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Clinical Reasoning & Decision Making in Shoulder Case

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38 views

Clinical Reasoning & Decision Making in Shoulder Case

Uploaded by

dianmargiutami12
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Clinical

Reasoning &
Decision Making
in Shoulder Case
Noor Sadhono K, Ftr.,Msi
• Age is not predominant factors
• Elderly → arthritis
• Referral : medical diagnosis usually based on ICD
• Pain :
• Local lesion or from cervical
• pain character (myogenic, neurogenic, osteogenic, vasculogenic, somatic)
• Inner/middle/end/whole range pain
• Paraesthesia : neural symptom → brain/spinal
• Limitation of movement : capsular / non capsular → ROM measurement, endfeel,
Scapulo-Humeral Rhytm, Joint Play Movement
• Hypermobility : giving way sensation, subluxation → JPM
• Weakness :
• Pain
• Atrophy
• Rupture/tear
• Neural lesion
• When : acute – sub acute – chronic → healing phase & treatment
choice
• How :
• Spontan : no specific trigger : bursitis, steroid sensitive arthritis
(adhesive capsulitis)
• Overuse/repetitive : tendinitis
• Trauma : tendinitis, rupture (ligament, tendon), SLAP, fracture

• What influence the pain (aggravating


/ relieving) : usually related to
activities, beware of psychosomatic
pain
• Evolution : better – worse –
unchanged
• Evolution :
• Location of the first complaint
• Centralization / peripheralization
• Spreading : neural (dermatomal) /
MTPS (referred pain)
Evolution • Pain quality :
• VAS/NPRS
• More pain, more radiation →
• Constant / periodic / episodic : twinges at rest, during/after
activity, during the day/at night
• “Morning sickness” : inflammation
• Night pain → red flags ?

• Paraesthesia :
• Rare in shoulder
• Neural symptoms : cervical
Functional limitation

Poliarthritis ? Don’t treat radiology


imaging
Inflamasi Atrofi

Inflamasi

Step deformity RC atrophy


Sulcus sign SC joint subluxation

Winging Scapula Scapula


scapula tipping shruging
• Always confirm the pre-test pain & whether the test influence the pain : where &
when (inner/middle/end/whole range pain)
• Active : ROM & pain, Passive : ROM, pain & endfeel, Resisted : pain & weakness
• Painfull arc :
✓ Mostly supraspinatus tenoperiosteal; Ex-Rot : subscapularis, Int-Rot : infraspinatus;
Flex+ExRot : long biceps
✓ Passive painfull arc : severe calcification
• P GH abd : block scapula movement
• P Rotation :;
✓ PA → chronic subdeltoid bursitis (SB)
✓ End range pain in passive Flex-InRot → chronic SB or AC joint (+ Hor-Add) or sprain
lig coracoclav (pain in scapular mov)
• Painfull & non capsular limitation : acute SB
• R Abd :
• Pain : tendinitis supraspinatus, chronic SB; deltoid lesion is extremely rare
• Weakness : partial rupture supraspinatus, C5/axillary/suprascapular nerve lesion,
• R Add :
✓ Pain : PecMay (anterior pain), LatDor (extensor), teres major (InRot) & minor
(ExRot)
✓ Weakness : C7 nerve lesion
• R InRot : pain : subscap, PecMay, LAtDor, TerMay; weakness : rarely
• R ExRot : pain : infraspinatus/TerMay lesion, compression SB; weakness : rupture/C5/
suprascapular nerve lesion
• R elbow flexion : biceps
• pain : bicipital groove or intracapsular (+ PArc : long head/SLAP)
• Weakness : rupture or C5/C6 nerve lesion
• R elbow ext : pain on triceps or SB (pain relieve under traction); weakness : C7/radial
Section 5 : Accesory Functional Examination
• P Hor Add : + pain in AC joint, subcoracoid bursitis,
subscapularis tendinitis
• P ExRot in 900 abd :
• Subcoracoid bursitis : increase in ROM
• Anterior capsular adhesion : no increase in ROM
• Coracoclavicular lig : end range pain
• Apprehension – Relocation test : instability
• Wall push : serratus anterior weakness → scapular
winging
• Resisted scapula add : trapezius weakness
• Resisted backward-forward 900 abd : deltoid
• Resisted Hor Add : PecMay
• Resisted antepulsion : coracobrachialis muscle
• Resisted Add with elbow flex 900 : SLAP

NOTE : if pain provoked in standing position & less pain


in supine → compression of inert tissue
• Palpation : after functional exam
→ specific structure & localized
the lesion

• Double lesion is possible


• Repeat the exam procedure

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