Shoulder Assessment
Select All
Clear All
Clear CBG free text
Expand All
Collapse All
+
Subjective
Patient unique id
Please convert the information below into a Physiotherapy SOAP note, incorporating clinical and biomechanical analysis, and include a final section with a deep and detailed clinical and biomechanical analysis, as well as Opportunities for Improvement.
Type of assessment
Initial Evaluation
Follow Up Note
+
Side
Left
Right
Bilateral
+
Objective Assessment
+
On examination
+
ROM Shoulder
Flexion
Full range of motion - 0–180°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Extension
Full range of motion - 0–30°
Reduced range of motion
Reduce range of motion due to pain
Full range of motion with pain
Abduction
Full range of motion - 0–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Adduction
Full range of motion - 0–30°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Internal rotation
Full range of motion - 0–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
External rotation
Full range of motion - 0–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
+
ROM Cervical Spine
Flexion
Full range of motio - 50–60°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Extension
Full range of motion - 60–70°
Reduced range of motion
Reduce range of motion due to pain
Full range of motion with pain
Rotation Right
Full range of motion - 70–90°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Rotation Left
Full range of motion - 70–90°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Right Lateral Flexion
Full range of motion - 35–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
Left lateral Flexion
Full range of motion - 35–45°
Reduced range of motion
Reduced range of motion due to pain
Full range of motion with pain
+
Muscle Power Shoulder
Flexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Extension
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Abduction
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Adduction
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Internal rotation
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
External rotation
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
+
Muscle Power Cervical Spine
Flexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Extension
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Right lateral flexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Left lateral flexion
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
5 – Full movement against gravity with strong resistance (normal strength) with pain
Right rotation
0 – No visible or palpable contraction
1 – Slight contraction, no movement
2 – Full movement with gravity eliminated
3 – Full movement against gravity, no added resistance
4 – Full movement against gravity with moderate resistance
5 – Full movement against gravity with strong resistance (normal strength)
+
Dermatomes Cervical Spine
C2 - Right [Occiput / upper posterior neck]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C3 - Right [Lateral neck]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C4 - Right [Supraclavicular / top of shoulder]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C5 - Right [Deltoid]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C6 - Right [Outer aspect of the forearm and thumb]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C7 - Right - [Middle finger]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C8 - Right [Little finger and medial aspect of the forearm]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
T1 - Right [Medial epicondyle]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C2 - Left [Occiput / upper posterior neck]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C3 - Left [Lateral neck]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C4 - Left [Supraclavicular / top of shoulder]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C5 - Left [Deltoid]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C6 - Left [Outer aspect of the forearm and thumb]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C7 - Left [Middle finger]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
C8 - Left [Little finger and medial aspect of the forearm]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
T1 Left [Medial epicondyle]
Normal
Reduced
Absent
Heightened
Allodynia
Paresthesia
Dysesthesia
+
Myotomes Cervical Spine
