Does The Clinical Evidence Support Your Decision?

December 31, 2006

A 42-year-old man complains of persistent right shoulder pain that for the past 6 months hasprevented him from participating in his usual weight-lifting routine and affected daily activities.He is able to comb his hair and scratch his back with his right hand with no increase in pain, butreaching across his body causes discomfort. NSAIDs provide only modest relief.

PATIENT PROFILE:

A 42-year-old man complains of persistent right shoulder pain that for the past 6 months hasprevented him from participating in his usual weight-lifting routine and affected daily activities.He is able to comb his hair and scratch his back with his right hand with no increase in pain, butreaching across his body causes discomfort. NSAIDs provide only modest relief.The patient has no pertinent medicalconditions. His medical history is significantfor a fall from a ladder approximately 20 yearsearlier that resulted in right shoulder discomfortfor several weeks afterward (this eventuallyresolved on its own). He is right-handed andworks in management.

WHAT WOULD YOU DO NOW?


A.

Perform the "empty can test" to evaluate for arotator cuff problem.

B.

Test for weakness of internal rotation.

C.

Perform the crossed arm adduction test.

D.

Palpate the shoulder to evaluate fortenderness.

E.

All of the above.

Case 1:

THE CONSULTANTS' CHOICEEach of the tests listed has a role in a thorough examination.Thus,

choice E

is correct. As in any musculoskeletalexamination, palpation (choice D) precedes allprovocative tests. Here, palpation reveals tenderness overthe acromioclavicular (AC) joint. AC joint tenderness isassociated with AC joint pathology, which includes acuteshoulder separation and AC joint arthritis.The crossed arm adduction test (choice C) consistsof forward flexion of the arm to 90 degrees followed byadduction of the shoulder, so that the hand touches thecontralateral shoulder (

Figure 1

). This movement compressesthe AC joint and produces pain if the joint isarthritic. The crossed arm adduction test is positive in thispatient.The empty can test (choice A) is performed with thepatient's shoulder abducted to 90 degrees and forwardflexed about 30 degrees, with the thumb pointed down asthough he were emptying a can. A positive empty can testis indicative of supraspinatus impingement and rotator cuffproblems. Internal rotation weakness, which is also associatedwith rotator cuff problems, is tested with the patient's arm behind his back (choice B). Have him reach as far uphis back as he can with the hand on the affected side, thenwith the other hand; compare the results.This man's ability to comb his hair with ease makes arotator cuff problem unlikely, and his lack of difficulty inscratching his back indicates that he does not have weaknessof internal rotation. Nonetheless, the above 2 testshelp to more definitively rule out rotator cuff pathology.

Case 2:

WHAT WOULD YOU DO NOW?


A.

Order radiographs of the shoulder andAC joint.

B.

Order an MRI scan of the shoulder andAC joint.

C.

Inject the AC joint with lidocaine andcorticosteroids.

D.

Prescribe ice massage and NSAIDs.

Case 2:

THE CONSULTANTS' CHOICEThe tenderness over the AC joint, the positivecrossed arm adduction test, and the history of prior traumato the shoulder all suggest AC joint arthritis, whichresults from degeneration of the cartilaginous meniscusbetween the acromion and the clavicle. This degenerationcontributes to loss of AC joint integrity and the developmentof osteoarthritis in the joint over time. ACjoint arthritis can develop with no relevant history, butoften there is a history of trauma to the AC joint at somepoint in the past. Less severe (grade I or II) AC joint separationinjuries are usually associated with developmentof arthritis. This patient's earlier injury was probablygrade I or II.The history and all the findings are consistent withosteoarthritis of the AC joint. Thus, imaging studies(choices A and B) will add little at this point to what youalready know and will unnecessarily increase costs.Initial treatment of AC joint arthritis includes rest, icemassage, and NSAIDs (

choice D

).Although ice and NSAIDs should always be triedfirst, in our experience, a corticosteroid and lidocaine injectioninto the AC joint using an anterosuperior approach(choice C) is required to relieve most patients' pain. Suchan injection relieves pain in 35% to 40% of those who receiveit. This patient received a corticosteroid and lidocaineinjection.

For the first 3 weeks after the injection, the patient feelsbetter. However, after 3 more weeks, the patient reportsthat the pain has recurred and is as severe as it was whenhe first sought treatment. A follow-up examination againreveals a positive crossed arm adduction test and tendernessat the AC joint.

Case 3:

WHAT WOULD YOU DO NOW?


A.

Reinject the patient's shoulder withcorticosteroids.

B.

Order radiographs of the AC joint.

C.

Refer the patient to an orthopedist forconsultation.

D.

Any of the above.

Case 3:

THE CONSULTANTS' CHOICEAny of the first 3 choices (

choice D

) would be appropriateat this time. The option selected depends on whatthe patient prefers. The fact that this man's symptomshave returned full-blown suggests that injection may failagain. After you alert him to this possibility, let him decidewhether he wants to continue to try nonsurgical therapy.Most experts recommend limiting injections to the ACjoint to three over 3 to 6 months.

1

A plain radiograph (

Figure 2

) would be helpful atthis point. Radiographs can confirm the diagnosis, ruleout other rare problems (such as a neoplasm), and helpassess the severity of the osteoarthritis. Look for typicaldegenerative changes--bony sclerosis, subchondral cysts,osteophytes, and joint-space narrowing--that would indicatesignificant osteoarthritis of the AC joint. MRI scansare of questionable value in this setting because they usuallydo not correlate with the clinical findings.

2

Orthopedic consultation to consider operative managementmay be needed in patients who do not respondto conservative management. Arthroscopic resection ofthe distal clavicle yields good results in the hands of askilled surgeon and can alleviate persistent pain.

3

This patient opted to have his shoulder reinjected,which helped for a short time. Currently, he takes NSAIDsdaily and has full functioning with mild discomfort.

References:

REFERENCES:


1.

Johnson RJ. Acromioclavicular joint injuries: identifying and treating “separatedshoulder” and other conditions.

The Physician and Sportsmedicine.

2001;29.World Wide Web version available at: www.physsportsmed.com/issues/2001/11_01/johnson.htm. Accessed February 10, 2004.

2.

Jordan LK, Kenter K, Griffiths HL. Relationship between MRI and clinicalfindings in the acromioclavicular joint.

Skeletal Radiol.

2002;31:516-521.

3.

Nuber G, Bowen MK. Arthroscopic treatment of acromioclavicular joint injuriesand results.

Clin Sports Med.

2003;22:301-317.