Clinical Evaluation of Shoulder Problems

Female patients also tend to present in far greater numbers than males with adhesive capsulitis ¹ This is in contrast to the idiopathic stiff and painful frozen shoulder, which is equally prevalent among male and female patients and describes restricted shoulder ROM associated with pain. A frozen shoulder can result from any number of pathologic processes such as post-traumatic stiffness, immobilization, and tendinitis. Adhesive capsulitis is a specific diagnosis most prevalent in women 40 to 60 years of age. It is associated with an idiopathic inflammatory process involving the glenohumeral joint capsule and synovium that results in capsular contraction and adhesion formation.

Although massive rotator cuff tears probably occur in greater numbers in men, it is the women, classically older than 70 years, who develop the sequelae of these massive cuff tears. The diagnosis of cuff tear arthropathy as defined by painful collapse of the humeral head with superior migration (not iatrogenically provoked by prior release of the coracoacromial ligament) favors geriatric women much more than men for unclear reasons.

Patients with rotator cuff tears and impingement often note that in placing the affected arm over their head, they find significant improvement in their pain. Often this arm position is the only way they can find meaningful sleep. This is called the Saha position (Fig. 4-1), named for the Indian orthopaedic surgeon who recognized this phenomenon. He postulated that with the arm resting overhead, there is a balance of tension of the cuff muscles in their least tense state. When the arm is passively elevated overhead in the supine patient, the supraspinatus is subject to its least tension, and pain diminishes in many patients.

FIGURE 4-1 The Saha position often provides relief from pain related to rotator cuff pathology.

Alleviating factors can include activity modification, medications, narcotics, antiinflammatories, injections, and physical therapy. Physical therapy for stretching over long time spans usually improves symptoms and needs to be assessed during history taking.

The response to local anesthetic injections when placed in specific anatomic locations around the shoulder can be very instructive and diagnostic. In a patient with chronic subacromial impingement, 5 mL of 1% lidocaine placed in the subacromial space provides immediate and dramatic relief of pain (Fig. 4-2). This response becomes diagnostic of a subacromial process, and it becomes especially valuable when trying to discern whether the patient’s perceived pain is originating in the shoulder or whether it is referred pain from the neck. A similar local injection test is useful in evaluating the acromioclavicular joint as a source of the patient’s pain. Alleviation of pain with arm adduction following an injection directly into the acromioclavicular joint strongly suggests pathology at this joint. Intra-articular injections can provide similar supporting information regarding the source of a patient’s symptoms.

FIGURE 4-2 Subacromial injection technique from the posterior aspect of the shoulder. The thumb is resting on the inferior border of the spine of the scapula.

These specific injection tests are valuable in defining the pathologic process, and in the case of subacromial impingement, the response to the local anesthetic can predict response to surgical treatment. Moreover, a negative response to a subacromial local anesthetic can predict a negative response to subacromial surgical treatment.

Response of Symptoms to Self-Prescribed Treatment

With the advent and ubiquity of the Internet, patients have now become more involved in their health care decisions. There are countless websites dedicated to patient information, and these help them self-diagnose, although not always with great clarity or accuracy. There are likely even more websites from which patients can receive a wide variety of treatment recommendations for their self-diagnosed shoulder malady. Searching for “physical therapy” brings up millions of hits, and searching for shoulder-specific physical therapy brings up well more than 1 million websites. No doubt then that it is the rare patient who arrives at your office without some knowledge, opinion, and effort at self-management of shoulder pain.

It is important to take time to explore what methods, medications, and modalities the patient might have tried before coming to the physician. Explore the realm of nutraceuticals and ask specifically about the common ones, including glucosamine, chondroitin, shark carti-lage, and methylsulfonylmethane (MSM), because many patients do not consider these to be medicines and do not include them in their medication lists. Patients consume seemingly countless vitamins and vitamin combinations in their effort to improve their physical well-being. With the exception of glucosamine and chondroitin, which themselves have not been subjected to the rigors of the scientific method to prove their efficacy, there is little published objective information to make recommendations to patients. Nevertheless, we have all seen patients who are certain that some combination of these herbs, vitamins, and supplements have affected their medical condition in some way or another. It is important to query and document these treatments in the overall evaluation of the patient with a shoulder problem.

Box 4-1 lists the facets of pain that need to be explored during a patient history.

Instability

In this discussion, it is imperative that the concept of instability is understood to mean the patient has symptoms of some shoulder problem. Many asymptomatic shoulders exhibit increased joint translation and are clearly loose during a physical examination. Such asymptomatic shoulders are defined as lax, not unstable. To have shoulder instability, by definition, means the shoulder is symptomatic for the patient.

In the younger and active age groups, the symptom of shoulder instability may be the patient’s presenting complaint. Although there is often a history of acute traumatic event resulting in the initial well-defined onset, in many cases no such traumatic event occurred. Indeed, it has only been since the 1980s that genetic factors in ligamentous laxity have been recognized as significant factors in patient perceptions of shoulder instability.

