Examination
Examination consists of look, feel, move and X-ray.
PATIENT'S SELF ASSESSMENT SHEET: SHOULDER
NAME.....................................................................................................
SHOULDER AFFECTED: RIGHT/LEFT
TODAY'S DATE.....................................................................................
SEVERITY OF PAIN
Choose one of the following by ringing the number.
1 I have no pain.
2 I have mild discomfort.
3 I have moderate pain which forces me to make concessions.
4 I have pain bad enough to need painkilling tablets.
5 I have severe pain.
FREQUENCY OF PAIN
Choose one of the following by ringing the number.
1 I have no pain.
2 I have occasional pain after unusual activity.
3 I have occasional pain on movement.
4 I have pain whenever I move my shoulder.
5 I have pain present all the time, even at rest.
PAIN AT NIGHT
Choose one of the following by ringing the number.
1 I have no pain at night.
2 My sleep is disturbed occasionally by pain in my shoulder.
3 I am woken at least once every night by pain in my shoulder.
4 I am woken several times each night by pain in my shoulder.
5 I am unable to get enough sleep every night because of pain in my shoulder.
PAINFUL MOVEMENTS
Ring all the numbers which apply to you.
1 Pain occurs when reaching behind my neck.
2 Pain occurs when reaching behind my waist.
3 Pain occurs when reaching above my head.
4 Pain occurs when reaching sideways.
5 Pain occurs when reaching forwards.
FUNCTIONAL LOSS
Ring which number is true when using your 'bad' arm.
1 I cannot reach between my shoulder blades.
2 I cannot reach a shelf above my head.
3 I cannot comb my hair.
4 I cannot reach behind my waist.
5 I cannot wash the back of my neck.
6 I cannot reach the base of my spine.
7 I cannot wash under the opposite arm.
1 I cannot do usual sport. (Name sport).
2 I cannot do usual work. (Name work).
3 I cannot sleep on that side at night.
CHANGE SINCE LAST ATTENDANCE Compare your shoulder now with how it was when you last saw the doctor. Ring the number which best describes it.
1 My shoulder is much better.
2 My shoulder is a little better.
3 My shoulder is the same.
4 My shoulder is worse.
Figure 2.5 Sample shoulder assessment sheet (filled in by patient).
ASSESSMENT OF THE SHOULDER
Name .... Address
Dominant hand R/L
SHOULDER ASSESSMENT SHEET
One form to be completed for each shoulder.
DOB.......................... Diagnosis..........................
Hospital No. Previous treatment
................................. Drug..................................
Injection ..........................
Other ..............................
Surgery............................
Type of operation
L or R
Occupation............................................................... Date ......
Surgeon
Other upper limb problems ...........................................................
OPERATION DATE (ring arrow) Date (this assessment)
I 1st visit 2nd visit 3rd visit 4th visit 5th visit
PAIN At rest
On movement
TAKING ANALGESICS (yes/no)
Type
Number
MUSCLE WASTING Deltoid
Supraspinatus
Infraspinatus
STRENGTH (S) + PAIN ON TEST (P)
S P S P S P S P S P
Abd
Flex
1 rot
E rot
PAIN ON REST OR MOVEMENT
0 = None
1 = Slight or occasional
2 = After unusual activity
3 = Moderate - alters use
4 = Marked - limits activity
5 = Severe - loss of sleep
WASTING
PAIN ON TEST (P)
0 = None
1 = Mild
2 = Moderate
3 = Severe
STRENGTH (S)
0 = Normal
1 = Mild weakness
2 = Severe weakness
3 = Paralysis
RANGE OF MOTION (standing)
A P A P A P A P A P
ACTIVE (A) + Abd
PASSIVE (P) Flex
1 rot
E rot
(Arm by side - segment covered
by back of hand)
(Arm by side)
CHANGE
(since operation/treatment)
ASSESSOR'S INITIALS:
GRADE:
CHANGE
1 = Much better
2 = Better
3 = Same
4 = Worse
Figure 2.6 Sample shoulder assessment sheet (filled in by surgeon).
Figure 2.7 The shoulder shrug associated with a full thickness rotator cuff tear.
