Shoulder Pain: Diagnosis and Management
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1 Shoulder Pain: Diagnosis and Management Thomas J. Gill, M.D. Director, Boston Sports Medicine and Research Institute Associate Professor of Orthopedic Surgery Tufts Medical School
2 The Shoulder Sternoclavicular joint Acromioclavicular joint Scapulothoracic joint Glenohumeral joint
3 History Key points - age, chief complaint Young - instability, A-C, acute injuries Old - rotator cuff, arthritis Mechanism Chronicity Associated sx s Referred pain
4 History Instability - injury in ABD / ER A-C Joint - direct blow Rotator cuff - pain at night; overhead
5 Physical Examination Must be undressed Observation» walking into room» taking off shirt» ROM» asymmetry» atrophy» skin» popeye» winging Palpation» based on knowledge of anatomy» S-C, clavicle, A-C, acromion, greater tuberosity, biceps groove Motion» active / passive FF ( ), ER (30-60), ERA (70-90), IR (T4-T8) Strength» supraspinatus» ER,» O Brien s
6 Neurovascular Testing Sensory C5 - lateral arm C6 - thumb C7 - middle finger C8 - small finger T1 - medial arm Reflex C5 - biceps C6 - brachioradialis C7 - triceps Pulses Adson/Wright, Roos tests
7 Radiographic Studies True AP Axillary Trans-scapular Y CT U/S MRI Arthrograms
8 Case #1 45 y.o construction worker fell from scaffold 4 weeks ago pain over superior/posterior shoulder not getting better despite NSAID s, P.T.
9 Rule out Referred Pain Herniated cervical disc Cervical stenosis Burners / Stingers Cervical strain Remote etiologies - Phrenic nerve irritation» e.g. diaphragmatic abscess, pancoast tumor
10 Cervical Strain Hx: My neck hurts No radicular / arm symptoms PE: Tender paraspinal muscles No provocative neurologic tests
11 Cervical Strain X-ray: depends on history Loss of cervical lordosis Rx: heat, massage, strengthening, NSAID s? Collar acutely
12 Whiplash Cervical strain Typically MVA Forced flexion / extension Must rule out cervical instability X-ray: lateral flexion / extension! Rx: like cervical strain» often takes months
13 Disc Herniation Relatively rare in office setting Hyperflexion / trauma Hx: true radicular complaints» occasionally just pain +/- spasm PE: neuro exam, L Hermitte s, Spurling s Rx: NSAID s, tincture of time for stable exam»? decompression
14 Burners Upper cervical root neurapraxia» C5, C6 My arm went dead Lateral neck flexion, arm distraction Return to sports/work when no sx s Rule out cervical disc / stenosis Prevention - neck roll in football
15 Fractures H/o trauma When in doubt, X-ray! Don t forget ligamentous injuries Immobilize Refer
16 Definitions Sprain - ligament injury Strain - muscle injury Tendon - muscle to bone Ligament - bone to bone Laxity - joint translation Subluxation - pathologic laxity Dislocation - no contact of joint surfaces
17 Anatomy of Muscles / Nerves
18 Anatomy of Ligaments / Capsule
19 Common Soft Tissue Injuries Separated shoulder Dislocation / subluxation Overuse injury (tendinitis, impingement) Rotator cuff tear Biceps tendinitis / rupture SLAP lesion
20 Case #2 31 y.o. hockey player Hit into glass C/o shoulder pain
21 Separated Shoulder Types I-VI I, II - non-operative III -? IV, V, VI - surgery
22 A-C Sprain: Separated Shoulder Etiology: direct blow to shoulder; very common PE: tender over AC joint; pain with cross-body adduction X-ray: A-C joint widening / dislocation Ice, compression? Injection acutely (marcaine, steroid) P.T. not needed, but maintain ROM Indications for surgery
23 Case #3 49 y.o female c/o pain electrician night difficulty reaching overhead can t swim, play tennis weak trauma?
24 Impingement Syndrome Most common cause of pain Rotator cuff tendinitis, bursitis Cuff tears rare in patients < 35 y.o.
