What it is built on
- Subacromial shoulder pain pathway. British Elbow and Shoulder Society / British Orthopaedic Association, Patient Care Pathway: Subacromial Shoulder Pain
- Function. Shoulder Pain and Disability Index, SPADI (Roach et al., 1991)
How to use it: Free Evidence-Based Physiotherapy Note Templates
Subjective
- History of the presenting problem Written answer Onset, mechanism, duration, behaviour over 24 hours, aggravating and easing factors.
- Pain now (0–10) Scale 0 to 10
- Pain at worst in the last week (0–10) Scale 0 to 10
- What it stops them doing Written answer Work, sleep, sport, daily tasks.
- Patient's goals Written answer In their words.
Serious causes screened
- Trauma with loss of movement or a possible unreduced dislocation Tick box
- Red, hot, swollen joint or fever Tick box
- Unexplained mass, weight loss or history of cancer Tick box
- New weakness or numbness in the arm Tick box
- Pain that may come from the neck, heart or abdomen Tick box
- None of the above Tick box
Objective
- Body chart Body chart, drawn on
- Active and passive range of movement Written answer Loss of passive external rotation suggests frozen shoulder.
- Strength Written answer External rotation, abduction, internal rotation.
- Special tests Written answer
- SPADI score (%) Number
Assessment and plan
- Most likely pattern Choose one: Rotator cuff related shoulder pain · Frozen shoulder · Shoulder instability · Acromioclavicular joint · Referred from the neck · Unclear — review
- Clinical impression Written answer
- What was explained to the patient Written answer
- Treatment today Written answer
- Home program given Written answer
- Plan and expected number of visits Written answer
- Referral or imaging needed? Choose one: No · Yes — to GP · Yes — imaging · Yes — specialist · Yes — urgent / emergency
A starting point, not clinical advice. Check that it fits your patients, your practice and the rules where you work before you use it.