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 °

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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

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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?