Shoulder Pain

Size: px

Start display at page:

Download "Shoulder Pain"

Milo Wiggins
5 years ago
Views:

1 Shoulder Pain

2 Outline Shoulder Anatomy and Biomechanics Patient History and Pain Patterns Etiology and Differential Diagnoses Physical Examination Stepwise Clinical Approach Confimatory Tests Radiography

3 Introduction Shoulder pain is an extremely common MSK complaint in family practice Multiple etiologies of pain, often difficult to differentiate Infrequently well examined Accurate diagnosis infrequently obtained

4 Shoulder Anatomy Greater mobility than any other joint in body Three bones: Clavicle Scapula Proximal humerus Four articular surfaces: Sternoclavicular joint Acromioclavicular joint Glenohumeral joint Scapulothoracic approximation

5 Glenohumeral Structures Shallow depth of joint and limited contact at joint allow tremendous mobility Make susceptible to injury Stability required from extrinsic supports Static stabilizer = glenohumeral ligament, labrum Dynamic stabilizer = rotator cuff muscles

6 Rotator Cuff Supraspinatus Abduction Infraspinatus External rotation Subscapularis Internal rotation Teres minor External rotation

7 Rotator Cuff

8 Extraglenohumeral Structures Acromioclavicular joint Common site of injury Sternoclavicular joint Scapulothoracic articulation Provides solid base from which RC moves shoulder Tendon of Long Head of Biceps

9 Patient History and Pain Patterns

10 History Exclude Trauma Standard Pain History (OLD CARS) Key features can exclude extrinsic causes of pain Intrinsic Pain can be: Provoked by specific movements Associated with stiffness Associated with weakness/loss of function Associated with instability

11 History of Trauma Blunt trauma: fractures and dislocations Falls onto shoulder: AC separation Direct blow: clavicular fracture FOOSH: proximal humeral fracture Seizure: dislocation

12 Anterolateral Shoulder Pain: Key Historical Points Impingement, Tendonitis: aggravated by reaching overhead Tear: pain + weakness Adhesive capsulitis: pain + stiffness, history of DM, Hx of lack of use AC joint: well localized/ one finger Glenohumeral Joint: multidirection pain Long Head of Biceps: aggavated by carrying shopping bags

13 Posterior Shoulder Pain Least common pattern of pain to present with Think about: RC external rotators (teres minor & infraspinatus): focal pain/pain over scapula C-spine: pain over superior trapezius Labrum Injury

14 History of Poorly Localized Pain Often extrinsic Think about: Cervical n. root: radiates to post. Shoulder Depression: shoulder pain without physical findings Tumors of thorax and chest Adhesive capsulitis

15 Etiology and Differential Diagnosis

16 Extrinsic Causes of Pain Neurologic Cervical root compression (C5, C6) Supraspinatus n. compression Brachial plexus lesions Herpes zoster Spinal cord lesion Cervical spine disease Abdominal Hepatobiliary disease Diapragmatic irritation Cardiovascular Mycardial ischemia Axillary vein thrombosis Thoracic outlet syndrome Thoracic Upper lobe pneumonia Apical lung tumor Pulmonary embolus

17 Intrinsic Causes of Pain Adolescents and young adults Overuse Injuries Pain and loss of function associated with particular athletic activity Acromioclavicular sprain Hx of trauma, focal pain over AC Shoulder instability Minor trauma, high risk recurrence

18 Intrinsic Cause of Pain Middle-aged and older individuals Rotator cuff tendonitis/impingement Rotator cuff tears Subacromial bursitis Adhesive capsulitis Bicipital tendinitis Osteoarthritis Myofascial pain Labral tears

19 Rotator Cuff Injury Anatomy makes RC susceptible to impingement Most common cause of shoulder pain Spectrum of disease Impingement Inflammation Calcification Degenerative thinning tear

