Telemedicine has a very important role in today’s healthcare system, which has been accentuated during the SARS-CoV-2 pandemic. Virtual medical evaluations offer a myriad of benefits for both patients and providers. Evaluations of the musculoskeletal system, however, present unique challenges because diagnosis significantly relies on a physical examination, something not easily accomplished by virtual means. The shoulder, a complex region with four separate articulations, is no exception. Nevertheless, a properly planned and executed telemedicine visit may yield successful results even with challenging shoulder pathologies. This narrative review aims to offer clinicians who are novices in the practice of telemedicine a basic framework with instructions, questions, and some examples of interpretation of patient answers to guide them through encounters for the evaluation of shoulder complaints via telephone and video consultation.
Introduction & Background
Stay-at-home and social distancing measures implemented during the SARS-CoV-2 pandemic highlighted the need to improve access to medical care for patients unable to see their physicians in person [1,2]. Some people avoid healthcare facilities for multiple reasons, such as fear of germ exposure or difficulty in transportation, and therefore unnecessarily miss or defer medical appointments. Also, some metropolitan areas have overburdened healthcare systems, and obtaining medical appointments may result in weeks or months of waiting time; moreover, many pathologic conditions, if not addressed promptly, may lead to poor outcomes. Direct telephone and video evaluations are a safe, productive, and convenient alternative to ensure people continue to receive medical care when in-person visits are not possible [3-5]. As technology and audiovisual devices improve and become more readily available and user-friendly, the benefits of telemedicine become clearer.
Some studies suggest that virtual medical visits may have similar health outcomes and patient satisfaction to traditional in-person visits. A randomized controlled trial by Buvik et al. involving 389 patients divided the study population into two groups, traditional face-to-face orthopedic consultation and video-assisted telemedicine, and compared health outcomes and patient satisfaction measured with self-reported questionnaires . They found no statistically significant difference in patient satisfaction or health outcomes measured 12 months after the consultations, suggesting that video-assisted telemedicine orthopedic consultation can be as satisfactory for the patient as a traditional in-person medical visit. Furthermore, 86% of the patients receiving video-assisted consultations expressed they would choose the same telemedicine method as their next medical visit . Results from this study suggest that most people may prefer virtual medical visits as their primary method of consultation while maintaining similar health outcomes. This interesting finding highlights the importance of universally offering patients the option of virtual medical visits.
Evaluating musculoskeletal conditions through telemedicine presents unique challenges because physical examinations are a key component of diagnosis and are not easily achieved through virtual means. Shoulder evaluation is no exception. The shoulder, with four separate articulations and six directions of freedom, is the most mobile joint in the body; however, this tremendous degree of mobility comes with a vulnerability to injury . Shoulder ailments may be debilitating and can lead to pain and suffering. They may also worsen symptoms of depression or cause patients to miss work . In addition to pain stemming from intrinsic shoulder pathology, other concerning conditions such as myocardial ischemic events, cholelithiasis , and herniated cervical intervertebral discs may often manifest as “shoulder pain” and, if not recognized promptly, may result in permanent disability, dysfunction, or death . These conditions may be recognized during a telemedicine encounter and proper steps to prevent further complications may then be taken.
Despite the benefits of remote visits, some patients may be reluctant to engage in telemedicine due to multiple reasons . To maximize the benefits of virtual consultations, physicians must have a thorough understanding of shoulder anatomy, mechanics behind injuries, classical findings during evaluations, and be familiar with current treatment and management guidelines. Physicians must also develop a mental framework for guiding patients to adequately describe their symptoms and perform physical self-evaluations. This article can be a reference guide for clinicians who are novices in the practice of telemedicine for the evaluation of shoulder complaints.
