Shoulder Pain (History and Exam, No diagnosis)

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Patient presents with pain in the shoulder
Side:

History:
No stiffness or restriction
No excessive movement / instability
No weakness
Rough / smooth

No history of significant injury
The pain does not keep the patient awake at night
There is no stiffness in the neck
No pain on touching the shoulder blades
No pain on brushing hair
Pain is not worse in the morning
No aching in both shoulders or hips
No pain associated With sporting activity, including weight training and house work, dressing or other activities
Believes able to thorw a ball underhand for 10-20 metres and overhead 20-25m
Feels can lift a 2L container level with shoulder
Believes can carry a 20-30kg weight by their side

Examination:

Cervical spine exam is normal

Inspection:  The shape and contour or the shoulder joints appears normal
Normal posture and position of the scapula
No evidence of deformity,swelling or muscle wasting

Palpation:  The following joints were palpated:
AC Joint
The subacromial space
The supraspinatous tendion
 the long head of biceps

Palpation of the subacromial bursa did not reveal any tenderness or inflammation

There was no evidence of muscle spasm over the supraspinatus or infraspinatus muscles

There was no evidence of lymphadenopathy in the axilla

Movement:
Flexion:
- Normal ROM
- No pain
- No scapulo thoracic rotation

Extension:
- Normal ROM
- No pain
- No scapulo thoracic rotation

Abduction:
- Normal ROM
- No pain
- No scapulo thoracic rotation

External Rotation:
- Normal ROM
- No pain
- No scapulo thoracic rotation

Internal Rotation:
- Normal ROM
- No pain
- No scapulo thoracic rotation

Restricted Movement:
Abduction: Normal
INternal Rotation (Subscapularis) : Normal
External Rotation: Normal

Special Tests:
Supraspinalis/infraspinatus rapid differentiation test (Thumbs up / Thumbs down):  Normal

Long Head of Biceps Test: Normal

The Brachial Plexus Tension Test: Normal

Impingement Test: Normal

Keywords:  Shoulder Pain, +shoulderpain

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