M10

Case Study

Margaret Stevens is a fit, healthy and suprisingly attractive 62 year old, retired school teacher who suffered an injury to her right shoulder 10 weeks ago. She fell off her cycle onto her shoulder which was immediately painful; an x-ray at the time revealed a fractured neck of humerus. She was treated with a collar and cuff followed by mobilisation. The shoulder is stiff with pain over the area of the right deltoid radiating down the arm to the elbow. Although the pain and stiffness are easing, shoulder movements are restricted in a capsular pattern. Mrs Steven’s GP is a among her many admirers and has referred Ms Stevens to physiotherapy for assessment and management. She takes NSAIDs which help to control of her symptoms.

Anatomy and Pathology

Anatomy

Explain local anatomy of shoulder and humerus - focusing more finally on the aspects of the glenoid cavity and proximal humerus relevant to this case study:

Demonstrate these where appropriate on your model.

bony parts:

clavicle, coracoid process, spine of scapula,acromium process, medial border of scapula, acromium process, inferior border of scapula,bicipital groove, greater tuberosity (lateral of bicipital groove ) & lesser tuberosity ( medial to bicipital groove ) of humerus surgical and anatomical neck of humerus


Muscles - origin/insertion - action - demonstrate these on your model

Trapezius - occiput,C7,T1-T12/lateral clavicular 1/3rd,acromium,scapularspine -
elevates,retracts,depresses scapula
Levator Scapulae - C1-C4/upper medial scapular border - elevates scapula
Rhomboid Minor and Major - C7-T1/medial scapular border - retracts scapula
Serratus Anterior - upper 8,9 ribs/anterior scapular fossa - protracts scapula
Pectoralis Major - clavicular & sternal heads - adducts & medially rotates shoulder
Teres Major- inferior lateral border scapula/bicipital groove - medially rotates adducts shoulder
Teres Minor- lateral border scapula/posterior of greater tubercle of humerus
Deltoid- clavicle,acromium,scapula/deltoidtuberosity-flex,extend,medial,lateral abduct shoulder
Supraspinatus - hollow above sacpular spine/greater tubercle - initiates abduction
Infraspinatus - below scapular spine/greater tubercle - laterally rotates shoulder

Joints : Shoulder Joint - ball and socket
Acromioclavicular joint - gliding joint
Sternoclavicular joint - double arthroidal joint


focus on : humeral fracture / capsular patterns

Humeral fractures - more common at surgical rather than anatomical neck - introduce idea of displacement - in fracture the broken bits can moved away and twist form their original positions

Capsulat pattern "Dr. James Cyriax was the first to extensively study soft tissue lesions. When inflammation of a joint is present (known as synovitis or capsulitis), not only does passive stretching of the capsule cause pain but a limitation of range of motion of the involved joint is always found to be in a specific pattern; this pattern is always similar for that particular joint, although each joint has a different and instantly recognizable capsular pattern"

Capsular pattern for shoulder is lateral rotation abduction and medial rotation.


Pathology

Humeral Fracture :- fracture of the proximal humerus is comon in elderly patiets. Most fractures don't show displacement and can be treated without surgical fixation. Resetting tends to occur if displacement is >1cm or 45 degrees. Normal diagnosis is by x-ray. Patients typically have severe pain - swelling and bruising. Pain is usually worse with any movement - loss of feeling indicates neural injury. With inimal displacement such as Ms Stevens appears to have suffered - a sling is usually enough and can begin an exercise program consisting of pendulum and circumduction exercises from as little as the first week. Isometric exercises of the deltoid and the rotator cuff can be encouraged within the first 2 weeks and after 3 weeks the sling can be worn part time or removed completely if pain is minimal. Patienst often report a subsequent pain and loss of range of motion in the shoulder

Adhesive Capsulitis :- Inflamtion of joint capsule which makes the joint stick - restricts motion - both active and passive - by 50% in a capsular pattern - with pain at range's limit. Typically Patients experience and early "freezing phase" followed by a "thawing phase" which can take between 6 months to 2 years to resolve. Patients also complain of pain and diffuse tenderness at the deltoid inesrtion. The shoulder joint is a c5 structure and thies are is the dermatome for the auxillery nerve which may be restricted by the inflamation at the glenoid cavity. Common between 40 and 60 years of age and diabetes is a risk factor. Minimal long term functional deficet - although some loss of motion may remain. X rays should be taken to ensure joint surfaces are smooth and to rule out any other abnormailty such as oseophytes and tumours. Condition m ay be bilateral - affect both shoulders.

