Transcript Respiratory Infection, Resistance and Rational Therapy

Shoulder Syndromes
VOMA
September 2011
P. Gunnar Brolinson, DO, FAOASM, FACOFP, FAAFP
Head Team Physician, Virginia Tech
Chief of Sports Medicine
Edward Via Virginia College of Osteopathic Medicine
Director Primary Care Sports Medicine Fellowship
Objectives
• Review anatomy of the shoulder
complex
• Review motions of the shoulder complex
• Describe the functional biomechanical
evaluation of the shoulder
• Understand and be able to perform an
evaluation of shoulder using various
functional and special tests
• Review some common shoulder
problems
Introduction
• Shoulder injury is very
common in the active
patient population.
• It is a complex joint and
presents unique challenges
to diagnosis and subsequent
treatment.
Introduction
• Shoulder Pain is the third most
common MS complaint in
primary care offices
– Second to knee pain for referrals
to ortho/sports medicine
physicians
• Incidence 25/1000 patients
– Peak incidence in 50-70 year
olds
• 8-13% of athletic injuries
involve the shoulder
Introduction
• The shoulder complex is a
loosely constructed highly
mobile complex of bones,
muscles and ligaments.
• It is designed for increased
mobility to the upper
extremity with only sufficient
stability to provide a proper
foundation for muscular
function which is vital for the
performance of sports or
activities of daily living
(ADL)
Introduction
• Effective diagnosis and
treatment of the shoulder
requires a mastering of
the relationship of
structure and function of
this complicated joint.
Anatomy
• It is composed of 3 joints
(sternoclavicular,
acromioclavicular and
glenohumeral) and one
articulation
(scapulothoracic).
• All four work together in a
synchronous rhythm for full
range dynamic motion.
Anatomy…SC Joint
• The sternoclavicular joint (SCJ) enables the
humerus to achieve 180 degrees of Abduction.
• It is a saddle shaped joint made up of the medial
end of the clavicle, the manubrium sternum and
the cartilage of the 1st rib.
• There is an articular disc separating the surfaces
which adds strength to the joint.
SC Joint
Anatomy…AC Joint
• A plane synovial joint that
augments the range of
motion (ROM) in the
humerus.
• It is made up of the
acromiom process of the
scapula and the lateral
edge of the clavicle.
Anatomy…AC Joint
• It is surrounded by a fibrous
capsule and an articular disc
separates the surfaces.
• Primary strength is supplied
by the acromioclavicular and
coracoclavicular ligaments
– trapezoid ligament
– conoid ligaments
AC Joint
AC Joint
• Type I 17%
• Type II 43%
• Type III 40%
• Type III found in up to
80% of RC tears
• Compared with 3% in
Type I
AC Joint/Subacromial Articulation
• Impingement
–
–
–
–
Greater tubercle
Acromion
Coracoacromial ligaments
Supraspinatus tendon
• Between 48-72% of
shoulder pain in PCP office
is subacromial
impingement
Anatomy…GH Joint
• A multi-axial ball and
socket joint surrounded
by a capsule.
• Most of the support is
provided by the rotator
cuff muscles.
Anatomy of GH Joint
• The glenoid labrum is a
ring of fibrocartilage that
surrounds and deepens the
glenoid fossa which
increases the available
contact area by
approximately 70%.
Functional Anatomy…GH Joint
• The relaxed position of the humerus has it placed
in the upper portion of the glenoid cavity.
• Contraction of the rotator cuff muscles pulls the
humerus down into the lower/wider portion of the
glenoid cavity.
• Without the “dropping down”, full Abduction is
impossible.
GH Joint
• Static stabilizers
– Labrum
– Capsule
– Adhesion-cohesion
• Intra-articular pressure
• Dynamic stabilizers
–
–
–
–
–
RC muscles
Deltoid
Long head of biceps
Scapulothoracic muscles
Proprioceptive feedback
GH Joint…Static Restraints
• Labrum
– Ring of fibrocartilage
– Deepens the glenoid fossa
– Increases contact area ~70%
• Ligaments
– Superior Glenohumeral
– Middle Glenohumeral
– Inferior Glenohumeral (important
when shoulder is abducted and
externally rotated)
The Scapulothoracic Articulation
• The scapula serves as a
mobile platform from
which the upper limb
operates.
