Evaluation of the Rough Shoulder.
Last updated Thursday, February 10, 2005
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 9 - Radiographs of dejenerative joint disease Diagnostic techniquesHistory 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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