Subjective Exaination

Symptoms

Where - she reports : decreasing stiffness in a capsular pattern and pain at deltoid insertion -
you expect - pain at limit of capsular motion & pain in subscapularis is common
- so you ask her about this

When - reports : <>Concerns/Red Flags & Differential diagnosis - oseophtyes from humeral malunion can affect the joint. Adhesive capsulitis should be distinguished from the pain which occurs with rotator cuff tear and impingement syndrome - neither of these conditions do not show passive loss of ROM

Patient's Primary Outcome
ask this what this is for Ms Stevens - you can expect possibly a request to increase range and/ or decrease pain.

Working Hypothesis for Objective Examination - Patients is experiencing frozen shoulder - rule out rotator cuff tear and impingement syndrom - check for malunion of humerus.

Main Outcome
ask this - you can expect possibly an a request to increase range and/ or decrease pain

Objective Examination


Consent - before beginning objective examination examination explain proceedure : observations - assesed movements - palpation and possibly measurements - then obtain consent

Observations

Skin Colour - expect bruising from fracture to have gone
Swelling - expect none - inflammation is internal
Posture - some imbalance across shoulder may appear
Muscle Bulk - possibly some due to rest and underuse
Deformity - none

Active Movements - ask patient to perform the following on both shoulders -on affected shoulder - the capsular pattern (*) should show 50% loss of movement in normal range

abduction (*) - main loss of rom
adduction
medial rotation (*) - some loss of rom
lateral rotation (*) - main loss of rom
flexion
extension

Passive Movements - perform the following on both shoulders - on affected shoulder restriction in range will distinguish the condition from rotator cuff tear and impingement syndrome. Stiffness should limit the (*) movements - where possible "listen" with you hands for any grinding or grating which may indicate humeral malunion. Expect pain to comes as the joint reaches its maxium range.

abduction - (*) - main stiffness
adduction
medial rotation - (*) - main stiffness
lateral rotation - (*) - some stiffness
flexion
extension
Restricted Movements - perform the following - expect some muscle weaness compared with opposite shoulder - particulary in the (*) movements which not have been so active.

abduction - (*) - possible main loss
adduction
medial rotation - (*) - possible main loss
lateral rotation - (*) - some possible loss
flexion
extension

Special Tests

Loss of capsular rom is the key feature of frozen shoulder. No other test are neecesary. Hawkins and empty can test for shoulder impingement which we would expect has already been ruled out. They effect medial rotation - so since they might produce pain for the patient as well as possiblty being impaired by loss of rom - they should be avoided.


Similarily the drop arm test - for rotator cuff tear should have been demonstarted to be unncessary - it effects abduction - which again might produce unnecesary pain for the patient.

Palpation
expect to elicit pain while palpating the deltoid insertion and also down the arm


Concluding advice and expected treatment

Tell patients symptoms might be worse following exam.

NSAID, nonnarcotic analgesiscs , and moist heat are indicated followed by a gentle streching program. often ice is used after streching to control swelling. TENS units may help control pain. Home streching program should be done over a gentle range - advise it may take 1 to 2 years for complete recovery.



external rotation in an adducted position tends to be the most restricted - home exercise program should include streching into external rotation with the arm at no greater than 30 to 45 degrees of abduction - therapy which is too agreesive may aggravate symptoms and/or cause fracture of the humerus




failure to show signifcant improvement in pain and motion after 3 months of constant rehabilitation require further evaluation. Frozen shoulder is common after trauma. If the fracture of the humerus was more complicated than thought at first it could knit badly and cause permanent disturbance to the joint capsule.