Shoulder Evaluation and Initial Interventions

In physical therapy school, therapists are taught a broad spectrum of knowledge. Orthopedic examination, treatment, and prognosis is covered in-depth. For example, we learn more than 50 special tests to diagnose shoulder impingement, rotator cuff dysfunction, biceps pathology, and labral tears. Despite all this knowledge, therapists lack the ability to prioritize these tests. Many therapists gather information without considering ‘why’ we perform each measure. We soon realize that the special tests are not very special! Upon finishing their clinical examination, they are drowning in information that only minimally changes their patient’s prognosis or intervention selection. The therapist has found several secondary and tertiary impairments without identifying the primary cause of the problem. In this post, I am going to discuss how I perform a shoulder evaluation and review some of my regular day 1 shoulder exercises.

Shoulder Examination: Efficiency and Reliability

During a shoulder examination, it is important to assess the cervical and thoracic spine, rib cage, and static and dynamic postures of the upper quarter. Each one of these regions can impact shoulder mechanics. For example, during shoulder flexion, the thoracic spine extends, side bends, and rotates; ribs one and two depress, while ribs three through five elevate. 

Understanding the biomechanics can be a great starting point for assessing a painful region of the body. A lack of mobility or stability in any local region can impact one's pain perception, altering their response to stimuli.

For new clinicians, it is important to develop an efficient and reliable examination. This combination of efficiency and reliability will minimize any redundancy of testing while maximizing time for treatment. Below is my template for performing an efficient examination. For the purpose of efficiency, it is divided by patient position. You will notice that only a few special tests are performed and the biggest focus is on assessing regional joint mobility. ​

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CLINICAL EFFICIENCY: ARRIVING AT THE CORRECT PHYSICAL THERAPY DIAGNOSIS AND DETERMINING THE APPROPRIATE PLAN OF CARE WITHOUT PERFORMING UNNECESSARY TESTS AND MEASURES

Want a More Efficient Exam?

View the Guide to Efficient PT Examination!

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Shoulder Interventions: Day 1 Treatment and More

Upon completion of the shoulder examination, the next step is selecting appropriate interventions. From my clinical experiences, the shoulder joint is typically irritable in the acute stages. Therefore your exercise selection and manual interventions should address the patient's pain. My Day 1 interventions heavily focus on desensitizing the painful tissue through graded tissue exposure. Additionally, I spend a significant amount of time discussing the different mechanisms that impact pain. These exercises often include range of motion exercises and posterior shoulder muscle activation. If the patient has low irritability, further strengthening and mobility exercises can be initiated early in the plan of care.

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The video below discusses 3 common exercises I give to patients on the first day.
 ​If you find this video useful, I encourage you to check out our Insider Access pages. 

Questions or comm​ents? 
Let us know what initial interventions you typically use when working with shoulder patients!
-​Jim Heafner PT, DPT, OCS