Evaluation of Shoulder Pain Tim Garner, PT, OCS. Disclaimer

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Evaluation of Shoulder Pain Tim Garner, PT, OCS Disclaimer I do not have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated, with or without

1 Evaluation of Shoulder Pain Tim Garner, PT, OCS Disclaimer I do not have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated, with or without recognition within this presentation. Objectives Review shoulder anatomy Review elements of subjective history Application of clinical and imaging diagnostic tests Discuss current treatment regimens Anatomy: Shoulder Passive stabilizers: GH ligament, AC ligament, labrum/joint capsule Active stabilizers: Rotator cuff, lat, pec, deltoid, biceps, rhomboids, serratus a and p. Bony considerations: Scapula, Clavicle, Humerus, and Thoracic spine Healthy Shoulder XR Subjective History Mechanism of injury!!!! What happened? the specifics of HOW will usually point you in the direction of a correct diagnosis Swelling. Less noticeable in the shoulder.but usually immediate if dislocation, fx, or ligament sprain, and muscle specific if strain/tear. What increases the pain you are describing?

Mechanism of Injury Subjective History: Prevalence Shoulder pain

population, and is associated with age, medical history and daily

65% RCT full or partial, tendinitis (multiple etiologies) 11%

10% AC joint pain (but 40% of athletic injuries) 5% Referral pain

2 Mechanism of Injury Subjective History: Prevalence Shoulder pain affects 25% of the U.S. population, and is associated with age, medical history and daily activity level. 65% RCT full or partial, tendinitis (multiple etiologies) 11% localized tenderness of periscapular ms. 10% AC joint pain (but 40% of athletic injuries) 5% Referral pain from cervical region 3% Glenohumeral OA 2% Adhesive capsulitis Subjective History: Pain patterns EXAMINATION OBSERVATION PALPATION DIFFERENTIAL TESTING OBSERVATION Important to see the complaint.

3 Observation Active motion vs Passive motion Deformity Discoloration Edema *screening for fracture, infection or circulatory issues Active ROM ROM (using a Goniometer): - Flexion: 180 degrees (GH and Scap- thor) - Extension: 50 degrees - Abduction: 180 degrees - Adduction: Not usually measured - Internal Rotation in 90 degrees shoulder abduction: (shoulder complex), (pure GH motion) - External Rotation in 90 degrees shoulder abduction: (shoulder complex), 90 (pure GH motion) Palpation Note areas of pain as described without palpation as well. (Referred patterns). Bony abnormality Substitution or Muscular splinting Trigger points active vs. latent Differential testing Structural/bony integrity Ligamentous stability Tendon/muscular stability Referred pain Differential testing aids The practice of diagnosing through differential tests requires patience and repetition. Don t get discouraged!!! Some aids to assist you: 1. Ortho Notes clinical examination pocket guide Videos: (specific shoulder exam maneuvers) 3. YOUTUBE!! From reliable sources Examination: Where to start?

clinical cervical radiculopathy and correlated CT scan findings with clinical exam findings using the Spurling's test.

4 Any injury resulting from an impact or fall warrants a simple AP XR if motion is restricted OR concern regarding distal findings. OTHERWISE Differential testing Cervical clearing: Spurling s test: quick and easy Not completely trustworthy unless radicular patterns are correlated In 2011, one study evaluated 257 patients with clinical cervical radiculopathy and correlated CT scan findings with clinical exam findings using the Spurling's test. The Spurling's test was 95% sensitive and 94% specific for diagnosing nerve root pathology. Spurling s Compression test Rotate the cervical spine toward the side to be tested. Direct the head into extension to load the facets. Compress an axial load through the side being closed. Negative test: point tenderness at facet or no pain reproduction Positive test: reproduction of symptoms AND may indicate an underlying cervical pathology in addition to the shoulder issue.so don t stop here LIGAMENTOUS INVOLVEMENT Acromioclavicular ligament injury Usually occurs during a fall directly on the lateral aspect of the shoulder Tested with : - CROSS ARM FLEXION test - AC COMPRESSION test AC Injury

5 AC compression test With the arm at rest, the tester places one hand on the clavicle, and hand on the spine of the scapula. Then applying an approximating squeeze, if symptoms are reproduced, or a clunk or grind is felt at the AC, it is a positive test. Positive test usually indicates 2 nd or 3 rd degree (or greater*)sprain. This test is not necessary, if confirmation can be made visually. Cross arm flexion test Elevate the arm to 90 degrees and adduct the arm, reaching to the opposite shoulder. If pain is elicited at the AC joint, the AC joint is indicated. Positive test indicates pathology only. Can be AC sprain or OA. This test can also produce pain associated with impingement syndrome. Glenohumeral Stability Capsule - Sulcus test - Apprehension test - Load and Shift test Glenohumeral Stability Posterior dislocation Glenohumeral Stability Xray is the diagnostic of choice ASAP as not to disrupt vascular structure.. Glenohumeral Stability Sulcus test Test for inferior capsule integrity. - With the arm grasped inferior traction is applied. The examiner watches for dimpling of the skin below the acromion. Palpation reveals widening of the subacromial space between the acromion and the humeral head. Glenohumeral Stability Apprehension/Relocation Test for anterior capsular integrity Glenohumeral Stability Load and shift test Test for ant/post capsule Labrum Pathology

