Clinical scenario – Orthopaedics – Cuff tear/impingement/frozen shoulder – Detailed discussion and how to approach such a case ?

Discussion –

This is a detailed discussion of a shoulder case which is a very common scenario in any clinical exam and is easy to learn.

Main Stem

Now stem goes like this in most of the scenarios.

A 29-year-old male presents to you with pain on his right shoulder started three months ago while throwing the ball during a baseball game. It could be any sport, basketball, baseball, basically anything, or any other sports.

The main complaint is a constant nagging pain and unable to work without pain and aching of the shoulder, even at night, so three months of chronic pain that started suddenly and is gradually progressing is when they’re not improving ae the main cracks of the stem that they give you what you do in the scenarios usually, you need to stick to a very focused history and do simple clinical examination, deduce the differentials and the examiner may ask you for treatment in this matter  depending upon which exam you are sitting.

Usually pretty straightforward and is usually what they are looking for is a differential diagnosis rather than anything else. So, have a look at some of the key points that you should keep in mind while dealing with such kind of scenario.

Take a focused history of pain to start with. Pain in the shoulder for two months. It is getting worse. Go by SOCRATES for pain history.

Okay, now the general examination tells me that the patient is comfortable there is no obvious deformity. There’s some flattening of the deltoid muscles and limited abduction up to 30°.It’s very important to do a neurovascular examination as well.

A focused examination is by starting the general and go to the local. Basically look, feel, move, especially when it comes to any extremity examination or an orthopedic case.

Patient sitting comfortably, look for deformity and you found that there is flattening of the deltoid muscle which may indicate disuse atrophy of the muscles or maybe some kind of a tear of muscles around the shoulder. The patient cannot abduct up to 30°. So basically, that is very clear indication that is something going wrong with the muscles now.

Neurovascular examination should be part of a every examination in the body, especially when it comes to extremities. We found that there is no sensory loss in power.

Based on this focus history, the stem that’s been given to you and brief examination, you have to first deduce what the differentials of the case would be –

Some of the common ones include

1.cervical spondylosis

2.glenohumeral arthritis

3.shoulder dislocation

4. rotator cuff

5. frozen shoulder

6. impingement in some

fewer common ones include

7. super scapular nerve impingement

8. biceps tendinitis

So how do you proceed first. Proceed to take proper history of pain. Where is the pain so this this history is usually by Socrates

S – Site – the maximum site of pain

O – Onset – would stand for onset when and how did the pain start? was it certain gradual also include whether it’s progressive or constant.

C – Character – sharp stabbing pain or dull ache

R – Radiation – The pain radiated anyway.

A – Association – signs or symptoms associated with pain.

T – Time course – Does the pain follow any pattern?

E – exacerbating or relieving factors.

S – severity – How bad is the pain

so that’s Socrates brief for you.

Also, try to get a proper history. Apart from this the history of pain

Was there any injury

Functional history

· Neck pain

· Difficulty in wearing clothes

· Can you play sports?

· Can you lift heavy?

· does a pain increase in sporting activities, etc. coexisting history is part of any history that is needed in you get and includes past medical, social and family history less relevant now?

Examination

Inspection

Starting the inspection of the shoulder look, feel, move is always how we proceed with any extremity or orthopedics or musculoskeletal examination. So, shape and contour the shoulder joints, look for any obvious deformity, look for any muscle wasting.

Palpation

Then you start with palpation. Look for any increase in temperature. You look for tenderness around the joints like AC joint subacromial space. You try to palpate the supraspinatus muscle and tendon of biceps and also palpate for supraspinatus fossa and infraspinatus fossa to look for any wasting.

Movements

Last but not the least story is checking for movements. Movement should always be checked as active and passive movements

Special tests

Empty Can Test

The examiner’s other hand applies downward pressure on the superior aspect of the distal forearm and the patient resists.

considered positive if there is significant pain and/or weakness

Neer’s Impingement test

stabilize the patient’s scapula with one hand, while passively flexing the arm while it is internally rotated. If the patient reports pain in this position, then the result of the test is considered to be positive.

Drop arm test

Take the patient’s arm to the side and let it fall, if there is a complete rotator cuff tear then it will fall as the cuff muscles are not able to hold it there

Resisted Rotations

Flex the elbow at 90 degree and ask the patient to internal or externally rotate against resistance, this checks the power of internal and external rotators

Thank you

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