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Evaluation of the Painful Shoulder PowerPoint Presentation

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Slide 1-

Evaluation of the Painful Shoulder J. Lindsay Quade, MD Clinical Instructor Internal Medicine/Pediatrics, Sports Medicine University of Michigan Health System
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Objectives To improve physician comfort with obtaining relevant history in the evaluation of the painful shoulder To improve physician comfort with physical examination of the shoulder, including special testing To improve physician comfort with diagnosis and management of common causes of shoulder pain
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The Shoulder Shoulder pain is common in the primary care setting, responsible for 16% of all musculoskeletal complaints. Taking a good history, paying special attention to the age of the patient and location of the pain, can help tailor the physical exam and narrow the diagnosis. Knowledge of common shoulder disorders is important as they can often be treated with conservative measures and without referral to a subspecialist.
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Shoulder Anatomy
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Shoulder Anatomy
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Shoulder Anatomy
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Shoulder Anatomy
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MSK Shoulder Pain Differential Articular Causes Glenohumeral (GH) and acromoclavicular (AC) arthritis Ligamentous and labral lesions GH and AC joint instability Osseus: fracture, osteonecrosis, neoplasm, infection Periarticular Causes Chronic impingement and rotator cuff tendinitis Bicep tendinitis Rotator cuff and long biceps tendon tears Subacromial bursitis Adhesive capsulitis
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Taking Your History Age Hand dominance Occupation Sports/physical activities Trauma Onset Location Character Duration Radiation Aggravating/relieving factors Night pain Effect on shoulder function Stiffness/restriction of movement Grinding or clicking Weakness Numbness/tingling Pain
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The Physical Exam Inspection Asymmetry Bony deformity or abnormal contour Muscle atrophy or bulge Scapular winging
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The Physical Exam Range of Motion Active Passive Apley’s “scratch” test Scapular movement Strength Testing
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The Rotator Cuff Muscles Supraspinatus Abduction Infraspinatus External rotation Subscapularis Internal rotation Teres minor External rotation
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The Physical Exam Palpation AC, SC, and GH joints Biceps tendon Coracoid process Acromion Scapula
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Special Tests Rotator Cuff “Drop-arm” “Empty can,” push-off, and resistance testing Impingement Neer’s Hawkins
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Special Tests Biceps Speed’s Yergason’s AC Joint Cross-arm
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Special Tests Shoulder Instability Sulcus sign Apprehension, relocation, release Load and shift
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Special Tests Labrum O’Brien’s Crank test SLAPprehension
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Specific Examples Rotator Cuff Pathology “Frozen Shoulder” Shoulder Instability AC Joint Separation Arthritis Labral Tear “SICK Scapula” Main points: Presenting symptoms PE findings Diagnosis Conservative treatment or refer?
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Rotator Cuff Pathology Presentation & symptoms: PAIN +/- weakness Age?  trauma vs chronic Physical exam findings: Pain with ROM & resistance testing (+empty can, +push-off) + drop arm if full-thickness tear + Neer’s and Hawkins if impingement
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Rotator Cuff Pathology Diagnosis: Xray – often negative Ultrasound Consider MRI if planning for surgery Management: Tendinopathy or impingement – conservative treatment, PT, subacromial GC injection Partial-thickness tear – PT (up to 12 weeks), possibly subacromial GC injection Full-thickness tear – Ortho referral
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“Frozen Shoulder” (Adhesive Capsulitis) Presentation & symptoms: Pain, often >3 months Progressive loss of ROM Age >40yo Risk factors: immobility, DM, hypothyroidism Physical exam findings: Limited active ROM, external rotation often 50% normal Endpoint with passive ROM
