Evaluating shoulder injuries in primary care Bethany Reed, MSn, AGPCNP-BC One Medical Group
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1 Evaluating shoulder injuries in primary care Bethany Reed, MSn, AGPCNP-BC One Medical Group
2 Disclosures There has been no commercial support or sponsorship for this program. The planners and presenters have declared that no conflicts of interest exist. The program co-sponsors do not endorse any products in conjunction with any educational activity.
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4 How often do you assess shoulder injuries in your practice? A. Daily B. Weekly C. Monthly D. Yearly E. Never
5 Session objectives Discuss anatomy of the shoulder joint. Identify common injuries/conditions of shoulder injuries in the primary care setting including typical presentation and mechanisms of injury. Review physical examination skills and orthopedic testing. Participation analysis case scenarios for your reference to test your skills. Discuss operative and non-operative approaches for the treatment and rehabilitation process.
6 Common shoulder injuries Acute Onset Fractures Dislocations/subluxations Sprains/strains Contusions Rotator cuff tears Bicep tendon ruptures Calcific tendonitis Adhesive capsulitis Chronic Osteoarthritis Rotator cuff impingement Cervical disease
7 Case Study 38 yo female right shoulder pain worsening 3 weeks after starting CrossFit program with heavy lifting. Pain began 2/10 and has progressed to 7/10. Pain comes and goes with overhead and cross body reach. Also c/o pain w/ sleeping on right side. Denies trauma. Doesn t recall acute injury. Denies numbness, tingling in right extremity. Mild improvement w/ rest, ice, Advil. PMH: Asthma, HLD ROS: As above, all others negative VS: HR 78, RR 14, B/P 130/85, T 99.1 Exam: Visual inspection unremarkable for edema, erythema, deformity. Tenderness over anterior GH joint. ROM limited flexion, abduction, and external rotation. (+) painful arc. (-) empty can, neurovascular intact (-) imaging
8 Diagnosis A. Acute rotator cuff tear B. Labrum tear C. AC separation D. Osteoarthritis
9 Shoulder anatomy Bony Humerus Scapula Clavicle Joints Scapulothoracic Glenohumeral Acromioclavicular Coracoclavicular Soft tissue Trapezius, rhomboids, serratus, pectoralis minor/major, latissimus dorsi, deltoids, SCM Rotator cuff supraspinatus, infraspinatus, teres minor, subscapularis Capsule and ligaments Labrum Tendons Rotator cuff tendons, long head of biceps Subacromial and subdeltoid bursa
10 hospitalforspecialsurgery.interactive.understand. com/view/shoulder/rotator-cuff-anatomy
11 Shoulder pain: Differential diagnoses Traumatic disorders Instability AC joint disease Rotator cuff disease Tears Bursitis/tendonitis [impingement] Calcific tendonitis Adhesive capsulitis (frozen shoulder) Osteoarthritis Cervical disease
12 Rotator cuff pathology Impingement syndrome Calcific tendonitis Rotator cuff tears Partial thickness tears Full thickness tears Massive tears
13 Musculoskeletal work-up History Inspection Palpation Range of Motion Other Tests Strength Neurovascular Resisted wrist extension tests radial nerve, Resisted opposition of thumb test median nerve, Resisted digit abduction tests the ulnar nerve
14 history Age Hand dominance (RHD, LHD) Occupation CC: pain, weakness, instability, strength Location where is the pain? What is the quality of the pain? Onset Precipitating and alleviating factors Associated medical conditions and social history Most importantly smoking! Previous treatments: surgeries, medications, PT, injections Neurological complaints: numbness, tingling, weakness
15 Shoulder disorders by age Age Labral tears Instability Traumatic disorders Age Rotator cuff disease Calcific tendonitis Adhesive capsulitis Age Rotator cuff Tears Impingement Calcific tendonitis Osteoarthritis Adhesive capsulitis
16 Algorithm History of severe trauma? Deformity? Severe acute pain? Fracture? Dislocation? If Yes, refer for X-ray, A&E, specialist. If No, do they have referred pain? Cervical pathology degenerative disc disease, costochondritis, cardiac myocardial ischemia, pericarditis, pulmonary pneumonia, diaphragmatic irritation ulcer If No, do they have systemic illness? Polymyalgia rheumatica, malignant tumor, brachial neuritis, Herpes Zoster, Paget s Disease, Fibromyalgia If Yes, refer, investigate, treat accordingly If No.....
17 Algorithm Acute Fractures of clavicle, humerus and scapula Glenohumeral dislocations AC joint sprain separation Rotator cuff injury/tear Chronic Rotator cuff tendonitis (including biceps tendon/ bursitis/tears) Frozen Shoulder (Adhesive Capsulitis) Arthritis of the glenohumeral joint
18 Physical examination Observation/Inspection Erythema Swelling Ecchymosis Deformity Bony or soft tissue Asymmetry Atrophy
19 Shoulder and physical exam Palpation C spine Upper trapezius AC joint Long head of the bicep Greater tuberosity
20 Shoulder and physical exam Range of Motion Neck and shoulders Always compare bilaterally Active and passive Forward elevation External rotation Internal rotation with adduction (to vertebral level)
21 Shoulder physical exam
22 The empty can test should be done with the thumbs pointing up toward the ceiling? A. True B. False
23 Rotator cuff testing
24 What is the name of this useful assessment test? A. Empty Can test B. Lachman test C. Hawkins-Kennedy test D. Neers test
25 Testing Active ROM shoulder flexion, extension, abduction, adduction, external rotation, internal rotation, posterior scratch test (adduction/ external rotation) and (adduction/ internal rotation) Assess strength of rotator cuff muscles drop arm test evaluates for supraspinatus muscle tear abduct shoulder to 90, flex to 30, and point thumbs down test is + if patient is unable to keep arm up after examiner releases Resistance known as Empty Can (Jobe s test) test evaluates supraspinatus muscle strength--+ result indicates tendonopathy or tear Infraspinatus and teres minor muscle strength test resisted external rotation pain or weakness + for tendonopathy or tear Subscapularis muscle strength test resisted internal rotation or push off test adduct arm and internally rotate behind back resist patient s hand as pushes hand away from back Hawkin s-assesses for rotator cuff impingement stabilize scapula, passively abduct shoulder to 90, flex shoulder to 30, flex elbow to 90 and internally rotate the shoulder--+ if painful... Also, Neer s-stabilize scapula with thumb pointing down and passively flex arm--+ if painful Cross arm flexion test AC arthritis or subluxation flex shoulder 90 and adduct across body--+ pain at AC joint.
