图解肩袖检查.doc

Examination of the rotator cuffSJ Drew and RJ Emery Figure 1: Palpation of the bulk of the infraspinatus muscle. Figure 2: Palpation for a defect in the superior aspect of the rotator cuff. Figure 3: The lift-off test of Gerber, with the addition of the application of resistance.   Figure 4: Demonstration of a positive internal rotation lag sign where the patient is unable to actively maintain the hand held backwards off the back. Figure 5: The belly press test. The patient is unable to prevent the humerus and elbow falling back into extension because of a subscapularis tear. Figure 6: An inability to resist the examiners downward pressure because of a tear of the supraspinatus.  Figure 7: An inability to resist an internal rotation force because of a tear of the posterior cuff (infraspinatus and teres minor).  Figures 8 & 9: The patients arm is passively taken into maximal external rotation (figure 8) and asked to maintain this position when the examiner lets go of the arm. An inability to maintain this position so that the arm swings back towards the neutral position demonstrates a positive external rotation lag sign (figure 9). Figure 10: A positive hornblowers sign on the right. Whilst the expansion and improvement in imaging techniques most notably ultrasound and MRI has undoubtedly improved our understanding of rotator cuff pathology the management of rotator cuff tears can be based almost entirely on clinical findings.The aims of the clinical examination especially when one is considering operative intervention are to determine: 1) That the shoulder is not stiff 2) The source of the pain. This may arise from a variety of sources including; Subacromial inflammation/bursitis, mechanical impingement, fatigue (pain experienced on activity from a weak easily fatigued muscle) and intrinsic cuff pathology. 3) The site of the rotator cuff tear. It is particularly important to determine if there is a subscapularis tear since this would not be easily accessible via a standard approach used for cuff surgery such as a deltoid split. 4)  The size of the rotator cuff tear. If the tear is very large as demonstrated as will be discussed later by the presence of lag signs, then it may not be possible to surgically repair the tear. A muscle transfer such as a Latissimus dorsi transfer should be considered in these situations in which case the patient would need to be positioned in the lateral position. 5) The presence of fatty degeneration most notably in teres minor. The presence of fatty degeneration may well influence ones decision to operate since fatty degeneration of the motor unit tends to preclude a good result from surgical repair. There are a vast number of clinical signs of rotator cuff tears that can be very elegantly demonstrated (and often are at clinical meetings) but how many of these signs are really useful or bear much resemblance to clinical practice? If the test or sign has not been validated it should be treated with a healthy degree of scepticism. The purpose of this paper is to identify those signs we feel are useful in clinical practise i.e. what we look for in the clinic when faced with a patient with a possible rotator cuff tear. Wasting of the motor unit is an important sign that can be both observed and palpated. It is important to determine if the wasting is global, involving the whole of the shoulder girdle musculature or isolated to the spinati. The bulk of trapezius should be noted, as should the presence of any ptosis of the shoulder. Wasting of the infraspinatus is easier to observe than wasting of supraspinatus because of the presence of the overlying trapezius muscle, which may mask supraspinatus wasting. We therefore feel that a better idea of muscle bulk can often be obtained by palpation of both spinati in the supraspinatous and infraspinatous fossa respectively (figure 1). A finger placed over the antero-superior aspect of the humeral head can usually palpate a defect in the superior aspect of the cuff such as the leading edge of supraspinatus, which is a very common site for a tear (figure 2). However, since the wideness of the rotator interval is variable, as is the amount of cover afforded by the acromium, the arm should be taken into 30-40o of abduction and then externally and internally rotated. The defect can often be palpated under the finger together with the presence of crepitus. If the leading edge of supraspinatus is intact and the cuff tear is behind it then the defect may be more difficult to feel. The posterior aspect of the cuff is hidden underneath the acromium so is far less accessible. Extension and external rotation will bring a variable amount (dependent on the amount of cover from the acromium) of the posterior aspect of the cuff far enough forward to be palpated. Palpation more medially between the coracoid process and the long head of biceps with the glenohumeral joint taken into extensi。