How should I document a shoulder musculoskeletal examination?

How to Document a Shoulder Musculoskeletal Examination

Document your shoulder examination systematically using a standardized anatomical approach that includes inspection, palpation, range of motion testing, and specific provocative maneuvers for rotator cuff, instability, and impingement pathology. 1

Essential Documentation Components

Patient Positioning

Document the patient's position for each examination component:

• Sitting position with 90° elbow flexion
• Hand positioned in supination on the patient's thigh
• Note whether active or passive movements were performed 1

Systematic Examination Sequence

1. Inspection Document:

• Visible deformities or asymmetry
• Muscle atrophy (particularly supraspinatus and infraspinatus fossae)
• Swelling or ecchymosis
• Scapular positioning and winging

2. Palpation Findings Chart specific anatomical landmarks examined:

• Acromioclavicular joint
• Bicipital groove and long head of biceps tendon
• Greater tuberosity
• Subacromial space
• Scapular spine
• Note any tenderness, warmth, or crepitus 2, 3

3. Range of Motion (ROM) Document both active and passive measurements:

• Forward flexion (normal: 0-180°)
• Abduction (normal: 0-180°)
• External rotation at 0° and 90° abduction
• Internal rotation (document vertebral level reached posteriorly)
• Note any pain arc or limitations 1

Specific Provocative Maneuvers

Chart which maneuvers were performed and their results:

For Rotator Cuff Pathology:

• Supraspinatus testing (empty can/full can test)
• Infraspinatus/teres minor strength (external rotation resistance)
• Subscapularis testing (lift-off test, belly press test)
• Document as positive/negative and note pain versus weakness 4, 3

For Impingement:

• Neer sign (forced forward flexion)
• Hawkins-Kennedy test (internal rotation at 90° flexion)
• Document reproduction of patient's pain 4, 3

For Instability:

• Apprehension test (anterior instability)
• Relocation test
• Load and shift test
• Document patient apprehension versus actual subluxation 3

For Labral Pathology:

• O'Brien's test (active compression test)
• Speed's test (biceps/labral pathology)
• Document location and character of pain 4, 3

Neurovascular Assessment

Always document:

• Axillary nerve function (deltoid sensation and strength)
• Radial, median, and ulnar nerve function distally
• Distal pulses if trauma or vascular concern 3

Documentation Structure

Use this template format:

SHOULDER EXAMINATION:
Position: Sitting, 90° elbow flexion

INSPECTION: [Normal/abnormal findings]

PALPATION: 
- AC joint: Non-tender
- Bicipital groove: [findings]
- Greater tuberosity: [findings]

RANGE OF MOTION:
- Active forward flexion: [degrees] - [pain/no pain]
- Passive forward flexion: [degrees]
- Active abduction: [degrees] - [pain arc at ___°]
- External rotation (0°): [degrees]
- Internal rotation: [vertebral level]

STRENGTH TESTING:
- Supraspinatus (empty can): [5/5,4/5, etc.] - [pain/weakness]
- External rotation: [strength grade]
- Internal rotation: [strength grade]

SPECIAL TESTS:
- Neer sign: Positive/Negative
- Hawkins-Kennedy: Positive/Negative
- Apprehension: Positive/Negative
- [Other tests performed]

NEUROVASCULAR: Intact distally

Critical Documentation Pitfalls to Avoid

1. Don't document "full ROM" without specific degrees—this lacks precision for follow-up comparison 2

2. Distinguish pain from weakness in strength testing—a patient may have 5/5 strength with pain, which has different implications than true weakness 4, 3

3. Document the position for each maneuver—external rotation strength differs significantly at 0° versus 90° abduction 1

4. Record negative findings—documenting what was normal is as important as abnormal findings for medicolegal purposes and clinical decision-making 2

5. Note bilateral comparison when asymmetry is relevant, particularly for ROM and strength 3

Age-Specific Considerations

For patients < 35 years: Emphasize instability testing and labral pathology assessment, as these are more common than rotator cuff tears 5

For patients ≥ 35 years: Focus more extensively on rotator cuff integrity and impingement signs, as degenerative rotator cuff disease predominates 5

This systematic approach ensures comprehensive documentation that guides imaging decisions, treatment planning, and provides a baseline for monitoring treatment response 4, 2, 3.