Download Common shoulder problems

COMMON SHOULDER
PROBLEMS
Kevin deWeber, MD, FAAFP, FACSM
Director, Sports Medicine Fellowship
USUHS
Objectives

Review anatomy
– Makes for better diagnoses
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Discuss common shoulder problems
Describe current treatments
Anatomy
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Scapula
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Glenoid
Acromion
Coracoid
Subscapular fossa
Scapular spine
Supraspinous fossa
Infraspinous fossa
Anatomy
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Bursae
– Subacromial
(Subdeltoid)
– Subscapular
Joints of the Shoulder
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Acromioclavicular
Glenohumeral
Sternoclavicular
Scapulothoracic
– Not a “true” joint
Movement control
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Flexion: Pectoralis Major, Deltoid (Anterior),
Coracobrachialis
Extension: Deltoid (Posterior), Teres Major
Abduction: Deltoid, Supraspinatus
Adduction: Pectoralis Major, Latissimus,
Subscapularis, Infrapspinatus, Teres Minor
Internal Rotation: Subscapularis, Pectoralis Major,
Deltoid (A), Latissimus
External Rotation: Infraspinatus, Teres Minor,
Deltoid
Shoulder: Physical Exam
Inspection
 Palpation
 Range of Motion
 Strength
 Neuro-Vascular
 Special Tests
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Range of Motion
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Forward flexion:
160 - 180°
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Extension: 40 - 60°
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Abduction: 180◦
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Adduction: 45 °
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External rotation:
80 - 90 °
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Internal rotation:
60 - 90 °
Strength Testing
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Rotator Cuff Muscles
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S – Supraspinatus
I – Infraspinatus
t - Teres minor
S- Supscapularis
Abduction: Supra
IR: subscap
ER: infra, TM
Other muscles
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Deltoid
Biceps
Pecs
Scapular stabilizers
Anatomy
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Muscles
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Deltoid
Trapezius *
Rhomboids *
Levator scapulae *
Rotator cuff
Teres major
Biceps
Pectoralis muscles *
Serratus anterior *
* Scapular stabilizers
Radiographic Anatomy
Common Shoulder
Problems
•Instability
•Impingement
•Rotator
cuff tears
•AC joint sprains and degeneration
•Adhesive capsulitis
•Labral tears
•Biceps tendinopathy
•Clavicle fractures
Glenohumeral Instability
– DEFINITION: painful feeling of slippage, looseness,
“going in and out”
Instability Eval: “FEDS”
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Frequency
– 1-times
– 2-5
– “frequent” >5
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Etiology: Traumatic vs. Atraumatic
Direction (predominant)
– anterior
– posterior
– inferior
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Severity: Dislocation vs. Subluxation
Anterior Instability
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Dislocation: impact to
externally rotated,
abducted arm
Acute findings:
prominent acromion,
anterior fullness
Special Tests:
Apprehension,
Relocation
Anterior Dislocation
Injuries
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Bankart Lesion
– Anterior capsule torn
– Anteroinferior labrum torn
– Recurrent dislocations likely
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Hill-Sachs Lesion
– Humeral compression
fracture
Posterior Instability
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Dislocations:
Electrocutions, Seizures
Acute findings: internal
rotation, adduction
Special tests:
– Posterior drawer
– Load-shift
Inferior Instability
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Usually atraumatic
Special tests:
– Sulcus sign
Instability Imaging
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4-view
Radiographs:
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AP
Axillary
scapular “Y”
AC joint
MRI
Anterior Dislocation
Posterior
Dislocation
Anterior Dislocation
Reduction
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Attempt ASAP
Intra-articular
Lidocaine HELPS!
Use 2-3 techniques
until successful
Failure: to ER
– sedation
Anterior Dislocation
Treatment
– Referral to Ortho &
PhTh
Surgery for
younger/athletic patients
 Rehabilitation for others
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– Immobilization
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Sling
Impingement
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Definition: compression of
the rotator cuff in the
subacromial space
Symptoms:
– Pain with Overhead position or
flexion/Internal Rotation
– Anterior, lateral shoulder pain
– Night Pain
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Risk Factors:
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Overhead activities
Micotrauma
GH Instability
Shape of Acromion
DJD
Impingement
Impingement screening
tests
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Neer: full Flexion
– “Neer to the Ear”
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Hawkins: Internal
Rotation
Impingement
confirmatory test
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Full Can Test:
Resistance applied
in forward flexion
and abduction
(SCAPULAR PLANE)
Neer test: Subacromial
Injection relieves pain
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5cc 1% lidocaine
25-27g needle
Postero-laterally
Wait 10 minutes for
result
>50% pain
reduction confirms
Impingement
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Imaging not initially needed
– 4-view shoulder series
– MRI if considering surgery
Failed rehab
 Pain with ADLs
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Impingement Treatment
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Acute Phase:
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Avoid Exacerbating Factors
Control Pain/Inflammation
Physical Therapy
Corticosteroid Injection
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Recovery Phase: ROM,
Strength, Proprioception
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Maintenance Phase:
Longer, Intense Workouts
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Surgical Intervention: Failed
Conservative Measures,
Signifcant Disability
Rotator Cuff Tears
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Similar presentation as
Impingement
Failed rehab for
impingement
Persistent
pain/weakness after
Neer injection test
Imaging: x-rays, MRI
Rotator Cuff Tear Exam
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Supraspinatus:
– drop-arm test
