Importance of Physical Exam when Diagnosing Shoulder Injuries

In Sports Medicine, we see a number of injuries to the shoulder and reaching the proper diagnosis involves several important steps. These include

1. Obtaining a complete history of the injury from the patient
2. Performing a Physical Exam
3. Ordering diagnostic test

Occasionally a patient will come to our office and mention a previous physician ordering an MRI and scheduling surgery following positve test results without performing a physical exam.  While diagnostic test are important, the history as well as the physical exam are equally as important.  All work together to insure the proper diagnosis is made.  This article will focus on the physical exam. 

The Shoulder

The shoulder is the most mobile joint in the body. Unfortunately because of this mobility, the shoulder does not have the stability of other large joints.  This instability makes the shoulder more susceptible to injuries; especially in sports with overhead activities, including  baseball, softball, volleyball, swimming and weight lifting.  When a patient comes to our office with a new injury we will first obtain an x-ray.  This will be reviewed during the physical exam.  After obtaining a thorough history, we will proceed with the office exam.

Your physician should use their hands to feel all of the  bony structures in your shoulder. There are several different bones to examine on both the front and back of your shoulder.

 In addition, your physician should physically exam a number of the tendons and muscles within the shoulder joint.

Once your physicians has complete this portion of the exam, they may perform a variety of examine room test to evaluate strength and function.  We have included a link to The University of California, San Francisco Department of Orthopaedic Surgery.   Here you will find a very comprehensive article on each test.

When the physical exam is complete, your physician will determine if more diagnostic studies are needed. These may include Magnetic Resonance Imaging or Nerve Studies to rule out a neurovascular condition.

On occasion, a patient will schedule an appointment with our office for a second opinion.  They may have seen another physician and had an MRI performed. The diagnosis is a shoulder injury requiring surgery.   Even as a second opinion, with a positive MRI, it is important to perform the full physical exam mentioned earlier.  Only after this can we agree or disagree with the original diagnosis.

Bottom line…Make sure your orthopedic surgeon spends time with “hands on” your injury before taking you to surgery.

Total Knee Patient Featured in Local News Story

The local NBC affiliate, WAFF-48 recently ran a story on one of our TKA Patients, Charles House. The story focused on his return to an active life style after years of suffering with osteoarthritis.  He had several prior surgeries back in the 1970s related to sports injuries.  Although the procedures provided him with some relief, over the years his knee continued to degenerate and osteoarthritis forced him to give up the actitives he once enjoyed.

We used the Wright Medical Medial Pivot Evolution implant in Mr. House.  This implant provides great stability for our active patients.  While resutls vary among patients, Mr. House's positive attitude, good health and committment to the prescribed rehab served him well.  As he states in the story, he was back dancing with his wife, Sherry 4 weeks after surgery.  Mr. House has been active in a number of our patient education efforts including the production of a Total Knee Replacement Patient DVD we hand out to all of our patients preparing to undergo TKA surgery.  

If you would like more information on this procedure, please contact us at 256-705-4158.

Staying In the Game! Prevention of Throwing Injuries

Now that baseball and softball are in full swing, we are seeing more throwing injuries in the clinic. Overhand throwing is the main culprit. The reason being is that in the late cocking and early acceleration phases, the greatest stresses are applied to the shoulder. With the arm up and stretched behind the body ( shoulder is abducted and externally rotated ) the labrum and ligaments have to resist a tremendous amount of stress. The labrum is subjected to damage at the attachments of the ligaments in the front and top.

Additionally, the rotator cuff muscles and tendons must resist these high stresses in order to keep the ball optimally located in the socket. These high stresses can create damage at the tendon level in the form of tearing.

Adaptive changes to long term throwing can lead to tightness in the back of the shoulder. This can cause abnormal stresses to be applied to the shoulder which will result in symptoms. The muscles that control the shoulder blade, if not strong and coordinated will cause problems as well.

When a throwing athlete presents with pain from throwing, we must look at each of these potential problems. Treatment of each of these is beyond the scope of this discussion and will be reserved for another posting.

Our goal in this discussion is to prevent these throwing injuries.

The best preventative measure is to keep the muscles strong and balanced with the rotator cuff, the shoulder blade, and the core. A strengthening program for both in season and off season should be maintained.  Any imbalance and weakness can easily lead to symptoms. In most cases, when an athlete presents with shoulder pain from throwing, we will find weakness and imbalances with their strength.

Before formal practice begins, the athlete should institute a graduated throwing program so his /her arm is ready. Going into practice with a deconditioned arm is asking for a sore shoulder and/or elbow.  For the baseball pitcher, throwing within the designated pitch counts is key. Overuse injuries are some of the most common now.

When a throwing athlete begins to have problems, the best course of action is to seek an evaluation from an Orthopaedic Sports Medicine Specialist. Getting a diagnosis and early treatment plan often  keeps the athlete playing safely. The greater the delay, the more likely the condition can worsen and playing time can be lost.

Any athlete that has experienced a sore shoulder or elbow during the season, should be evaluated and follow up at the end of the season. Rest alone (in the off season) may alleviate the pain and discomfort but without the proper rehabilitation and strengthening program, you may be asking for additional problems next season. It often means the difference between playing symptom free verses struggling the next season. This is all  too often a scenario we see which could have been prevented.

Throwing injuries are certainly common this time of year.  Nothing is more frustrating than trying to compete with a sore arm. It is often very difficult to resolve once the season has started. By following the guidelines above, there is a greater  chance to avoid getting into trouble.

Pitching...From the Mound or Flat Ground?

We recently hosted a dinner for area baseball and softball coaches.  I presented a program on throwing injuries and was asked a question on pitching training.  A baseball coach wanted to know whether it was advisable to do more throwing from a flat surface verses a mound. At the time I couldn't give him a firm opinion one way or the other. So I decided to research the topic again.

The logic of training from flat ground compared to the mound is to reduce the stresses seen by the shoulder and elbow. Obviously, trying to prevent injuries is the main goal. Studies have shown lower stresses when throwing from flat ground. However, the stress reduction is not significant enough to make a substantial argument for injury reduction.

Opponents of training from flat ground argue that the mechanics of throwing have to change to accommodate the difference from the mound. Differences in stride length and velocity may lead to adaptations that have to be overcome when getting back on the mound.

Certainly, one can find favorable arguments to both implement flat ground pitching as well as train from the mound.  I am still not able to give a firm opinion either way. My recommendation is to use this training technique if you think it works good for your players, otherwise don't jump on the bandwagon.

If you would like to read more on this topic, the Journal of Orthopaedic & Sports Physical Therapy offers an aritcle you might find insightlful.

Eric W. Janssen, MD

Exciting Trends in Sports Medicine

I read quite a bit in the Sports Medicine and Orthopedic Journals and often come across articles that not only interest me, but might interest the patient population.  Following up on my last post about Platelet Rich Plasma, I recently read an article by Dr. Brian Cole and the growing trend toward Biologics in Orthopedic Treatment.  For those that are interested I am including the link to his article.  To return to the blog simply press the back button.

Dr. Brian Cole: 3 Exciting Trends In Sports Medicine Research 

Please let me know if you have any topics of interest you would like for me to feature in our Blog.

Dr. Eric W. Janssen MD