C1 - Right [Neck flexion]
Normal
Weak
Painful
No contraction
Fatigable
C2 - Right [Neck flexion (longus capitis, rectus capitis anterior)]
Normal
Weak
Painful
No contraction
Fatigable
C3 - Right [Neck lateral flexion ]
Normal
Weak
Painful
No contraction
Fatigable
C4 - Right [Shoulder elevation (trapezius, levator scapulae)]
Normal
Weak
Painful
No contraction
Fatigable
C5 - Right [Shoulder abduction / elbow flexion (deltoid, biceps)]
Normal
Weak
Painful
No contraction
Fatigable
C6 - Right [Wrist extension (extensor carpi radialis group)]
Normal
Weak
Painful
No contraction
Fatigable
C7 - Right [Elbow extension / wrist flexion]
Normal
Weak
Painful
No contraction
Fatigable
C8 - Right [Thumb extension / finger flexion]
Normal
Weak
Painful
No contraction
Fatigable
T1 - Right [Finger abduction/adduction]
Normal
Weak
Painful
No contraction
Fatigable
C1 - Left [Neck flexion]
Normal
Weak
Painful
No contraction
Fatigable
C2 - Left [Neck lateral flexion]
Normal
Weak
Painful
No contraction
Fatigable
C3 - Left [Shoulder elevation]
Normal
Weak
Painful
No contraction
Fatigable
C4 - Left [Shoulder elevation]
Normal
Weak
Painful
No contraction
Fatigable
C5 - Left [Shoulder abduction / elbow flexion]
Normal
Weak
Painful
No contraction
Fatigable
C6 - Left [Wrist extension]
Normal
Weak
Painful
No contraction
Fatigable
C7 - Left [Elbow extension / wrist flexion]
Normal
Weak
Painful
No contraction
Fatigable
C8 - Left [Thumb extension / finger flexion]
Normal
Weak
Painful
No contraction
Fatigable
T1 - Left [Finger abduction/adduction]
Normal
Weak
Painful
No contraction
Fatigable
+
Postural Deviations & Biomechanical Variations of the Shoulder
Postural Deviations (Static Observation)
Rounded shoulders / Protracted scapulae – (tight pecs, weak rhomboids & lower traps)
Elevated shoulders – (overactive upper traps, levator scapulae tension)
Depressed shoulders – (long-term load carriage, weak upper traps)
Scapular winging – (weak serratus anterior, long thoracic nerve palsy)
Scapular tilt anterior tilt
Scapular tilt posterior tilt
Altered Scapulohumeral Rhythm
Normal: ~2:1 ratio of GH to ST motion during abduction.
Variation: Excessive GH motion, reduced scapular upward rotation, early scapular elevation.
Hypolordosis / “flat back” (reduced inward curve)
Scapular Dyskinesis
Type I: Inferior angle prominence (anterior tilt).
Type II: Medial border prominence (winging).
Type III: Superior border elevation (shrugging pattern).
Other variations
Glenohumeral Internal Rotation Deficit (GIRD)
Excessive External Rotation
Superior Humeral Head Migration
+
Postural Deviations & Biomechanical Variations of theCervical Spine
Cranio‑Cervical Alignment (Sagittal Plane)
Neutral cranio‑cervical posture
Anterior head translation (forward head posture)
Posterior head translation (retracted head posture)
Upper cervical extension (“chin poke”)
Upper cervical flexion (“chin tuck”)
Cervical Curve (Lordosis)
Physiologic cervical lordosis
Cervical hypolordosis (flattened/straightened curve)
Cervical hyperlordosis (excessive inward curve)
Shoulder Girdle / Upper Thorax
Scapular girdle level and symmetrical
Right shoulder elevation
Left shoulder elevation
Bilateral shoulder protraction (rounded shoulders)
Excessive thoracic kyphosis (hyperkyphosis)
Reduced thoracic kyphosis (hypokyphosis)
Scapula Position - Right
Neutral
Protracted
Retracted
Elevated
Depressed
Downwardly rotated
Upwardly rotated
Winging
Scapula Position - Left
Neutral
Protracted
Retracted
Elevated
Depressed
Downwardly rotated
Upwardly rotated
Winging
+
On Palpation Shoulder Left
Supraspinatus tendon → anterior to acromion, shoulder in extension & IR; tender in tendinopathy/impingement.
Infraspinatus tendon → posterior greater tuberosity, arm in flexion & adduction; tender in cuff tear.
Teres minor tendon → below infraspinatus, palpate with hand on opposite shoulder; tender in throwers.
Subscapularis tendon → lesser tuberosity, shoulder in ER; painful in subscapularis lesion.
Deltoid (anterior/mid/posterior) → shoulder cap, palpate with isometric contraction in each plane; tender in bursitis/strain.
Biceps long head tendon → bicipital groove, elbow at 90°, forearm supinated; tender in bicipital tendinitis.
Pectoralis major → chest to humeral insertion, arm in 90° abduction & ER; tight in rounded shoulders.
Pectoralis minor → under coracoid, palpate with arm relaxed at side; tender in postural tightness.
