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DOC Right Shoulder Exam
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DOC Shoulder Pathway
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Inspection (swelling, erythema, ecchymosis, warmth, masses)
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Inspection
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Swelling?
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Ecchymosis?
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Erythema?
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Increased Warmth?
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Open Wounds?
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Deformity?
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Masses?
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Inspection Comments
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Tenderness (ant bicep, lat, ant/lat, post, A/C joint)
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Tenderness
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Over Anterior Bicep?
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Lateral?
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Ant/Lat?
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Posteriorly?
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Over AC Joint?
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Tenderness Comments
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AROM (FF/ABD, ER, IR, pain)
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AROM
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Decreased FF/ABD
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Decreased ER?
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Decreased IR?
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Is AROM Painful?
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AROM Comments
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PROM (FF/ABD, ER, IR, pain)
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PROM
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Decreased FF/ABD
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Decreased ER?
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Decreased IR?
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Is PROM Painful?
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PROM Comments
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Cuff Strength (ER, IR, subscap)
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Cuff Strength
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ER Strength
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IR Strength
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Subscap Pushoff Strength
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Cuff Strength Comments
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Tests
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Any Tests Performed?
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Drop Arm Test Positive?
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Comments
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Was Hawkins Test Positive?
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Comments
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Was Neer Test Positive?
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Comments
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Was Speed Test Positive?
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Comments
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Was O'Brien's Test Positive?
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Comments
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Was SLAP Test Positive?
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Comments
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Instability (ant, post, inf)
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Instability
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Is there Anterior Instability?
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Is there Posterior Instability?
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Is there Inferior Instability?
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Instability Comments
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Neurologic (median, radial, ulnar, axillary)
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Neurologic (median, radial, ulnar, axillary)
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Median Nerve Intact?
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Comments
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Radial Nerve Intact?
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Comments
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Ulnar Nerve Intact?
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Comments
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Axillary Nerve Intact?
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Comments
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***Overall Exam Comments***
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Exam Comments
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Dx and Pathways
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Diagnoses
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Impingement
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Impingement
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AC Sprain
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AC Dislocation
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Anterior Dislocation
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Initial
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Subsequent
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Posterior Dislocation
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Initial
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Subsequent
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Rotator Cuff Tear
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Rotator Cuff Tear
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Partial
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Complete
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Glenohumeral Arthritis
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Glenohumeral Arthritis
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ACJ Arthritis
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ACJ Arthritis
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Labral Tear
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Labral Tear
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Initial
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Subsequent
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Biceps Tendonitis
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Biceps Tendonitis
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Multi-directional Instability
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Multi-directional Instability
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Adhesive Capsulitis (frozen shoulder)
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Calcific Tendonitis
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Biceps Proximal Rupture
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AC Separation Grade 1 or 2
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Initial
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Subsequent
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AC Separation Grade 3 (100-200%)
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Initial
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Subsequent
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AC Separation Grade 5 (>200%)
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Initial
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Subsequent
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Fx and Pathways
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Fractures
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Clavicle Fx
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Clavicle Fx
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Clavicle Fx
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Active
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Closed Displaced
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Open Displaced
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Closed Nondisplaced
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Open Nondisplaced
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Routine Healing
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Closed Displaced
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Closed Nondisplaced
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Delayed Healing
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Closed Displaced
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Closed Nondisplaced
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Nonunion
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Closed Displaced
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Closed Nondisplaced
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Malunion
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Closed Displaced
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Closed Nondisplaced
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Proximal Humerus Fx
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Proximal Humerus Fx
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Proximal Humerus Fx
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Active
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Closed Displaced
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Open Displaced
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Closed Nondisplaced
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Open Nondisplaced
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Routine Healing
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Closed Displaced
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Closed Nondisplaced
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Delayed Healing
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Closed Displaced
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Closed Nondisplaced
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Nonunion
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Closed Displaced
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Closed Nondisplaced
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Malunion
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Closed Displaced
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Closed Nondisplaced
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Greater Tuberosity Fx
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Greater Tuberosity Fx
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Greater Tuberosity Fx
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Active
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Closed Displaced
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Open Displaced
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Closed Nondisplaced
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Open Nondisplaced
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Routine Healing
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Closed Displaced
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Closed Nondisplaced
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Delayed Healing
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Closed Displaced
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Closed Nondisplaced
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Nonunion
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Closed Displaced
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Closed Nondisplaced
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Malunion
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Closed Displaced
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Closed Nondisplaced
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Lesser Tuberosity Fx
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Lesser Tuberosity Fx
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Active
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Closed Displaced
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Open Displaced
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Closed Nondisplaced
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Open Nondisplaced