• It is made up of the body
of the scapula and the
muscles covering the
posterior chest wall.
The Scapulothoracic Articulation
• The GHJ moves 120
degrees as the scapula
swings about 60 degrees
around the chest wall in a
smooth 2:1 ratio.
The Scapulothoracic Articulation
• The articulation allows
the scapula to glide
medially, laterally,
superiorly and inferiorly
and rotate over the
posterolateral chest cage.
• Asymmetry of position
usually indicates
asymmetry of motion.
The Scapulothoracic Articulation
• In any given arm position, the scapula aligns itself
to allow the glenoid cavity to be in the best
position to receive the head of the humerus.
• The apparent simple motion of the scapula is
neurologically complex due to relatively little
“direct” muscle action.
Scapulothoracic Articulation
Extrinsic Muscles of the Shoulder Region
• Deltoid
– Anterior (Flex/IR)
– Mid-portion (ABd)
– Posterior (Ext/ER)
• Pectoralis Major
(ADd/flex/IR)
• Biceps (Flex)
• Triceps (Ext)
• Teres Major (ADd/IR)
• Latissimus dorsi
(Ext/ADd/IR)
Intrinsic Muscles of the Shoulder Region
• Rotator Cuff
•
•
•
•
Supraspinatus (ABd)
Infraspinatus (ER)
Teres Minor (ER)
Subscapularis (IR)
Muscles of the Scapulothoracic Articulation
“Scapular Stabilizers”
• Trapezius
– Superior (Elev)
– Middle (Retract)
– Inferior (Depress)
•
•
•
•
Levator Scapulae (Elev)
Pectoralis Minor (Depress)
Rhomboids (Retract)
Serratus anterior (Protract)
Shoulder Stability
• The shoulder consists of
passive and dynamic
stabilizers.
Static Shoulder Stability
• The static stabilizers are:
–
–
–
–
Glenoid
glenoid labrum
capsule
ligaments
• (superior glenohumeral,
middle glenohumeral and
inferior glenohumeral),
– joint cohesion
– Intra-articular negative
pressure.
Dynamic Shoulder Stability
• The dynamic stabilizers
are the rotator cuff
muscles along with the
long head of the biceps.
• The scapulothoracic
stabilizers are the
rhomboids, trapezius,
serratus anterior, and the
pectoralis minor.
Ultimately Our Goal is Joint Congruence
• Maintenance of the articular
surfaces’ apposition is the
keystone to avoiding injury
• Altered engrams (motor activation
patterns) increases loads on
tissues, resulting in a singular
macrotrauma or repetitive
microtraumas
• More than a tight capsule and
strong rotator cuff…
Shoulder Examination
HISTORY
“Listen to the patient long enough and they will tell you what is
wrong with them”
•
•
•
•
•
•
•
•
Where/when/what/how/why
Specific mechanism of injury (MOI) (if any?)
Chronic vs. acute
What makes symptoms better or worse
Instability/weakness
Pain (0/10)
Crepitation
Radicular symptoms (pain radiation)
Shoulder Examination
HISTORY
• Pain in shoulder coming from rotator cuff or
bursa radiates to lateral deltoid – NOT past
elbow!
