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Re: Teaching Rounds on Clinical Examination of the Rotator Cuff
Letters to the Editor Re: Teaching Rounds on Clinical Examination of the Rotator Cuff To the Editor, It was with great interest that I read the clinical review “Teaching Rounds on Clinical Examination of the Rotator Cuff” by Jain et al [1]. Physical examination skills in medicine in general and in musculoskeletal medicine specifically have become a lost art in this age of limited patient visit times and rapid referral for imaging studies. Therefore I appreciate the efforts by Jain et al in presenting their review on clinical examination of the rotator cuff. The authors nicely outlined the various aspects of physical examination of the shoulder, beginning with inspection and then range of motion, manual muscle testing, and special tests. I have had a special interest in musculoskeletal physical examination, and in particular, physical examination of the shoulder, since I was an attending physician at the Mayo Clinic. In fact, it was the inquiry of a resident regarding the Yergason test that initiated the beginnings of the premise for proceeding with an entire textbook on musculoskeletal physical examination [2]. Part of this interest was sparked by the fact that many of the described physical examination maneuvers are not presented as described by the original authors. In this regard, the article by Jain et al includes a description of the hornblower’s sign with a reference to Walch et al [3] regarding this sign. Unfortunately, Figure 7 in the article by Jain et al does not depict what was described by Walch et al but rather is a reproduction of a photograph presented in our textbook, Musculoskeletal Physical Examination: An Evidence-Based Approach [2]. This photograph was based on the findings of a fine-wire electromyography study that was performed in the Mayo Clinics biomechanics laboratory, which noted that the optimal position to activate the infraspinatus was a forward flexed position to 90° in the sagittal plane with resisted external rotation [4]. Although this position is similar to what is described by Walch et al, the actual figure and description of hornblower’s sign is different than noted in the article by Jain et al [1]. Regarding the description of range of motion in this article, one important aspect that is not discussed and should be stressed (particularly when one is assessing internal and external rotation) is the necessity of stabilizing the scapula to avoid compensatory movement and improper assessment of true glenohumeral internal and external range of motion. Most clinicians assess external and internal rotation in the more functional position of 90° of abduction, rather than at the side position as described in this report. In addition, it is important for the physician to assess not only glenohumeral motion but the PM&R 1934-1482/13/$36.00 Printed in U.S.A.
interplay of the glenohumeral joint with scapulothoracic motion, which has been nicely described by multiple authors, particularly Kibler et al [5]. Finally, the authors note that research regarding sensitivities and specificities have “wide ranges from different studies and in some cases are low, which may lead to missed cases.” The authors further note that “the clinician should rely on his or her clinical judgment and not solely on these tests.” A detailed review of the sensitivities and specificities of various shoulder maneuvers has been described [2,6-8]. A common theme from these reviews is that each individual test is of little value in and of itself without correlation with the history and the findings of other physical examination maneuvers. The sensitivities and specificities of physical examination are greatly enhanced when the findings from multiple physical examination maneuvers are combined. I would therefore encourage all the readers of this report to continue to explore and enhance their physical examination skills, as well as to understand the current medical literature regarding the sensitivity and specificity of these test maneuvers, in an effort to properly incorporate the findings in formulating a specific diagnosis that will result in a specific treatment plan and successful outcomes. It is my opinion that if these physical examination tests are properly performed and understood, we can avoid unnecessary and often illogical imaging studies. Gerard A. Malanga, MD Founder, New Jersey Sports Medicine, LLC New Jersey Regenerative Institute Cedar Knolls, NJ Director, Research Atlantic Sports Health Director, Pain Management Overlook Pain Center Clinical Professor UMDNJ-New Jersey Medical School Newark, NJ G.A.M. Disclosure: nothing to disclose http://dx.doi.org/10.1016/j.pmrj.2013.03.001
REFERENCES 1. Jain NB, Wilcox RB 3rd, Katz JN, Higgins LD. Teaching rounds on clinical examination of the rotator cuff. PM R 2013;5:45-56. 2. Malanga GA, Nadler SF, eds. Musculoskeletal Physical Examination: An Evidence-Based Approach. Philadelphia, PA: Elsevier/Mosby; 2006. 3. Walch G, Boulahia A, Calderone S, Robinson AH. The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. J Bone Joint Surg Br 1998;80:624-628. 4. Jenp YN, Malanga GA, Growney E, An K. Activation of rotator cuff muscles in generating isometric shoulder rotation torque. Am J Sports Med 1996;24:477-485.
