Download Shoulder

Shoulder
Anatomy
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Shoulder motion
o Is increased at the expense of stability
Joint capsule, RC muscles, bursa occupy the subacromial space
o Bursa facilitates motion of RC muscles under acromion
Limited subacromial space is available for structures
History
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OLD CARTS / PQRST
ROS:
o Any other joints pains?
 could lead you to think osteoarthritis or rheumatoid
o Any numbness? Any tingling?
 could lead you to think nerve impingement
o Any rash?
 could lead you to think shingles
o Any swelling?
 could lead you to think trauma
o Any fever or chills?
 could lead you to think septic joint
o Any weight loss?
 could lead you to think bone cancer
PMH:
o Chronic illnesses?
o Congenital abnormalities?
o Medications?
Family hx:
o Arthritis?
o Genetic disorders?
Social hx:
o Employment hazards?
o Exercise?
o Tobacco? Alcohol?
o Nutrition?
Surgical hx:
o Past surgeries on shoulder, etc.?
Shoulder pain patterns
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Helps with differential
Anterior pain
o Biceps tendinitis
Lateral deltoid pain
o Referred
Pain w/clicking
o Labral, bursa
Superior pain
o AC joint/scapula/neck
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Radicular
o Lightning/paresthesia
o Cervical spine or shoulder dislocation
Exam
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General appearance
Inspection
o Patient must be exposed so that both shoulders can be viewed and compared
o Look for asymmetry, muscle atrophy, ecchymosis, swelling
o “Sulcus” sign b/w acromion and humeral head-indicates multidirectional instability
Palpation
o TART (tissue texture changes, asymmetry, restrictions, tenderness)
o Structural lesions in C & upper T spine
o Acute vs chronic pain and/or injury
 Acute
 Edematous, boggy, increased moisture, asymmetry present, restrictions are present,
severe pain with movement
 Chronic
 Decreased edema, ropy skin, fibrotic, asymmetry is present with compensation, little or
no dull, achy pain
o Bony structures
 Humerus, clavicle, scapula
o Muscles
 Deltoid & “SItS”
 Supraspinatus, infraspinatus, teres minor, subscapularis
o Ligaments/joints
 acromioclavicular, sternoclavicular, GH joints, & scapulothoracic articulation
 Note the glenoid, labrum, & bursa
ROM
o GH joint
 Ball & socket joint
 Rotation, translation (gliding), & rolling (combination of rotation and translation)
 Labrum- ring of fibroid cartilage that surrounds & deepens the glenoid fossa
 Increase the surface area by 70%
 Scapula must upwardly rotate to allow overhead activity
 1st 30-45 degrees of humeral abduction is GH w/little motion of scapula
 Then, for every 15 degrees of abduction, there is 10 degrees at GH joint & 5 degrees at
the scapulothoracic joint
o Therefore, ROM ratio GH joint to scapulothoracic is 2:1!
o Normal motion of scapula depends on normal motion of both AC & SC joints
 Mobility at the AC joint allows the scapula to move in 3 dimensions following the curved
contours of the ribcage
o AC joint
 Between the clavicle & the acromion
 Synovial joint
 Has small cartilage plate (meniscus) between acromion & clavicle
 Permits motion in 3 planes:
 AP gliding of acromion during protraction (ext rotation) & retraction (internal rotation)
of scapula
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SC joint
 Between sternum & clavicle
 Synovial joint w/meniscus
 Enables humerus 180 degrees of abduction
 Strong ligaments stabilize the joint:
 Costoclavicular ligaments
 Sternoclavicular ligament
 Motion
 Glides down with overhead
 Glides inward with push-up motion
 Elevation/depression
 Protraction/retraction
 Rotation
o Total motion = 40 degrees during arm elevation
 Motion is reciprocal with AC joint motion
Rotator cuff muscles
 Supraspinatus
 Abducts the humerus
 Infraspinatus
 Externally rotates humerus
 Teres minor
 Externally rotates the humerus
 Subscapularis
 Internally rotates the humerus
 Painful arc sign Patient abducts arm
 70-120 degrees (impingement)
 70-180 degrees (AC joint)
Shoulder girdle
 Deltoid
 Anterior (Flex/IR)
 Mid-portion (ABd)
 Posterior (Ext/ER)
 Pectoralis major
 Add/flex/IR
 Biceps
 Flex
 Triceps
 Ext
 Teres major
 ADd/IR
Measure motion- Compare both sides!