The diagnosis of shoulder instability can be very easy when the patient presents with an appropriate history of trauma. Nearly always there has been a trip to the ED and radiographs to document the events. However, with the increasing availability of sports trainers at most of the high school, college, and professional competitions, reduction of a dislocation by those personnel results in a history only; there are no ED records or radiographs. Although the history in these situations is still strong, an examination and radiographs even a few days following the event makes this a less-than-challenging diagnosis.

The more challenging problem occurs in the patient with a sense of slipping and looseness in their shoulder without a history of macrotrauma. More often than not, this more subtle instability pattern is associated with a nondescript level of discomfort and diffuse pain around the shoulder girdle. The discomfort is poorly localized and may be more scapular in location. The association of such symptoms with paresthesias down the arm is nearly always related to shoulder instability. A history of repetitive microtrauma is elicited. Such activities might include frequent swimming, gymnastics, and ballet. Although these activities would not appear to be highly stressful to the joint, they do demand muscle function defined by high endurance. Conventional thought suggests that when the ligament quality and integrity do not contribute to joint stability, the surrounding muscle activity and appropriate proprioceptive activity become more important to maintaining a functioning joint.

The sense of instability might occur with the arm only in certain positions or it may be present regardless of arm placement or position. True symptomatic multidirectional instability is typically symptomatic in midrange positions before ligament tension reaches the end of the range. The physician must carefully inquire about which activities and arm positions provoke the symptoms. Patients with this type of instability might have symptoms that are incapacitating enough that they tend to avoid extremes of glenohumeral motion. Pain is the more common symptom with a shoulder instability based on ligamentous laxity (AMBRI), and apprehension is more common with unidirectional traumatic instability (TUBS). (TUBS stands for traumatic etiology, unidirectional instability, Bankart ligamentous detachment, and surgical repair. AMBRI stands for atraumatic etiology, multidirectional instability, bilateral shoulders, rehabilitation with rotational strengthening, and inferior capsular tightening [surgery performed when conservative therapy fails].)

The classic patient with traumatic instability is a male athlete who sustained an identifiable traumatic event during the course of a violent activity. Football tackling, a high-speed fall or collision while downhill skiing, and a hyperextension force on an extended arm (basketball blocking shot) are very common scenarios that result in an acute traumatic shoulder dislocation. Conversely, the classic patient with multidirectional shoulder instability is the young asthenic female ballet dancer, swimmer, or volleyball player with nondescript shoulder pain that also involves the scapula and provokes paresthesias down the arm occurring in the absence of a defined traumatic event.

Isolated symptomatic posterior shoulder instability is most often associated with a very specific event or process. Although falling on the outstretched arm is a common scenario, because the arm is most often placed in the scapular plane to brace the fall and protect the head, a posterior force is only placed on the hand. As the body continues to fall to the ground, the arm is extended at the shoulder, placing an anterior force on the shoulder. This results in the much more common anterior dislocation under such circumstances; posterior shoulder dislocations are rarely associated with traumatic events that include falls.

Posterior shoulder instability is seen most often in the scenario of electric shocks and epilepsy. It appears that electrical stimulation to the muscles around the shoulder, when provided in a pathologic setting, can result in posterior shoulder dislocations. Severe electrical discharges, whether from within (major grand mal seizure) or extrinsically provided (such as an electric shock), appear to result in the posterior shoulder musculature actually pulling the shoulder out of joint. Historically, there is an associated increase in posterior dislocations of the shoulder associated with excessive use of ethanol and the social activities that can follow. Falling asleep on a park bench with the arms over the back of the bench while inebriated has been associated with posterior shoulder dislocations.

Box 4-2 lists the queries that should accompany a history that suggests instability.

Paresthesias

The most common shoulder-related pathology associated with a perception of numbness, tingling, or paresthesias down the arm is instability. The patient’s perception of the neurologic symptom is usually nondermatomal if the process occurs in the shoulder girdle. A person with multidirectional instability might note a tingling all the way down the arm involving several peripheral nerve dermatomes. By contrast, a cervical root irritation of a herniated cervical disc predictably results in a known dermatomal pattern of symptoms. An intrinsic shoulder problem such as a rotator cuff tear can result in secondary neurologic symptoms. In an effort to support the painful arm, the patient might rest it on an armrest for a prolonged time and develop a cubital tunnel syndrome. Similarly, a patient who is protecting the arm and minimizing functional elevation can develop carpal tunnel symptoms from inadequate fluid mobilization and prolonged dependency of the limb.

Weakness

Common causes of weakness include cerebral dysfunction, nerve transmission dysfunction, musculotendinous deficiency, pain, and biochemical causes. With cerebral dysfunction, the patient is not generating the electrical signal (malingering). Nerve transmission dysfunction can result from primary neuronal injury (Parsonage-Turner syndrome). Biochemical problems result from synaptic biochemical pathology as in myasthenia gravis, polymyalgia rheumatica, and dystrophies.