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Infraspinatus or
Teres Minor
– External rotation lag
sign
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Subscapularis
– Belly press test
Rotator Cuff Tears
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Treatment
– Conservative: Similar to Impingement
– Surgical:
Young patient, large tears, dominant arm
 Failed Conservative Therapy
 High-Level Athlete
 Unable to perform vocational activities
 Success depends upon degree of tendon
damage and degeneration
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Ultrasound of RC tear
Prolotherapy for RCTs
– 25% Dextrose
– Platelet-Rich Plasma (PRP)
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Concentration of platelets and their
growth factors
Process: (30 minutes)
– 20-60cc blood is drawn, then centrifuged to
produce 3-6ml of PRP
– Ultrasound-guided injection
AC Joint Sprain
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Mechanism: Fall on
shoulder
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Presentation: superior
shoulder pain
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Exam:
– AC jt TTP
– +/- deformity or
swelling
– Cross-chest (“scarf”)
test
AC Joint Sprain
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Cross Chest (“scarf”)
Test
Active Compression
(“AC) test
AC Joint Sprain
AC Joint Sprain
AC Joint Sprain
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Imaging
– Bilateral AP
– Zanca View
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10-15 degrees of
cephalic tilt
– Axillary View
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Evaluates clavicular
displacement
AC Joint Sprain:
Treatment
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Grade I and II: Conservative
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Grade III: Controversial; refer to Ortho for counseling
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Immobilization
Ice, Analgesics
ROM, Strengthening
Anesthetic injection if rapid RTP needed
Immobilization for up to 4 weeks
Most studies indicate conservative treatment is better
Surgical management with higher rate of complications1
Conservative management with mean time of 2.1 weeks to
return to work2
Grade IV-VI: Surgical
1.
Taft TN, et al. Dislocation of the acromioclavicular joint. An end-result study. J Bone Joint Surg Am 1987
2.
Sep;69(7):1045-51.
Auwojtys EM; Nelson G. Conservative treatment of Grade III acromioclavicular dislocations. SOClin Orthop Relat
Res. 1991 Jul;(268):112-9.
AC Joint Arthritis
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Chronic pain at AC joint
Exam: ACJ ttp, + scarf test, + active
compression test
X-rays: narrowed AC jt, +/- osteophytes
Tx:
– Avoid painful activities
– Steroid injections
– Surgical removal of distal clavicle (Mumford)
Adhesive Capsulitis
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Painful restriction of
active and passive GH
ROM
Risk Factors
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Idiopathic
Diabetes Mellitus
Female Gender
Ages 40-60
Immobilization
Inflammation
Stroke
Adhesive Capsulitis
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Stage I
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– 1-3 months
– Pain with normal ROM
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Stage II: “Freezing”
– 3-9 months
– Pain and progressive
ROM restriction
Stage III: “Frozen”
– 9-15 months
– Severe ROM restriction
with decreased pain
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Stage IV: “Thawing”
– 15-24 months
– Progressive restoration
of ROM
Adhesive Capsulitis:
Treatment
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Anti-Inflammatories
ROM, Stretching
Steroid injection
into subacromial
space or GH jt
Surgical
– Dilatation
– Manipulation
Labral Tears
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Causes: Traction Injuries,
FOOSH, Overhead motion
overuse, MVA Trauma
Locations:
– Superior Labral AnteriorPosterior (SLAP) tear
– Posterior
– Anterior (from dislocation)
Labral Tears
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History:
– Pain with overhead or
cross-body activity
– Popping, clicking,
catching
– 85% incidence of
coexisting pathology
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Physical (none
diagnostic):
– Crank Test
– Anterior Slide Test
– Yegason Test
SLAP Tears
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Type 1: Fraying Injury
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Type 2: Biceps tendon
detached
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Type 3: “Buckethandle” tear
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Type 4: “Buckethandle” with Biceps
detached
Labral Tears
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Diagnostic: Radiograph, MR arthrogram
Treatment:
– Physical Therapy for > 3 months
– Usually don’t heal. Aim for PAIN CONTROL
– Surgery:
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Types I and III: Debridement
Types II and IV: Debridement and Reattachment
– Post-Op Rehabilitation
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Immobilize for 3 weeks
Progress with AROM
Return to full activity after 12-14 weeks
Biceps Tendinopathy
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Rarely seen in isolation
– Labral tears
– Rotator cuff tears
– Impingement
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Exam findings non-specific
Biceps Tendinopathy
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Speed’s Test:
Resistance against
Shoulder Flexion
Yergason’s Test:
Resistance against
Supination
Biceps Tendinopathy
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Treatment:
– Rehab exercise
– Sports Medicine referral if
fails
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Prolotherapy injection
– Refractory: MRI, surgery
Clavicle Fractures
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Clinical Features
– Clear Painful event
– Pain with arm motion
– Lump and possible
tenting of the skin
Clavicle Fractures
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Diagnosis
– History & physical
– X-ray – AP & axillary views, AP
with 45° tilt
– CT for proximal & distal
clavicle fractures
Clavicle Fractures
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Surgery indications:
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Open fracture
Neurovascular compromise
Displacement > shaft width
Healed clavicle lump not
desirable
– Floating shoulder
(concurrent scapular neck
fracture)
Clavicle Fractures
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Conservative tx:
– Rest
– Immobilization
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sling proven BETTER than fig-8
Pain control, NO NSAIDs
No overhead activity for 4-6 wks
F/U 2-4 wks; x-rays for healing
PhTh referral for rehab
Surgery if fails
Questions?