Trapezius (upper) → neck to clavicle, palpate with shoulder shrugged; spasm in stress.
Trapezius (middle/lower) → along scapular spine, palpate with scapular retraction/depression.
Levator scapulae → superior angle of scapula, palpate with hand behind back; tender in postural strain.
Rhomboids → medial scapular border, palpate with hand resting on small of back.
Latissimus dorsi → posterior axilla, palpate with shoulder internally rotated.
Teres major → just above lats in axilla, palpate with arm resisted into extension.
Serratus anterior → lateral ribs, palpate during wall push-up (protraction); winging if weak.
Subacromial/Subdeltoid bursa → beneath acromion, palpate during passive abduction; tender in bursitis.
+
On Palpation Shoulder Right
Supraspinatus tendon → anterior to acromion, shoulder in extension & IR; tender in tendinopathy/impingement.
Infraspinatus tendon → posterior greater tuberosity, arm in flexion & adduction; tender in cuff tear.
Teres minor tendon → below infraspinatus, palpate with hand on opposite shoulder; tender in throwers.
Subscapularis tendon → lesser tuberosity, shoulder in ER; painful in subscapularis lesion.
Deltoid (anterior/mid/posterior) → shoulder cap, palpate with isometric contraction in each plane; tender in bursitis/strain.
Biceps long head tendon → bicipital groove, elbow at 90°, forearm supinated; tender in bicipital tendinitis.
Pectoralis major → chest to humeral insertion, arm in 90° abduction & ER; tight in rounded shoulders.
Pectoralis minor → under coracoid, palpate with arm relaxed at side; tender in postural tightness.
Trapezius (upper) → neck to clavicle, palpate with shoulder shrugged; spasm in stress.
Trapezius (middle/lower) → along scapular spine, palpate with scapular retraction/depression.
Levator scapulae → superior angle of scapula, palpate with hand behind back; tender in postural strain.
Rhomboids → medial scapular border, palpate with hand resting on small of back.
Latissimus dorsi → posterior axilla, palpate with shoulder internally rotated.
Teres major → just above lats in axilla, palpate with arm resisted into extension.
Serratus anterior → lateral ribs, palpate during wall push-up (protraction); winging if weak.
Subacromial/Subdeltoid bursa → beneath acromion, palpate during passive abduction; tender in bursitis.
+
On Palpation Left Cervical Spine
+
Tenderness
Superficial Anterior / Lateral Neck
Sternocleidomastoid
Anterior scalene
Middle scalene
Posterior scalene
Posterior Cervical Extensors and Stabilizers
Splenius capitis
Splenius cervicis
Semispinalis capitis
Semispinalis cervicis
Cervical multifidus
Levator scapulae
Upper trapezius
Scapular and Shoulder Girdle Muscles
Middle trapezius
Lower trapezius
Rhomboid major
Rhomboid minor
Serratus anterior
Pectoralis minor
Pectoralis major
Latissimus dorsi
Teres major
Teres minor
Supraspinatus
Infraspinatus
Subscapularis
Suboccipital Group
Rectus capitis posterior major
Rectus capitis posterior minor
Obliquus capitis superior
Obliquus capitis inferior
+
On Palpation Right Cervical Spine
+
Tenderness
Superficial Anterior / Lateral Neck
Sternocleidomastoid
Anterior scalene
Middle scalene
Posterior scalene
Posterior Cervical Extensors and Stabilizers
Splenius capitis
Splenius cervicis
Semispinalis capitis
Semispinalis cervicis
Cervical multifidus
Levator scapulae
Upper trapezius
Scapular and Shoulder Girdle Muscles
Middle trapezius
Lower trapezius
Rhomboid major
Rhomboid minor
Serratus anterior
Pectoralis minor
Pectoralis major
Latissimus dorsi
Teres major
Teres minor
Supraspinatus
Infraspinatus
Subscapularis