20 Impingement Syndrome Symptoms and signs from compression of tendons and bursa below acromion Presentation nearly identical to tendonitis Pain over deltoid with overhead actions Risk factors: Rounded shoulders Poor musculature Repetitive work at or above shoulder level

21 Rotator Cuff Tendonitis Inflammation of supraspinatus or infraspinatus tendons most common Results from repetitive activity at/above shoulder height Associated with pain with reaching, pushing, pulling, lifting, lying on affected side Classic Sign: hand over deltoid, rubbing up/down while describing pain

22 Rotator Cuff Tendon Tear Loss of integrity of tendon Result of chronic impingement/trauma Patient reports shoulder weakness and popping/catching + night pain Acute presentation: FOOSH, fall onto shoulder, vigorous pulling, heavy pushing Chronic presentation: age >40 yrs, hx of impingement Function Normal if longitudinal tears Weakness and loss of function with transverse

23 Labral Tear Produced by many of same mechanisms as rotator cuff injury Associated with repetitive overhead activities Symptoms: Deep shoulder pain Catching sensation Instability crepitus

24 Adhesive Capsulitis (Frozen Shoulder) Stiff glenohumeral joint with decreased ROM Reversible contraction of capsule Risks: Injury/pain that limits motion Rotator cuff tendonitis Diabetes mellitus Stroke Patients complain of pain and restriction of motion

25 Acromioclavicular Pain Joint susceptible to trauma and arthritis Complain of grinding or popping with overhead or reaching across chest Usually localize pain well

26 Biceps Tendonitis Associated with repetitive lifting and overhead reaching Chronic inflammation, microtearing and degenerative changes Symptoms aggravated by lifting, carrying and overhead reaching

27 Shoulder Instability Subluxation Vague, non-specific symptoms Dead-arm Looseness Crepitus Common: Young women with poor musculature/joint laxity Large RC tears Athletes (ex swimmers, throwers)

28 Glenohumeral Arthritis Wear and tear of articular cartilage of glenoid fossa, labrum, humeral head Most often preceded by remote trauma or inflammatory arthritis Gradual development of anterior or deep shoulder pain and stiffness (months to years)

29 Physical Examination And Special Tests

30 Inspection Extremely Important Get the patient undressed!!!!! Look from front and back of patient Examine for: Deformity or asymmetry Muscle atrophy Abnormal motion Watching patient take of shirt may provide clues

31 Neurovascular Assessment Screening exam appropriate in all patients More thorough exam if suspected on history or mechanism of injury

32 Palpation Palpate each structure individually Clavicle including SC and AC joints Acromion and subacromial space Biciptal groove, greater and lesser tubercles Scapular spine and musculature/tendon insertions Cervical spine Glenohumeral joint is deep, even large effusions may not be appreciated

33 Palpation Acromioclavicular joint Follow clavicle to AC joint Anterior/lateral/posterior edges of acromion well demarcated Sternoclavicular joint Junction of proximal clavicle and sternum Subscapular bursa Superior-medial angle of scapula and closest underlying rib Have patient hold opposite shoulder

34 Palpation Subacromial space tenderness Palpate below acromion Extend shoulder Tenderness Impingement Rotator cuff tendonitis Rotator cuff tear Subacromial bursitis Muscle contusion Humeral lesion

35 Range of Motion Screening test NFL Touchdown sign Requires normal glenohumeral joint, intact RC tendons, functional AC joint Painless ROM suggests extrinsic Severe pain acute RC tendonitis/inflammatory joint Weakness tear/atrophy/nerve palsy Failure to attempt dislocation/ac separation/fracture

36 Range of Motion Proceed to assessment of full range of motion Active range of motion Symptom reproduction suggests contractile structure is injured (ie. Muscle/tendon) Passive range of motion Symptom reproduction suggests non-contractile structure is injured (ie. Bone/cartilage

