Valor diagnóstico de la exploración física en la patología del hombro doloroso

Resum

ABSTRACT The objective of this doctoral thesis was to create a physical examination protocol for patients with painful shoulder. This protocol consisted on a sequence of specific orthopedic maneuvers that allow the physician to establish a diagnosis as accurate as possible. For this purpose, inter-observer reliability and diagnostic accuracy of physical examination were analyzed by comparison with the magnetic resonance pathologic findings. A sample of 58 patients with painful shoulder were examined by two expert orthopedic surgeons. It was analyzed and the inter-observer reliability of active motion (measure with the help of a goniometer of abduction and internal/external rotations), palpation tests (greater tuberosity of humerus, bicipital groove and acromioclavicular joint) and specific orthopedic shoulder maneuvers (painful arc test, Apley scratch test, Jobe, full-can test, shrug sign, drop-arm test, Hawkins, Neer sign, Yocum, forced horizontal adduction, bear-hug test, modified belly-press test, modified resisted lift-off test, Yergason, Speed, dynamic Speed and active compression). Then 214 patients with shoulder pain were examined obtaining the magnetic resonance findings in 190 in order to achieve a diagnostic precision study. After the analysis of the results it was concluded that the physical examination of the shoulder pain by trained expert physicians has an acceptable level of inter-observer reliability for clinical practice. The measure of active range of motion of the shoulder by using a goniometer offers an excellent inter-observer reliability. The palpation tests showed an inter-observer reliability good/very good, as well as the majority of specific orthopedic maneuvers used in this study, with the exception of scratch Apley test in external rotation, Yocum, forced horizontal adduction and bear-hug test (only moderate inter-observer reliability). The presence of shoulder night pain is indicative of rotator cuff injury in more than 90% of the cases. The absence of it can exclude rotator cuff lesion. A 50-70 year-old woman is more likely to have subacromial bursitis. A man of the same age is more likely to have a partial tear of rotator cuff. Traumatic antecedent in people over 50 years old is a predictive factor for subacromial impingement syndrome. A negative Hawkins test or Neer sign can exclude partial tear of rotator cuff. The Jobe test is also useful for the diagnosis of full thickness rotator cuff tear. A painful arc over the 120 degrees of abduction suggests a long head of bicipital tendon tear. The combination of data related to age and physical examination in painful shoulder improves the diagnosis accuracy for subacromial impingement syndrome. Therefore, a patient with painful shoulder over 50 years old with pain at the greater tuberosity of humerus area by palpation suggests subacromial impingement syndrome in more than 95% of cases. Neverhteless, if the patient is less than 60 years old, has negative greater tuberosity palpation test and negative Neer sign with negative forced horizontal adduction, a full thickness rotator cuff tear can be excluded in 80% of cases.