Overview of Medical Evaluation of Shoulder Disorders
A functional shoulder is an essential physical requirement for all LEOs. Post-injury evaluation and management of shoulder injuries in an occupational setting is complicated by many factors including age-related degeneration and pre-existing loss of strength and mobility of the shoulder girdle. Peer-reviewed studies can provide a framework for functional outcomes and timing of return to activities after a shoulder injury; however, much of the reviewed literature on return to high-demand activities is focused on the sport-specific activities of baseball (pitching), tennis (serving), and volleyball (hitting). Despite the limitations in comparing specific athletic requirements to the essential job functions of a LEO, successful return to sport requires a highly functional shoulder. Therefore, there should be minimal differences in assessing the ability to return to play for an athlete and return to unrestricted duty as a LEO.
History – The most important part of the initial examination is to obtain a proper history focused on both the mechanism of injury and the development of shoulder symptoms. General review should include any injuries associated with sports activities, motor vehicle crash or other traumatic events. A focused history on the shoulder should also include a review of any prior shoulder trauma that places an individual at risk for shoulder injury or instability. In addition, a general medical review to include such medical disorders as diabetes, chronic seizure disorder, or history of any rheumatological problems.24
Range of motion – Successful return to play for sport-specific shoulder activities typically requires that the athlete achieve normal elevation (abduction) of the shoulder and minimal loss of external rotation compared with the uninjured shoulder.25,26 Given that shoulder movement is the combination of movements at the sternoclavicular, acromio-clavicular, scapulothoracic, and glenohumeral joints,27the traditional evaluation of the separate range-of-motion assessments of flexion, extension, internal and external rotation of the glenohumeral joint fails to capture the necessary coordinated movements needed for successful return to sport. In addition, this method fails to account for pre-injury range of motion limitations. Internal rotation of the shoulder should also be assessed functionally (i.e., internal rotation sufficient to access equipment on the duty belt) – however, the examiner should recognize that these assessments are not specific for internal rotation at the glenohumeral joint.28
Strength – It is important to recognize that most of the muscles in the shoulder girdle are either scapular stabilizers (trapezius, serratus anterior, levator scapula, rhomboids) or shoulder joint compressors (teres major, supraspinatus, infraspinatus, subscapularis, teres minor).29 Therefore, isolated testing of each muscle adds little information in return to work determinations. (Note: strength testing of the shoulder has not been found to correlate with athletic outcomes, suggesting that an athlete’s subjective reports of function are the primary predictor of successful return to play).25
Proposed assessment for medical clearance for any shoulder disorder:
1. Documentation of initial injury/disorder including any concomitant injuries to same-side hand, wrist, elbow, thorax.
2. Documentation of clinical evaluation (including imaging) that led to the diagnosis.
3. Timeframe from initial injury to current evaluation – most if not all rehabilitation pathways are time-dependent for increasing activities.
4. Documentation of treatment of condition (operative vs. non-operative).
5. Pain medication – Document if pain mainly occurs during or after training activities (likely to be cleared for unrestricted duty if pain is not incapacitating) or if pain has prevented return to training activities (disqualifying condition).
6. Objective data
Range of motion:
- Elevation (abduction). While elevation is measured in the scapular plane for throwing athletes, non-sport specific athletes can be measured in their self-selected plane of elevation. LEOs who have asymmetry of motion >20° or are unable reach objects above their shoulder, or are unable to elevate the shoulder beyond 140° require further job simulation testing.
- External rotation at 90°/90°. External rotation is measured with the shoulder at 90° of abduction with an elbow flexion of 90° in the standing position. In this position, the forearm should be parallel to the floor, palm down which represents 0° of external rotation. More than a 20° loss of external rotation in the injured shoulder compared to the unaffected arm is a potentially disqualifying condition and requires job simulation testing.
- Posterior Reach. The term posterior reach is preferred to internal rotation for functional assessment of the upper extremity in order to distinguish it from internal rotation measures performed at 90°/90°. Posterior reach (internal rotation) is defined as having the patient reach behind their back, back of the hand against the back and documenting the vertebral level reached by the tip of the thumb. It is the consensus of the Task Force that LEOs should be able to: 1) achieve similar posterior reach with both upper extremities; and 2) have posterior reach to at least the level of the intercristal line (defined as the line joining the superior aspect of the iliac crests posteriorly)30 or require job simulation testing.
7. Documentation of physical activity level since the treatment of the condition.
8. Documentation of any instances where the affected shoulder has given way or failed during sports and/or vigorous activity. Document any activities the LEO has avoided since injuring the shoulder.
9. If the police physician is concerned with the LEO’s ability to return to unrestricted duty, the following job simulation tasks may be suggested to the agency as part of the return-to-work decision making: climbing (fence, ladder, over obstacles), pushing dragging and lifting heavy objects without assistance (weight to be define by the agency), practicing defensive tactics, accessing a long gun from the partition of the patrol car (if this is an essential job function).
10. Before returning to unrestricted duty, the LEO has to successfully return to training activities without difficulties. Achieving pre-injury function in sports specific activities (i.e., throwing, serving in tennis) are not considered necessary to return to unrestricted duty as a LEO.
11. Instability Testing (as indicated by history)
- Apprehension test. a Often predictive of anterior instability, particularly for individuals at risk for re-dislocation. (Testing is useful for individuals with a dislocation who are being treated nonoperatively in predicting risk for re-dislocation/instability).31,32,33,34
- Sulcus sign. If present often indicates multidirectional instability or capsular laxity.
The presence of any instability on testing or prior dislocation requires further evaluation.
a. Safran et al., used the apprehension test to assess the risk of recurrent dislocation after initial anterior shoulder dislocation. At 24-month follow-up, a recurrent dislocation had occurred in 36.8% and 71.4% of those with a negative and positive 6-week apprehension sign respectively.32