• Pain that wakes on rolling over in bed
suggests bursitis
• Pain that wakes from sleep suggests rotator
cuff tear
– 88% sensitive, 20% specific
Shoulder Exam
• Physical exam should be done in the same manner
each time so that nothing is forgotten:
– Inspection
– Palpation
– ROM
• Active and Passive
– Strength and Neurologic Testing
– Regional Osteopathic Structural Examination
– Special Testing
Shoulder Pain Diagram
Shoulder Exam
• Inspect
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Expose the area
Step offs
Deformities
Ecchymosis
Asymmetry
ROM
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•
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Forward flexion 1800
Extension 450
ABduction 1800
ADduction 450
IR 550
ER 40-450
A/PROM tests
•
•
•
•
Apley “scratch” test:
ER and aBduction (C7)
IR and aDduction (T7)
Asymmetry can be indicative
of:
– limited GH adduction
– internal/external rotation
– scapular movement
• Painful arc of motion
– 33% sensitive
– 81% specific
Scapular Dyskinesis
• Functional base for shoulder
• Alterations in the resting position
affects timing and magnitude of:
– Acromial upward rotation
– Excessive movement of the glenoid
– Decrease maximal RC activation
• Often associated with other upper
extremity disorders
Range of Motion
• Asymmetry is the Key!
• Master the feel of normal/abnormal endpoints and
restrictions of motion.
• Extra-articular blockage: rubbery feel and gives
slightly under pressure
• Intra-articular blockage: inflexible and ROM ends
abruptly
Physical Exam
• Neurologic exam
• Muscle & tendon pain worse
with:
– Passive stretch
– Active contraction in a neutral
position
– Palpation
• Ligaments/capsule pain worse
with:
– Passive & active loading,
usually only at the end ROM
– Palpation
Reflex and Sensory Testing
Spurling’s Test
• Puts pressure on
posterolateral complex
(articular pillars, facets, &
neural foramina
• Could be a ligament,
muscle/tendon, disc,
osteoarthritis, nerve root
inflammation (virus, etc.),
or tumor
Lhermitte’s Sign/Test
• the “Barber Chair” phenomenon
• Trauma to cervical spinal cord
• Space occupying lesion (tumor,
disc)
• Multiple sclerosis
• Cervical spondylosis
• Vitamin B12 deficiency
Muscle Testing
• Range of “normal”
muscle strength.
• When testing for strength,
keep in mind that you are
also testing for
neurological function.
Special Testing
• Special testing can be done to add information for
the diagnosis of the problem.
• Structured to uncover a specific type of pathology
or dysfunction.
• Shoulder special testing includes but not limited
to the following….
Specific Special Tests
• Biceps tendonitis
• Impingement
– Yergason’s
– Speed’s
– Hawkins
– Neer’s
• Rotator Cuff
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–
–
–
Empty Can
Full Can
Lift Off/Napolean
Scapular Retraction
• Instability
–
–
–
–
–
Apprehension
Jobe relocation
Anterior Release
Glide/Load and Shift
Sulcus Test
• Cross Arm Adduction
• SLAP lesion
–
–
–
–
–
O’Brien’s
Clunk or Crank
Resisted Supination/ER
Biceps load I and II
Zaslav
• TOS
– Adson’s
– Roos
Biceps Tendonitis
Yergason’s Test
• Patient flexes elbow to 900
• Physician grasps the elbow with
one hand and the wrist with the
other
• The examiner resists as patient
attempts to supinate and flex the
elbow
• The test is positive if pain is
elicited as the biceps tendon or
bicipital groove
Biceps Tendonitis
Speed’s Test
• Patient fully extends the
elbow, flexes the shoulder
and supinates the forearm
• Physician resists further
flexion
• The test is positive when
there is tenderness in the
bicipital groove
Supraspinatus Testing
• Position the arms in a position of 900
ABduction and 300 forward flexion
with the thumbs pointing down
• Apply a downward force as the patient
resists
• The test is positive with weakness or
pain
– 89% sensitive; 68% specific
• “Full Can Test”
– Less impingement
– Minimized infraspinatus
– 86% sensitive; 74% specific
Supraspinatus Test
Scapular Retraction Test
• Scapular dyskinesis may decrease
