Is This Really a Musculoskeletal Problem?

Is This Really a Musculoskeletal Problem? UCSF Orthopedics Primary Care Sports Medicine Anthony Luke MD, MPH Annual Review in Family Medicine 2015

Disclosures Founder, RunSafe Founder & CEO, SportZPeak Inc. Sanofi, Investigator initiated grant Intel, Industry grant

Outline How do you use symptoms? LOOK - FEEL - MOVE - SPECIAL TESTS Discussion = Differential Diagnosis & Approach Neck Nerve Scapular dyskinesis Vascular -TOS Mobility

Differential Diagnosis Rotator cuff tendinopathy Rotator cuff tears SLAP Lesion Calcific tendinopathy Frozen shoulder (adhesive capsulitis) Acromioclavicular joint problems Scapular weakness Cervical radiculopathy

Red Flag Symptoms Severe disability Numbness and tingling Night pain Constitutional symptoms (fever, wt loss) Swelling with no injury Systemic illness Multiple joint injury

Case 1 Who? 15 year old male football player When? Last season What? Had a right arm stinger last year after getting hit; sometimes gets some neck pain with contact but not everytime

Impingement Signs Neer Passive full flexion Positive is reproduction of shoulder pain Sens = 83 % Spec = 51 % PPV = 40 % NPV = 89 % MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301.

Impingement Signs Hawkin s test Flex shoulder to 90º Flex elbow to 90º Internally rotate Positive - reproduce shoulder pain Sens = 88 % Spec = 43 % PPV = 38 % NPV = 90 % MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301.

Spurling s test - Cervical radiculopathy Sens = 64% Spec = 95% PPV = 58% NPV = 96%

Burners / Stingers Axial loading, hyperflexion, hyperextension or sudden rotation can cause injury to cervical spine and surrounding soft tissues

C e r v i c a l Torg Ratio = y/z = 0.8 S p i n e Atlantoaxial instability Multiple level fusion Significant cervical stenosis Consider risk of spinal cord injury during sports participation Select low risk sport Discuss with specialist

Posture Lines: ear lobeacromion-iliac crest Lordosis, kyphosis Pelvic inclination - ASIS lower than PSIS

LOOK SEADS Swelling Erythema Atrophy Deformity Surgical Scars

Suprascapular Nerve

Ulnar nerve Cubital tunnel syndrome Elbow Flexion test Tinel sign Ulnar nerve subluxation

TIPS Peripheral Neuropathy Look for occult onset of pain, weakness, numbness Might follow acute trauma Think compression or traction Look for specific muscle atrophy Check for dermatomal numbness or focal weakness 28

Case 2 Who? 48 year old female, looks exhausted What? Has had severe 12/10 pain When? 2 nights Where? Diffuse shoulder pain, will NOT let you move it How? No trauma, woke with the pain

WHAT DO YOU DO? 30

Impingement/Rotator Cuff Tears Partial Cuff Tear Full Thickness Tear Impingement

Calcific tendinosis 32

Calcific Tendinosis Severe acute pain in shoulder Patient unwilling to move shoulder X-ray may show calcium deposits Ultrasound more sensitive than MRI Can consider subacromial steroid injection

Tendon Pain May be present at the start of an activity then warm-up Sore when the muscle is used May occur in compensation for other structural problems near by Check for underlying spondyloarthropathy: Psoriasis, GI symptoms, STD

3 Basic P/E findings for tendinopathy 1. Tenderness on direct palpation 2. Reproduction of pain with resisted contraction (eccentric loading) 3. Reproduction of pain with passive stretch

Elbow Tendinopathies Lateral epicondylosis Tender lateral epicondyle Resisted third digit extension Resisted wrist extension Medial epicondylosis Resisted pronation/wrist flexion Distal biceps Resisted supination

Bone Pain Constant Sharp Greater load = greater pain (i.e. weightbearing) May have pressure features

Greater tuberosity fractures Indications for Greater tuberosity fractures > 2 mm Isolated axillary nerve injury Subacromial impingement (common)- due to displacement of fragment or even scar tissue formation, especially extension and external rotation Green A, Norris TR. Skeletal Trauma: Basic science, management, and reconstruction (3rd edition). Elsevier Science, 2003, p. 1558.

Other problems in the area Acromioclavicular joint osteoarthritis Sternoclavicular joint injuries Osteolysis of the distal clavicle

Acromioclavicular Joint Swelling, tenderness +/- step deformity over AC joint Cross over sign Sens = 64% Spec = 95% PPV = 58% NPV = 96%

Take Home Points - Symptoms Ask More About Function (as well as Pain) How does this problem affect your day to day function? What can t you do that makes this a problem? If you could take this problem away immediately (magic), how would your life be? 41

Case 3 Who? 40 year old male with R anterior shoulder and scapular pain and winging What? Pain with overhead activities and sleeping When? He has had pain progressively worsening over 6 months How? Had an injury skiing around 6 months ago but only vague history; Works as auto mechanic Where? Shoulder radiating to lateral arm