In a clinical setting, the most common cause of weakness is likely a rotator cuff tear, and although some tears are pain free, most patients have some complaint of pain associated with the weak arm. Nevertheless, it is important to ascertain other potential causes of weak-ness in the complete evaluation of a shoulder-related complaint.

Crepitus

A patient’s perception of crepitus around the shoulder is rarely seen without other associated symptoms. Chronic rotator cuff tendinitis and chronic inflammation of the subacromial bursa can result in a crunching sensation and cause the patient to report a noise coming from the shoulder. Because these are inflammatory conditions, they are nearly always associated with some perception and complaint of pain as well. Scapulothoracic bursitis and snapping scapula syndrome can cause a painful crunching sensation in the patient’s upper chest posteriorly when the patient elevates the arm. This usually is also associated with some pain.

Following surgery for rotator cuff repair, patients often become aware of painless crepitus in the subacromial space. Although the exact etiology remains unclear, it is likely related to the regeneration of the bursa that had been excised as part of the initial surgical procedure. It seems to become most apparent during physical therapy rehabilitation at about the sixth week and can linger for several months. Although patients predictably hear the crepitus and perceive the vibrato, only rarely is there an accompanying complaint of pain.

Other intra-articular processes can cause noise to be perceived in the shoulder. Minor subluxations may be perceived as a thunk; labral tears similarly can cause a low-frequency noise that a patient either hears or feels. Chasing down noises and their specific causes can be frustrating and elusive. Fortunately, many other history and physical examination features offer substantive clues as to a correct diagnosis.

PHYSICAL EXAMINATION

Cervical Spine (Neck)

The physical examination of the shoulder begins at the neck. Pathology within the cervical spine can manifest with arm pain and nerve symptoms that radiate down the arm. The patient might believe the source of the problem is somewhere other than the neck. The examiner begins by standing behind the patient and observing the neck and shoulder girdle for symmetry, muscle mass, scars, and deformity. The examiner assesses the ROM including extension, flexion, rotation, and bending. This is best done while standing behind the patient. Because it is difficult to use a goniometer to make measurements, surface relationships are commonly substituted.

Neck extension (Fig. 4-3) is recorded by noting that the imaginary line from the occiput to the mentum of the chin extends beyond the horizontal. Flexion is recorded by noting how many fingerbreadths the chin is from the chest when the patient flexes the neck as much as possible (Fig. 4-4). The patient leans the head to the side while looking forward (Fig. 4-5), and the distance from the shoulder to the ear is recorded for lateral flexion. Lastly, the patient turns the head from side to side and the examiner notes the degree of rotation. These cervical spine motions are made actively (by the patient) rather than passively (by the examiner).

FIGURE 4-3 Neck extension is measured by imagining a line drawn from the occiput to the mentum of the chin and estimating the angle subtended between this line and a horizontal plane.

FIGURE 4-4 Neck flexion is measured by imagining a line drawn from the occiput to the mentum of the chin and estimating the angle subtended between this line and a horizontal plane.

FIGURE 4-5 Lateral bending of the cervical spine is assessed by estimating the distance between the ear and the shoulder.

The Spurling test (Fig. 4-6) is performed by placing the cervical spine in extension and rotating the head toward the affected shoulder. An axial load is then placed on the spine. Reproduction of the patient’s shoulder or arm pain is considered a positive response.

FIGURE 4-6 The Spurling test is performed by axially loading the top of the head with the cervical spine extended and the head rotated toward the affected shoulder. A positive test reproduces the shoulder pain.

Although a detailed neurologic examination is beyond the purview of most shoulder examinations, clinical judgment determines the degree of peripheral nerve assessment necessary to establish a correct and complete diagnosis. Examining the strength of the trapezius, deltoid, spinati, and biceps and triceps muscles suffices for most general shoulder examinations. However, in some situations a more thorough examination needs to be completed, which includes assessment of motor and sensory distributions of each peripheral nerve of the upper extremity or extremities.

Shoulder

Inspection

Inspection of both shoulders can reveal pathology that would otherwise go unnoticed if the examiner relied solely on the patient history or physical examination. Both shoulders need to be exposed (Fig. 4-7). First, observe the clavicles for deformity at both the sternoclavicular joint and acromioclavicular joint. A prominent sternoclavicular joint can be due to an anterior dislocation, inflammation of the synovium, osteoarthritis, infection, or condensing osteitis. A loss of sternoclavicular joint contour is consistent with a posterior dislocation of the medial clavicle, which is worked up urgently to confirm the diagnosis. The acromioclavicular joint is often prominent secondary to osteoarthritis and needs to be compared to the opposite side for symmetry.