Question

MUSCULOSKELETAL CASE STUDY

E. B. is a 42 year old male patient that presents with right shoulder discomfort.

Subjective

Pain rating a 6/10 in right shoulder

States his right should started to hurt after weight lifting

PMH: fracture of left forearm, anxiety, appendectomy

Objective

T 98.3, P 110, BP 152/86, RR 20

Hunched position of right shoulder

Limited abduction of right shoulder

Questions

1. From the readings, subjective data, and objective data, what is the most probable cause of the shoulder pain?

2. What other methods of assessment should the nurse perform?

3. What assessment findings would you expect based on your diagnosis in #1 when performing these assessment techniques?

Answer 1

From the readings, subjective data, and objective data, what is the most probable cause of the shoulder pain?

From the subjective data of pain at the severity of 6/10 in right shoulder after weight lifting and objective data of limited abduction the most probable cause is rotator cuff injury. The patient is also having a fracture of the left arm which points toward the overuse of the right hand.

Rotator cuff tears are the leading cause of shoulder pain and shoulder-related disability. Rotator cuff is a group of four muscles that include the supraspinatus, infraspinatus, teres minor, and subscapularis that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate the arm.

The abduction of the shoulder is carried out by the deltoid and the supraspinatus in the first 90 degrees. From 90-180 degrees it is the trapezius and the serratus anterior. When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Often biceps tendon is also involved in rotator cuff injury.

A tear can be acute which occurs when falling with an outstretched arm or with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative, or chronic, rotator cuff tears result from degenerative changes with age, repetitive stress from using same shoulder motions again and again which like in some sports (eg baseball, tennis, rowing, and weightlifting) and certain jobs (carpenters, painters) or from bony spur or overgrowth. Degenerative injury of tendons usually begins as fraying progressing to a partial tear. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.

Rotator cuff tears often present with shoulder pain, weakness, and loss of range of motion. These symptoms are not unique to rotator cuff tears and the differential diagnosis includes labral tears, glenohumeral ligament tears or sprains, coracoacromial and acromioclavicular ligament tears and sprains, osteoarthritis, adhesive capsulitis, proximal peripheral neuropathies, and cervical radiculopathy.

What other methods of assessment should the nurse perform?

· A careful history collection about activities of daily, participation in sports, occupational history, history of trauma, family history of arthritis

· Structured physical examination is most useful and can often establish the diagnosis of rotator cuff tear eliminating the need for expensive imaging studies.

· Imaging studies like MRI and ultrasound to diagnose rotator cuff disorders. They are expensive and findings are confounded with age-related changes shown in the test.

1. What assessment findings would you expect based on your diagnosis in #1 when performing these assessment techniques

Inspection of the rotator cuff: It assesses supraspinatus and infraspinatus atrophy in the suprascapular and infrascapular fossae. Muscle atrophy is examined with tactile assessment feeling for the loss of muscle bulk and comparison with the contralateral side. In cases of massive rotator cuff tears the humeral head can be appreciated to be superiorly displaced abutting the acromion.

Range of motion: It is usually limited to the assessment to an active range of motion only since rotator cuff tears lead to loss of active range of motion and passive range of motion is often preserved. Passive motion is typically limited in glenohumeral articular disorders.

The range of motion is measured in degrees and best assessed with a goniometer. If this is not possible then subjective assessment of the range of motion and comparison with the contralateral shoulder is recommended.

Movement	Assessment Technique
Forward Flexion	ask the patient to raise the arm straight up in front of them as high as he can with the thumb pointing upwards. The flexion angle is formed by aligning the goniometer with the lateral epicondyle of the humerus, the middle of the glenoid fossa, and a vertical line in the coronal plane
Isolated Abduction	ask the patient to raise the arm at the side as high as they can with the examiner stabilizing the scapula by holding it down. The abduction angle is formed by aligning the goniometer with the lateral epicondyle of the humerus, the middle of the posterior glenohumeral joint line, and a vertical line in the sagittal plane
External Rotation at 0 Degrees (in neutral)	Performed with the patient in 0 degrees of glenohumeral joint abduction, 90 degrees of elbow flexion, and neutral supination/pronation forearm position. The patient is then asked to keep his elbow to his/ her waist and rotate the arm outwards. The external rotation angle is formed by aligning the goniometer with the ulna styloid process, the olecranon process of the ulna, and a horizontal line in the transverse plane
External/ Internal Rotation at 90 Degrees (in abduction)	patient is in 90 degrees of glenohumeral abduction, 90 degrees of elbow flexion, and neutral supination/pronation of forearm. The patient is then asked to keep the elbow at 90 degrees and move the forearm upwards as high as they can and then downwards as low as they can. The external rotation and internal rotation angles in 90 degrees of abduction are formed by aligning the goniometer with the ulnar styloid process, the olecranon process of the ulna, and a horizontal line in the horizontal plane

Highest Posterior Anatomy Reached with Thumb

The patient is asked to reach his back with the dorsum (back) of his/ her thumb. The patient is then asked to reach as high as they can along the spine. The highest level that the patient can reach is marked. The bony landmarks are the inferior border of the scapula that corresponds to the T7 level and the top of the iliac crests that correspond to the L4 level.