Preparation for virtual encounters
Telemedicine visits rely on the quality of the technology used. Voice clarity, image quality, patient preparation (including proper attire), and patient positioning are crucial for conducting an adequate virtual physical examination. During a video encounter, the patient should be in a well-lit room with the light source facing the patient (not coming from behind) and the camera should not be facing mirrors or windows with bright lights, as this may cause excessive backlighting and obscure details . Patients should position the camera on a steady surface, at a distance of approximately six feet away (different cameras have different features) and at a height of at least 4-5 feet off the ground (e.g., on a table, counter, or stairs) with enough room to extend arms in all directions . In a telephone encounter, it is ideal for the patient to have a large mirror in lieu of the camera, so they may self-inspect during the physical examination, and describe what they see to the physician. Patients should wear a tank top to expose their shoulder joints. A sturdy chair or stool with a comfortable height should be used. Some provocative tests (see ahead) are ideally executed with the patient lying down flat on the side of a stable bed or couch.
Items of known weight appropriate for each patient (small dumbbell, can of vegetables, a container with water, etc.) may be used to simulate resistance for the physical examination segment of the encounter. Fragile or glass containers are discouraged due to the risk of being dropped and broken. These requirements should be made clear to the patient a few days prior to the interview so that there is ample time to prepare. For video encounters, a screen-sharing function may be helpful to allow the physician to show surface anatomy and pain diagrams to the patient.
Shoulder evaluation by telephone
Shoulder evaluation by audio-only (i.e. by telephone), without the benefit of video, is likely to be more challenging. However, a carefully carried-out telephone consultation when visualization by video is not possible may still have a positive outcome for patients. In cases when a patient does not have access to a healthcare facility and is visually impaired, lacks the technology or understanding of video platforms, has inadequate lighting or poor video conditions, or is trying to get first access during a crisis situation, a physician may still be able to obtain important information to evaluate shoulder complaints using a telephone visit.
As with any medical consultation, the first step in a telephone visit is to take an exhaustive and meticulous patient history to formulate an initial differential diagnosis. Specific details regarding the main complaint, medical, surgical, and social history, previous injuries, current medications, jobs, hobbies, and activities, and a review of each organ system, should be carefully obtained . The clinician must be able to verbally guide patients through certain actions to explore a range of motion, pain, visual and tactile features, etc., in order to formulate questions that elicit detailed responses. The clinician should be mindful about choosing words that patients understand and reformulate questions when they provide unclear answers. It is also important for the patient to have a large enough mirror to see their limbs during self-inspection.
The patient’s age can help narrow down this list. For example, a young patient with a traumatic event who feels their shoulder could “come out” (as a subluxation or dislocation is commonly described) can be deemed to have shoulder instability, in which case, imaging, in-person visit, or physical therapy referral may be warranted. In contrast, a middle-aged woman with a thyroid disorder and diabetes who has a gradual onset of shoulder pain and stiffness might be suffering from adhesive capsulitis. In an older patient with sharp pain who has just suffered trauma to the shoulder, a sudden inability to raise the arm over the head would raise concern for dislocation or fracture, requiring urgent imaging and in-person follow-up . If, however, an older patient suffers from gradual progressive weakness and pain while reaching overhead, a rotator cuff pathology or impingement syndrome may be suspected, which can be managed conservatively without imaging. Providers should also remember to specifically ask questions regarding the cervical spine during assessment because referred pain is commonly misinterpreted by patients as primary shoulder pain.
Physicians may also ask the patient to take pictures of any outstanding findings during the self-inspection with a cellular telephone camera, perhaps with the help of a family member or friend, and ask them to send the pictures to an office smartphone or email. This would allow the physician to quickly visualize and evaluate anything the patient finds striking, which may afford important clues to the overall condition.
Table 1, Figures 1A-1C, and Figure 2A provide questions and instructions that may be formulated by clinicians via telephone and possible implications of the responses [15-19]. Table 2, Figures 2B-2C, and Figures 3A-3C provide questions and instructions for common provocative shoulder tests [18,20-25]. It is up to the physicians to determine whether they feel confident enough with patients following these instructions in an accurate manner to gain reliable information from provocative tests.
By considering patients’ detailed history and information gained through questions and self-physical examination, it is possible to exclude emergencies and formulate a feasible differential diagnosis for shoulder conditions via telephone. Table 3 provides sample notes for findings during a normal shoulder during a telephone visit.
