Transcript My Sore Shoulder!

“My Sore Shoulder!”
Guide to Diagnosis and
Conservative Treatment
Shoulder Anatomy
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Acromioclavicular
(AC) joint
Glenohumeral joint
Glenoid labrum
Humerus
Rotator cuff
Biceps
muscle/tendon
Deltoid muscle
Common Shoulder Conditions
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Rotator cuff injuries
Impingement
Instability
Labral tears
Bicipital tendonitis
AC joint disorders
Suprascapular nerve entrapment
Rotator Cuff Injuries
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Rotator cuff serves as a stabilizer for the
shoulder
Cuff is comprised of the supraspinatus,
infraspinatus, subscapularis and teres
minor muscles
Common rotator cuff injuries occur to the
underside of the supraspinatus tendon
Increase in risk of tear at age 40
Impingement
(Bursitis/Tendonitis)
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Can include inflammation of the bursa
overlying the rotator cuff, inflammation
within the rotator cuff tendons, or
calcium deposits within the rotator cuff
tendons caused by wear and tear
Can be caused by frequent extension of
the arm at high speed under high load
(i.e. throwing a baseball)
Potential outcome is a rotator cuff tear
Instability
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Shoulder laxity needs to be differentiated
from frank instability
Laxity is common in the swimmer and
throwing athlete, as the shoulder must be
loose enough to allow excessive external
rotation
Instability is unwanted translation of the
humeral head on the glenoid, and
compromises the comfort and function of the
shoulder
Labral Tears
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Frequently seen in
throwing athletes
Glenohumeral joint
receives
compressive and
shearing forces
during the movement
of the humeral head,
anteriorly to
posteriorly
Bicipital Tendonitis
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Inflammation of the biceps tendon
Diagnosis made principally by palpation
of the tendon during clinical examination
Occurs frequently in the throwing athlete:
• Modest biceps activity during cocking and
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acceleration phase
High level of biceps activity during followthrough phase
AC Joint Disorders
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Most sprains to the
AC joint occur as the
result of a fall or a
blow to the lateral
acromion
Symptoms of a
separation may
range from pain over
the AC joint to a
frank deformity
Suprascapular Nerve
Entrapment
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Suprascapular nerve supplies the
supraspinatus and infraspinatus muscles
of the rotator cuff
The nerve can be compromised by
traction injuries or compression injuries
Athlete may present with subtle
weakness and vague complaints of
posterior shoulder girdle pain
The Subjective Evaluation
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What?
How?
When?
Where?
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Pain?
Instability?
Weakness?
Deformity?
The Clinical Examination
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Inspection
Examination of the cervical spine
Palpation
Range of motion assessment
Strength assessment
Glenohumeral stability assessment
Neurovascular examination
Special tests
Inspection
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Should be performed from different
perspectives (front, side, back, top)
Should assess for symmetry, atrophy,
hypertrophy, deformities, bruising and
swelling
Note scars as evidence of prior surgical
procedures
Examination of the Cervical
Spine
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Have the patient look up at the ceiling,
touch his chin to his chest, look over
each shoulder
Any numbness, tingling or pain referred
to the affected shoulder points to the
cervical spine as the etiology of the
shoulder pain
Palpation
Bony Landmarks:
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SC joint
Clavicle
AC joint
Acromion
Bicipital groove
Scapula
Soft Tissue:
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Biceps tendon
Supraspinatus
insertion to the
proximal humerus
Deltoid
Posterior capsule
Range of Motion
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Includes testing of both active and
passive range of motion
For example, in the setting of a rotator
cuff tear, passive range of motion will be
normal but active range of motion will be
diminished due to the tear in the muscle
Range of Motion (norms)
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External rotation in a 0° plane (90°)
External rotation in a 90° plane (90°)
Abduction (150°)
Internal rotation (90°)
Forward flexion (180°)
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ALWAYS compare both shoulders!
