Evaluation of the Painful Shoulder
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1 Evaluation of the Painful Shoulder J. Lindsay Quade, MD Clinical Instructor Internal Medicine/Pediatrics Primary Care Sports Medicine Michigan Medicine
2 Objectives Review important shoulder anatomy Review MSK shoulder pain differential and history taking Demonstrate musculoskeletal shoulder exam, including special testing Determine what, if any imaging, is needed Discuss common MSK causes of shoulder pain, including diagnosis and management
3 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 surgical subspecialist.
4 Shoulder Anatomy
5 Shoulder Anatomy
6 Shoulder Anatomy
7 Shoulder Anatomy
8 (MSK) Shoulder Pain Differential Rotator Cuff & Biceps Tear Strain Tendinopathy Other Muscle Tear Arthritis Glenohumeral (GH) Acromioclavicular (AC) Referred pain from spine Adhesive Capsulitis Impingement Scapular Dyskinesia Glenohumeral Instability Labral Tears Fracture Humerus Clavicle Scapula Nerve Entrapment/Thoracic Outlet/Neuropraxia
9 Taking Your History Age Hand dominance Occupation Sports/physical activities Trauma/injury Onset Location Character Duration Radiation Aggravating/relieving factors including position Night pain Effect on shoulder function Stiffness/restriction of movement Grinding or clicking Weakness Numbness/tingling Pain Position of shoulder at injury
10 The Physical Exam Inspection from the front and back! Asymmetry Bony deformity or abnormal contour Muscle atrophy or bulge Scapular winging Posture
11 The Physical Exam Range of Motion Active Passive Apley s scratch test Scapular movement Strength Testing/Resisted Movements
12 The Rotator Cuff Muscles SITS Supraspinatus Abduction Infraspinatus External rotation Teres minor External rotation Subscapularis Internal rotation
13 The Physical Exam Palpation AC, SC, and GH joints Biceps tendon Coracoid process Acromion Scapula Musculature
14 Special Tests Rotator Cuff Drop-arm Empty can, lift-off, and resistance testing Impingement Neer s Hawkins/Kennedy
15 Special Tests Biceps Speed s Yergason s AC Joint Cross-arm
16 Special Tests Shoulder Instability Sulcus sign Apprehension, relocation, release Load and shift
17 Special Tests Labrum O Brien s Crank test SLAPprehension
18 Imaging Questions to ask myself: Will this provide additional beneficial information? Is the diagnosis unclear? Was there a traumatic injury? Were there concerning findings on exam? Will the result affect my management? When ordering the imaging study: Start small Provide all necessary details (ie left shoulder pain versus acute left lateral shoulder pain after fall, eval for fracture) Decide if special views or instructions are needed
19 Imaging Xrays When? UM Routine Views include AP & Axillary Lateral Consider adding internal and external rotation for good views of lesser and greater tubercles Internal External Case courtesy of Dr Craig Hacking, Radiopaedia.org, rid: 37498; Case courtesy of Dr Matt Skalski, Radiopaedia.org, rid: 23096; Case courtesy of Dr Matt A. Morgan, Radiopaedia.org, rid: 37170
20 Imaging Grashey Xrays Traumatic Injury? Scapular Y (true lateral) Arthritis? Grashey (glenoid or true AP ) Case courtesy of Dr Craig Hacking, Radiopaedia.org, rid: 37498; Case courtesy of Dr Matt A. Morgan, Radiopaedia.org, rid: AC joint? UM includes AP and obliques (Case courtesy of Dr Craig Hacking, Radiopaedia.org, rid: 37930) Clavicle? UM includes AP, 30 degree cephalad & caudal (Case courtesy of Dr Craig Hacking, Radiopaedia.org, rid: 36886)
21 Imaging Ultrasound Evaluate rotator cuff and adjacent muscles, bursa, long head of biceps, fluid collections Diagnose tendinopathy, tears, bursal thickening, impingement However, not great at quantifying large tears Less expensive, non-invasive Static and dynamic evaluation Upper Extremity US
22 Imaging MRI Multiplanar, non-invasive Can better characterize large RC tears, can diagnose occult fractures, more information on ligaments and nerves More expensive, static Do not need immediately if full ROM and only complains of pain and weakness Add arthrogram (contrast) for labral pathology