26 Rotator cuff testing
27 External rotation Positive findings: Decreased strength or pain on resisted testing. Significant weaknesssuprascapular nerve palsy secondary to trauma, ganglion cyst or injury
28 What shoulder muscle is this test assessing strength of? A. Infraspinatus and teres minor B. Pectoralis minor and serratus anterior C. Supraspinatus and teres minor D. All of the above
29 Subscapularis lift-off test Evaluates the muscular strength of the subscapularis Positive findings: Inability to lift the dorsum of hand off the back
30 Impingement/rotator cuff (Special Tests) Neer s Impingement Assesses the presence of impingement of the rotator cuff, primarily the supraspinatus, as it passes under the subacromial arch during forward flexion Positive findings: Pain in the anterior should or reproduction of the patient s symptoms
31 Hawkins Kennedy Impingement Test Evaluates impingement of rotator cuff and subacromial bursa. Positive findings: Pain in the anterior shoulder or reproduction of the patient s symptoms with the test.
32 Rotator cuff disease impingement syndrome Tendonitis/bursitis Subacromial Supraspinatus History: Pain reaching to side and back, overhead Pain sleeping Physical exam findings: Little to no weakness + Neer s Impingement + Hawkins Kennedy + Jobe s/empty can + Scapular retraction
33 Rotator cuff disease impingement syndrome Treatment NSAID s Rehabilitation Postural training, periscapular stabilization, strengthening of rotator cuff and scapular muscles Posterior stretching Activity modification Injections Lidocaine + corticosteroid Surgical intervention
34 Calcific tendonitis Calcification within rotator cuff tendon supraspinatus ACUTE onset, very painful Painful arc of motion Treatment: NSAID s Injection PT Surgery
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36 Rotator cuff tears Follow impingement Can start small and progress Trauma Physical exam findings Weakness TREATMENT Rehabilitation Injections Surgery Arthroscopic repair Not all tears require surgery
37 Adhesive capsulitis frozen shoulder Painful shoulder Restricted ROM Insidious Active and passive X-ray is normal Shoulder capsule thickens r/t inflammation Etiology Idiopathic Diabetes Mellitus Post traumatic Post surgical Treatment: NSAID s, PT, intra-articular injection, TIME.
38 Ac separation Various types Fall on tip of shoulder Possible bony deformity Pain on palpation of AC joint Pain on cross body adduction Differential diagnoses include AC arthropathy, AC osteoarthritis Treatment: Sling for comfort NSAID s PT Surgery in severe cases
39 Labral tear
40 Speed s test
41 Suspected labral tear No real reason for acute MRI Start PT and NSAID If no improvement in 6 weeks obtain MRI MRI shows labral tear
42 Glenohumeral osteoarthritis Degenerative process Progressive pain Limitation in ROM Active and passive Forward elevation External rotation Internal rotation Abduction Treatment: NSAID s PT Injections Surgery joint replacement
43 SUMMARY With careful history and physical examination the diagnosis can be made in most cases... not everyone needs an MRI. MRI if suspected large rotator cuff tear, or in patients who fail to progress with other treatment. Never too much of a downside to giving someone 1-2 weeks of therapy or rest and re-examining the shoulder. At least from a surgeon standpoint... Immediate MRI in everyone with work injury may lead to incidental findings i.e. What am I supposed to do with this information?
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46 Keep in mind... Thoracic outlet syndrome Additional labral tear tests Spurling s for cervical root impingement Glenohumeral joint sulcus Impingement signs
47 Case Study 38 yo female right shoulder pain worsening 3 weeks after starting CrossFit program with heavy lifting. Pain began 2/10 and has progressed to 7/10. Pain comes and goes with overhead and cross body reach. Also c/o pain w/ sleeping on right side. Denies trauma. Doesn t recall acute injury. Denies numbness, tingling in right extremity. Mild improvement w/ rest, ice, Advil. PMH: Asthma, HLD ROS: As above, all others negative VS: HR 78, RR 14, B/P 130/85, T 99.1 Exam: Visual inspection unremarkable for edema, erythema, deformity. Tenderness over anterior GH joint. ROM limited flexion, abduction, and external rotation. (+) painful arc. (-) empty can, neurovascular intact (-) imaging
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Joint G*H. Joint S*C. Joint A*C. Labrum. Humerus. Sternum. Scapula. Clavicle. Thorax. Articulation. Scapulo- Thoracic
A*C Joint Scapulo- Thoracic Articulation Thorax Sternum Clavicle Scapula Humerus S*C Joint G*H Joint Labrum AC Ligaments SC Ligaments SC JOINT AC Coracoacromial GH GH Ligament Complex Coracoclavicular
Anatomical Considerations/ Pathophysiology The shoulder is the most mobile joint in the body. : Three bones:
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Review shoulder anatomy Review the physical exam of the shoulder Discuss some common causes of acute shoulder pain Discuss some common causes of
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