SHOULDER JOINT ( PATIENT HISTORY) PART II

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 The following questions should be part of the 

SHOULDER JOINT 

PATIENT HISTORY




  • Most commonly , the patient complains of pain , especially on movement, restricted motion or shoulder instability.
AGE- RELATED

  • Many problems of the shoulder can be age related.
  • Rotator cuff degeneration usually in patients who are between 40 and 60 years of age . 
  • Rotator cuff tear occurs at any age .It осcur when external rotators and abductor muscles of shoulder are weak

  • Primary impingement due to degeneration occurs at any age above 35 years.

  • Secondary impingement occurs at teenage or twenties or due to overhead vigorous activities like swimmers or pitcher in baseball.

  • Chondrosarcomas occur at any age above 30 years

  • Frozen shoulder are seen in person between age of 45 and 60 years if it result from causes other than trauma .

  • Frozen shoulder due to trauma occur at any age.

PAIN IN MOVEMENT 

  • Patient support the upper limb in protected position due to pain .


  • If there is an acute problem in the shoulder or one of the shoulder joint is unstable , patient hesitate to move the shoulder .
  • The patient is subluxing the shoulder . This may or may not be pathological but it is a sign of voluntary instability in which the patient uses his or her muscles to sublux the humerus in the glenoid stressing the labrum and inert tissues.


ANY INJURY 
  • If the patient fall on outstretched hand , which could indicate the fracture or dislocation of glenohumeral joint 
  • If the patient fall or recieve a blow to the tip of the shoulder or the patient land on the elbow ( driving the humerus against the acromion) , this may indicate an acromioclavicular disclocation or subluxation .
  • During movement , the patient feels his or her shoulder is unstable or feel like it coming out during movement 
  • when performing any activity , the patient arm "go dead"
MOVEMENT OR POSITION THAT CAUSE THE PATIENT PAIN OR SYMPTOMS 
  • Patient who have recurrent dislocation /instability of the shoulder may find that any movement involving the lateral rotation bothers them , because this movement is involved in anterior dislocation of the shoulder.
  • Recurrent disclocators may sometimes show pain at extreme of medial rotation when the humeral head is tightened against the anterior glenoid.
  • Long head of bicep pathology causes pain that moves medially and laterally with medial and lateral rotation of the shoulder.
  • Excessive abduction and lateral rotation may lead to "dead arm syndrome "
  • In throwers,the condition may be referred to as a SICK SCAPULA ( MALPOSITION OF SCAPULA,PROMINENCE OF ANTERIOR MEDIAL BOARDER OF SCAPULA,CORACOID PAIN AND MALPOSITION , SCAPULAR DYSKINESIA )
  • Anterior instability should be considered , if the patient complains of pain in specific phase of pitching ( late cocking and acceleration phase)
  • Night pain and resting pain are often related to rotator cuff tear and on occasion, to tumors.
  • Activity related pain usually signifies paratenonitis.
  • Arthritis pain occur at the extreme of motion 
  • Acromioclavicular pain  is evident at greater 90 degree of abduction and tends to be localized to the joint .
  • Sternoclavicular pain is localized to the joint and increaseson horizontal adduction 
BEHAVIOR OF PATIENTS PAIN 
  • Deep, boring toothache-like pain in the neck or shoulder region or both may indicate thoracic outlet syndrome or acute brachial plexus neuropathy.
  • Strain of the rotator cuff usually cause dull,toothache-like pain that is worse at night
  • Acute calcific tendinitis usually cause a hot, burning type of pain .
ACTIVITIES THAT INCREASED THE PATIENTS PAIN 
  • Bicipital paratenonitis or tendinosis are often seen in skiers .
  • Elite swimmers may train for more taht 15000 m daily which can lead to stress overload ( repetitive microtrauma) of the structure of the shoulder .
ACTIVITIES THAT DECREASED THE  PATIENTS PAIN 
  • Patient with nerve root pain may find that elevating the arm over the head relieves the symptoms .
ABILITY TO PERFORM  FUNCTIONAL ACTIVITIES
  • If the patient is unable to talk or swallow or if the patient is hoarse , it indicate the injury of the sternoclavicular joint or posterior dislocation of the joint beacause the pressure is applied to the trachea.
DURATION OF THE PROBLEM
An idiopathic frozen shoulder last for 3 to 5 months.

INDICATION OF MUSCLE SPASM , DEFORMITY , BRUISING,WASTING, PARESTHESIA OR NUMBNESS
  • These findings can help the examiner determine the acuteness of the condition and potentially the structure injured .
PATIENT COMPLAIN OF WEAKNESS AND HEAVINESS IN THE LIMB AFTER ACTIVITY
  • If the patient complain of weakness and heaviness in the limb after the activity or the limb tired easily , these finding may indicate vascular involvement 
  • If the venous symptoms present such as swelling or stiffness that extend all over the fingers or the Arterial symptoms present such as coolness or pallor in  upper limb may results from the pressure on an artery , a vein or both (Thoracic outlet syndrome)
INDICATION OF NERVE INJURY 
  •  Any history of weakness,numbness and paresthesia may indicate nerve injury 
  • The suprascapular nerve injury lead to atrophy and paralysis of supraspinatus and infraspinatus msucles.
  • Potential nerve injury(axillary nerve or musculocutaneous nerve)  after the dislocation of the glenohumeral joint .
  • Axillary nerve injury lead to atrophy, weakness and paralysis of deltoid and teres minor muscle .
  • The radial nerve injury ocuur when the humeral shaft is fractured ,if this nerve is damaged ; the extensors of elbow,wrist and fingers are afftected.
DOMINANT SIDE
  • Dominant shoulder is lower than the non-dominant shoulder and the ROM may not be the same for both .


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