23 Case 1 History: 54 yo M engineer 4 months of lateral shoulder pain without injury Starting doing cross-fit for weight loss Pain aggravated by overhead and behind back movements Exam: Full ROM but painful arc between degrees of abduction No significant weakness, but pain with resisted ROM + empty can, Hawkins for pain Xrays mild OA, mild cortical irregularity of greater tubercle
24 Rotator Cuff Pathology Strains/ bursitis Common in athletes or with increase in physical activity Sudden onset of pain, some functional limitations Exam: ROM limited by pain, some weakness due to pain, musculature ttp +/- Xrays Respond quickly to rest, activity modification, stretching, NSAIDs
25 Rotator Cuff Pathology Tendinopathy Increased load/overuse apoptosis disorganization of collagen matrix Chronic progression of pain +/- weakness, more common in older population Worse with abduction, reaching behind, overhead Exam: Pain with AROM and resistance testing, + empty can and lift off for pain, +/- Hawkin s TTP over proximal humerus Imaging: Xrays often negative US Treatment: Activity modification, PT (up to 12 weeks!), consider subacromial steroid injection if no improvement or plateau in PT due to pain
26 Rotator Cuff Pathology Partial and Full Thickness Tears Typically older population Degenerative tears versus acute traumatic tears Pain +/- weakness, difficulty sleeping Exam: Similar to tendinopathy If acute tear, expect + drop arm test, decreased AROM or helping from other arm, more severe weakness with resistance testing Xray may show OA, cortical irregularity, or humeral head migration US/MRI for confirmation of diagnosis Treatment: acute versus chronic? conservative versus Ortho referral
27 Rotator Cuff Pathology Impingement Ethos Health Mechanical irritation of RC tendons as result of narrowing of subacromial space Anatomical causes (beaked acromion, osteophytes) Muscular weakness or imbalance (scapula, RC, deltoid) Exam: Inspection posture, scapular movement Pain with active abduction + Hawkin s, Neers Xrays may show anatomical cause US +/- bursal thickening, dynamic testing Treatment: Activity modification/rest, PT, steroid injection, rarely surgical decompression
28 Case 2 History: 19yo F college volleyball player Pain with hitting and overhead serving Pain improves during off-season Exam: Prominence of medial border of scapula on right with elevation Full AROM with pain above 90 degrees of abduction + Hawkin s Pain with wind-up phase when demonstrating hitting/serving Xrays - normal
29 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 Can result in impingement type symptoms
30 SICK Scapula Diagnosis: Clinical Management: Physical Therapy & kinetic-chain based rehabilitation Pain free ROM Strengthening Proprioception exercises
31 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
32 Shoulder (GH) Instability Diagnosis: Clinical Xrays often normal, could show Hill Sach s lesion 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
33 Case 3 History: 68 yo F, multiple medical problems including DM 6 months of shoulder pain, decreased ROM, can t do ADLs No injury, nothing makes it better Exam: Active ROM quite limited, particularly with external rotation (15 degrees) No improvement with passive ROM Pan positive exam, difficult to get in position for special maneuvers Xrays mild/moderate OA
34 Frozen Shoulder (Adhesive Capsulitis) Presentation & symptoms: Pain, often >3 months Progressive loss of ROM Age >40yo Risk factors: immobility, DM, thyroid disorders Physical exam findings: Limited active ROM, external rotation often 50% normal Endpoint with passive ROM
35 Frozen Shoulder (Adhesive Capsulitis) Diagnosis: CLINICAL! Xray if need to rule-out fracture or OA US if concerned for RC pathology Management: Set expectations recovery can take 18+ months! Pain control, gentle ROM exercises/pt If severe, intra-articular CS injection with capsular distention followed by PT session within hrs If recalcitrant, consider surgical manipulation (Ortho)
