Orthopedics — Shoulder Evaluation Template

Patient Information

Date: [Date]
Visit type: New / Follow-up / Post-injury / Post-operative
Side: Right / Left / Bilateral
Dominant hand: Right / Left

Chief Complaint

[Primary shoulder symptom]
Duration: [Onset, timeline]
Current status: Improving / Stable / Worsening

History of Present Illness

Mechanism of injury: [If traumatic]

• Date: [Date]
• Activity: [Fall on outstretched hand, direct blow, dislocation, overhead activity]
• Position of arm: [Abducted, extended, etc.]
• Dislocation: Yes / No — Reduced: [Self, ED, required anesthesia]
• Number of dislocations: [If recurrent]

Onset: Acute traumatic / Gradual / Insidious / Overuse
Symptoms:

• Pain location: Anterior / Lateral / Posterior / Superior / Diffuse
• Pain timing: Constant / Activity-related / Night pain: Yes / No
• Overhead activities: Painful / Limited / Unable
• Weakness: Yes / No — [Specific motions]
• Instability: Yes / No — Direction: [Anterior, posterior, multidirectional]
• Stiffness: Yes / No — AM / Constant
• Clicking/popping: Yes / No
• Numbness/tingling: Yes / No — Distribution: [X]

Functional Impact

Reaching overhead: Able / Difficult / Unable
Reaching behind back: Able / Difficult / Unable
Lifting: [Weight limitation]
Carrying: [Limitation]
Sleep: Unaffected / Cannot sleep on affected side / Night pain awakens
Dressing: Able / Difficulty with [specific]
Work: Full duty / Modified / Unable
Sports: [Current participation vs prior]

Prior Shoulder History

Previous injuries (this shoulder): None / [Dislocation, fracture, tear]
Previous surgeries (this shoulder): None / [Procedure, date, surgeon]
Previous injections: None / [Type, date, response]
Physical therapy: [Prior treatment, response]
Contralateral shoulder: Normal / [Issues]

Risk Factors

Age: [X] years
Activity level: Sedentary / Recreational / Overhead athlete / Manual laborer
Sport(s)/occupation demands: [List]
Hyperlaxity: Yes / No
Smoking: Yes / No

Physical Examination

Inspection (Both Shoulders)

Symmetry: Symmetric / Asymmetric
Atrophy: None / Supraspinatus / Infraspinatus / Deltoid
Scapular winging: None / Present
Swelling: None / [Location]
Deformity: None / AC prominence / Clavicle / Other

Palpation

Tenderness:

• AC joint: Yes / No
• Sternoclavicular joint: Yes / No
• Bicipital groove: Yes / No
• Greater tuberosity: Yes / No
• Subacromial space: Yes / No
• Posterior joint line: Yes / No
• Scapular spine: Yes / No
• Trapezius/periscapular: Yes / No

AC joint: Stable / Unstable / Step-off [Grade]
SC joint: Stable / [Abnormality]

Range of Motion (Active/Passive)

Affected Contralateral
Forward flexion: [X]°/[X]° [X]°
Abduction: [X]°/[X]° [X]°
External rotation (0°): [X]°/[X]° [X]°
External rotation (90°):[X]°/[X]° [X]°
Internal rotation: [Vertebral level] [Vertebral level]
Cross-body adduction: [X]°/[X]° [X]°
Painful arc: None / [Degrees]
Scapulohumeral rhythm: Normal / Abnormal [Description]

Strength Testing (0-5)

Forward flexion: [X]/5
Abduction (0-90°): [X]/5
External rotation (arm at side): [X]/5
Internal rotation: [X]/5
Elbow flexion: [X]/5
Grip: [X]/5

Rotator Cuff Testing

Supraspinatus:

• Jobe test (empty can): Negative / Positive [pain, weakness, both]
• Full can test: Negative / Positive
• Drop arm test: Negative / Positive

Infraspinatus/Teres Minor:

• External rotation strength: Intact / Weak
• Hornblower's sign: Negative / Positive
• External rotation lag sign: Negative / Positive

Subscapularis:

• Lift-off test: Negative / Positive
• Belly-press test: Negative / Positive
• Bear-hug test: Negative / Positive
• Internal rotation lag sign: Negative / Positive

Impingement Testing

Neer impingement sign: Negative / Positive
Hawkins-Kennedy test: Negative / Positive
Cross-body adduction: Negative / Positive (AC vs subacromial)

Instability Testing

Anterior apprehension: Negative / Positive
Relocation test: Negative / Positive
Anterior/posterior load and shift: [Grade 1/2/3]
Sulcus sign: Negative / Positive — [cm], Resolves with ER: Yes / No
Hyperabduction test: Negative / Positive
Beighton score: [0-9] (generalized laxity)

Labral Testing

O'Brien test (active compression): Negative / Positive
Biceps load test: Negative / Positive
Speed's test: Negative / Positive
Yergason's test: Negative / Positive

Cervical Spine Screen

ROM: Full / Limited
Spurling's test: Negative / Positive
Axial compression: Negative / Positive

Neurovascular

Sensation: Intact / [Deficit - axillary nerve, etc.]
Pulses: [Radial, brachial assessment]
Distal motor: Intact / [Deficit]

Imaging Review

X-rays: [Date]

• AP: [Acromion morphology, joint space, calcification]
• Axillary: [Glenoid, Hill-Sachs, bone loss]
• Scapular Y: [Acromion morphology, outlet view]
• Zanca view: [AC joint if applicable]

MRI/MR arthrogram: [Date if available]

• Supraspinatus: Intact / Tendinopathy / Partial tear / Full tear [size]
• Infraspinatus: Intact / [Findings]
• Subscapularis: Intact / [Findings]
• Biceps: Intact / Tendinopathy / Subluxation / Tear
• Labrum: Intact / SLAP tear [type] / Bankart / Reverse Bankart
• Capsule: Normal / Thickened / Lax
• Glenoid bone: Intact / Bone loss [%]
• Humeral head: Intact / Hill-Sachs [size]
• Muscle quality: Normal / Fatty infiltration [Goutallier grade]
• AC joint: Normal / Arthrosis / Osteolysis

CT: [If obtained for bone loss assessment]

Assessment

1) [Primary diagnosis] — [Side]
[Classification if applicable]
2) [Secondary diagnoses]

Plan

Conservative Management (if applicable)

1) Activity modification:

• Avoid: [Overhead activities, heavy lifting, etc.]
• Sling: [Duration if needed]

2) Physical therapy:

• Focus: [ROM, rotator cuff strengthening, scapular stabilization, stretching]
• Frequency: [X] times/week for [X] weeks

3) Medications:

• [NSAIDs, analgesics as appropriate]

4) Injections (if indicated):

• Subacromial: Corticosteroid / [Other]
• AC joint: Corticosteroid
• Glenohumeral: Corticosteroid / HA

Surgical Management (if indicated)

Procedure: [Specific procedure]

• Rotator cuff repair: [Arthroscopic vs open, repair type]
• Instability: [Bankart repair, Latarjet, remplissage]
• SLAP repair / Biceps tenodesis / tenotomy
• Arthroplasty: [TSA, reverse TSA, hemiarthroplasty]
• Decompression / Distal clavicle excision

Timing: [Urgent, elective, after PT trial]
Pre-operative: [Clearance, imaging, PT prehab]

Follow-up

Return: [Timeframe]

• Sooner if: Significant weakness, trauma, worsening symptoms

Patient Education

Diagnosis explanation, treatment rationale, activity restrictions, home exercises, ice for pain/inflammation, posture and sleeping position, warning signs, expected recovery timeline.