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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