Shoulder examination: a systematic approach

The shoulder is a complex joint with static and dynamic stabilising structures working synchronously. These allow a full range of movement while preserving stability of the joint. Patients may present with pain, stiffness, weakness, deformity or instability. The authors suggest a systematic examination sequence to ensure that important pathology is not overlooked. Adopting this approach allows common pathologies, including tears of the rotator cuff, impingement and tendinopathy, to be easily identified. This shoulder examination sequence may be used by all healthcare professionals and can also act as a revision aid for those undergoing exams in this field, at different levels of training.

THE APPLICATION OF USING GEL PAD AS A MEDIUM FOR ULTRASOUND SHOULDER

Background: A conductive medium on ultrasound is a medium that is used to obtain sound wave transmission by minimizing air between the transducer and the skin. This study used materials that are easily found such as gel wax and paraffin for making the gel pad. A good oil and mineral based wax gel are used as a basic ingredient for ultrasound gel making. Gel pad can be used to minimize the structure of unauthorized organs. One of which is the shoulder. Objective: This study aims to determine the quality of the image in the use of standard gel, and the use of gel pad as a medium for ultrasound shoulder. Method: Gel pad is made by mixing gel wax and paraffin ingredients. This gel is used to obtain images from ultrasound investigation. The study used 16 samples with a total of 64 images obtained in which 32 images using standard gel and gel pad in the long axis position and 32 images using standard gel and gel pad in the short axis position. The analysis of image results is done using matlab image processing to assess SNR. The image quality obtained from the results of the questionnaire was assessed by a specialist in radiology. Image quality processing based on SNR was tested using independent T test. Meanwhile, the results of image quality from the questionnaire assessment were tested using Wilcoxon. Result: As many as 64 objects were obtained using standard gel. The gel pad showed that there were significant differences in the results of image quality based on SNR values. In the results of the questionnaire assessment, there are several anatomic organs that have no significant differences. Conclusion: The use of standard gel was still higher compared to the use of gel pad. The gel pad is able to become a standard gel alternative on ultrasound shoulder examination.

Shoulder examination in the athlete

The shoulder is the second most commonly injured joint in Sports Traumatology. A thorough clinical examination is mandatory for a strategic therapy regime. A standardized and, importantly, gentle and pain sparing, physical examination not only builts the basis for above mentioned, yet also provides a base in the doctor-patient relationship. The following guideline is meant to aid in these regards. Nonetheless, clinical experience is of utmost importance in combination with a correct physical examination. Hence, if hesitation is present about the diagnosis or treatment, there should be no hesitation in consulting an expert.

Clinical Examination of Hip Dysplasia/Instability

Clinical examination is one of the main skill that clinicians acquire through training and experience, and its contribution to diagnosis is a key addition to history taking. Mike Reiman is a physical therapist, author of the excellent textbook «Orthopedic clinical examination», who just conpleted his PhD (congrats!) under the supervision of Kristian Thorborg (Denmark), looking at the validity of the most frequently used clinical examination tests around the hip area. We tend to think that “specialized” tests have great significance for the examination of a particular structure of pathology, yet as we have already learned from multiple studies on this very question around the shoulder examination tests, this is deceptive. In this article, Dr Reiman looks at what we know for hip instability tests, and the conclusion is not very different. Some tests can help in ruling in a pathology (higher specificity than sensibility), but should by no means be considered decisive. At #SportSuisse2018, he presented his PhD work on femoro-acetabular impingement tests, and the findings are not dissimilar to this article. We should be very careful with the interpretation we make of positive clinical tests. First, the tests should be properly standardized and executed. Second, the clinician must understand when a test is to be interpreted as positive: do we look for pain (reproduces the patient’s complaint or a different pain?), clicking or limitation in range of motion? Not all tests look for the same thing. Third, the clinician must acknowledge the validity of each test. One way to look at it is, that the act of clinical examination must be executed and chosen wisely, whilst the results of the tests can only be interpreted in the context of the history, the aggregate of tests, the additional imaging when advisable and the experience of the clinician. This is the art of clinical work informed by science, but let’s not overstate our findings too “artistically”.