 Forward flexion 180 degrees
 Extension 45 degrees
 Adduction 50 degrees (bringing arm across body, arm is straight)
 Abduction 150 degrees
 External rotation 90 degrees
 Internal rotation 90 degrees
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Active vs passive
 Test active first, passive if there are restrictions
o Apley Scratch Test
 Positive result = loss of ROM (RC/tight capsule problem)
 Internal rotation (measured by vertebral levels) measured on both sides
 Dominant side normally has less ROM and lower by two vertebral levels
Strength
o RC
 Strength is tested on a 0-5 scale- TEST BOTH SIDES
 0- no muscle contraction detected
 1-barely detectable trace of contraction
 2- active movement w/o gravity
 3- active movement against gravity
 4- active movement against gravity & some resistance
 5- active movement against full resistance (NORMAL)
 To test supraspinatus:
 Test done in “scaption”
o The position where the arm is approximately the same plane as the scapula. 45
degrees abduction and 45 degrees to 90 degrees forward flexion
 “Full can” or “empty can”
o Thumb up or “the full can” test moves the greater tuberosity of the humerus
away from the acromion, lessening the contribution of impingement to pain or
weakness during the exam
o The empty can test or “thumbs down” position places the greater tuberosity
closer to the acromion and increases the contribution of impingement to the
test
 Doctor pushes down
 **Positive test when patient has pain or weakness- indicates supraspinatus tendinitis or
muscle or tendon tear
Supraspinatus
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To test infraspinatus & teres minor- external rotation
 Difficult to separately test
 Tests external rotation strength
o Stabilize the arm at the elbow to prevent abduction
o Patient externally rotates, doctor internally rotates
o If pain or weakness, positive test
Examiner
internally
rotates
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To test subscapularis:
 “lift-off” test
o Best test for subscapularis
o Elbow at 90 degrees; patient lifts arm off of waist line against resistance
o Hard for patient with impingement
o Patients “cheat” and use triceps
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Testing against belly
o Close; less precise than “lift-off” test
o Patient holds arm against abdomen
o Resists examiner attempt to externally rotate arm off of abdomen
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Do not forget to examine the proximal & distal joints to the shoulder (c-spine & elbow)
 Shoulder pain may come from neck
 Radiculopathy
 Origin of trap, levator scapulae
 Spurling’s maneuver
 Positive test indicates cervical nerve root disorder
Stability
o Static stabilizers
 Capsule
 Glenoid
 Labrum
 Ligaments (thickening of the capsule aid in restraint)
 Superior glenohumeral
 Middle glenohumeral
 Inferior glenohumerol
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Patient
externally
rotates
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**most important ligamentous stabilizer when shoulder is abducted &
externally rotated
Dynamic stabilizers
 RC muscles & long head of biceps tendon
 Compresses the humeral head into the glenoid
 Scapulothoracic stabilizers:
 Scapular Retractors
o Rhomboids
o Trapezius (middle fibers)
 Scapular Protractors
o Serratus anterior
o Pectoralis minor
 Scapular Rotators
o Trapezius (upper and lower fibers)
o Serratus anterior (lower fibers)
 Abnormal motion:
o Classic “winging”
 long thoracic nerve injury-serratus anterior-anchors scapula to ribcage
 Weakness of rhomboids
 Compensation for posterior instability
 Rib/thoracic somatic dysfunction
To assess Glenohumeral joint instability/dislocation:
 AKA-Apprehension tests-tests are positive when they present an unpleasant sensation of the
shoulder coming out of the joint
 Simple pain from these tests can be from rotator cuff or labrum injury rather than
instability
 Anterior apprehension
 Doctor gives anterior pressure to humerus and externally rotates arm
 Positive=apprehension of patient that shoulder will dislocate indicating anterior
glenohumeral instability
 Posterior apprehension
 (Opposite) apply posterior force to ant shoulder
 Positive= Posterior instability
 Remember the vast majority of shoulder instability is anterior
 Relocation test
 Anterior to posterior pressure is place by the examiners right hand to “relocate”
shoulder – if symptoms are relieved test is positive indicating anterior instability
 Anterior release test
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Special testing