Strength Testing

Strength testing is performed using a portable hand-held dynamometer. Numerous devices are commercially available for this purpose and measure strength in kilograms or pounds. After positioning the shoulder for each of the maneuvers patient is asked to push into the dynamometer as hard as he can. Once the examiner feels that they have matched the subject’s resistance so that the muscle contraction is truly isometric the patient is asked to continue pushing into the dynamometer, while the tester resists the force exerted by the subject, maintaining positional equilibrium throughout the 5 second period of exertion. The examiner lets them know when the 5 seconds are up. The examiner disregards the muscle performance measurement if it is determined that the patient appropriately used other musculature to complete the desired task. All maneuvers are performed twice on each arm with a 10 second rest between repetitions. The scores are then averaged for each arm and evaluated for symmetry.

Special Tests :

special tests for each of the rotator cuff tendons are useful in clinical examination to diagnose rotator cuff tears. A positive test of the rotator cuff below implies that the respective tendon is torn. A positive test for the biceps tendon implies biceps tendonitis/tenosynovitis.

Tendon	test	procedure
Subscapularis	Life-off test (and lag sign)	The examiner assists the patient to get in a position where he/ she touches their lower back with the arm fully extended and internally rotated. A test is judged positive if the patient is unable to lift the dorsum of his hand off his/her back reflecting the weakness of the subscapularis. The examiner passively brings the patient’s arm behind the body into maximal internal rotation (around the lower back region and pull it backward away from the back). The result of this test is considered normal if the patient maintains maximum internal rotation after the examiner releases the patient’s hand. The test is positive if the patient cannot maintain this position due to weakness of the subscapularis.
	Belly press test	The examiner instructs the patient to press the abdomen with the hand flat and attempts to keep the arm in maximum internal rotation. The test result is normal when the elbow does not drop backward, meaning that it remains in front of the trunk. A positive test, sign of subscapularis weakness, is when the elbow drops back behind the trunk
	Belly-off sign	The examiner assesses the subscapularis in this test by passively bringing the shoulder of the patient into flexion and maximum internal rotation with the elbow 90° flexed. The elbow of the patient is supported by one hand of the examiner while the other hand brings the arm into maximum internal rotation placing the palm of the hand on the abdomen. The patient is then asked to keep the wrist straight and actively maintain the position of internal rotation as the examiner releases the wrist. If the patient cannot maintain the above position, lag occurs and the hand lifts off the abdomen resulting in a positive belly-off sign. Otherwise, the test is negative
	Bear hug test	The examiner instructs the patient to place the palm of the involved side on the opposite shoulder, extend the fingers (so that the patient could not resist by grabbing the shoulder), and position the elbow anterior to the body. The examiner then asks the patient to hold that position (resisted internal rotation) as the examiner tries to pull the patient’s hand from the shoulder with an external rotation force applied perpendicular to the forearm . The test is considered positive indicating subscapularis weakness if the patient cannot hold the hand against the shoulder or if he or she shows weakness of resisted internal rotation of greater than 20% compared with the opposite side. If the strength is comparable to that of the opposite side, without any pain, the test is negative.
Supraspinatus and Infraspinatu	External rotation lag sign	The patient is seated with his or her back to the physician. The elbow is passively flexed to 90°, and the shoulder is held at 20° elevation (in the scapular plane) and near maximum external rotation (i.e., maximum external rotation minus 5° to avoid elastic recoil in the shoulder) by the physician. The patient is then asked to actively maintain the position of external rotation as the physician releases the wrist while maintaining support of the limb at the elbow. The sign is positive when a lag, or angular drop, occurs. The magnitude of the lag is recorded to the nearest 5°. A positive test indicates postero-superior cuff (supraspinatus and infraspinatus) deficiency External Rotation Lag Sign at 90 Degrees (Drop Sign) The patient is seated with his or her back to the physician, who holds the affected arm at 90° of elevation (in the scapular plane) and at almost full external rotation, with the elbow flexed at 90°. In this position the maintenance of the position of external rotation of the shoulder is a function mainly of the infraspinatus. The patient is asked to actively maintain this position as the physician releases the wrist while supporting the elbow. The sign is positive if a lag or ‘drop’ occurs. The magnitude of the lag is recorded to the nearest 5°. A positive test indicates postero-inferior cuff deficiency.
	Jobe’s test (empty can test)	This test is performed by first assessing the deltoid with the arm at 90° of abduction and neutral rotation. The shoulder is then internally rotated and angled forward 30°; the thumbs should be pointing toward the floor. Manual muscle testing against resistance is performed with the examiner pushing down at the distal forearm. This test is regarded as positive when there is weakness to resistance with arm in 90° of abduction as compared with when it is angled forward 30°, and is indicative of supraspinatus pathology.
	Drop arm test	This test assesses the supraspinatus and is performed by passively abducting the patient’s shoulder to 180 degrees and then observing as the patient slowly lowers the arm to the waist. This test is positive when the arm drops to the side. The patient may be able to lower the arm slowly to 90 degrees (because this is a function mostly of the deltoid muscle as opposed to the supraspinatus) but will be unable to continue the maneuver as far as the waist. In this case, too, the test is positive.
Teres Minor	Hornblower’s sign	The examiner supports the patient’s arm at 90 degrees of abduction in the scapular plane with elbow flexed at 90 degrees. The patient then attempts external rotation of the forearm against resistance of the examiner’s hand. If the patient cannot externally rotate, they assume a position characteristic of a positive hornblower’s sign
Biceps Tendon	Speed’s test	The patient is asked to flex his shoulder (elevate it anteriorly) against resistance (from the examiner) while the elbow is extended and the forearm supinated. The test is positive when pain is localized to the bicipital groove for biceps tendon pathology

These all assessment tests will help in identifying rotator cuff injury and isolating specific tendon involved.

It will also rule out other causes of pain and abduction difficulty as well as need of expensive imaging studies. These tests are simple and will not take much time to perform.