ASSESSMENT AND DIAGNOSIS stage of the injury.

Stage ■ Stage 1 - reversible sub-acromial oede- ma and haemorrhage, usually under 25 years of age, as a result of overuse, responds to conservative treatment.

■ Stage 2 - fibrosis and tendonitis, usual- ly 25-40 age group, follows repeated episodes of mechanical inflammation, irreversible by conservative treatment.

■ Stage 3 - bony changes and cuff tears, usually aged over 40, does not respond to conservative treatment.

Whilst the classification is a useful starting point, it is important to note the age ranges are not set in stone and recent evi- dence as well as the author’s experience suggests that stage 2 and partial cuff tears do respond to conservative treatment (5,6).

History of present condition Onset ■ Traumatic/related to specific incident ■ Insidious ■ Overuse.

A traumatic incident is more likely to be the cause of partial cuff tears, acute sub- acromial bursitis or joint capsulitis. Overuse is more likely to be a slow, insidi- ous onset (7).

Pain ■ Type - usually sharp, catching on eleva- tion or lowering arm from elevation fol- lowed by dull aching after use (2).

■ Distribution - over anterior and deltoid region of shoulder, sometimes radiating into the C5 dermatome which extends to the anterolateral aspect of the arm and forearm as far as the base of the thumb (7). Infraspinatus, however, often refers pain posteriorly as far as the elbow (8). The distribution of the pain also gives an indication of the depth of the structure involved and the severity of irritation. The deeper a structure lies, the further into the dermatome it refers, likewise the more aggravated a structure is, the further it refers (7). The ACJ is likely to give very localised pain as it is superficial.

■ Aggravating/easing factors - aggravated by elevation or lowering arm from ele- vation - all overhead activities whether

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sporting, work-related or personal daily living tasks. Sometimes painful at night lying on affected side - rotator cuff tears are implicated due to compression of the lesion, but can also indicate instability (2) or chronic sub-deltoid bursitis (2). Only avoiding the aggravat- ing factors gives ease of symptoms.

Special questions ■ Does the joint feel unstable/feel as if it will subluxate/dislocate when the arm is overhead? This indicates underlying instability (9)

■ Is there clicking? This may indicate a SLAP tear (10)

■ Is there crepitus? This may indicate par- tial rotator cuff tear (11)

■ Does the arm feel heavy or “dead”? This may indicate multidirectional instability or anterior subluxation (2).

Thorough subjective questioning will assist in directing the objective examination as much information has already been obtained.

BOX 1 - SUBJECTIVE ASSESSMENT

■ How old is the patient? ■ Is the injury traumatic or of insid- ious onset?

■ Where is the pain located and when?

■ Are there answers to any special questions?

Objective examination Before proceeding with the examination, always ask the nature of the pain at that present time to avoid being misled and risking a misdiagnosis.

Inspection ■ Trauma - look for signs of redness, swelling and deformity which may indi- cate areas of inflammation or trauma.

■ Muscle bulk - pay particular note to atrophy of supraspinatus, infraspinatus and deltoid. This obviously locates a problem but also gives an indication of the length of time the problem has existed. Muscle atrophy may also indi- cate a neurological or spinal cause. Trapezius muscle bulk is useful for detecting scapula muscle imbalances. For example is there an imbalance between the upper and lower fibres - is upper trapezius hypertrophied and

therefore overworking to assist elevation of the arm or is lower trapez- ius atrophied indicating poor scapula control?

Postural analysis Time is never wasted performing a full pos- tural analysis, particularly in the sporting arena. However particular attention should be paid to the position of: ■ Head ■ Cervical spine ■ Thoracic spine ■ Pectoral girdle, especially scapula ■ Lumbar spine ■ Pelvis

It is important to look along the kinetic chain. As an analogy, consider pelvic and lumbar alignment as the foundations of a house. If the foundations are not secure and in the correct position, the brickwork of the house will develop cracks and lines of stress rendering it unstable. The same is true of the human body. If the foundations are wrong, the rest of the body will be compensating along the chain. The true foundations of the human body are the feet, so it may be necessary, particularly with athletes, to look as far down the chain as this. The pelvis is key to spinal alignment and consequently to shoulder girdle position.

Posterior pelvic tilt for example, will result in a flattened lumbar lordosis. This conse- quently results in an increased thoracic kyphosis leading to scapula protraction and abduction with or without lateral rotation. The cervical spine is likely to be hyper- extended with a head forward position. The anterior chest and shoulder is thus placed in a shortened and tight position, the pos- terior capsule of the shoulder is tightened drawing the humeral head anteriorly, lead- ing to the potential for SIS to occur.

There is currently little evidence to refer to with respect to the postural implications and static scapula position on SIS. After 10 years experience and successful outcomes with sometimes only addressing the pos- tural component in SIS, however, I recom- mend including this as part of the assess- ment and tackling any issues highlighted in the treatment plan. In an ideal world we would all like to practise knowing the evi- dence base is there to support our work but there are limitations to using evidence- based medicine alone (12). Good science is

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