25 Impingement Syndrome Repetitive overhead activity» throwers, tennis, swimmers, craftsmen
26 Diagnosis of Impingement History» pain with overhead activity» pain at night; +/- weakness Examination» Neer and Hawkins impingement signs» forward flexion; adduction/ir Injection test - very helpful for diagnosis AND treatment» up to 3 sometimes needed
27 Treatment of Impingement NSAID s Rotator cuff strengthening Injections x 3 (if needed) Up to 6 months rehab Arthroscopic decompression
28 Theraband Program
29 Rotator Cuff Tears Can be very debilitating / painful don t ignore
30 Diagnosis of RTC Tear Hx: PE:» pain at night» pain with overhead use» impingement signs» supraspinatus / ER resistance» discrepancy between active / passive ROM Injection test
31 Imaging for RTC Tears MRI confirms PE findings Ddx:» Impingement tendinitis, SLAP lesions, partial vs. full tears
32 Treatment of RTC Tears P.T. role - to restore ROM pre-op, not avoid surgery Small tears tend to become large tears Large tears difficult/impossible to repair» high rate of complications
33 RTC Repair Most full-thickness tears should be repaired, depending on patient co-morbidities
34 Case #4 62 y.o. female C/o shoulder pain Limited ROM PMH: Diabetes
35 Adhesive Capsulitis ( Frozen Shoulder ) Limited active and passive ROM Differentiate 1º vs. 2 º Different phases of pathology Hx: Pain, stiffness Diabetes
36 Adhesive Capsulitis: Treatment NSAID s Physical Therapy Subacromial Injection(s) Role of surgery
37 Case #5 28 y.o. man c/o pain night overhead reaching into back seat
38 Shoulder Instability Must differentiate between shoulder dislocation and subluxation
39 Shoulder Instability: History Pathology occurs along a spectrum of severity Complaints or shoulder pain more common than instability
40 Shoulder Instability: History Does your shoulder feel loose? Have you ever dislocated your shoulder? Do you avoid placing your arm in certain positions? Do you have difficulty reaching behind you, throwing, or pushing open a heavy door? Is it difficult to lift a heavy bag?
41 Shoulder Instability: Physical Exam Apprehension test Relocation test
42 Shoulder Instability: Imaging MUST have axillary view or trans-scapular Y-view! AP alone NOT acceptable Hill-Sachs, Bankart lesion
43 Management of Instability Acute dislocation» reduction, nv assessment > 40 years old» r/o rotator cuff tear! Sling» symptomatic relief only» does not decrease recurrence rate
44 Management of Instability Re-establish early ROM Rotator cuff strengthening Recurrence rate» > 90% less than 20 years old» < 25% over 40 years old
45 Management of Instability Role for arthroscopy and early stabilization in young, athletic patients
46 SLAP Lesion Superior Labrum, Anterior to Posterior tear
47 SLAP Diagnosis Etiology: eccentric contraction of biceps muscle tears superior labrum at biceps anchor; deceleration phase of throwing; fall on outstretched arm
48 SLAP Diagnosis History» anterior shoulder pain» rotator cuff symptoms Examination» O Brien s sign» resistance in humeral adduction/flexion/ir» weakness on rotator cuff testing
49 Treatment of SLAP Lesions MRI - can be very helpful in ddx Rx: Arthroscopic repair for persistent pain/weakness
50 Biceps Rupture Proximal - long head of biceps at biceps groove or glenoid attachment Distal - biceps tuberosity at elbow
51 Treatment of Biceps Ruptures Hx: I felt a pop/tear in my arm PE: Popeye deformity; loss of elbow flexion / supination strength; tenderness Early surgical repair for distal ruptures Proximal repair - controversial;? rehab alone If surgery is needed, the earlier, the better
52 Shoulder: Fractures Clavicle Greater tuberosity Proximal humerus Physeal (children, especially throwers)
53 Case #6 72 y.o. man pain limited ROM getting worse can t sleep
54 Glenohumeral Arthritis Shoulder is typically not a weight-bearing joint Less common than in hip or knee Dx:» crepitus on ROM; limited ROM Need true AP X-ray of glenohumeral joint» Graci view
55 Glenohumeral Arthritis Mild DJD Mod DJD - NSAID s, preserve ROM -? Indication for arthroscopy Severe DJD - total shoulder arthroplasty» TSA indicated for pain, not necessarily ROM
56 Team approach: Don t hesitate to ask a colleague
57 Thank you
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