Appendix B
Curriculum: Evaluation and Treatment of the Painful Shoulder, Day #1
Problem Identification: Musculoskeletal complaints are one of the most common reasons for primary care visits. Symptoms
referable to the shoulder are the second most common musculoskeletal complaint after back pain. The unique anatomy of the
shoulder allows for unrestrained motion in all planes. While this motion is unparalleled by other joints in the body it also creates a
lack of inherent stability and presents several areas for potential problems. Fortunately a thorough history and physical examination
can help identify most causes of shoulder pain. In addition, most cases can be treated without referral to a subspecialist.
Needs Assessment: To assess the learning needs of the BIDMC medical residents in terms of their knowledge of evaluation and
treatment of the painful shoulder, each learner is asked to complete: (a) self-evaluation form, assessing their skills in examining and
treating a painful shoulder. The evaluation form consists of a five-point Likert scale measuring the residents’ satisfaction with their
physical examination, diagnostic, and treatment skills, and (b) a written pre-test to assess knowledge of these skills. The questions on
the pre-test are designed to stimulate the residents’ recall of previously encountered musculoskeletal cases. The pre-test is largely
case-based with multiple-choice answers (Appendix A). In addition, we surveyed the residents to determine preferred instructional
methods.
Overall Curriculum Goals:
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To prepare residents to evaluate and treat competently shoulder pain complaints of their patients.
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To provide residents the knowledge base necessary to effectively perform a subacromial space injections.
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To give residents the knowledge base necessary to refer appropriate patients to a subspecialist.
Objectives:
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Residents will be able to correctly identify the anatomy of the shoulder.
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Residents will be able to identify common presenting history of painful shoulder conditions including impingement syndrome
(subacromial bursitis, supraspinatus tendonitis); bicipital tendonitis; adhesive capsulitis; acromioclavicular joint separation;
cervical radiculopathy; glenohumeral subluxation.
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Residents will be able to identify the most common causes of shoulder pain in the primary care setting, as well as the most
common causes by age group.
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Resident will be able to perform an appropriate history and physical examination for a patient presenting with shoulder pain.
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Residents will be able to identify appropriate treatment methods including anti-inflammatory medications, subacromial steroid
injections, and physical therapy.
Shoulder Pain—Day #1
Educational Strategies
Content
Anatomy
Bones/Joints
Methods
1) Presentation of anatomy
Resources
White board with markers
through discussion, diagrams,
Diagram Shoulder Anatomy
and anatomical model.
Anatomical Shoulder Model
Muscles
Movement
Range of Motion
2) Learners identify anatomical
landmarks on themselves and
colleagues.
3) Learners identify and perform
movements associated with
specific muscle groups.
History
Common Presenting Complaints
Common Causes of Shoulder Pain in
Clinical Case Discussion
1) Case discussion and role-play to
elicit key historical elements in
Primary Care Setting
Common Causes by Age Group
Causes of Pain by Location
a patient with impingement
syndrome
2) Question and answers to elicit
further detail and to narrow
differential diagnosis
Physical Examination
Inspection
Palpation
Range of Motion
Active vs. Passive
Specific Maneuvers
1) Case discussion and role-play to
actively engage audience.
2) Open and closed questions help
facilitate discussion.
3) Group narrows differential
diagnosis and helps identify
Empty Can
correct diagnosis based on
Neer’s Test
findings
Hawkins’ Test
4) Alternate diagnoses discussed
Clancy Maneuver
by addition of new findings on
Drop Arm
examination (i.e., positive “drop
arm” test)
5) Digital video and audience
volunteers both utilized to
demonstrate examination
maneuvers
6) Group practices examination on
each other with close faculty
guidance and feedback
Treatment
Physical Therapy
NSAIDS vs. Steroid Injection*
1) Group creates a treatment plan
for their “patient.”
2) Physical Therapy modalities
demonstrated
End of Day #1++
*Subacromial Steroid injections methods are taught on Day #3 utilizing anatomic models
++
Days 2 and 3 builds on information learned in first day, highlighting and repeating key elements while adding new information
in a similar format (cases, role-play, group discussion, question and answer).
Evaluation:
In addition to pre- and post-self assessment evaluations, and pre- and post-curriculum tests to assess knowledge and skill, residents
were asked to participate in a single station Objective Structured Clinical Examination (OSCE) three months following the curricular
series). The OSCE is conducted to evaluate knowledge retention, measure post-intervention skills, and determine competency at
relevant musculoskeletal physical examination, diagnostic, and procedural skills. Appendix C provides a sample of one of our
OSCEs.