Evaluation of the Rough Shoulder.

Figure 1 - Age at the time of presentation for degenerative joint disease

Figure 2 - Age at the time of presentation for rheumatoid arthritis

Figure 3 - Age at the time of presentation for capsulorraphy arthropathy

Figure 4 - Age at the time of presentation for avascular necrosisavascular necrosis

Figure 5 - Age at the time of presentation for cuff tear arthropathy

Figure 6 - Anteroposterior view in the plane of the scapula

Figure 7 - Lateral view in the plane of the scapula

Figure 8

Figure 9 - Radiographs of dejenerative joint disease

Figure 10

Figure 11

Diagnostic techniques

History

The history includes a description of the onset of the problem, the mechanism of any injuries, and the nature and progression of functional difficulties. Systemic or polyarticular manifestations of sepsis, degenerative joint disease, or rheumatoid arthritis may provide helpful clues. A past history of steroid medication, fracture, or working at depths may suggest the diagnosis of avascular necrosis. Past injury or surgery increases the risk of infection, scarring, or abnormal surface contours. Disuse may give rise to abnormal relative positions of the moving surfaces.

The symptoms from lack of smoothness typically occur during use of the shoulder. Often the patient can describe certain motions that are problematic or specific maneuvers that are required to "unlock" or get past a certain sticking point. Occasionally patients will describe a sensation of apparent instability or unwanted shifting of the shoulder. The positions and circumstances which elicit the functional problem must be carefully defined in the history. The patient should also be asked about the response of the shoulder to previous treatment, including exercises, injections, physical therapy, and surgery.

The age of the patient at the time of presentation may provide valuable clues to the diagnosis. We have some data on the age at the time of presentation for: degenerative joint disease (see figure 1), rheumatoid arthritis (figure 2), capsulorraphy arthropathy (figure 3), avascular necrosis (figure 4), and cuff tear arthropathy (figure 5).

The physical examination

Physical examination includes the careful observation of the patient's posture for asymmetrical shoulder drooping and muscle atrophy. The rhythm of active rotation and elevation in different planes is observed for breaks in continuity. The patient is asked to demonstrate any maneuvers which produce roughness, catching, snapping, or locking and to localize the site of the problem by pointing with the opposite finger. Patients are usually quite able to indicate one of the five anatomic sites commonly associated with roughness.

The examiner can help distinguish scapulothoracic roughness from glenohumeral problems or from problems at the humerothoracic motion interface by selectively restricting the motion at first one site and then the other. Shrugging, protracting, and retracting the scapula while the examiner disallows glenohumeral motion permits independent assessment of the smoothness of the scapulothoracic motion interface. Palpation for the site of roughness may localize the problem to the superior medial border of the spine of the scapula. Alternatively, rotating and elevating the arm while the examiner stabilizes the clavicle, acromion and scapular spine on the chest wall allows independent evaluation of the glenohumeral joint and the humeroscapular motion interface. Roughness in the subacromial area of the nonarticular humeroscapular motion interface is usually manifested on rotation of the arm near 90 degrees of humerothoracic elevation, a position in which the capsule is normally lax. Crepitance on this maneuver, which reproduces the patient's complaint, constitutes a positive subacromial "abrasion sign." Roughness between the subscapularis insertion and the short head of the biceps is evident on rotation of the arm at the side while the biceps is isometrically tightened. Crepitance at the glenohumeral joint is often best palpated posteriorly just beneath the angle of the acromion. It may be accentuated by pressing the humerus toward the glenoid while the joint is rotated. Symptoms from the sternoclavicular or acromioclavicular joints are usually easy to localize on physical examination.

The tenor, as well as the location of the noise, gives a clue to its etiology. For example, a snapping scapula usually produces a low-pitched clunking, similar to the noise produced when two sets of knuckles are rubbed against each other. Subacromial abrasion usually produces a higher-pitched crepitance, like the sound of wadding up a piece of paper. Dry, bone-on-bone grating is typical of roughness of the glenohumeral articular cartilage, producing a grating like sandpaper on wood.

Because shoulder roughness may be accompanied by shoulder stiffness and weakness, the range of glenohumeral and scapulothoracic motion and the strength of the shoulder motors should be recorded.