o Neer’s sign
 Doctor fully flexes patient arm in pronation while stabilizing shoulder
 Pain during flexion indicates subacromial impingement or bursitis
o Hawkins’ Test
 Examiner grasps patients elbow w/one hand & their wrist w/the other
 Examiner passively externally rotates the shoulder (impinges the subscapularis m against the
coracoacromial arch) & then passively internally rotates the shoulder (impinges supraspinatus
m, teres minor m, and infraspinatus m)
 Pain suggests impingement of the affected rotator cuff muscles
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AC joint testing
 Crossed arm adduction test
 Arm at 90o FF and elbow at 90o patient grabs opposite shoulder
 Extreme horizontal adduction – this maneuver worsens AC joint pain
 Pain at AC is positive test
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The “Chuck Norris” test
 Patient with arm at 90o FF and elbow at 90o
 Forcefully abducts against examiner
 Pain at AC is positive test
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Drop Arm Test
 Evaluates for possible rotator cuff tear
 Physician passively abducts shoulder then observe the patient slowly lower the arm to the waist
 The arm will drop if the patient has a rotator cuff tear or supraspinatus dysfunction
 The patient may be able to lower to 90 degrees because this action is done by the deltoid but pt
will not be able to continue lowering slowly
o Yergason’s:
 Resistance of supination while palpating the biceps tendon
 Testing for impingement & biceps tendinitis
o Speeds:
 A straight arm resisting shoulder extension
 Testing for impingement & biceps tendinitis
Neurovascular status
ALSO examine the neck/elbow
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Diagnoses
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Bursitis
o Bursa (a fluid filled sac, decreases friction)
 Subacromial bursa- principle bursa of the shoulder
 Positioned between the acromion and the head of the humerus and overlying the
supraspinatus tendon
 Abduction of the shoulder compresses the bursa
 Usually the bursa is not palpable but if injury (bursitis), may be tender below tip of
acromion, pain w/abduction & rotation
 Small subacromion space + bursitis = impingement & pain
 Subacromial space- small area below acromion
 On overhead activity, the Subacromial bursa can become pinched between the greater
tuberosity of the humerus and the acromion.
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Edema and hemorrhage occur and the bursa becomes inflamed i.e. bursitis which
causes impingement and pain
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History
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PE
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Pain in the shoulder, top, posterior or radiating to lateral deltoid area
Worse after overhead activity
Onset after repetitive activity
Cannot fasten bra
Wakes if rolls over on it
No atrophy
Limited active ROM
 Positive arc sign (70-120 degrees)
o Pain made worse by abduction
 Joint is stable
 Positive Hawkins &/or Neer’s
 Neer’s- extreme forward flexion w/arm pronated
o Positive if pain
 Hawkins- examiner exerts internal rotation of humerus w/90 degree of forward flexion
& 90 degrees of elbow flexion
o Positive if test is reproducing pain
Management
 Assessment
 Impingement/Bursitis
 Plan
 RICE (rest, ice, compression, elevation)
 NSAIDs for acute stages
 For severe cases
o Sling
o Steroid injection
 OMT should be directed at the shoulder complex, upper thoracic, and ribs to free up
motion and loosen the fascia of the shoulder to expedite the healing process
 XRs
o Not likely needed in this case
o But consider if direct trauma or suspect fracture
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Supraspinatus tendon tear
o Key Historical Features
o Atrophy
 May be present – Where?
o ROM
 Passive normal
 Active abnormal (?)
o Strength
 Specific RC weakness
o Stability
o Hawkin’s, Neer’s (?)
o PE
 Inspect the visible rotator cuff for signs of disuse – atrophy
 Here there are signs of supraspinatus (Above the scapular spine) atrophy in the supraspinatus
fossa
 There is also obvious atrophy in the infraspinatus fossa
 Findings suggests rotator cuff injury
 Historical findings are related mechanically to what you see
o Assessment
 Rotator Cuff Tear
 (usually traumatic in younger patients, in elderly-a result of chronic impingement)
o Plan
 X-ray – may show decreased subacromial space, osteophytes
 MRI-shows tears
 Rehabilitation, especially in older patients. Surgery in younger patients and/or if completer tear.