37 Apley Scratch Test Tests range of motion of joint (Abduction, adduction, external and internal rotation) Steps: Reach across chest to touch other shoulder Reach behind head and touch superior scapula (T4) Reach behind back and touch inferior scapula (T8) Limitation of rotation: Adduction in AC disease Rotator cuff tendonitis Adhesive capsulitis Arthritis of glenohumeral joint

38 Apley Scratch Test

39 Full Range of Motion Actions

40 Impingement Important test if considering rotator cuff pathology If evidence of impingement present, individual rotator cuff tendons should be tested Tests: Neer Test (Painful arc) Hawkins Test

41 Strength and Tendon Integrity Used to assess neurologic integrity and identify injury of specific structures Significant focal weakness with lancinating/radiating pain = cervical n. root impingement or peripheral n. entrapment Weakness with nonradiating dull or achy pain often rotator cuff or other muscle tear Goal is to distinguish between pain with or pain without weakness

42 Abduction and Supraspinatus Responsible for abduction in the mid-arc (30 to 90 degrees) Pain with normal strength = tendonitis Pain with weakness = tear or tendonitis Weakness alone = RC tear, atrophy, radiculopathy, suprascapular n. palsy Tests: Isometric strength Drop arm test Empty can test

43 Isometric Strength Test Abduct to 45 degrees, 30 degrees forward flexion Resist while examiner adducts arm Sensitive but not specific for tendon injury No correlation with tear size

44 Supraspinatus Strength Drop Arm Test Lower arms from fully abducted position Positive if unable to lower with smooth coordinated motion Highly specific but insensitive for tear Empty Can test Straight arm at 90 degrees of abduction, 30 degrees forward flexion, internal rotation of shoulder Resist attempts to adduct Pain = tendonitis Pain + weakness=tear

45 Internal Rotation and Subscapularis Responsible for internal rotation Push-off Test Hands behind back and push posteriorly against resistance Pain vs. pain + weakness

46 External Rotation and Infraspinatus Responsible for external rotation (small contribution from teres minor) Patient resists attempt to internally rotate the shoulder Pain= tendonitis Pain + weakness= tear, etc.

47 Scapulothoracic Articulation Observe from behind through abduction Abnormal motion may compensate for GH pathology Scapular Instability Push-off test Winging = instability

48 Biceps Tendonitis Speed s Test Forward flexion to 30 degrees, elbow extension and supination against resistance Yergason s Test Adduction, elbow flexion and supination, resists pronation

49 Neer Test Passive painful arc Internally rotate the arm with the thumb facing downward, and abduct and forward flex the arm Pain 90 degrees mild Pain at moderate Pain at < 45 degrees severe

50 Hawkins Test Stabilize shoulder, with other hand internally rotate shoulder with arm bent at 90 degrees Pain with internal rotation is positive test

51 Combined Testing for Rotator Cuff Supraspinatus weakness + weakness of external rotation + impingement 98% likelihood of rotator cuff tear >60 years - 2/3 of above 98% likelihood of rotator cuff tear Absence of these features < 5% risk of rotator cuff tear 1-2/3 features Need imaging to clarity diagnosis

52 Instability Instability may be cause for discomfort Multi or unidirectional Anterior and inferior laxity most common Tests: Sulcus sign Apprehension test Relocation test Release test

53 Sulcus Sign Downward movement of humeral head when arm is pulled 1/4 inch normal >1/4 inch consistent with hypermobility

54 Apprehension Test Patient places arm in throwing position Brace posterior shoulder while pushing back on the wrist, increasing abduction and external rotation Sensation of impending dislocation is positive test

55 Relocation and Release Tests Begun at end of apprehension test Reverse forces being applied Brace anterior shoulder and push the humerus posteriorly Relief of sensation of dislocation is postive test Release test: Release of posterior humeral pressure Sensation of impending dislocation is positive test

