I'm going to see an orthopedic surgeon for the first time in my life. My problem is a bum shoulder. I injured it years ago and it's starting to catch up with me. I am interested in being a good consumer of health care, so what should I expect at this first appointment?

You should expect to be interviewed by the physician (or a member of his or her staff). Any good medical interview allows the patient an opportunity to tell what's wrong and how it happened. The examiner tries to fill in with questions that give him or her a full understanding of the your daily activities. This includes hobbies, athletic participation or other physical activity, and desires/goals from treatment.

The patient interview actually continues as the examiner begins to assess pain, inspect the shoulder complex, measure range-of-motion, and test strength. You should report any unusual symptoms such as if the shoulder locks up or catches. The examiner will want to listen and feel for this during the exam. Some provocative tests may be done that reproduce the pain. That can be very useful information when sorting through a wide range of possible reasons for shoulder pain.

There is no single test that will quickly uncover the problem. Usually, several tests combined together give the examiner information that leads to a diagnosis. Researchers have not been able to package together a group of tests that can be used routinely with each shoulder pain patient for the most accurate diagnosis.

It may be necessary to go through quite a few of the available tests before discovering what's wrong. Sometimes normal tests are more helpful than abnormal ones. At least the examiner can tell what's working right. Abnormal test results have a way of muddying the waters because there can be several possible corresponding problems.

The physician or physician's assistant should conduct a very thorough exam. A full range-of-motion assessment is important. Any compensatory motions, loss of motion, or changes from one side to the other should be noted. That will help determine which shoulder-specific tests to perform.

Each muscle group can be tested for strength/weakness. Specific tests can be conducted for impingement, rotator cuff tears, labral tears, biceps tear or rupture, and nerve impingement or blood vessel compromise. Pulses, sensation, grip strength, and reflexes are useful tests to look for a neurologic or vascular (circulation) problem.

When it's all said and done, the examiner steps back and takes a look at the big picture. Are there any other health problems? Does the patient have neck or back involvement? Are there any constitutional symptoms? Constitutional symptoms are those signs and symptoms that come in a cluster with any systemic disorder no matter which system is involved. For example, fever, chills, fatigue, unexplained perspiration, and nausea or vomiting are common constitutional symptoms.

Shoulder exams take time to complete. No one test is sensitive enough or accurate enough to draw any final conclusions from it. The results of each test point to the next test to conduct or consider. Putting all the pieces together of the history and interview with the clinical findings from the tests performed can result in an accurate differential diagnosis. The examiner who uses a systematic approach with each patient will be efficient yet thorough.

The final step is conveying to the patient the interpretation of the results. In other words, what's wrong and what can be done about it? The physician may be able to give you a provisional diagnosis (what is the most likely cause of the pain). The final diagnosis may have to wait until the results of any blood or X-ray tests have come through.

Reference: 

Allison Tobola, MD, et al. Identifying Shoulder Pain in Older Patients: The History, Physical Examination, and Testing. In The Journal of Musculoskeletal Medicine. June 2009. Vol. 26. No. 6. Pp. 216-221.

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