C. Christopher Smith, M.D. Associate Professor of Medicine Harvard Medical School Beth Israel Deaconess Medical Center

Evaluation and Treatment of the Painful Shoulder in the Primary Care Setting C. Christopher Smith, M.D. Associate Professor of Medicine Harvard Medical School Beth Israel Deaconess Medical Center

A 65-year-old woman with a history of type II DM presents for evaluation of new left shoulder pain. The pain is in her anterior and lateral shoulder and has gradually worsened over the last three weeks. It is dull and constant and keeps her up at night. She also notices marked discomfort when she combs her hair and cannot get sweaters from the top of her closet due to pain and weakness. She denies any trauma or prior injuries. She works as an investment banker.

The Painful Shoulder Recognize, diagnose and treat the most common cause of shoulder pain in the primary care setting Know how to differentiate it from other common causes of shoulder pain

The Painful Shoulder Anatomy History Differential based on patient s age and location of pain Physical exam maneuvers Initial treatment

Anatomy of the Shoulder UpToDate, 2006

The Rotator Cuff Muscles UpToDate, 2006

Causes of Shoulder Pain Acromioclavicular Osteoarthritis Adhesive Capsulitis Biceps Tendonitis Brachial Plexus Neuritis Cervical Radiculopathy Glenohumeral Arthritis Instability Impingement Syndrome Systemic Inflammatory Disorders Referred Pain - Diaphragmatic, Subdiaphragmatic and Intrathoracic Causes

In the primary care setting, what is the most common cause of nontraumatic shoulder pain? A. Bicipital Tendonitis B. Impingement Syndrome C. Adhesive Capsulitis (Frozen Shoulder) D. Osteoarthritis of the Glenohumeral Joint E. Acromioclavicular Joint Osteoarthritis

Causes of Shoulder Pain in the Primary Care Setting: Impingement Syndrome > 70% Adhesive Capsulitis 12% Bicipital Tendonitis 4% A/C Joint OA 7% Other 7% Smith, J Gen Intern Med, 1992

So what is impingement syndrome?

Impingement Syndrome UpToDate, 2006

Typical History of Impingement Syndrome Any age, but risk increases with age Anterior or lateral shoulder pain Pain exacerbated by abduction and forward flexion Night pain common

Age and Shoulder Pain Young (< 30 y.o.) Dislocations/Instability of Glenohumeral Joint Separation of AC joint Overuse injury Less Young (30-60 y.o.) Impingement Syndrome Adhesive Capsulitis (especially in diabetics) Separation/Overuse as above Older (> 60 y.o.) Impingement Syndrome (non-traumatic tears) Adhesive Capsulitis Systemic Conditions (if bilateral, PMR, RA)

Physical Examination Inspection Palpation

Physical Examination Inspection Palpation Range of Motion Passive and Active Strength and Sensation Specific Maneuvers to Confirm Diagnosis

Maneuvers to Verify Impingement Syndrome http://www.clinicalexams.co.uk/painful-arc-syndrome.asp Painful arc

Maneuvers to Verify Impingement Syndrome Empty Can Test

Maneuvers to Verify Impingement Syndrome Neer s Test Neer, Clin Orthop 1983

Maneuvers to Verify Impingement Syndrome Hawkins Test Hawkins, Am J Sports Med 1980

A 65-year-old woman with a history of type II DM presents for evaluation of new left shoulder pain. The pain is in her anterior and lateral shoulder and has gradually worsened over the last three weeks. It is dull and constant and keeps her up at night. She also notices marked discomfort when she combs her hair and cannot get her sweaters from the top of her closet due to pain and weakness. She denies any trauma or prior injuries. She works as an investment banker.

On inspection, her left humerus was riding slightly higher than her right. There was pain with palpation of the lateral subacromial space. ROM revealed pain with abduction and forward flexion; it was worse with active than passive movement. Positive empty can, Neer and Hawkins test.

What is the most appropriate initial treatment for this patient? A. NSAIDs alone B. NSAIDs with Physical Therapy C. Subacromial Steroid Injection with PT D. NSAIDs plus Steroid Injection E. Orthopedic consultation

Treatment Reduce offending activities Physical Therapy Aimed at improving mechanical dysfunction and shoulder motion NSAIDs or Subacromial injection Each is better than placebo Little long term difference No benefit in combination treatment White, J Rheumatol 1986 Petri, Arthritis Rheum 1987

You passively abduct the arm to 160 degrees and ask the patient to slowly lower her arm. At approximately 90 degrees, she is unable to continue to lower her arm due to weakness and she drops it to her side.

