Dr.N. K.

Choudhary
(PT)
Assessment Format for Shoulder Joint

NAME:

AGE/SEX:

ADDRESS:

OCCUPATION:

HEIGHT: WEIGHT: BMI:

HAND DOMINANCE:

AFFECTED SIDE:

SOCIOECONOMIC CONDITION:

CHIEF COMPLAINTS:

HISTORY:

 Present History

 Past Medical History

 Family History

 Personal History

 Surgical History
o Date of Admission
o Date of Operation
o Brief explanation about the procedure

o Date of Discharge
o Date of Examination

 Pain Assessment (OPQRST):

 o Onset :
o Site of pain:

o Quality of Pain:
o Temporal Variations:
o Numerical Rating Scale / Visual Analog Scale:
o Precipitating Factors:

o Relieving Factors:

ON OBSERVATION:

GENERAL

 Facial Expression:
 Posture:
o Lying

o Sitting:

 Anterior view

 Posterior view

 Lateral view

o Standing:
 Anterior view

 Posterior view

 Lateral view
 Gait

 External Aids

LOCAL
 Attitude of limb / Deformity
 Swelling / Wasting
  Redness
 Scar
 Trophic Changes

ON PALPATION:

 Temperature
 Tenderness
 Spasm:- Difference in tissue tension
 Swelling
 Crepitus / Abnormal sounds

ON EXAMINATION:

 Range of Movement : Active and Passive Range of Movement

Right Side Left Side

Active ROM Passive Active Passive
ROM ROM ROM
Shoulder Flexion

Extension

Abduction

Adduction

Internal
rotation
External
rotation

 Endfeel

 Capsular patterns
 Manual Muscle Testing

 Resisted
Right Muscle Left Isometrics
Side Side
Upper Trapezius
 Middle Trapezius Tightness
Lower Trapezius
 Scar Rhomboids (Major and Minor) Examination:
Pectoralis Major
o Serratus Anterior Mobile/
Deltoid Immobile
Latissimus Dorsi
o Healed / Not
Supraspinatus
Infraspinatus Healed
o Teres minor Painful /
Subscapularis Painfree
Biceps Brachii
 Girth Brachailis
Brachioradialis
Triceps Brachii
Measurement

Level Right side Left Side Difference

Acromion Process
(Reference Point)
2” below reference
point
4” below reference
point
6” below reference

 Sensations:

o Superficial

o Deep
 o Combined cortical

 Reflexes:-
o Biceps Jerk
o Triceps Jerk
o Brachioradialis Jerk

 Special Tests:-
o Load and Shift Test
o Sulcus sign
o Hawkins- Kennedy Test
o Apley’s Scratch Test
o Drop Arm Test
o Yergason’s Test
o Empty Can Test
o Tests for Cervical Spine
o Tests for Thoracic Outlet Syndrome

 Functional Assessment:-
o Shoulder Pain And Disability Index (SPADI)
o Upper Extremity Functional Scale

PROVISIONAL DIAGNOSIS:

INVESTIGATIONS:

DIFFERENTIAL DIAGNOSIS:

CLINICAL (FINAL) DIAGNOSIS:

MANAGEMENT: Goals / Treatment / Home advices