Subjective Exam

Subjective Examination

1. Patient Profile

2. Symptoms

   • mechanism of onset

   • type/description/location

   • behavior (SINS)

3. Origin of Symptoms

   • other musculoskeletal/neuromuscular origins

   • non-musculoskeletal origins

   • review of systems with special screenings and questions

4. Patient Reported Outcome Measures

Risk Factors

Adhesive Capsulitis: ages 40-65 years, female>male, diabetes, thyroid disease

Shoulder Fracture: older, female adults

Acromioclavicular Sprain/Strain: ages <40 years, male 5x more likely than females

Labral Tear: 30-50 years

DeQuervain’s Synovitis: Female > male; individuals why text frequently

Lateral Epicondylitis: ages 40-50 years; tennis players; RUE hand dominance

Wrist Fracture: risk increases with age

Patient Profile Cont.

Occupation and Recreation

• uterus/repetitive - overhead

• acute trauma - arm outstretched, fall

Social/Home Situation

• are basic needs being met?

• support system

Hand Dominance

Patient Goals and Expectations

Symptoms: Mechanisms of Onset

New occurrence vs previous episodes

Gradual - chronic overuse

Sudden - acute trauma (FOOSH)

Acute exacerbation of overuse

Pattern of flares and remissions (rheumatoid arthritis-progression overtime

Symptoms Type/Description

• clicking, popping, clunking

• heaviness, weakness, dead-arm

• locking

• apprehension

• painful arc

• parastesias

• numbness

Symptoms: Location

• specific and localized - pointing with one finger

• generalized area involving the shoulder region

• investigate if symptoms include areas above and or below the joint of interest

Common Areas of G-H Joint Pain Referral

Common Areas of A-C & S-C Joint Pain Referral

Behavior of Symptom: Aggravating

• reach up, across, behind

• carrying

• lifting

• throwing

• sleeping - on shoulder, back

• cervical spine movement

Behavior of Symptoms: Easing

• rest

• movement

• support

  • position

  • pillow

  • sling

• medications, heat/cold modalities

Behavior of Symptoms: 24 Hours

• awakened from sleep

  • inability to lie on affected side

  • ability to fall back to sleep

• sleeping position

• rising

• AM/PM

Framework to Determine the appropriate rigor/intensity of examination

SINS

S: Severity

I: Irritability

N: Nature

S: Stage

SINS - Severity

S: Severity - seriousness of the problem

• intensity level (pain scale: 0/10, 1-3/10 min, 4-6/10 mod, 7-10/10 (max)

• constant or intermittent

• type of symptoms

• limitations of activities

• complexity of presentation

• patients may present with a range of severity

SINS - Irritability

I: Irritability: degree of tissue response/action

• type of aggravation

• amount of aggravation - time to provoke an increase in symptoms from the lowest baseline

• the level to which symptoms increase; at least ask for type and amount of activity that provokes the highest level

• the type of easing factor and how long it takes to decrease the symptoms to the lowest//baseline level

• latency of aggravation of symptoms; symptoms that come on or increase well after cessation of the provoking/aggravating factor, which might make the actual aggravating factor more difficult to determine

Types of Irritability

Max Irritability: takes a relatively short time to aggravate and longer to ease

Mod-max: characteristics from both mod and max presentations

Mod irritability: it takes approximately the same time to aggravate and ease

Min-mod: characteristics from other mod and max presentations

Min irritability: it takes a relatively long time to aggravate and shorter to ease

SINS - Nature

Nature: Type of problem

• non-musculoskeletal - requires referral to other health care professional

• neuromusculoskeletal or musculoskeletal - requires further investigation by the pt and potentially outside referral

  • mechanical - symptoms related to or reproducible by movement or posture

  • contractile vs non contractile - tissue involvement

  • chemical - signs of inflammatory process; underlying conditions such as rheumatoid arthritis

SINS - Stage

S: Stage: current status of the problem based on time since onset on current presentation

• progression/stability of sx (getting better, getting worse, or staying the same)

• described as either acute, subacute, chronic based on tissue healing properties

• one may identify a problem as chronic with exacerbation if they have had the problem previously