maximum RC activation
• With arm in empty can test
position, scapula is lightly held in
retraction by forearm pressure on
the medial scapular border while
the patient exerts maximum
resistance
• Strength values increased by 24%
in injured group, and 13% in
control
Subscapularis Test
Gerber Lift Off Test/Napoleon Test
• Internal rotation
• Minimal activation of
pectoralis and latisimus
• Ability to “lift off”
• 62% sensitive
• 100% specific
Infraspinatus Test
• 00 abduction and 450 IR
of humerus
• Minimal activation of
supraspinatus and deltoid
– Contribute more from 00 to
450 ER
GH Instability
• Apprehension Test
– Causes anterior translation (subluxation)
– Sens 40%, Spec 87%
• Jobe Relocation Test
– Posterior pressure on the head alleviates
the discomfort (relocation)
– Sens 56%, Spec 93%
• Anterior Release Test
– Allows for quick anterior
translation/apprehension returns
– Sens 92%, Spec 89%
GH Instability
Glide Test
• This test is performed to
assess of A/P instability
• Compare bilaterally
• The test is positive if
there is excessive
mobility
GH Instability
Load and Shift Test
• Patient lie flat on the back so
that the center of the scapula
is on the edge of the table
• The physician holds the arm
out 900 abduction
• Assess movement in the
shoulder joint in the anterior
and posterior directions
• Grade 0-3
• “Lachman” of the shoulder
0
1
2
3
Inferior GH Instability
Sulcus Test
• Apply traction in an inferior
direction with the arm relaxed
• The test is positive if it causes
inferior subluxation of the
humeral head and widening of
the sulcus between the
humerus and the acromion
• About 25% of patients with
MDI will have sulcus of 2cm
or more
Multidirectional Instability (MDI)
• Usually not difficult to
diagnose
• Laxity in at least the anterior
and posterior planes, inferior
is usually lax as well
• Can be overlaid by another
pathology
• Often a laxity in a joint is the
compensatory result of
restriction elsewhere
• Imaging not usually
necessary or helpful
Multidirectional Instability (MDI)
Treatment considerations
• Neuromuscular retraining
• Maintenance of joint
congruence
• Kinetic chain
• TX Somatic Dysfunction
• Reduction of capsule laxity
– Prolotherapy
– Bankhart or capsular
plication
Impingement Syndrome
• Primary
– Repetitive overhead motion
– Supraspinatus impinges on acromion
– Prominent coracoacromial ligament
• Secondary
– GH laxity and instability of shoulder
– Cephalad migration of humeral head
– Labral lesion possible
• Internal (posterior-superior glenoid)
– Inferior supraspinatus trapped between greater tuberosity and posterior
superior labrum
– Posterior superior synovitis and partial under-surface tears
• Tensile failure
– Often as a result of fatigue and tears with eccentric loading
Impingement Tests
Neer’s Test
• Patient seated, passively IR arm so
that thumb is downward
• Flex the arm while stabilizing
scapula
• The test is positive if discomfort or
pain is elicited
• Impingement of the humerus against
the coracoacromial arch
• 81% sensitive
• 50% specific
Impingement Tests
Hawkins Test
• Tests supraspinatus impingement
against the coracoacromial ligament
• Elevate the patients shoulder to 900,
flex the elbow to 900 and place the
forearm in neutral position
• IR the humerus
• The test is positive when there is
pain or discomfort
• 90% sensitive, 60% specific
Impingement Syndrome
Treatment
• Injection
– Diagnostic
– Therapeutic
– Larger volume
• PT
– Up to 6 mos
– 60-90% resolve
• OMT
AC Joint/Posterior Capsule
Cross Arm Test
• With the patient seated, bring
the arm across the chest as far
as possible
• The test is positive if there is
pain elicited at the AC joint
• By comparison with the
opposite side one can
ascertain the tightness or
laxity of the posterior capsule
Superior Labral Anterior Posterior
Lesions (SLAP)
•
•
•
•
•
Anterior pain
Posterior tightness
Clicking or popping
Dominant arm
Mechanisms
– Eccentric loading of biceps during
throwing
– Fall with compressive load
– Forced Abd/ER