What is your diagnosis now? A. Bicipital Tendonitis B. Impingement Syndrome C. Adhesive Capsulitis (Frozen Shoulder) D. Tear of Supraspinatus Tendon E. Glenohumeral Joint Osteoarthritis

Supraspinatus Tendon Tear Positive Drop-Arm Test Supraspinatus weakness External Rotation weakness Impingement Signs Greater than 60 years old Murrell, Lancet 2001

Diagnosing Rotator Cuff Tear # Positive signs* Age Probability of rotator cuff tear All 3 Any 98% Any 2 > 60 98% Any 2 < 60 64% Any 1 > 70 76% Any 1 < 40 12% None Any 5% * supraspinatus weakness, weakness in external rotation, positive impingement signs Murrell, Lancet 2001

Diagnosis of Rotator Cuff Tear http://seattleclouds.com/myapplications/albertosh/shoulder/exploramanguito.html Internal Rotation Lag Sign

http://www.youtube.com/watch?v=7usacorkquk External Rotation Lag Sign

Clinical Tests for Rotator Cuff Disease and Tears Test + LR - LR Painful Arch (RCD) 3.7 0.36 Drop Arm (RCD) 3.3 0.82 External Resistance (RCD) 2.6 0.49 External Lag (Full Tear) 7.2 0.57 Internal Lag (Full Tear) 5.6 0.04 RCD=Rotator Cuff Disease Hermans. JAMA, 2013

Diagnosis of Rotator Cuff Tear Internal Rotation Lag Sign

External Rotation Lag Sign

A 55-year-old male with IDDM, HTN and GERD presents with three months of worsening left lateral shoulder pain, which is worse at night. He reports pain with most any movement. Range of motion testing reveals pain and restricted movement in most directions. Symptoms are present with both passive and active movement.

Adhesive Capsulitis or Frozen Shoulder Thickening and contraction of the capsule surrounding the glenohumeral joint Insidious onset of pain Night pain Pain in deltoid, but no tenderness to palpation Pain and limited active and passive ROM Need AP X-ray of glenohumeral joint to rule out glenohumeral arthritis Treatment: Physical Therapy

What is the most significant risk factor for adhesive capsulitis? A. Diabetes B. Hypothyroidism C. Immobility D. AVN of glenohumeral head E. Reflex sympathetic dystrophy

46 year old male who moves furniture on the weekends and works as a handyman during the week, presents with right anterior shoulder pain. The pain began after a particularly heavy move, where he moved over a hundred boxes. No fever, chills, night sweats; no weakness or numbness. No prior injuries. He points to his anterior shoulder with one finger. He has a normal ROM and good strength and positive Yergason and Speed s tests.

What is your diagnosis? A. Bicipital Tendonitis B. Impingement Syndrome C. Adhesive Capsulitis (Frozen Shoulder) D. Tear of Supraspinatus Tendon E. Glenohumeral Joint Osteoarthritis

Anterior View of Shoulder UpToDate, 2006

Biceps Tendonitis Inflammation of long head of the biceps tendon 95% associated with impingement syndrome Repetitive lifting, overhead reaching or forearm supination Anterior humeral pain Tenderness in bicipital groove Exacerbated with resisted elbow flexion or forearm supination Yergason and Speed s Tests Impingement signs Treatment Rest, restriction of lifting, reaching and supination Anti-inflammatory therapy & Ice Physical Therapy Holtby, Arthroscopy 2004

Yergason Test Evaluate biceps tendon by palpating bicipital groove while patient flexes elbow to 90 degrees and supinates against resistance Woodward, Am Fam Phys 2000

Speed s Test With elbow extended and hand supinated, palpate bicipital groove while patient attempts to forward flex shoulder 30 degrees against resistance Siegel, Am Fam Phys 1999

A 62 year old man was pulling a dead branch from a tree when he felt a sudden pain in his upper arm and heard an audible snap. Now, two weeks later, he has no pain and only minimal loss of strength. His exam is significant for the finding below. Which is the most likely diagnosis? A. Rotator cuff strain B. Proximal biceps tendon rupture C. Distal biceps tendon rupture D. Biceps tendonitis

Biceps Tendon Tear Proximal aspect of long head of biceps tendon After especially vigorous lifting Often in setting of chronically inflamed tendon Weakness of elbow flexion/supination Popeye Sign - bulge just proximal to antecubital fossa Risk Factors: Recurrent tendonitis Prior tear of rotator cuff or biceps Age > 50 RA

A proximal bicipital tendon tear can usually be treated conservatively, avoiding surgery. A. True B. False

Summary Impingement syndrome most common cause of shoulder pain in the primary care setting Systematic approach to physical exam Range of Motion: pain with abduction, forward flexion; active > passive; painful arc Empty can, Neer, Hawkins tests to confirm Drop arm, internal and external lag signs indicate a complete tear - especially in patients > 60 years old

Summary Adhesive Capsulitis DM or Immobile shoulder Limited ROM in most planes Pain with both active passive ROM Biceps Tendonitis Associated with impingement syndrome Reproduced with Yergason and Speed s tests Popeye sign for biceps tendon tear

Summary A careful history and physical examination can correctly diagnose most common causes of shoulder pain. http://jama.jamanetwork.com/multimediaplayer. aspx?mediaid=5975016

Questions from the Audience?