© 2013 by the American Academy of Physical Medicine and Rehabilitation Vol. 5, 445-446, May 2013
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5. Kibler WB, Chandler TJ, Livingston BP, Roetert EP. Shoulder range of motion in elite tennis players. Effect of age and years of tournament play. Am J Sports Med 1996;24:279-285. 6. McFarland EG. Examination of the Shoulder: The Complete Guide. New York, NY: Thieme; 2006. 7. Tennent TD, Beach WR, Meyers JF. A review of the special tests associated with shoulder examination. Part I: The rotator cuff tests (review). Am J Sports Med 2003;31:154-160. 8. Jia X, Petersen SA, Khosrav AH, Almareddi V, Pannirselvam V, McFarland EG. Examination of the shoulder: The past, the present, and the future. J Bone Joint Surg Am 2009;91:10-18.
REPLY We are delighted to respond to Dr. Malanga, whose comments make it clear that he shares with us an appreciation for a careful physical examination. He raises 3 issues that we address in this reply. First, Dr. Malanga suggests that our depiction of the hornblower’s sign is not based on Walch et al but on a “reproduction” of a picture in his textbook. The article by Walch et al [1], which was published in 1998, notes, “the examiner supports the patient’s arm at 90° of abduction in the scapular plane. The elbow is then flexed to 90° and the patient is asked to rotate the forearm externally against the resistance of the examiner’s hand. If the shoulder cannot be externally rotated in this position ‘hornblower’s sign’ is said to be present.” Dr. Malanga’s textbook Musculoskeletal Physical Examination: An Evidence-Based Approach was published in 2006 [2]. It is well written and has served as an essential learning tool for trainees and clinicians. The textbook notes, “The infraspinatus-teres minor muscles were isolated with the arm in the sagittal plane and the humerus elevated to 90 degrees in mid-range of external rotation. This is also referred to as the ‘hornblower’s position.’” In our article, we describe the hornblower sign as follows: “To test for the hornblower sign, the examiner supports the patient’s arm at 90° of abduction in the scapular plane with the elbow flexed at 90°. The patient then attempts external rotation of the forearm against resistance of the examiner’s hand. If the patient cannot externally rotate, then he or she assumes a position characteristic of a positive hornblower sign.” As the reader will appreciate, our description of the hornblower’s sign matches the description of the article by Walch et al, which was published before the textbook that Dr. Malanga published. Our pictorial depiction of the hornblower’s sign is also based on the description by Walch et al, which states that in the absence of strength to resist external rotation, the patient will assume a position of a “hornblower.” The picture in the article by Walch et al for a positive hornblower’s sign is depicted after the patient was asked to “bring both hands to her mouth but was unable to do so without abducting the affected arm.” As noted by Walch et al, this was first reported in obstetric
LETTERS TO THE EDITOR
brachial plexus palsy. We have not described the hornblower’s sign as the inability to bring both hands to the mouth but rather based Figure 7 on the posture that the patient assumes when unable to resist external rotation. Moreover, the picture in Dr. Malanga’s textbook is that of the actual test maneuver, whereas our picture is that of a positive hornblower’s sign test. Therefore our description of the hornblower’s sign and its pictorial representation is based on the description by Walch et al of this test and not on Dr. Malanga’s textbook, which was published after that article. The second issue raised by Dr. Malanga is the necessity of stabilizing the scapula to assess true glenohumeral internal and external rotation. He cites Kibler et al [3] for their work on scapulothoracic motion. He also notes that most clinicians assess external and internal rotation in abduction rather than at the “side position,” as described in his opinion of our article. We refer the reader and Dr. Malanga to page 48, paragraph 3, of our published article [4], which describes “external and internal rotation at 90° (in abduction).” With reference to Dr. Malanga’s comments on glenohumeral versus scapulothoracic