Deepens the concavity of glenoid Acts as a bumper Increases the surface area of contact Stabilizing role during rotator cuff contraction Labrum: SLAP vs Bankart Labrum testing and

6 What is the labrum? Glenoid Labrum Fibrous ring attaching to the glenoid Articular cartilage Long head of biceps blends with superior labrum IGHL blends into the inferior labrum Glenoid Labrum Deepens the concavity of glenoid Acts as a bumper Increases the surface area of contact Stabilizing role during rotator cuff contraction Labrum: SLAP vs Bankart Labrum testing and diagnostics Multiple tests with differing sensitivity and specificity. Kuhn s test Bicep load2/provocation Jobe relocation Crank test O Brien s test Labrum SLAP (superior labrum A- P) Kuhn s test: rule out SLAP (combination of 3) - 3 negatives rule out SLAP - 2 or more positives indicate 66% chance of a SLAP tear being correct diagnosis. Labrum

7 Bicep load 2/ provocation - The arm is abducted to 120, externally rotated maximally, elbow in 90 flexion and forearm supinated. If this test position reproduces pain then perform active elbow flexion against resistance. Labrum Crank test Labrum Jobe relocation - The examiner performs the apprehension test and notes the amount of external rotation before the onset of apprehension. Return to the start position and apply a posterior stress over the humeral head. Then repeat the external rotation maneuver and again note amount of external rotation at onset of apprehension. Labrum O Brien s - flex the arm to 90 with the elbow fully extended and then adduct the arm medial to sagittal plane. then maximally internally rotated and the patient resists the examiner's downward force. The procedure is repeated in supination. The O'Brien Test is designed to maximally load and compress the ACJ in position 1 and superior labrum in position 2 For maximal results the authors stress that the patient should resist the examiner's downward force rather than the examiner resisting forward flexion. Non operative treatment Activity Restriction 6 weeks NSAIDs Physical Therapy : RC strengthening/periscapular strengthening Immobilize in 30º of ER Further Treatment Ortho consult for failed physical therapy, recurrent dislocation or increasing severity of discomfort/instability. Imaging: MRI with contrast (still not as good as a clinician!!!) Adhesive Capsulitis Primarily in year old, women more frequent than men. Primary diagnosis Secondary due to prior injury/surgery.

8 Primary limitations: ER>flex>IR, without loss of strength. Adhesive Capsulitis shoulder trauma, surgery, diabetes, inflammatory conditions, inactivity of the shoulder, autoimmune disease, cervical cancer, and hyperthyroidism. Approximately 20% of people who have had a frozen shoulder will also develop frozen shoulder in their other shoulder in the future. Adhesive Capsulitis Imaging: X- rays or MRI to rule out other causes of shoulder pain. X- rays are not able to diagnose frozen shoulder. MRI or preferably MRA can provide a definitive diagnosis. A double- contrast shoulder arthrography is the traditional diagnostic method. Freezing.(RED) pain relieving techniques including gentle shoulder mobilization, muscle releases, acupuncture, dry needling for pain relief, and Intracapsular corticosteroid injection is considered when pain is unbearable. Frozen and Thawing.(PINK & WHITE) continued pain control and increased shoulder mobilization and stretching. Multidirectional instability Tested as a whole, and in general directions to indicate the area of the capsule involved. Hypermobility syndrome vs. Ehlers Danlos, if other indicators are present. Easy to overlook but only 1 in 5,000 incidence Side note.ehlers Danlos Syndrome. Loose to extremely loose joints, stretchy skin, and family history. Can be ruled out with genetic testing of a blood sample Frequently overlooked diagnosis for repeat orthopedic offenders. The importance is that it can lead to severe visceral and cardiac detriment and death (although only a small percentage of patients have the vascular form) Positive testing warrants consultation on risk factors for athletics and high impact activities and pregnancy Multidirectional Instability

so they do what comes easiest to get the job done. - Posture and mechanics Tendon and Muscle testing Rotator cuff.

