lie.
These expert clinicians employed diagnostic clinical
reasoning that used both a hypothetico-deductive and a
pattern recognition model. There was consensus about the
primacy of items from the history and standard physical
examination procedures in this process, and the use of a
constellation of signs and symptoms for pattern recognition.
Although specific pathological diagnoses were in the
diagnostic model, the process also highlighted non-specific
movement impairments. And although diagnostic reasoning
dominated, there were also examples of narrative and
patient-centred reasoning and recognition of the context-
dependent nature of the patient information.
eAddenda: Appendix 1 and Tables 2–5 available at AJP.
physiotherapy.asn.au
Ethics: The Leeds (East) Research Ethics Committee
approved this study (REC ref number: 07/Q1206/12).
Informed consent was gained from all participants before
data collection began.
Acknowledgements: The authors thank all the participating
therapists who contributed their time, effort and knowledge
so generously to this study. The analysis was ours, but the
source of information was all theirs.
Corresponding author: Stephen May, Faculty of Health
and Wellbeing, Sheffield Hallam University, Sheffield, UK,
S10 2BP. Email: s.may@shu.ac.uk
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