Download Common Problems of the Shoulder - UCSF

Common Problems of the
Shoulder
Part One
Age >40
First, a little Anatomy
Shoulder Girdle Muscles
Shoulder Pain
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Rule out Extrinsic Sources
Referred
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Abdomen: subdiaphragmatic
Pulmonary disease: Pancoast tumor
Radicular
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Cervical Spine
Cervicogenic Pain
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Spondylosis: “degeneration”
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Ache into shoulders
Pain reproduced with ROM
Radiculopathy (weakness)
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C 4-5: 5 root, pain to shoulder, (deltoid)
C 5-6: 6 root, lat forearm, thumb (biceps, ECRL)
C 6-7: 7 root, middle finger (triceps)
C 7-8: 8 root, small finger (finger flexion)
C8-T1: T1 root, medial arm (finger abduction)
Common Diagnoses
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Impingement
Rotator cuff tear
AC joint disease
Frozen shoulder
Rare: Glenohumeral arthritis,
contusion, infection.
Shoulder Pain
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Symptoms:
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Pain overhead
Pain and weakness
Pain with anything
Duration of symptoms
Duration of Symptoms
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If pain is acute (<12weeks), you can
cure the patient with activity
modification (no activity with elbow
away from side), once a day stretch
fully overhead, ice, and +/- NSAID or
narcotic.
Pain > 12weeks is harder.
Pain > 6 months will need a miracle.
Impingement
The most common diagnosis
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Friction
Overuse--rare to get it in the history
Bursitis-->Tendinitis-->Rotator Cuff
Tear
Impingement
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Bursitis= pain but not when testing cuff
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Tendinitis=hurts when cuff muscles are
tested
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Rotator cuff tear=weakness, frequently
without pain
Impingement/Bursitis
Pain with overhead activity
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Pain felt at lateral shoulder
Pain at night
Can also be coming from the AC joint
EXAM: Impingement Sign vs AC joint
tenderness and Cross Arm Adduction
Test
Tests
Impingement Sign
Tests
Cross Arm Adduction
(pain must be at AC joint, not posterior capsule)
AC Joint
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Tenderness directly over joint.
Pain increased with adduction,
overhead activity
Treat like arthritis anywhere else.
Injections are frequently helpful
diagnostically and therapeutically.
AC Joint Arthritis
Impingement Treatment
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Activity modification: no activity with
elbow away from side, in the gym, or
at the computer.
Once a day stretch fully overhead.
NSAID and Ice
Injection in 3-6 wks prn.
Physical Therapy: After pain subsides:
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Regain ROM, strengthen rotator cuff
Keeping shoulder healthy
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Once pain subsides, start rotator cuff
strengthening.
Continue cuff program at the gym and
at home.
BOTH shoulders.
Pain and Weakness
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Does this mean a Rotator Cuff Tear?
Can’t assess rotator cuff when there is
pain
Treat pain first: NSAID, PT, ice, rest-4
wks
Cortisone shot (once) if above doesn’t
work
Test cuff when pain subsides.
Refer after 6 weeks of treatment, not
Rotator Cuff Tests
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Best single test is External Rotation
Strength (Infraspinatus and Teres
Minor).
Can get extra credit testing
Supraspinatus
Advanced placement if massive tear
picked up testing Subscapularis (hand
push off test with hand dorsum resting
on low back)
Tests
Rotator Cuff
External Rotation
Tests
Rotator Cuff
Supraspinatus
Rotator Cuff Treatment
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Cuff tear is rare in age<50.
Autopsy and MRI studies show most
males over have RC tear and never
had symptoms
Beware of the Repeat Injectee who
has weakness.
Surgery decision is based on pain
Biceps Tendon Rupture
Proximal
Special Case: Rupture of long
head of Biceps
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Usually occurs without much trauma
Rupture of attrition (like a rope rubbing
over a rock), remember long (lateral)
head is intra-articular and part of the
cuff.
Problem is the shoulder, not the
tendon
Some supination power lost, not elbow
flexion
Pain with Anything
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Usually severe symptoms, not acute
Motion usually very restricted, passive
and active (really can’t examine
patient)
Frozen vs. “freezing” shoulder
PT, PT, PT (pain isn’t harmful)
Lots of support needed, injection might
help.
Frozen Shoulder
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Not an “-itis”, more like Dupuytrens
contracture in the hand.
DDx: Shoulder joint infection (GH
joint), Shoulder joint arthritis (DX with
XR)
Best Dx test: no passive external
rotation.
Frozen shoulder vs. Arthritis
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Age
XR:
Shoulder Infection
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Red, angry looking shoulder=septic
arthritis of AC joint, not glenohumeral
joint.
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Aspirate point of maximal angriness
(over superior AC joint), get labs, xray,
and refer
Glenohumeral Joint Infection
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Very rare
Increased incidence in diabetics,
immuno-compromised patients.
Shoulder looks normal, just bigger.
SEVERE pain. Any motion hurts.
Often a fever. Get labs (CBC, blood
cultures, ESR, CRP), XR, then:
Get a consult.
Who needs an Xray?
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1st visit, routine Hx/PE: No
No improvement after Tx: Yes
Odd Hx or PE, h/o fracture or injury:
Yes
Pre-referral: Yes
Recommended XR: AP/outlet views
Shoulder Xrays
What about a MRI?
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If it will change what you do, order it.
False positives
Helpful if cervical spine is bemuddling.
Some orthopedists like it prior to
referral; doesn’t hurt to check for local
customs.
Shoulder MRI