motion, we refer him to page 46 of our article, where we describe “isolated abduction” and mention the role of stabilizing the scapula. We do not typically stabilize the scapula when assessing internal and external rotation in abduction, but this has been described by Kibler et al [3]. Dr. Malanga raises a good point about the role of imaging studies and how a good history and physical examination can often suffice to reach a diagnosis, and we appreciate his thoughtful and careful assessment of our work. Nitin B. Jain, MD, MSPH Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Department of Orthopaedic Surgery, Brigham and Women’s Hospital and Harvard Shoulder Service, Harvard Medical School Boston, MA N.B.J. Disclosure related to this publication: grant, NIH, Foundation for PM&R, Biomedical Research Institution
Reginald Wilcox, PT Department of Rehabilitation Brigham and Women’s Hospital Boston, MA R.W. Disclosure: nothing to disclose
Jeffrey N. Katz, MD, MS Department of Orthopaedic Surgery and Division of Rheumatology, Immunology, and Allergy Brigham and Women’s Hospital and Harvard Medical School Boston, MA J.N.K. Disclosure: nothing to disclose
interplay of the glenohumeral joint with scapulothoracic motion, which has been nicely described by multiple authors, particularly Kibler et al [5]. Finally, the authors note that research regarding sensitivities and specificities have “wide ranges from different studies and in some cases are low, which may lead to missed cases.” The authors further note that “the clinician should rely on his or her clinical judgment and not solely on these tests.” A detailed review of the sensitivities and specificities of various shoulder maneuvers has been described [2,6-8]. A common theme from these reviews is that each individual test is of little value in and of itself without correlation with the history and the findings of other physical examination maneuvers. The sensitivities and specificities of physical examination are greatly enhanced when the findings from multiple physical examination maneuvers are combined. I would therefore encourage all the readers of this report to continue to explore and enhance their physical examination skills, as well as to understand the current medical literature regarding the sensitivity and specificity of these test maneuvers, in an effort to properly incorporate the findings in formulating a specific diagnosis that will result in a specific treatment plan and successful outcomes. It is my opinion that if these physical examination tests are properly performed and understood, we can avoid unnecessary and often illogical imaging studies. Gerard A. Malanga, MD Founder, New Jersey Sports Medicine, LLC New Jersey Regenerative Institute Cedar Knolls, NJ Director, Research Atlantic Sports Health Director, Pain Management Overlook Pain Center Clinical Professor UMDNJ-New Jersey Medical School Newark, NJ G.A.M. Disclosure: nothing to disclose http://dx.doi.org/10.1016/j.pmrj.2013.03.001
REFERENCES 1. Jain NB, Wilcox RB 3rd, Katz JN, Higgins LD. Teaching rounds on clinical examination of the rotator cuff. PM R 2013;5:45-56. 2. Malanga GA, Nadler SF, eds. Musculoskeletal Physical Examination: An Evidence-Based Approach. Philadelphia, PA: Elsevier/Mosby; 2006. 3. Walch G, Boulahia A, Calderone S, Robinson AH. The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. J Bone Joint Surg Br 1998;80:624-628. 4. Jenp YN, Malanga GA, Growney E, An K. Activation of rotator cuff muscles in generating isometric shoulder rotation torque. Am J Sports Med 1996;24:477-485.
© 2013 by the American Academy of Physical Medicine and Rehabilitation Vol. 5, 445-446, May 2013
445
446
5. Kibler WB, Chandler TJ, Livingston BP, Roetert EP. Shoulder range of motion in elite tennis players. Effect of age and years of tournament play. Am J Sports Med 1996;24:279-285. 6. McFarland EG. Examination of the Shoulder: The Complete Guide. New York, NY: Thieme; 2006. 7. Tennent TD, Beach WR, Meyers JF. A review of the special tests associated with shoulder examination. Part I: The rotator cuff tests (review). Am J Sports Med 2003;31:154-160. 8. Jia X, Petersen SA, Khosrav AH, Almareddi V, Pannirselvam V, McFarland EG. Examination of the shoulder: The past, the present, and the future. J Bone Joint Surg Am 2009;91:10-18.