 OMT-for minor tears-direct treatment at freeing up restrictions in the glenohumeral area.
Adhesive Capsulitis
o AKA “frozen shoulder”
o Pain and restriction of shoulder motion that increasingly gets worse over the course of one year- a
progressive loss of ROM
o Pain is often present at the end ranges of motion
o Typically caused by prolonged immobility of the shoulder
o Adhesions in joint
o Associated with medical conditions:
 Diabetes, Scleroderma, thyroid, CVA, mastectomy, rheumatoid arthritis, lung ca, tuberculosis,
COPD
o Patients > 40,
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15% of patients bilateral
May follow trauma
Complaints:
 Vague pain in shoulder
 Inability to retrieve wallet or undo bra straps.
Symptoms
 Progressive stiffness
 Pain if rolling over on joint
Treatment
 Main goal is PREVENTION- early mobilization following shoulder injury is essential
 NSAIDS
 Intra-articular injection:
 Lidocaine & steroids
 Manipulation under anesthesia followed by PT
 OMT, especially Spencer techniques, should be directed at improving motion and lysing
adhesions
Osteoarthritis
o PE Generalized osteoarthritis finding in hands
 Shoulder pops with limited ROM
 RC strong but a little muscle wasting is noted
 Joint stable
o Diagnosis
 Can affect any joint
 Not abnormal blood tests
 Result of chronic “wear and tear”
 AKA Degenerative joint disease
 How to diagnosis?
 Exam, x-ray
o Treatment
 Injection, Acetaminophen, PT
 Joint replacement
 OMT- free restrictions, work on getting good ROM and increase strength
Biceps Tendonitis
o Inflammation of tendon and sheath along the long head of the biceps
o Usually due to overuse leading to adhesions that bind the tendon to the bicipital grove
o Symptoms:
 pain over bicipital grove, aggravated by resisted flexion of forearm
o Treatment:
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 rest and ice for acute injury, NSAIDS
 OMT- freeing restrictions in glenohumeral area and myofascial release
Biceps tendon rupture
o Leading to “Popeye” muscle
o Anterior pain but usually a painless “pop”
o 96% involve long-head
o PE Pain at bicipital groove
o Treatment Repair for younger patients, body builders, etc.
 Older patients- patient education & rehabilitation
Spencer Technique
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An articular technique
AKA the Seven Stages of Spencer
A low velocity, direct technique that increases range of motion in a restricted shoulder joint
o The physician engages the restrictive barrier and uses gentle repetitive forces (springing) to increase
ROM
Respiratory cooperation and /or muscle energy activation and frequently added to further stretch tight
myofascial structures that limit articular motion
Purpose:
o Improve motion in the GH joint
Indications:
o Adhesive capsulitis
o Post-op patients
o Elderly patients with shoulder pain
o Shoulder strain
Contraindications:
o Fracture, severe OAA, metastatic cancer
7 Stages of motion are:
o Engage GH extension barrier with elbow flexed
o Engage GH flexion barrier with the elbow flexed
o Circumduction with compression
 Start small circles, then gradually increase size
 Clockwise and counterclockwise
 May also do ME of IR/ER barriers
o Circumduction with traction on straight arm
 Start small circles, then gradually increase size
 Clockwise and counterclockwise
o Engage abduction barrier
o Adduction/IR with elbow flexed
o GH pump with distraction and compression along straight arm
**mnemonic –
o Elephants: Extension
o Fart: Flexion
o Constantly: Circumduction (with Compression)
o To: Traction (with Circumduction)
o Annoy: Abduction
o Intelligent: Internal Rotation
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People: Pumping