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“Frozen Shoulder” (Adhesive Capsulitis) Diagnosis: CLINICAL! Xray if need to rule-out fracture or OA US later if concerned for RC pathology Management: Set expectations Pain control, gentle ROM exercises/PT If severe, intra-articular GC injection under fluoroscopy
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Shoulder (GH) Instability Presentation & symptoms: Pain Instability Age < 40yo Transient neurologic symptoms History of dislocation or subluxation Physical exam findings: + sulcus + apprehension & relocation + load & shift testing
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Shoulder (GH) Instability Diagnosis: Clinical Xrays often normal MR arthrogram if no improvement Management: Activity modification PT focused on aggressive strengthening Refer to Ortho if no improvement with PT or if recurrent dislocation
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Acute Shoulder Dislocation Physical Exam: External rotation & abduction, palpable humeral head Check innervation of skin over lateral deltoid! (Axillary nerve) Diagnosis: Clinical Xray Management: Relocate & immobilize ROM exercises within 7-10 days  aggressive rehab program
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AC Joint Separation Presentation & symptoms: Direct blow to shoulder or FOOSH Male contact sport athlete, ~20yo Pain/swelling Physical exam findings: Pain and swelling over AC joint “Stepped” deformity if more severe + cross-arm test + painful arc
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AC Joint Separation Diagnosis: Clinical + Xray Management: Types I-III: Non-operative (rest, ice, analgesics, sling for immobilization, PT) Types IV+: Ortho referral for surgery
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Shoulder Arthritis Presentation & symptoms: Age >50 Progressive pain with activity Decreased ROM Impingement symptoms History of rotator cuff injury, previous trauma, or shoulder surgery Physical exam findings: AC joint: tenderness over AC joint, pain at extreme internal rotation, + cross-arm test GH joint: decreased ROM, pain and crepitus at extremes of motion
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Shoulder Arthritis Diagnosis: Clinical + Xray Management: AC joint: Activity modification, NSAIDs, GC injection GH joint: Goal = maintain function with adequate pain control PT, glucosamine & chondroitin, intra-articular GC injection Referral to Ortho if conservative treatment fails
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Labral Tear Presentation & Symptoms: Pain +/- instability Clicking/popping Overhead athlete, history of dislocation, history of trauma Physical Exam: Pain with passive external rotation Pain with palpation of bicipital groove + Apprehension/relocation, O’Brien’s, SLAPprehension, crank tests Can also have + biceps testing
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Labral Tear Diagnosis: Xrays usually normal but may show Hills-Sach lesion MRI or MR arthrogram Management: Conservative: rest, NSAIDs  PT Operative: Ortho referral If conservative measures fail, larger tears, concomitant RC tear
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“SICK Scapula” Presentation & Symptoms: Pain Repetitive overhead activity Drooping shoulder on dominant side Physical Exam: Scapular malposition Inferior medial border prominence Coracoid pain and malposition Kinesis abnormalities of scapula
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“SICK Scapula” Diagnosis: Clinical Management: Physical Therapy & kinetic-chain based rehabilitation Pain free ROM  Strengthening Proprioception exercises
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Take-Home Points Shoulder pain is common Taking a good history can help narrow both your differential and your physical exam Having a good grasp of shoulder anatomy is necessary for interpreting physical exam findings Develop your own shoulder exam approach and follow it consistently Aim to know at least one special test for each category of shoulder pain
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Take-Home Points Rotator cuff pathology can often be diagnosed with US Frozen shoulder is a clinical diagnosis To be diagnosed with arthritis, there should be pain on exam and an abnormal xray If you are concerned about a labral tear, consider referral +/- an MR arthrogram Most chronic shoulder pain can be treated conservatively If patient is not improving clinically, refer to Sports Medicine
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YouTube! “Complete Musculoskeletal Exam of the Shoulder” by University of Michigan Family Medicine
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Questions?
