Background
The patient is 45 years old. Partnered, with an adult son. Works as a carpenter. Previously healthy, but a year ago had tendon inflammation in the right shoulder which was treated with Paracetamol and Ibuprofen.
The patient presents as an emergency after a fall from a ladder a couple of hours ago. The fall height was about two meters. The patient reports increasing pain in the right shoulder and that it is difficult to lift the arm.
Consultation video
Medical history
- Doctor
What happened?
- Patient
I fell from a ladder a couple of hours ago… and landed a bit on my arm.
- Doctor
How high was it?
- Patient
Maybe two meters.
- Doctor
What is the main problem now?
- Patient
It hurts in the shoulder… but the worst thing is that I cannot lift the arm properly.
- Doctor
Did the pain come immediately?
- Patient
Yes… and it has only gotten worse since.
- Doctor
Have you had problems with your shoulder before?
- Patient
Yes, a little tendon inflammation a year ago… but it went away.
Standard examination
Perform standard examination:
- 1 Inspection
- 2 Active movements
- 3 Passive movements
- 4 Isometric movements
- 5 Palpation
Tentative diagnosis
based on medical history and standard examination- Rotator cuff rupture in m. supraspinatus and m. infraspinatus.
Examination
Special tests to strengthen or weaken the likelihood of the tentative diagnosis.
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1. Inspection
Doctor
Conducts a systematic inspection.
Patient
Holds the arm close to the body, moves carefully, and avoids spontaneous movements in the shoulder.
Findings
- Functionally unloaded shoulder.
-
2. Active abduction
Doctor
Can you lift your arm out to the side?
Patient
The patient lifted, but stops early due to pain and lack of strength.
No… it doesn't work properly.
Findings
- Cannot lift the arm.
- Both pain (VAS about 5) and weakness.
-
3. Passive abduction
Doctor
Lifts the arm for the patient.
Patient
Less pain than with active movement.
It is a little better when you lift.
Findings
- Better passive than active function, an important differential point.
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4. Rotational movements
Doctor
I want to test the rotation in the shoulder.
Patient
The movements are performed almost normally, with slight pain at the extreme position.
It's okay... but a little painful at the very outer edge.
Findings
- Relatively normal range.
- Pain at the endpoint, especially during internal rotation.
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5. Isometric strength test
Doctor
Testing abduction with resistance for the first 20 degrees.
Testing external rotation with resistance and the shoulder joint in neutral position.
Patient
Cannot maintain resistance in abduction.
I cannot hold back.
Also gives way with external rotation.
It is weak… and painful.
Findings
- Reduced strength in abduction.
- Reduced strength and pain (VAS approximately 6) in external rotation.
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6. Empty Can Test
Doctor
Keep the arm up like this, and resist when I push.
Patient
The arm falls and the patient cannot resist.
No… it just fails.
Findings
- Positive test. The patient cannot resist during isometric strength test.
Learning points
- 1 Distinguish between pain inhibition and actual strength failure.
- 2 Classic pattern in rotator cuff rupture is active weakness and better passive mobility.
- 3 Empty Can Test detects weakness in m. supraspinatus. Isometric external rotation in the shoulder detects weakness in m. infraspinatus.