SHOULDER PAIN A Real Pain in the Neck Michael Wolk, MD Northeastern Rehabilitation Associates October 31, 2017
THE SHOULDER JOINT (S) 1. glenohumeral 2. suprahumeral 3. acromioclavicular 4. scapulocostal 5. sternoclavicular 6. costosternal 7. costovertebral
ROTATOR CUFF MUSCLES Supraspinatus attach to greater tubercle from above (Abduct) Infraspinatus attach to greater tubercle posteriorly (Ext. Rot.) Teres Minor attach to greater tubercle posteriorly (Ext. Rot.) Subscapularis attach to lesser tubercle anterior (Int. Rot.)
RANGE OF MOTION MOVEMENT Forward Flexion Extension (behind back) Abduction Adduction External rotation* Internal rotation* NORMAL RANGE 180 o 40 o 180 o (with palms up) 0 o 45 o (arm at side, elbow flexed) 55 o (arm at side, elbow flexed)
FORWARD FLEXION Arm straight and brought upward through frontal plane, and move as far as patient can go above his head 0 is defined as straight down at patient's side, & 180 is straight up
ABDUCTION Arm straight Hand palm up (arm supinated) ROM measured in degrees as for forward flexion
EXTERNAL AND INTERNAL ROTATION Arm at side, elbow flexed to 90 and held at waist Examiner externally or internally rotates arm
APLEY SCRATCH TEST FOR ER/IR* External rotation and abduction Reach for upper scapula Compare bilaterally note level reached Internal rotation and adduction Reach for lower scapula Compare bilaterally note level reached
STRENGTH TESTS Flexion Extension
STRENGTH TESTS* External rotation Infraspinatus Teres minor Internal rotation Subscapularis
STRENGTH TESTS Empty can test* Supraspinatus Lift off test* Subscapularis
SPECIAL TESTS Rotator cuff Impingement tests Speed s test Drop arm test Neer s sign Hawkin s test Biceps tendon Labral tear Instability tests O Brien s test Crank test Anterior release Relocation test
ROTATOR CUFF Empty Can Test Supraspinatus Lift off test Subscapularis integrity Drop Arm Test Rotator cuff tear or supraspinatus dysfunction
DROP ARM TEST Purpose: tears in the rotator cuff, primarily supraspinatus muscle Method: patient abducts (or examiner passively abducts) arm and then slowly lowers it May be able to lower arm slowly to 90 (deltoid function) Arm will then drop to side if rotator cuff tear Positive test: patient unable to lower arm further with control If able to hold at 90º, pressure on wrist will cause arm to fall
IMPINGEMENT NEER S SIGN* Patient seated with arm at side, palm down (pronated) Examiner standing Examiner stabilizes scapula and raises the arm (between flexion and abduction) Positive test = pain
IMPINGEMENT HAWKIN S TEST* Patient standing Examiner forward flexes shoulder to 90, then forcibly internally rotates the arm Positive test = pain in area of superior GH joint or AC joint
SPEED S TEST - BICEPS TENDON Forward flex shoulder against resistance while maintaining elbow in extension and forearm in supination Positive test = tender in bicipital groove (bicipital tendinitis)
LABRAL TEAR (SLAP) O'Brien's Active Compression Test Patient standing Arm forward flexed 90, adducted 15 to 20 with elbow straight Full internal rotation so thumb pointing down Examiner applies downward force on arm - patient resists Patient externally rotates arm so thumb pointing up Examiner applies downward force on arm - patient resists Positive test = Pain or painful clicking elicited with thumb down and decreased or eliminated with thumb up
LABRAL TEAR Crank Test Shoulder elevated to 160 in the scapular plane A gentle axial load is applied through glenohumeral joint with one hand, while other hand does IR and ER Positive test = pain, catching, or clicking in the shoulder
ROTATOR CUFF TEAR MRI ULTRASOUND
SHOULDER PATHOLOGY J Bone & Joint Surgery. 1995 March;77B(2):296-298. 1. 90 asymptomatic adults between the ages of 30 and 99 years using ultrasound 2. No statistically significant difference in the dominant arms or between genders 3. Increased prevalence as age Continued
