Sunday, October 18, 2015

Clinical evaluation of the shoulder - our approach

It is traditional for surgeons to strive for a diagnosis for the shoulder problem and to derive a treatment from the diagnosis. For us, however, the clinical evaluation is the beginning of the doctor-patient relationship. The goal is not so much to come up with a diagnosis that will drive to a specific treatment, but rather to carry out an evaluation of the patient that leads to a reasonable management plan.

We like to emphasize the importance of the 4 P’s that determine the outcome of treatment: the patient, the shoulder problem the patient is experiencing, the procedure used to treat the patient and the problem, and the physician rendering the treatment. We place the patient first on this list because as Osler is quoted as saying, “it is more important to know what patient a disease has than what disease the patient has.” When introducing ourself and shaking the patient’s hand we can sense a lot – healthy or frail, positive or negative, smelling of cigarettes or not. To learn a bit more, we ask the patient ‘where are you from and what do you do there?” In an instant we’ve done a lot to determine if the person might benefit from a surgical approach should one be appropriate for the problem.  Next, we like to ask “what can we help you with today?” giving the patient some uninterrupted time to answer. The patient with posterior instability may respond with “I can’t do my job”, “I need more pain medicine”, “my lawyer sent me” or “my shoulder keeps on slipping out when I lift something in front of me” – same diagnosis, four different problems.

We like to avoid dwelling on pain, so rather than asking ‘where does your shoulder hurt’, we prefer to ask ‘what does your shoulder problem keep you from doing?’ When does it bother you the most? Following with ‘how and when did that problem start?’ ‘how much force was applied to your shoulder in the injury and what position was it in when the force was applied? and ‘tell me about the treatment you’ve had for it up to now’.  Trying to learn more about the patient, we ask questions such as  “how is your overall health, how active are you, what medications are you on, have you had prior surgeries and how did they work out?

Our physical exam starts with a ‘no touch’ approach. “Show me what actions are difficult for your shoulder” “what does it feel like is happening when you do these things?” To check active motion we ask patients to show me with each shoulder how high they can reach overhead, how far they can externally rotate the shoulder  with the arm at the side, how far they can reach across the body, how far they can internally rotate the abducted arm, and how high they can reach up the back. If patients cannot raise the arm actively, we ask them to show how high they can raise it with the help of the opposite arm. At this point, without having ever touched the patient we usually have a fairly good understanding of the problem  and whether the patient is likely to be a good candidate for surgical intervention. The remainder of my history, physical examination and plain radiographs seek to refine this understanding.

There are many ‘tests’ that have been described for evaluating shoulder problems,  these tests are rarely capable of discriminating among the potential problems; a "Hawkins test" may be positive in  rotator cuff disease, arthritis, or frozen shoulder.  Instead our exam seeks more tangible findings, such as loss of the passive or active range of motion,  a palpable defect in the rotator cuff, minimal resistance to anterior translation of the humeral head pressed into the glenoid, palpable subacromial crepitance, muscle atrophy, loss of the biceps reflex, or an obvious ‘clunk’ on cross body adduction.

Bottom line, if the problem is not apparent on history, physical, and plain radiographs or if the patient does not appear to be an excellent surgical candidate, we're likely to recommend non-operative management.  This remains the case even if MRI’s show ‘acromioclavicular arthrosis’, ‘labral fraying’, a “HAGL” lesion, or ‘supraspinatus tendinosis’.

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