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Range of Motion
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During range of motion assessment is a
reasonable time to test for impingement
Impingement sign: with the arm abducted to
90° and the elbow flexed to 90°, externally
rotate the patient’s arm
Impingement test: forward flex the patient’s
arm to 180°
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Pain signifies a positive test
Strength Assessment
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Strength is easy to assess by standing behind
the patient who is seated on the exam table
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Strength is graded 0 to 5 over 5:
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0/5 = total paralysis
1/5 = palpable or visible contraction
2/5 = full ROM with gravity eliminated
3/5 = full ROM against gravity
4/5 = full ROM with decreased strength
5/5 = normal strength
Strength Assessment
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Supraspinatus: assessed at 90° of
forward flexion in the scapular plane with
the thumbs pointed to the floor;
downward pressure is resisted by the
patient
• Test is specific for supraspinatus function, and
evaluates cuff strength and integrity
Strength Assessment
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External rotators: with the patient’s arm
at his side and the elbow flexed to 90°,
he will externally rotate as if hitting a
tennis ball in a backhanded manner
against resistance
• Test is specific for the teres minor and
infraspinatus muscles
Strength Assessment
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Abduction: assessed in the coronal
plane against resistance
• May be suggestive of either deltoid or cuff
deficiency
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Subscapularis: with the dorsum of the
patient’s hand on his ipsalateral back
pocket, instruct him to push backward
against resistance
Glenohumeral Stability Assessment
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Subtle anterior
instability is not
uncommon in the
throwing athlete
In addition, the
hyperlax patient may
have some element
of multidirectional
instability
Glenohumeral Stability Assessment
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Sulcus sign: distraction force is placed
on the elbow and the space created
between the undersurface of the
acromion and the apex of the humeral
head is noted
• This distance is recorded in centimeters, and
indicates laxity in the joint
Glenohumeral Stability Assessment
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“Load and shift” test: with the humeral head
reduced (“loaded”) into the glenoid fossa, the
examiner steadies the limb girdle with one
hand and translates the humeral head both
anteriorly and posteriorly with the opposite
hand
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The amount of translation is graded as 1+, 2+, or 3+
This test is also repeated in the supine position
Glenohumeral translation depends upon the skill of the
examiner as well as the patient’s ability to relax
Glenohumeral Stability Assessment
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Apprehension test: evaluation of the
patient’s sense of pending anterior
subluxation or dislocation with the arm in
stressed external rotation abduction
• Can be performed sitting or supine, but works
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best with the patient supine
In order for a test to be positive, apprehension
must be present – pain alone does not
indicate a positive test
Glenohumeral Stability Assessment
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Relocation test: following the supine
apprehension test, apply posterior
pressure to the proximal humerus at the
same level of external rotation noted in
the apprehension test
• A positive relocation test is described when
the patient’s apprehension disappears with
the posterior stress
Neurovascular Examination
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Dermatomal sensory examination
Deep tendon reflexes at the wrist and
elbow
Cervical root testing – wrist extension,
finger abduction and adduction, thumb
abduction, elbow flexion
Palpation of the brachial and radial
pulses
Special Tests
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Drop arm test: the patient’s arm is
abducted to 90° and released
• A positive test
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is noted when the patient’s
arm falls down from the position
Indicative of a rotator cuff tear
Special Tests
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Speed’s test: with the shoulder in
forward flexion, elbow extended, and
hand supinated, resistance is applied
• Pain in the location of the bicipital groove
during resistance is indicative of bicipital
tendonitis
Special Tests
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O’Brien’s test: with the arm adducted
across the midline, elbow extended and
thumb down, the examiner applies
downward pressure; the patient’s thumb
is then turned up, and he again resists
downward pressure
• A positive test is indicative of a labral tear, and
is described when greater pain occurs with
the thumb pointed downward
Special Tests
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Clunk test: while the patient lies supine
the examiner abducts the arm past 90°
with one hand while pressing the
proximal humeral head anteriorly; the
examiner then rotates the shoulder
internally and externally
• A positive test is elicited when the patient
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feels a deep “clunk” in the shoulder
Indicative of a labral tear
Radiographic findings
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X-rays – what to look
for:
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Bony tumors
Fracture lines
Hook to the acromion
Degenerative changes
Dislocation
Radiographic findings
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MRI
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Good for ruling out
bad things
Can be misleading
Must be correlated
with clinical exam –
the radiologist does
not have the benefit of
examining the patient
Conservative treatment
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Physical therapy
• Excellent form of strengthening and
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rehabilitating weak or injured muscles
Formal physical therapy will reassure you that
the exercises are actually being done
The most successful conservative form of
therapy for the musculoskeletal system
Conservative treatment
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Oral anti-inflammatories
• Sometimes just a short course of anti-
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inflammatories can provide permanent relief
Non-selective COX inhibitors still work great if
the patient can tolerate them
COX-2 inhibitors:
• Celebrex 200 mg daily
• Vioxx 25 mg daily
• Bextra 20 mg daily
Conservative treatment
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Cortisone injection (short-acting + local)
• Can be a permanent cure, but is frequently a
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short-term fix
Relief from the injection gives an excellent
prognosis for surgical success
Should only be given every 3 months
If the above fail…
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Refer to orthopedic surgeon
Surgery is a measure of last resort!
“There is no pain so terrible that surgery can’t
make worse.”