CLINICAL HISTORY AND EXAMINATION

Although description of a detailed shoulder history and examination are beyond the scope of this textbook, certain aspects of the history and physical examination are important in preoperative planning for unconstrained shoulder arthroplasty. The shoulder-specific complaints of the patient are reviewed, such as the type of symptoms (pain, stiffness, weakness), duration of symptoms (weeks, months, years), and previous treatment (activity modification, nonsteroidal anti-inflammatory medications, corticosteroid injections, viscosupplementary injections, previous surgery). These shoulder-specific complaints help the surgeon decide which patients are candidates for shoulder replacement surgery. A patient with complaints of only mild pain, mild weakness, or mild stiffness (or any combination of these complaints) may initially best be treated with nonoperative (or nonarthroplasty) modalities, even if radiographs demonstrate end-stage glenohumeral arthritis. Similarly, a patient with a sudden onset of symptoms of a short duration to date may be experiencing a transient acute rotator cuff tendinitis concomitantly with chronic glenohumeral arthritis that has been well tolerated. In this situation, a period of nonoperative treatment would certainly be indicated. Special attention is given to factors that could make the operative procedure more difficult. Chronic use of nonsteroidal anti-inflammatory medications can result in excessive operative blood loss, so such drugs should be discontinued the week before surgery.

Any previous surgery merits special consideration. The type of surgery should be noted. Although previous arthroscopic procedures are usually inconsequential to the performance of shoulder arthroplasty, previous open procedures may introduce difficulties. Specifically, previous instability surgery may have resulted in severe stiffness, especially in external rotation, and may have caused excessive scar tissue that will make the surgical approach more difficult. The type of surgical procedure should be elucidated whenever possible. Procedures that alter normal anatomic relationships, such as tendon transfers (subscapularis transfers, i.e., the Magnusson-Stack procedure) and coracoid transfers, are especially important when considering the surgical approach. Previous rotator cuff surgery may focus attention on determining preoperative rotator cuff integrity.

Any symptoms of infection, especially in patients who have previously undergone surgery or injections, should be investigated further. If patients have a history of infection after shoulder surgery or have had symptoms suggestive of infection (systemic fever; shoulder warmth, redness), a preoperative infection workup, including hematologic evaluation with a complete blood cell count and differential, a sedimentation rate, and C-reactive protein, is indicated. Additionally, a fluoroscopically guided shoulder aspirate is obtained and the specimen submitted for aerobic, anaerobic, fungal, and mycobacterial culture. If the findings are suggestive or diagnostic of infection, shoulder arthroplasty is postponed or canceled until infectious disease consultation is obtained and the infection is appropriately treated (Table 7-1).

Table 7-1 WORKUP FOR INFECTION BEFORE UNCONSTRAINED SHOULDER ARTHROPLASTY

Any medical history of systemic illness (diabetes mellitus, cardiac problems) should be considered in the preoperative planning. Although these factors may not affect the actual surgical procedure, they may necessitate special considerations in the patient’s postoperative care. Appropriate medical consultations should be obtained well in advance of the surgery date. The availability of appropriate care, including consultants for these systemic illnesses, should be confirmed before surgery.

All our patients undergo a thorough shoulder examination. Motion and rotator cuff strength are of critical importance. Both active and passive mobility is recorded. Mobility parameters recorded are elevation in the plane of the scapula (Fig. 7-1), abduction (Fig. 7-2), external rotation with the arm at the side (Fig. 7-3), external rotation with the arm abducted 90 degrees (when possible) (Fig. 7-4), and internal rotation as determined by the vertebral level reached with an outstretched thumb (Fig. 7-5). Any incongruity of the glenohumeral joint as indicated by the presence of glenohumeral crepitus with motion is noted, as is any discrepancy in active and passive mobility.

Figure 7-1 A and B, Elevation in the plane of the scapula.

Figure 7-2 A and B, Abduction. The arm is kept in the coronal plane.

Figure 7-3 A and B, External rotation with the arm at the side.

Figure 7-4 External rotation with the arm abducted 90 degrees. Measurement of this mobility parameter is not possible in all patients because of limited mobility in severe cases.

Figure 7-5 Internal rotation as measured by the vertebral level reached with an outstretched thumb.

Rotator cuff examination consists of testing each tendon of the rotator cuff by isolating it as much as possible. Jobe’s test is used to test supraspinatus integrity (Fig. 7-6).¹ The external rotation lag sign and evaluation of external rotation strength with the arm at the side are used to test the infraspinatus (Figs. 7-7 and 7-8).² The teres minor is tested via the horn blower’s sign (Fig. 7-9).³ The subscapularis is tested with the belly press test and, when mobility allows, the lift-off test (Figs. 7-10 and 7-11).⁴

Figure 7-6 A and B, Jobe’s test for supraspinatus integrity. The patient elevates the pronated arm in the plane of the scapula and resists the downward force of the examiner.

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