SHOULDER PATHOLOGY J Bone & Joint Surgery. 1995 March;77B(2):296-298. 4. Partial of Full thickness tears present in: 15% 40-49 year old 35% 50-59 year old 55% 60-69 year old 75% 70-79 year old 85% 80-99 year old 5. Regard RTC tears as normal part of aging 6. Recommend treatment based on clinical findings, not on imaging results
SHOULDER PATHOLOGY J Shoulder Elbow Surgery. 1999 Jul-Aug;8(4):296-9. 411 asymptomatic volunteers u/s Tears RTC 23% overall Number Age - yrs % RTC tears Group 1 167 50-59 13 Group 2 108 60-69 20 Group 3 87 70-79 31 Group 4 49 >= 80 51
SHOULDER PATHOLOGY J Shoulder Elbow Surgery. 1999 Jul-Aug;8(4):296-9. Regard RTC tears as normal part of degeneration Not a cause of pain or functional impairment
SHOULDER PATHOLOGY "Prevalence and characteristics of asymptomatic tears of the rotator cuff: an ultrasonographic and clinical study J Bone Joint Surg Br. 2009 Feb;91(2):196-200. Moosmayer S, Smith HJ, Tariq R, Larmo A. Clinical and ultrasonographic examination of shoulders of 420 asymptomatic volunteers aged between 50 and 79 years. MRI was performed in selected cases Full-thickness tears of the rotator cuff were detected in 32 subjects (7.6%)
SHOULDER PATHOLOGY Prevalence increased with age: 50 to 59 years, 2.1% 60 to 69 years, 5.7% 70 to 79 years, 15% Tear localization was limited to the supraspinatus tendon in most cases (78%) Asymptomatic tears of the rotator cuff should be regarded as part of the normal aging process
DIAGNOSIS Recommend treatment based on clinical findings and not on imaging results Consider other diagnosis of shoulder weakness
PHYSICAL EXAM The Power Of P d
NERVES All shoulder joint muscles are innervated from the brachial plexus Lateral pectoral nerve arising from C5, C6, & C7 Pectoralis major (clavicular head) Medial pectoral nerve arising from C8 & T1 Pectoralis major (sternal head) Thoracodorsal nerve arising from C6, C7, & C8 Latissimus dorsi
NERVES Axillary nerve branching from C5 & C6 Deltoid Teres minor Sensation to lateral patch of skin over deltoid region of arm Upper subscapular nerves arising from C5 & C6 Subscapularis
NERVES Lower subscapular nerve arising from C5 & C6 Subscapularis Teres major Suprascapula nerve originating from C5 & C6 Supraspinatus Infraspinatus
NERVES Musculotaneous nerve branching from C5, C6, & C7 Coracobrachialis Sensation to radial aspect of forearm
NERVE ROOT Brachial Plexus Injuries The common mechanism for traction injuries of the brachial plexus is violent distraction of the entire arm from the rest of the body. These injuries usually result from a motorcycle accident or a high-speed motor vehicle accident. A fall from a significant height may also result in brachial plexus injury, either traction type or from a direct blow.
SYMPTOMS Pain, especially of the neck and shoulder. Pain in a nerve distribution is common with rupture, as opposed to lack of percussion tenderness with avulsion Paresthesias and dysesthesias Weakness or heaviness in the extremity
NERVE ROOT Brachial Plexus Injuries Cervical Root C5 C6 C7 C8 T1 Clinically Relevant Gross Motor Function Shoulder abduction, extension, and external rotation; some elbow flexion Elbow flexion, forearm pronation and supination, some wrist extension Diffuse loss of function in the extremity without complete paralysis of a specific muscle group, elbow extension, consistently supplies the latissimus dorsi Finger extensors, finger flexors, wrist flexors, hand intrinsics Hand intrinsics
NERVE ROOT Brachial Plexus Injuries Numbness and weakness in the upper extremity may persist. Symptoms are reproduced by extending, and side bending the neck. Function gradually returns from the proximal muscle groups to the distal muscle groups.
OUTLINE OF THE CAUSES OF PAIN FELT IN THE UPPER EXTREMITY
OUTLINE OF THE CAUSES OF PAIN FELT IN THE UPPER EXTREMITY
OUTLINE OF THE CAUSES OF PAIN FELT IN THE UPPER EXTREMITY
OUTLINE OF THE CAUSES OF PAIN FELT IN THE UPPER EXTREMITY