9 Treatment: Strengthen. Then strengthen, then retrain the activity with more strengthening. Surgery to shrink the capsule if all else fails. - As the only bony attachment, the SC must by stable, but allowing appropriate clavicular rolling muscles that attach the scapula to surrounding bony articulations.so they do what comes easiest to get the job done. - Posture and mechanics Tendon and Muscle testing Rotator cuff.sits group Bicep long head Pectoral minor and major Latissimus Active trigger points SICK Scapula Scapula Inferior Coracoid Dyskinesis. - Type 1: winging of inferior border (means tight pec minor and weak lower trap. - Type 2: winging into the middle border (weak rhomboids and middle trap in addition) - Type 3: winging into the upper border (indicating over use of upper trap and levator). - May simply be dyskinetic somewhat subjective. SICK SICK shoulder and pec minor. Posterior strength once motion is restored. Scapula treatment Stretch anterior

10 GIRD Glenohumeral Internal Rotation Deficit - Generally seen in throwing athletes, tightened posterior capsule and RC structures. - Leads to lack of IR, then superior migration of the humerus, and ultimately RC pathology. - Measure IR at 90 abduction GIRD TEST: Supine or sitting measurement at 90 degrees abduction, IR with >15 degree discrepancy is a positive sign for GIRD. GIRD Treatment: Sleeper stretch, then once motion is restored, appropriate strengthening Rotator cuff Provides dynamic stability by joint compression. Prevents superior migration of humeral head during abduction. Rotator cuff Neer Impingement Hawkins Kennedy Empty can/ drop arm Resisted ER and active abduction Push off test Rotator cuff Neer Impingement - To assess approximation of the humerus to the acromion with effect of the supraspin/infraspin complex. - Can give several false positives but won t miss an impingement. Rotator cuff Hawkins Kennedy - Test for external impingement, down sloping AC or spurring. - More specific to impingement only Rotator cuff Empty can/ Drop arm - Test patency of the supraspinatus tendon

11 Rotator cuff Active ER/ abduction - Test integrity of the infraspinatus and teres aspect with ER - and supraspinatus with abduction usually indicates full thickness tears Rotator cuff Push off test - Tests patency of the subscapularis. - Position: hand in small of back, facing posterior, with action to lift away from the spine. - 90% accurate for subscap tear. Rotator cuff repair 6-20 week protocol recovery depending on involvement. Bursitis Gradual onset of your shoulder symptoms over weeks or months. Pain on the outside of your shoulder. Pain made worse when lying on your affected shoulder. Painful arc of movement shoulder pain felt between of arm moving up and outwards. When your arm is by your side there is minimal pain and above 90 relief of pain. Shoulder pain with activities such as washing hair, reaching up to high shelf in the cupboard. Calcific Tendinitis Early Injury Protection: Pain Relief & Anti- inflammatory Tips Regain Full Range of Motion Restore Scapular Control Restore Normal Neck- Scapulo- Thoracic- Shoulder Function Restore Rotator Cuff Strength Restore High Speed, Power, Proprioception & Agility Return to Sport or Work Fibromyalgia Conditions that can mimic or contribute to features of fibromyalgia include an underactive thyroid (hypothyroidism), vitamin D deficiency causing the bone disease osteomalacia, rheumatoid arthritis and even sleep apnea. Linked to:??

Fibromyalgia Fibromyalgia is sketchy to diagnose, but it is estimated to affect about 5% of the

It tends to occur in women at a much greater frequency than men, and generally begins in middle

Thoracic Outlet May consider cervical spine X- rays to evaluate for the presence of a cervical

12 Fibromyalgia Fibromyalgia is sketchy to diagnose, but it is estimated to affect about 5% of the population. It tends to occur in women at a much greater frequency than men, and generally begins in middle age. Thoughts? Thoracic Outlet May consider cervical spine X- rays to evaluate for the presence of a cervical rib, or prominent C7 transverse process that may be contributing to the symptoms. Additional tests (e.g., MRI, EMG) can be used to rule out other causes. Costoclavicular maneuver or Adson s test. Thoracic Outlet Must evaluate posture as well. Trigger Point Trigg er Poin t R u

13 le out cervical lesion. Posture and Activity modification is key. PT, TDNeedling, massage, trigger injection for pain control. Scapular strengthening Pancoast Tumor Account for less than 5% of all bronchogenic carcinomas. Located in the apex of the lung and involve through tissue contiguous to the apical chest wall and/or the structures of the thoracic inlet. The tumors become clinically evident with the characteristic symptoms severe pain in the shoulder radiating toward the axilla and/or scapula and along the ulnar distribution of the upper arm, atrophy of hand and arm muscles and obstruction of the subclavian vein resulting in edema of the upper arm. Clinical symptoms with the radiographic findings of a mass or opacity in the apex of the lung infiltrating the 1 st and/or 2 nd ribs. Test review Spurlings Cross arm AC compression Sulcus sign Apprehension Load & Shift Kuhn s Bicep Load 2 Jobe relocation Crank O Brien SICK scap GIRD Neer Hawkins Kennedy Empty can/drop arm Resisted ER Lift off Painful arc Costoclavicular maneuver Adson s Thank you! tim@garnerrileypt.com Margarita time?

Joint GH. Joint SC. Joint A*C. Labrum. Humerus. Sternum. Scapula. Clavicle. Thorax. Articulation. Scapulo- Thoracic

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