Suboccipital Group
Rectus capitis posterior major
Rectus capitis posterior minor
Obliquus capitis superior
Obliquus capitis inferior
+
Special Test
+
Impingement Tests
Neer’s Test → Passive shoulder flexion with internal rotation
Negative
Postive
Hawkins-Kennedy Test → Shoulder at 90° flexion, elbow bent, examiner internally rotates
Negative
Positive
Painful Arc Test
Negative
Positive
+
Rotator Cuff Tests
Empty Can (Jobe’s) Test → Arm at 90° scaption, thumb down, resist abduction
Negative
Postive
Drop Arm Test → Patient lowers abducted arm slowly
Negative
Positive
External Rotation Lag Sign → Arm in ER position, inability to maintain
Negative
Positive
Lift-Off Test → Hand behind back, lift off against resistance
Negative
Positive
Belly Press Test → Palm on belly, press inwards
Negative
Positive
+
Biceps Tendon Tests
Speed’s Test → Resisted forward flexion with supination
Negative
Postive
Yergason’s Test → Resist supination with elbow at 90°
Negative
Positive
+
Labral Pathology Tests
O’Brien’s (Active Compression) Test → Arm flexed 90°, adducted, IR (thumb down), resist downward force; repeat in ER → pain in IR reduced in ER
Negative
Postive
Crank Test → Shoulder at 90° abduction, axial load + IR/ER rotation
Negative
Positive
Biceps Load Test II → At 120° abduction, resisted elbow flexion
Negative
Positive
+
Instability TestsTests
Apprehension Test → Abduction + ER → apprehension (not just pain)
Negative
Postive
Relocation Test → Same as above, apply posterior force
Negative
Postive
Anterior Drawer Test → Translate humeral head anteriorly
Negative
Positive
Posterior Drawer Test → Translate humeral head posteriorly
Negative
Positive
Sulcus Sign → Traction on arm
Negative
Positive
+
Acromioclavicular (AC) Joint Tests
Cross-Body Adduction (Scarf) Test → Horizontal adduction across chest
Negative
Postive
AC Shear Test → Compress clavicle and spine of scapula
Negative
Postive
+
Assessment
Diagnosis
+
Plan
+
Treatment given
+
Myofascial Trigger Point release Shoulder
Right side
Deltoid
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
Biceps Brachii (Long Head)
Pectoralis Major
Pectoralis Minor
Trapezius
Levator Scapulae
Rhomboids (Major & Minor)
Latissimus Dorsi
Serratus Anterior
Left side
Deltoid
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
Biceps Brachii (Long Head)
Pectoralis Major
Pectoralis Minor
Trapezius
Levator Scapulae
Rhomboids (Major & Minor)
Latissimus Dorsi
Serratus Anterior
+
Myofascial Trigger Point release Neck
Superficial Anterior / Lateral Neck
Sternocleidomastoid
Anterior scalene
Middle scalene
Posterior scalene
Posterior Cervical Extensors and Stabilizers
Splenius capitis
Splenius cervicis
Semispinalis capitis
Semispinalis cervicis
Cervical multifidus
Levator scapulae
Upper trapezius
Scapular and Shoulder Girdle Muscles
Middle trapezius
Lower trapezius
Rhomboid major
Rhomboid minor
Serratus anterior
Pectoralis minor
Pectoralis major
Latissimus dorsi
Teres major
Teres minor
Supraspinatus
Infraspinatus
Subscapularis
Suboccipital Group
Rectus capitis posterior major
Rectus capitis posterior minor
Obliquus capitis superior
Obliquus capitis inferior
Taping
Advised on do's and don'ts
Scapular strengthening
Shoulder girdle muscle strengtehening
Upper limb stretching videos shared
Core muscle Strengthening
Isometric Neck strengthening
Follow up
After 1 week
After 2 weeks
After 1 month
Patient Discharged
👁
Preview
Preview
Copy Preview
Copy for Word
Select All Preview
Copied! Now paste into Word.
Automatic copy is not supported. Click "Select All Preview", then press
Ctrl+C
(or
Cmd+C
) to copy, then paste into Word.