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References Beuerlein MJS, McKee MD, Fam, AG. (2010). The shoulder. In Lawry GV (2nd.), Fam’s musculoskeletal examination and joint injection techniques, (pp. 7-19). Philadelphia: Mosby. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008 Feb 15; 77 (4): 453-60. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part II. Treatment. Am Fam Physician. 2008 Feb 15; 77 (4): 493-7. Dodson CC, Altchek DW. SLAP lesions: an update on recognition and treatment. J Orthop Sports Phys Ther. 2009 Feb; 39 (2): 71-80. Edmonds EW, Denerink DD. Common conditions in the overhead athlete. Am Fam Physician. 2014 Apr 1; 89 (7): 537-41. Ewald, A. Adhesive capsulitis: a review. Am Fam Physician. 2011 Feb 15; 83 (4): 417-22. O’Connor, F, et al. (2013). ACSM’s Sports Medicine: A comprehensive review. Musculoskeletal injuries in the tennis player, (pp. 717). Philadelphia: Lippincott. Woodward TW, Best TM. The painful shoulder: part I. Clinical evaluation. Am Fam Physician. 2000 May 15; 61 (10): 3079-88. Woodward TW, Best TM. The painful shoulder: part II. Acute and chr onic disorders. Am Fam Physician. 2000 Jun 1; 61 (11): 3291-300.
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Photo References 1. Slide 4: http://www.chiro.org/LINKS/Shoulder.shtml 2. Slide 5: http://www.physiodc.com/shoulder-pain-with-yoga-adjust-your-downward-dog/ 3. Slide 6: http://www.njorthoclinic.com/need-biceps-tenodesis-labrum-tear/ 4. Slide 7: https://acewebcontent.azureedge.net/blogs/blog-examprep-091313-2.jpg 5. Slide 10: http://www.pic2fly.com/Biceps+Popeye+Deformity.html ; http://www.wheelessonline.com/userfiles/2010-07-19%2015_44_46.jpg 6. Slide 11: https://www.studyblue.com/notes/note/n/scapula--deltoid-regions/deck/3234274 (large picture); http://www.masmusculo.com.es/workout/el-apleys-scratch-test/ ; https://acewebcontent.azureedge.net/blogs/blog-examprep-091313.jpg (scapula pic) 7. Slide 12: http://jimmysmithtraining.com/six-pack-diet/good-hurt-bad-hurt (left); http://createperformance.blogspot.com/2012/09/thanks-to-g.html 8. Slide 13: http://www.physiodc.com/shoulder-pain-with-yoga-adjust-your-downward-dog/ 9. Slide 14: http://meded.ucsd.edu/clinicalmed/joints2.htm (top picture); http://chrisjohnsonpt.com/are-you-taking-your-shirt-off-properly-2/
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Photo References 10. Slide 15: http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=52373 (left picture); http://openi.nlm.nih.gov/detailedresult.php?img=2684214_12178_2008_9024_Fig4_HTML&req=4 11. Slide 16: http://www.arthritisresearch.us/rheumatoid-arthritis/the-shoulder.html (cartoon); https://www.youtube.com/watch?v=0_Y8twcQ9Ho 12. Slide 17: http://ameblo.jp/g-money0229/entry-11512342937.html (cartoon); https://www.youtube.com/watch?v=3G6mb1QQ90I 13. Slide 20: http://radiopaedia.org/images/1983198 14. Slide 21: http://www.myerssportsmedicine.com/frozen-shoulder/ 15. Slide 23: http://shawchiroandsport.com/shoulder-joint-increased-mobility-means-increased-risk-injury/hypermobile-shoulders 16. Slide 25: http://www.physiownc.com/shoulder-pain/ 17. Slide 26: https://www.studyblue.com/notes/note/n/unit-17-exam-2/deck/6899151 18. Slide 27: http://quoteimg.com/ac-joint-separation-classification/
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Photo References 19. Slide 28: http://grutter.us/ShoulderArm/AC%20arthritis.html 20. Slide 29: http://www.orthoinfo.org/topic.cfm?topic=A00222 21. Slide 30: http://josephhechtmd.com/slap-legion-surgery/ 22. Slide 31: http://www.appliedradiology.com/articles/mr-arthrography 23. Slide 32: http://www.sportsandortho.com/UserFiles/sick2.png 24. Slide 33: https://acewebcontent.azureedge.net/blogs/blog-examprep-091313-2.jpg 25. Slide 37: http://galleryhip.com/michigan-football-logo-go-blue.html All photos obtained through Yahoo! or Google image search