56 Stepwise Clinical Approach Putting it all Together

57 Stepwise clinical approach Shoulder is complex joint with many components Broad differential diagnosis Fortunately, pathology often presents in stereotypical fashion Following basic approach can help with diagnosis of most common complaints

58 Step One: Trauma vs No Trauma Shoulder Pain History Traumatic Non-Traumatic Physical Exam Localization of Pain X-Ray Deformity Dislocation Clavicle Fracture Humeral Fracture AC Separation Physical Exam Localization of Pain X-Ray No Deformity Soft Tissue Injury Perform Appropriate Exam

59 Step Two: Extrinsic vs. Intrinsic Non-Traumatic Intrinsic Extrinsic Vague, diffuse pain with other symptoms Or Sharp pain radiating to neck and arm History concerning for extrinsic Painless GH motion

60 Step Three: Glenohumeral vs Extraglenohumeral Pain Weakness Abnormal Motion Of GH Glenohumoral Rotator Cuff tendonitis Rotator Cuff Tear Impingement Adhesive Capsulitis Instability Arthritis Labral Tear Intrinsic Passive ROM GH normal Localize pain to specific site Extra-Glenohumeral Biceps tendonitis Biceps rupture AC arthritis Subscapular arthritis

61 Step Four: Glenohumeral Pathology Glenohumeral Anterolateral Pain Pain with supraspinatus and/or infraspinatus tests Positive impingement test Impingement and Rotator Cuff Tendonitis Age > 40 yrs Pain and weakness with Supraspinatus and/or infraspinatus tests Positive impingement test Rotator Cuff Tendon Tear Hx of DM or immobilization Decreased Active AND Passive ROM Adhesive Capsulitis

62 Step Four: Glenohumeral Pathology Glenohumeral History of remote shoulder trauma Progressive Pain Diminished active AND passive ROM Xray-sclerosis and decreased joint space Younger Patient (<40 yrs) Positive Sulcus Sign Positive Instability Tests Glenohumeral Osteoarthritis Multidirectional Instability

63 Confirmatory Tests

64 Lidocaine Injection Test Should result in 50% reduction in pain Exclude glenohumeral joint involvement Dramatic pain reduction and improvement in function after injection of subacromial bursa rules out glenohumeral joint process Confirm rotator cuff tendonitis Normal strength with pain relief Exclude rotator cuff tear Persistent weakness despite pain relief Determine degree of frozen shoulder Persistent loss of ROM despite pain relief

65 Radiographic Studies

66 Plain Radiographs Limited benefit in non-traumatic pain Views: AP Lateral Trans-axillar Y view Identify: Fractures of humerus, clavicle, scapula Glenohumeral dislocations Glenohumeral osteoarthritis AC joint arthritis or injury SC joint arthritis Rotator cuff thinning (subacromial space < 1cm)

67 MRI Preferred study for suspected shoulder complaints Impingement Sensitivity 93% Specificity 87% Normal MRI- <10 % likelihood of rotator cuff tear

68 Ultrasonography Accuracy found to be equivalent to MRI in hands of skilled operators Rotator cuff tears Labral tears Biceps tendon tears dislocations Less expensive Often preferred by patients Only test which can be performed dynamically

69 Arthrography Largely replaced by MRI

70 Summary

71 Shoulder Pain Common complaint Broad differential diagnosis Utilize History, Physical Exam, Special Tests Stepwise approach Traumatic vs Atraumatic Extrinsic vs Intrinsic Glenohumeral vs Extraglenohumeral Differentiating glenohumeral pathology

Shoulder Joint Examination. Shoulder Joint Examination. Inspection. Inspection Palpation Movement. Look Feel Move

Shoulder Joint Examination. Shoulder Joint Examination. Inspection. Inspection Palpation Movement. Look Feel Move Shoulder Joint Examination History Cuff Examination Instability Examination AC Joint Examination Biceps Tendon Examination Superior Labrum Examination Shoulder Joint Examination Inspection Palpation Movement