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Routine Healing
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Closed Displaced
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Closed Nondisplaced
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Delayed Healing
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Closed Displaced
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Closed Nondisplaced
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Nonunion
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Closed Displaced
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Closed Nondisplaced
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Malunion
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Closed Displaced
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Closed Nondisplaced
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Acromion Fx
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Acromion Fx
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Active
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Closed Displaced
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Open Displaced
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Closed Nondisplaced
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Open Nondisplaced
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Routine Healing
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Closed Displaced
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Closed Nondisplaced
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Delayed Healing
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Closed Displaced
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Closed Nondisplaced
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Nonunion
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Closed Displaced
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Closed Nondisplaced
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Malunion
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Closed Displaced
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Closed Nondisplaced
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Scapula Body Fx
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Scapula Body Fx
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Active
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Closed Displaced
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Open Displaced
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Closed Nondisplaced
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Open Nondisplaced
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Routine Healing
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Closed Displaced
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Closed Nondisplaced
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Delayed Healing
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Closed Displaced
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Closed Nondisplaced
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Nonunion
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Closed Displaced
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Closed Nondisplaced
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Malunion
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Closed Displaced
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Closed Nondisplaced
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Coracoid Fx
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Coracoid Fx
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Active
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Closed Displaced
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Open Displaced
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Closed Nondisplaced
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Open Nondisplaced
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Routine Healing
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Closed Displaced
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Closed Nondisplaced
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Delayed Healing
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Closed Displaced
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Closed Nondisplaced
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Nonunion
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Closed Displaced
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Closed Nondisplaced
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Malunion
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Closed Displaced
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Closed Nondisplaced
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Glenoid Fx
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Glenoid Fx
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Active
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Closed Displaced
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Open Displaced
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Closed Nondisplaced
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Open Nondisplaced
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Routine Healing
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Closed Displaced
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Closed Nondisplaced
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Delayed Healing
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Closed Displaced
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Closed Nondisplaced
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Nonunion
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Closed Displaced
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Closed Nondisplaced
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Malunion
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Closed Displaced
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Closed Nondisplaced
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Scapula Neck Fx
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Scapula Neck Fx
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Active
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Closed Displaced
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Open Displaced
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Closed Nondisplaced
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Open Nondisplaced
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Routine Healing
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Closed Displaced
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Closed Nondisplaced
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Delayed Healing
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Closed Displaced
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Closed Nondisplaced
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Nonunion
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Closed Displaced
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Closed Nondisplaced
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Malunion
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Closed Displaced
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Closed Nondisplaced
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Surgical Neck Fx (2 part)
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Surgical Neck Fx (2 part)
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Active
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Closed Displaced
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Open Displaced
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Closed Nondisplaced
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Open Nondisplaced
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Routine Healing
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Closed Displaced
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Closed Nondisplaced
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Delayed Healing
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Closed Displaced
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Closed Nondisplaced
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Nonuion
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Closed Displaced
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Closed Nondisplaced
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Malunion
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Closed Displaced
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Closed Nondisplaced
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Surgical Neck Fx (3 part)
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Surgical Neck Fx (part 3)
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Active
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Closed Displaced
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Open Displaced
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Routine Healing
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Closed Displaced
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Delayed Healing
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Closed Displaced
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Nonunion
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Closed Displaced
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Malunion
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Closed Displaced
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Surgical Neck Fx (4 part)
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Surgical Neck Fx (part 4)
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Active
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Closed Displaced
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Open Displaced
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Routine Healing
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Closed Displaced
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Delayed Healing
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Closed Displaced
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Nonunion
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Closed Displaced
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Malunion
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Closed Displaced
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Imaging and Labs
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Any Images/Labs Ordered?
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Shoulder X-Rays?
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Views
• • •
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Comparison
• • •
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Comparison Date and Comments
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Normal Findings
• • •
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Normal Comments
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Abnormal Findings
• • •
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Abnormal Comments
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Impression
• • •
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Shoulder Imaging Comments:
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Clavicle X-Rays? (2 Views)
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Comparison
• • •
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Comparison Date and Comments
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Normal Findings
• • •
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Normal Comments
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Abnormal Findings
• • •
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Abnormal Comments
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Impression:
• • •
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Clavicle Imaging Comments:
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MRI Reviewed?
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MRI Review Comments:
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Ultrasound Utilized?
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Normal US Findings
• • •
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Normal US Comments
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Abnormal US Findings
• • •
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Abnormal US Comments
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Impression:
• • •
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Ultrasound Comments:
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