Radiographs

The history and physical examination should point to the likely cause and the functional significance of the roughness. The clinical examination will suggest which radiographs may be helpful. Thus the radiographic evaluation is customized to the patient's clinical presentation, rather than ordered as part of a "routine."

Scapulothoracic roughness should be evaluated by an anteroposterior view in the plane of the scapula (see figure 6) and by a lateral view in the plane of the scapula (see figure 7) to reveal osteochondromata or malunited fractures of the scapula or ribs. Computerized tomography (CT) can help localize the sites of specific entities but is of minimal value in evaluating a snapping scapula resulting from abnormal posture.

A coned down view of the acromioclavicular joint and an axillary radiograph provide a good two-plane evaluation of this articulation.

Sternoclavicular roughness can be best evaluated with a CT scan.

The glenohumeral joint is radiographed using an anteroposterior view in the plane of the scapula and a true axillary view. If the arm is placed in the "centered position", the middle of the humeral articular surface is in the middle of the glenoid fossa (see figure 8). An anteroposterior view and an axillary view taken with the arm in this centered position provide excellent opportunities to evaluate the thickness of the cartilage space between the subchondral bone of the humerus and that of the glenoid, to assess the regularity of the subchondral bone, and to evaluate any translation of the head of the humerus relative to the glenoid. The anteroposterior radiograph taken in the scapular plane with the arm in the centered position places the humeral neck in maximal profile, which is required for accurate use of a humeral prosthesis template.

Fortuitously, the anatomy of the proximal humerus and the relationship of the scapula on the chest wall make it possible to obtain radiographs which reveal simultaneously the profile of the proximal humerus and glenoid. Because this view centers the head of the humerus on the glenoid, it also is the projection most likely to reveal the thinning of the central aspect of the humeral articular cartilage typical of degenerative joint disease (the "Friar Tuck" pattern), whereas radiographs with the arm in other positions may indicate the presence of a thicker layer of cartilage at the periphery of the head.

The relevant anatomy is straightforward. The plane of the scapula makes a 35 degree angle with the plane of the thorax. The humeral neck is in 35 degrees of retroversion with respect to the forearm of the flexed elbow. The humeral neck is also at 45 degrees with the long axis of the humeral shaft. Thus if the forearm of the flexed elbow is perpendicular to the plane of the thorax and if the humerus is abducted 45 degrees, the center of the humeral head is pointed at the center of the glenoid. With the arm in this position, an anteroposterior radiograph in the plane of the scapula will reveal the desired relationships (see figure 8).

In degenerative joint disease, these radiographs (see figure 9) typically show narrowing of the cartilage space between the humeral head and the glenoid, sclerosis, osteophyte formation, and a posterior wear pattern in which the humeral head is posteriorly subluxated in association with erosion of the posterior half of the glenoid. This posterior subluxation may be particularly marked in capsulorraphy arthropathy (see figure 10). In avascular necrosis, the predominant radiographic finding is collapse of the subchondral bone of the head of the humerus. In advanced rheumatoid arthritis (see figure 11), the predominant findings usually include loss of the cartilage space between the humerus and the glenoid, erosions at the margins of the humeral articular surfaces, medial erosion of the glenoid, and generalized osteopenia; these changes are often symmetrical, affecting both glenohumeral joints.

The bony anatomy of the humeroscapular motion interface can be seen on the anteroposterior view in the plane of the scapula, the lateral view of the scapula, and the axillary view. These radiographs may reveal a narrowed radiographic acromiohumeral interval, sclerosis of the undersurface of the acromion, acromial anomalies, traction spurs in the coracoacromial ligament, and malunited or nonunited fractures of the acromion. These views may demonstrate other potential causes of roughness in the nonarticular humeroscapular motion interface, such as anomalies of the proximal humerus, malunited tuberosity fractures, and functionally significant calcium deposits in the cuff tendons. We have not found the shape of the acromion itself to be useful for separating those shoulders having subacromial roughness from those which do not.

Imaging of the rotator cuff is only carried out if it will affect management of the patient. If the patient meets our criteria for exploration of the subacromial space, as described below, we will usually avoid cuff imaging because we will be able to evaluate the cuff directly at surgery and will have obtained preoperatively the patient's permission to perform any indicated cuff surgery.

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