Shoulder Evaluation by Video
After taking a thorough history, examination of the shoulder consists of inspection, palpation, range of motion testing, strength testing, and neurovascular assessment. Inspection and range of motion is relatively straightforward during a video consultation, while strength testing, palpation, and provocative testing may require more creativity. Provocative tests may need to be modified to be self-administered and results must rely on self-reported discomfort and/or weakness. The examination should begin with a visual inspection of entire shoulder joint, arms, chest, and back, looking for any asymmetry, abrasions, swelling, changes in skin color, or striking difference between sides. Afterwards, palpation should follow. The patient should be asked to point out the precise location of the most painful area. It may be helpful to show the patient diagrams and anatomy references of the structures found within the shoulder joint. Subsequently, range of motion, strength evaluation, and neurovascular assessment should follow.
Without a hands-on approach, range-of-motion testing is usually executed using active movements during a video encounter. Mobile applications that help measure shoulder range-of-motion have been validated to be accurate within 5° of goniometer measurements (such as Geniometer™ for Apple® devices or Geniometer Records™ for Android® devices) . Household items such as a television remote control (0.5 lbs.), a can of soup or vegetables (15 oz), and a gallon of milk (4-5 lbs.) can be used as weights to help gauge strength. Lastly, provocative tests may be completed if physicians consider they may yield important data for the case. Table 4 (Figures 1A-1C and Figure 2A) provides instructions to physical examination that may be given by video, things to look for while viewing the patient on screen, and possible implications of patient responses or clinician observations [15-19,27]. Table 2 (Figures 2B-2C and Figures 3A-3C) provides questions and instructions for common provocative shoulder tests [18,20-25]. Table 5 provides sample notes for typical shoulder findings during a video visit.
Radiographic studies are a very important complement if findings from a telemedicine visit are suggestive of osseous injury or are inconclusive. Patients may have studies done locally and uploaded into a virtual imaging system or physically mailed to the treating physician to be analyzed. Imaging results may help guide management, particularly if the etiology is not completely clear based on telephone or video evaluation alone.
Limitations of telemedicine
Despite supportive evidence, some physicians and patients may still feel hesitant to engage in telemedicine for a variety of reasons. However, a carefully planned and executed virtual medical visit may offer benefits and yield very useful information. Many physical examination tests normally performed during a shoulder evaluation may be executed by patients on themselves or a proxy examiner under the direction of a physician. All information from the patient history, physical examination (including multiple maneuvers), and imaging (if available) should be carefully considered and analyzed globally to increase the likelihood of obtaining the correct diagnosis.
Telemedicine only works well if the technology used is at least adequate (stable internet and software, suitable cameras, speakers, and microphones, etc.) and if the patients are familiar with said technology. These are sometimes limited in isolated places or developing nations. However, with future advancements in technology, audiovisual equipment become more user-friendly, higher quality, and readily available. Attempts at early adoption of telemedicine, when suitable, will make it a satisfactory option for assessment of the shoulder and perhaps other joints as well.
Telemedicine is likely to become a standard part of medical care in many places around the world. Since physical examination is particularly challenging during virtual visits, providers must carefully develop history-taking protocols to maximize the information gathering necessary to generate an accurate differential diagnosis. Musculoskeletal evaluations may be performed through telephone or video visits by asking patients to follow instructions. Musculoskeletal care is possible through telemedicine even with a joint as complex as the shoulder, and with both positive health outcomes and patient satisfaction. Beyond the COVID-19 pandemic, the ability to offer telehealth consultations is very valuable in society for a myriad of additional reasons.
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Shoulder Evaluation by Telephone and Video Visit: A Narrative Review
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Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
Cite this article as:
Applewhite A I, Gallo R, Silvis M L, et al. (February 21, 2022) Shoulder Evaluation by Telephone and Video Visit: A Narrative Review. Cureus 14(2): e22461. doi:10.7759/cureus.22461
Peer review began: February 02, 2022
Peer review concluded: February 13, 2022
Published: February 21, 2022
© Copyright 2022
Applewhite et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.