36 Case 4 History: 72 yo M upset with his golfing game Progressively worsening right shoulder pain and range of motion Feels crepitus with movement Multiple small injuries over the years Exam: Active ROM limited in all directions, including external rotation Decent strength with resistance testing, 4+/5 TTP around shoulder joint Xrays
37 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, can have + labral testing
38 Shoulder Arthritis Diagnosis: Clinical + Xray Management: AC joint: Activity modification, NSAIDs, GC injection GH joint: Goal = maintain function with adequate pain control PT, intra-articular GC injection Referral to Ortho for arthroplasty if conservative treatment fails for PAIN not ROM
39 Case 5 History: 38 yo M assembly line worker 1 week of anterior right shoulder pain after lifting injury at work Noticed a bulge in his upper arm Exam: Popeye deformity Some pain with active ROM TTP bicipital groove, distal biceps intact + Speeds test Xrays - normal
40 Biceps Pathology Similar to RC, can have strains, tendinopathy and tears Chronic issues often associated with RC pathology/impingement Pain is usually anterior in location, worse with lifting Tears usually in >40yo, initial sharp pain/snap pain soon subsides Exam: Possible swelling or deformity, bruising on exam if tear TTP at bicipital groove, + Speed s test, Yergason s Imaging Xray typically normal US/MRI - diagnostic
41 Biceps Pathology Treatment Strains/Tendinopathy/Partial Tears: Activity modification, PT, consideration of steroid injection (not for strains) Complete Tears (Proximal) Still typically conservative, PT Short head still attached so strength not severely affected Tenodesis more likely to be done if young, more for cosmetic reasons Distal Biceps Rupture Urgent Ortho referral surgery Diagnose clinically (+ hook test), can use US
42 Physical Therapy A Good Prescription for Formal PT Include your diagnosis AND any local biomechanical deficits Examples could include poor posture, inflexibility Duration and frequency (ex: 2x/week for 6 weeks), goals, restrictions,?modalities With rotator cuff injuries, request deltoid retraining Don t forget about the scapula!! Set reasonable expectations with patients Stress importance of homework (HEP) during and after formal PT (3-5x/week) If unable to do formal PT, give patient a good HEP
43 Extra Sports Medicine Pearls Clavicle Fracture Midshaft are most common Usually from fall onto shoulder Diagnose by xray Sling (ortho if shortening, complete, open) Typically heal in 4-6 weeks Proximal Humerus Fracture Fall on outstretched hand >60yo, osteoporotic women Usually nondisplaced, at greater tubercle Xray for diagnosis Sling 2-4 weeks, early mobilization, PT
44 YouTube! Complete Musculoskeletal Exam of the Shoulder by University of Michigan Family Medicine
45 Questions?
46 Thank You!
47 References Beuerlein MJS, McKee MD, Fam, AG. (2010). The shoulder. In Lawry GV (2 nd.), Fam s musculoskeletal examination and joint injection techniques, (pp. 7-19). Philadelphia: Mosby. Brukner P, Khan K, et al. (2006). Clinical Sports Medicine. Austrailia: McGraw-Hill. Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician Feb 15; 77 (4): Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part II. Treatment. Am Fam Physician Feb 15; 77 (4): Dodson CC, Altchek DW. SLAP lesions: an update on recognition and treatment. J Orthop Sports Phys Ther Feb; 39 (2): Edmonds EW, Denerink DD. Common conditions in the overhead athlete. Am Fam Physician Apr 1; 89 (7): Ewald, A. Adhesive capsulitis: a review. Am Fam Physician Feb 15; 83 (4): O Connor, F, et al. (2013). ACSM s Sports Medicine: A comprehensive review. Philadelphia: Lippincott. Woodward TW, Best TM. The painful shoulder: part I. Clinical evaluation. Am Fam Physician May 15; 61 (10): Woodward TW, Best TM. The painful shoulder: part II. Acute and chr onic disorders. Am Fam Physician Jun 1; 61 (11):
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