A 35-year old woman reports to her physician with pain in her right shoulder aft

Question

A 35-year old woman reports to her physician with pain in her right shoulder after painting the ceilings in her kitchen last weekend. She reports that the pain is worse when lifting her arm over shoulder height. The pain was worse during the examination when abducting against resistance. The patient’s passive range of motion was normal.

Form a hypothesis statement about the primary injury (i.e. what muscle or structure is injured)? Indicate whether you think this could be a rotator cuff muscle, the deltoid, or a shoulder joint structure that is likely injured. What tests should be performed to decide what is injured? What should be recommended to the patient?

Explanation / Answer

Ans) Considering the above case as examination reveals that the Passive range of motion is normal and there is pain while lifting the arm above shoulder height means ACTIVE range of motion , also the resisted abducted movement worsens the pain in shoulder are all symptoms of the ROTATOR CUFF TEAR ( Shoulder Impingement) , hence involvement of muscles of rotator cuff is there.

Rotator cuff is a group of four muscles Supraspinatus, Infraspinatus , Teres minor and Subscapularis (SITS) and tendons surrounding shoulder joint, which gives support to the shoulder joint , Rotator cuff injuries are most commonly seen in overhead motions involvement works or jobs like painters, carpenters , baseball players.

Muscles of rotator cuff arises from Scapula and inserts to the head of Humerus forming a cuff there. These muscles function in holding the head of humerus in shallow glenoid fossa of scapula, at Glenohumeral joint. For ABDUCTION to be carried out as a smooth motion of shoulder the rotator cuff muscles compresses the glenohumeral joint by (concavity compression) and hence allows DELTOID muscle to perform its function of Abduction. With injury to rotator cuff the abduction motion is thus painful.

TESTS- With proper Assessment including physical examination ( Inspection , Palpation of joint area) , Range of Motion testing and special tests .

Active and Passive range of motion tests are for the movements Flexion , Abduction and Internal rotation at 0 degrees to 90 degrees. Rotator cuff injury leads to loss of Active range of motion but intact passive range of motion.

Strength tests- This strength test includes testing muscle strength of rotator cuff which is performed by a hand held DYNAMOMETER. Different muscle function for different motions and thus motions are tested for all four muscles like External rotation for infraspinatus, abduction for supraspinatus, and internal rotation for subscapularis muscle.

Certain other tests could be performed for individual muscle testing like Lift off test , belly press , bear hug for subscapularis. For supraspinatus and infraspinatus Neer test, Jobe's test, Drop arm test.

Positive test will determine the torn of the muscle, A test is positive only when the normal movement is not being performed by the muscle.

According to the severity of the injury only, the treatment plan is designed, but the most important be Stabilize the joint. Rest , Ice , Stabilize. Further the medical practitioner could suggest the treatment whether conservative way could help or surgical treatment required according to the injury.

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