• persistant acute: acute presentation despite a longer time since onset that would be termed or associated with a chronic problem; sx never decreased from being more highly irritable

Origin of Symptoms

• patient center approach

• symptoms originating from other musculoskeletal/neuromuscular origins

• symptoms originating from non-musculoskeletal origins

Potential musculoskeletal/neuromuscular origins of symptom referral to the shoulder region

1. cervical spine joints

2. cervical spine nerves

   • referral from nervous tissue (spinal nerve roots C4, C5)

Nervous Tissue

Any neurological tissue including the brain, spinal cord > peripheral nerves

Motor Impairment

Muscular weakness

Sensory Impairment

Change in sensation

• increased, decreased, loss, numbness, tingling

Injury to Nerve

Can result in motor and/or sensory impairment

Proximal to Peripheral Brachial Plexus

Spinal cord → cervical nerve root → ventral ramus → BP roots → BP trunks → BP divisions → BP Cords → Peripheral Nerves

Peripheral Nerve Injury - Posterior Interosseous Syndrome

• Originates from the deep branch of the radial nerve

• the deep branch of the radial nerve originates from the posterior cord (C5-C8 and T1) of the brachial plexus

• results in motor impairment only: weakness to the supinator, wrist and finger extensors

• injury to the posterior cord of the brachial plexus results in sensory and motor impairments

  • sensory: regions of the upper extremity innervated by nerves from C5-C8 and T1

  • motor: muscles innervated by C5-C8 and T1

Cervical Spine Screen

AROM and AROM with overpressure

Cervical Spince Screen: Additional Tests/Measures

Additional Screening Measures

• PROM cervical spine

• myotomes (resisted isometrics)

• dermatomes (sensory assessment)

• upper limb neural tension tests

• quadrant test

• deep tendon reflexes

Referred Pain from Muscle Tissue

• trigger points

  • hyperirritable regions/spots to palpation within skeletal muscle or fascia

  • palpable densities within muscle fiber

  • causes: prolonged immobilization, excessive use

Potential Origin of Symptom Referral to the Shoulder Region Complex Regional Pain Syndrome

Symptoms follow a glove or stocking pattern

Potential Origin of Symptom Referral to the Shoulder Region

Symptoms follow innervation from the brachial plexus

Non Musculoskeletal Origin of Symptom Referral to the Shoulder Region

Spleen Rupture Referred Pain

Pain in L shoulder

Gallbladder/Liver/Stomach Referred Pain

Pain in R shoulder and scapular region

Diaphragm Referred Pain

Pain front of either or both shoulders/upper trapezius region

Cardiac Referred Pain

Pain in L shoulder, scapula, axilla, scapular region (and/or arm, neck, jaw)

Pancost Tumor (Apical lobes of lung) Referred Pain

Pain in R or L shoulder, ulnar distribution UE

Pancreas Referred Pain

L shoulder and/or thoracic spine

Pancoast’s Tumor

Tumor located in apex of lungs

• symptom presentation can mimic TOS

• C8, T1, T2 dermatomes

• lower trunks of brachial plexus

• C8-T1 nerve roots

• initially sharp posterior shoulder pain

• pain in axilla and sub scapular regions

Psychogenic Pain

Beliefs, fears, emotions, assumptions

Special Screen Questions

• General health, smoking, thyroid disease

• change in appetite

• weight loss or gain

• bowel/bladder issues or changes

• fever/chills

• skin changes/hair loss/nail bed

• other pain, stiffness, swelling, redness

• fatigue

• respiratory symptoms

• numbness

• gait disturbance

• headaches/dizziness

• coughing, sneezing

Diagnostic Tests

• Imaging

  • x-ray

  • MRI

  • CT

  • Bone scan

• blood draws

• nerve conduction velocity tests

  • stimulation of a nerve to identify impairments in the speed of nerve conduction

• electromyography tests

  • stimulation of a muscle to identify impairments of the ability of a nerve to stimulate muscle activity

Patient Reported Outcome Measures

SPADI (shoulder pain and disability index)

DASH (disability of the arm, shoulder, hand)

quick-DASH

Western Ontario Shoulder Instability Index

Time Functional Arm and Shoulder Test (TFAST)

Shoulder Performance Activity Test (SPAT)