REPLY We are delighted to respond to Dr. Malanga, whose comments make it clear that he shares with us an appreciation for a careful physical examination. He raises 3 issues that we address in this reply. First, Dr. Malanga suggests that our depiction of the hornblower’s sign is not based on Walch et al but on a “reproduction” of a picture in his textbook. The article by Walch et al [1], which was published in 1998, notes, “the examiner supports the patient’s arm at 90° of abduction in the scapular plane. The elbow is then flexed to 90° and the patient is asked to rotate the forearm externally against the resistance of the examiner’s hand. If the shoulder cannot be externally rotated in this position ‘hornblower’s sign’ is said to be present.” Dr. Malanga’s textbook Musculoskeletal Physical Examination: An Evidence-Based Approach was published in 2006 [2]. It is well written and has served as an essential learning tool for trainees and clinicians. The textbook notes, “The infraspinatus-teres minor muscles were isolated with the arm in the sagittal plane and the humerus elevated to 90 degrees in mid-range of external rotation. This is also referred to as the ‘hornblower’s position.’” In our article, we describe the hornblower sign as follows: “To test for the hornblower sign, the examiner supports the patient’s arm at 90° of abduction in the scapular plane with the elbow flexed at 90°. The patient then attempts external rotation of the forearm against resistance of the examiner’s hand. If the patient cannot externally rotate, then he or she assumes a position characteristic of a positive hornblower sign.” As the reader will appreciate, our description of the hornblower’s sign matches the description of the article by Walch et al, which was published before the textbook that Dr. Malanga published. Our pictorial depiction of the hornblower’s sign is also based on the description by Walch et al, which states that in the absence of strength to resist external rotation, the patient will assume a position of a “hornblower.” The picture in the article by Walch et al for a positive hornblower’s sign is depicted after the patient was asked to “bring both hands to her mouth but was unable to do so without abducting the affected arm.” As noted by Walch et al, this was first reported in obstetric
LETTERS TO THE EDITOR
brachial plexus palsy. We have not described the hornblower’s sign as the inability to bring both hands to the mouth but rather based Figure 7 on the posture that the patient assumes when unable to resist external rotation. Moreover, the picture in Dr. Malanga’s textbook is that of the actual test maneuver, whereas our picture is that of a positive hornblower’s sign test. Therefore our description of the hornblower’s sign and its pictorial representation is based on the description by Walch et al of this test and not on Dr. Malanga’s textbook, which was published after that article. The second issue raised by Dr. Malanga is the necessity of stabilizing the scapula to assess true glenohumeral internal and external rotation. He cites Kibler et al [3] for their work on scapulothoracic motion. He also notes that most clinicians assess external and internal rotation in abduction rather than at the “side position,” as described in his opinion of our article. We refer the reader and Dr. Malanga to page 48, paragraph 3, of our published article [4], which describes “external and internal rotation at 90° (in abduction).” With reference to Dr. Malanga’s comments on glenohumeral versus scapulothoracic motion, we refer him to page 46 of our article, where we describe “isolated abduction” and mention the role of stabilizing the scapula. We do not typically stabilize the scapula when assessing internal and external rotation in abduction, but this has been described by Kibler et al [3]. Dr. Malanga raises a good point about the role of imaging studies and how a good history and physical examination can often suffice to reach a diagnosis, and we appreciate his thoughtful and careful assessment of our work. Nitin B. Jain, MD, MSPH Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Department of Orthopaedic Surgery, Brigham and Women’s Hospital and Harvard Shoulder Service, Harvard Medical School Boston, MA N.B.J. Disclosure related to this publication: grant, NIH, Foundation for PM&R, Biomedical Research Institution
Reginald Wilcox, PT Department of Rehabilitation Brigham and Women’s Hospital Boston, MA R.W. Disclosure: nothing to disclose
Jeffrey N. Katz, MD, MS Department of Orthopaedic Surgery and Division of Rheumatology, Immunology, and Allergy Brigham and Women’s Hospital and Harvard Medical School Boston, MA J.N.K. Disclosure: nothing to disclose