– Excessive traction from weight lifting
– MVA from seatbelt
SLAP - O’Brien’s Test
• Shoulder 900 flexion, 10-200
adduction, thumb pointed
down
• Patient resists downward
pressure
• Rotate to supination and resist
flexion
• Test is positive if pain
alleviated in palm-up position
• Sensitivity 67%
• Specificity 49%
SLAP - Crank Test
• Patient shoulder aBducted to
900
• Axial load placed by examiner
• Humerus then IR
• The test is positive if pain is
noted with or without an
“clunk”, or reproduction of
activity related symptoms
• Sensitivity 59%
• Specificity 82%
SLAP - Resisted Supination ER Test
• Patient is supine with scapula near the
edge
• Examiner supports the limb in 900
aBduction, elbow flexed 60-700, forearm
in neutral
• Patient attempts to supinate, as examiner
resists and then gently externally rotated
to the maximal point
• The test is positive if anterior or deep
pain, clicking, or reproduction of activity
related symptoms
• 83% sensitive, 82% specific
SLAP - Biceps Load Test
• Loads the superior labrum via stress on the biceps tendon
during resisted flexion force
• Positive test is pain or apprehension
• Test I is 900/900 Sens 91%, Spec 97%
• Test II is 1200/900 Sens 90%, Spec 97%
SLAP - Zaslav Test
• Helps to differentiate labral tears from impingement
syndrome
• Positive test denoted by weakness, NOT pain
• Sensitivity 88%, Specificity 96%
Thoracic Outlet Syndrome (TOS)
• Compression of the neurovascular structures at the superior
aperture of the thorax
• Etiology
– Neurologic
• Brachial plexus (95%)
– Vascular
• Subclavian vein (4%)
• Subclavian artery (1%)
• Neurologic - Female-to-male ratio approximately 3.5:1
• Venous - More common in males than in females
• Arterial - No sexual predilection
TOS - Etiology
• Anatomic
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–
–
–
Scalene triangle (most common)
Cervical ribs (more common in arterial)
Congenital fibromuscular bands (up to 80% in neurologic)
Transverse process of C7 is elongated
• Trauma or repetitive activities
– MVA, hyperextension injury, with subsequent fibrosis and scarring
– Effort vein thrombosis (ie, spontaneous thrombosis of the axillary veins following
vigorous arm exertion)
– Playing a musical instrument: maintain the shoulder in abduction or extension for
long periods
• Neurovascular entrapment
– Costoclavicular space between the 1st rib and the head of the clavicle
– C8-T1 (90%)-ulnar n. distribution
TOS - Adson’s Test
• Patency of subclavian artery
• “Classic” maneuver
• Patient’s arm aBducted, extend and
ER
• Patient then takes a deep breath and
holds it while turning the head
towards the side being tested
• Then turn head to the opposite
direction
• Test is positive if diminished or
absent pulse or reproduces
symptoms
TOS - Roos Test
• Patient aBducts the shoulders to 900, ER, and flex the elbows to
900
• Then patient then slowly opens and closes the hands for 3 minutes
• The test is positive if the arm becomes heavy or there are
paresthesia of the hand
• Compression of subclavian artery and vein and the brachial plexus
Diagnostic Work-Up
• Depending on the injury,
there are many diagnostic
tests that can be done to
evaluate an injury:
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•
•
•
X-rays
CT Scan
MRI
CT/MR Arthrograms
• Selective injections
– Using anesthetic and/or
steroids
• Serial exams in office
• Ultrasound
• Dynamic ultrasound
– In office
– US guided injections
Imaging
• X-rays
– AP
– GH dislocation best seen
on axillary views, also on
scapular Y view
Imaging
• X-rays
– Outlet views are obtained
to evaluate impingement
– For instability, West Point
view or the Stryker notch
view are used to better
detect Bankart and Hill
Sachs' lesions
Imaging
• Arthrogram
– Detailed anatomical
information is obtained
when combined with CT or
MRI of the shoulder
– Excellent detail of capsular
attachments and of the
labrum
Thought for the Day…
• “Education is what
you remember after
you have forgotten
what you studied for
the test."
-Emerson