Transcript Common shoulder problems
COMMON SHOULDER PROBLEMS
Kevin deWeber, MD, FAAFP, FACSM Director, Sports Medicine Fellowship USUHS
Objectives
Review anatomy – Makes for better diagnoses Discuss common shoulder problems Describe current treatments
Anatomy
Scapula – Glenoid – Acromion – Coracoid – Subscapular fossa – Scapular spine – Supraspinous fossa – Infraspinous fossa
Anatomy
Bursae – Subacromial (Subdeltoid) – Subscapular
Joints of the Shoulder
Acromioclavicular Glenohumeral Sternoclavicular Scapulothoracic – Not a “true” joint
Movement control
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
Range of Motion
Forward flexion: 160 - 180 ° Extension: 40 - 60 ° Abduction: 180 ◦ Adduction: 45 ° External rotation: 80 - 90 ° Internal rotation: 60 - 90 °
Strength Testing
Rotator Cuff Muscles – S – Supraspinatus – I – Infraspinatus – t - Teres minor – S - Supscapularis – Abduction: Supra – IR: subscap – ER: infra, TM Other muscles – Deltoid – Biceps – Pecs – Scapular stabilizers
Anatomy
Muscles – 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”
Frequency – 1-times – 2-5 – “frequent” >5 Etiology : Traumatic vs. Atraumatic Direction – anterior – posterior – inferior (predominant) Severity : Dislocation vs. Subluxation
Anterior Instability
Dislocation: impact to externally rotated, abducted arm Acute findings: prominent acromion, anterior fullness Special Tests: Apprehension, Relocation
Anterior Dislocation Injuries
Bankart Lesion – Anterior capsule torn – Anteroinferior labrum torn – Recurrent dislocations likely Hill-Sachs Lesion – Humeral compression fracture
Posterior Instability
Dislocations: Electrocutions, Seizures Acute findings: internal rotation, adduction Special tests: – Posterior drawer – Load-shift
Inferior Instability
Usually atraumatic Special tests: – Sulcus sign
Instability Imaging
4-view Radiographs: – AP – Axillary – scapular “Y” – AC joint MRI
Anterior Dislocation
Posterior Dislocation
Anterior Dislocation Reduction
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 – Immobilization Sling
Impingement
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 Risk Factors: – Overhead activities – Micotrauma – GH Instability – Shape of Acromion – DJD
Impingement
Impingement screening tests
Neer: full Flexion – “Neer to the Ear” Hawkins: Internal Rotation
Impingement confirmatory test
Full Can Test: Resistance applied in forward flexion and abduction (SCAPULAR PLANE)
Neer test: Subacromial Injection relieves pain
5cc 1% lidocaine 25-27g needle Postero-laterally Wait 10 minutes for result >50% pain reduction confirms
Impingement
Imaging not initially needed – 4-view shoulder series – MRI if considering surgery Failed rehab Pain with ADLs
Impingement Treatment
Acute Phase: – Avoid Exacerbating Factors – Control Pain/Inflammation – Physical Therapy – Corticosteroid Injection Recovery Phase: ROM, Strength, Proprioception Maintenance Phase: Longer, Intense Workouts Surgical Intervention: Failed Conservative Measures, Signifcant Disability
Rotator Cuff Tears
Similar presentation as Impingement Failed rehab for impingement Persistent pain/weakness after Neer injection test Imaging: x-rays, MRI
Rotator Cuff Tear Exam
Supraspinatus: – drop-arm test Infraspinatus or Teres Minor – External rotation lag sign Subscapularis – Belly press test
Rotator Cuff Tears
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
Ultrasound of RC tear
Prolotherapy for RCTs
– 25% Dextrose – Platelet-Rich Plasma (PRP) 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
Mechanism: Fall on shoulder Presentation: superior shoulder pain Exam: – AC jt TTP – +/- deformity or swelling – Cross-chest (“scarf”) test
AC Joint Sprain
Cross Chest (“scarf”) Test Active Compression (“AC) test
AC Joint Sprain
AC Joint Sprain
AC Joint Sprain
Imaging – Bilateral AP – Zanca View 10-15 degrees of cephalic tilt – Axillary View Evaluates clavicular displacement
AC Joint Sprain: Treatment
Grade I and II: Conservative – Immobilization – Ice, Analgesics – ROM, Strengthening – Anesthetic injection if rapid RTP needed Grade III: Controversial; refer to Ortho for counseling – Immobilization for up to 4 weeks – Most studies indicate conservative treatment is better – Surgical management with higher rate of complications return to work 2 1 – Conservative management with mean time of 2.1 weeks to Grade IV-VI: Surgical 1.
2.
Taft TN, et al. Dislocation of the acromioclavicular joint. An end-result study. J Bone Joint Surg Am 1987 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
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
Painful restriction of active and passive GH ROM Risk Factors – Idiopathic – Diabetes Mellitus – Female Gender – Ages 40-60 – Immobilization – Inflammation – Stroke
Adhesive Capsulitis
Stage I – 1-3 months – Pain with normal ROM Stage II: “Freezing” – 3-9 months – Pain and progressive ROM restriction Stage III: “Frozen” – 9-15 months – Severe ROM restriction with decreased pain Stage IV: “Thawing” – 15-24 months – Progressive restoration of ROM
Adhesive Capsulitis: Treatment
Anti-Inflammatories ROM, Stretching Steroid injection into subacromial space or GH jt Surgical – Dilatation – Manipulation
Labral Tears
Causes: Traction Injuries, FOOSH, Overhead motion overuse, MVA Trauma Locations: – Superior Labral Anterior Posterior (SLAP) tear – Posterior – Anterior (from dislocation)
Labral Tears
History: – Pain with overhead or cross-body activity – Popping, clicking, catching – 85% incidence of coexisting pathology Physical (none diagnostic): – Crank Test – Anterior Slide Test – Yegason Test
SLAP Tears
Type 1: Fraying Injury Type 2: Biceps tendon detached Type 3: “Bucket handle” tear Type 4: “Bucket handle” with Biceps detached
Labral Tears
Diagnostic: Radiograph, MR arthrogram Treatment: – Physical Therapy for > 3 months – Usually don’t heal. Aim for PAIN CONTROL – Surgery: Types I and III: Debridement Types II and IV: Debridement and Reattachment – Post-Op Rehabilitation Immobilize for 3 weeks Progress with AROM Return to full activity after 12-14 weeks
Biceps Tendinopathy
Rarely seen in isolation – Labral tears – Rotator cuff tears – Impingement Exam findings non-specific
Biceps Tendinopathy
Speed’s Test: Resistance against Shoulder Flexion Yergason’s Test: Resistance against Supination
Biceps Tendinopathy
Treatment: – Rehab exercise – Sports Medicine referral if fails Prolotherapy injection – Refractory: MRI, surgery
Clavicle Fractures
Clinical Features – Clear Painful event – Pain with arm motion – Lump and possible tenting of the skin
Clavicle Fractures
Diagnosis – History & physical – X-ray – AP & axillary views, AP with 45° tilt – CT for proximal & distal clavicle fractures
Clavicle Fractures
Surgery indications: – Open fracture – Neurovascular compromise – Displacement > shaft width – Healed clavicle lump not desirable – Floating shoulder (concurrent scapular neck fracture)
Clavicle Fractures
Conservative tx: – Rest – Immobilization 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?