Winging Long Thoracic Nerve Serratus Anterior Less common Spinal Accessory Nerve (trapezius) Dorsal Scapular Nerve (rhomboids) Scapular Dyskinesis MOST COMMON Pain may alter mechanics or vice versa

Scapular Dynamic Stabilizers Levator scapulae Trapezius muscle Serratus anterior Rhomboids Latissimus dorsi Pectoralis minor

Scapulohumeral Rhythm Ratio of Scapular to Humeral movement Occurs via coupled movement of the scapular muscles Through elevation, scapula upwardly rotates, posteriorly tilts and externally rotates

Observation Rest Range of Motion Function!! Asymmetry Four point palpation

MOVE Painful Arc 60-120 Flexion and External rotation

MOVE External rotation Internal rotation

Diagnosis?

Rotator Cuff strength testing Supraspinatus Empty can Thumbs down abducted to 30º Horizontally adduct to 30º For tendonitis Sens = 77 % Spec = 38 % For tears, Sens = 19 % Spec = 100 % Naredo et al. Ann Rheum Dis, 2002; 61: 132-136.

Rotator Cuff strength testing Infraspinatus/teres minor - External rotation Keep elbows at 90º Patte s test at 90º shoulder abduction For tendonitis, Sens = 57 % Spec = 71 % For tears, Sens = 36 % Spec = 95 % Naredo et al. Ann Rheum Dis, 2002; 61: 132-136.

Rotator Cuff Tear vs Impingement? Difficulty lifting Pain vs weakness? Drop arm sign Fail conservative Tx Tears uncommon < 40 y.o. Sens = 10 % PPV = 100 % Bryant et al. J Shoulder Elbow Surg, 2002; 11: 219-224.

Take Home Points Scapular dyskinesis is common as a pattern of dysfunction, more than neurogenic winging Use impingement signs to rule in shoulder problems Rotator cuff strength tests help diagnose shoulder issues

Case 4 Who? 38 year old female secretary What? Neck pain with radiating pain to the right elbow and right arm numbness and some ulnar nerve symptoms When? She has had worsening pain over 3 months How? Talking on her phone is painful, sleeping is sore Where? Numbness to 4 th and 5 th fingers

Case 4 LOOK 5 5, 130 pounds Rolled forward shoulder posture, head forward posture FEEL Tender over cervical spine near R C7 facet joint MOVE C-spine - ROM 45 flexion 40 extension painful; right rotation 50 left rotation 70 ROM shoulder 180 flexion bilaterally SPECIAL TESTS Rotator cuff strength 5/5 Neer and Hawkin s negative test Spurling s test positive Roos test positive, Adson s positive on right Elbow flexion test positive Tinel s sign negative U/E 5/5, Reflexes normal, sensation intact to light touch

Sudden Death Round Thoracic Outlet syndrome Repetitive upper extremity use shoulder, elbow, hand assembly line computer with mouse and phone Poor posture Reaching Stress Apical breathing

Thoracic Outlet Syndrome tests Possible compression of the subclavian artery between the scalenes and any cervical rib Compression of neurovascular symptoms in the upper extremity by the pectoralis minor

Adson s Test Seated patient extends and turns head toward the tested shoulder Shoulder is abducted and extended. Subject inhales while the examiner palpates the ipsilateral radial pulse. Positive findings: Diminution or elimination of the pulse and reproduction of the paresthesias Studies show poor to good specificity and good sensitivity.

Wright s Hyperabduction Test With patient seated, the clinician hyperabducts and externally rotates the patient s arm while assessing the ipsilateral radial pulse Positive findings: Diminution or elimination of the radial pulse and reproduction of the paresthesias No studies have examined validity

Roos Stress Test Patient holds shoulders in abduction and external rotation at 90 degrees with elbows flexed at 90 degrees and repeatedly open and close their hands for three minutes. Positive findings: Reproduction of their symptoms or a sensation of heaviness and fatigue. No studies have examined validity of the Roos stress test as it pertains to thoracic outlet syndrome.

Case 4 Who? 38 year old female secretary What? Neck pain with radiating pain to the right elbow and right arm numbness and some ulnar nerve symptoms When? She has had worsening pain over 3 months How? Talking on her phone is painful, sleeping is sore Where? Numbness to 4 th and 5 th fingers

What is Normal Flexibility? Flexibility is the range of motion available at a joint or series of joints Hypermobility vs. Hypomobility Spectrum like hypertension

Modified Marshall Test Micheli Score Look at passive thumb abduction of the right hand Grade 1 = 0 Grade 2 = 45 Grade 3 = 90 Grade 4 = 135 Grade 5 = thumb touches forearm Can use + or for in between grades

Common Pictures Hyperlaxity OVERUSE & Postural problems Associations with subluxation of the hip, patella, shoulder, and proximal cervical spine, osteoarthritis, chondrocalcinosis, Bad sprains Tight Patellofemoral syndrome, hamstring and quad strains Tendinopathies Osgood-Schlatter s disease, Sever s disease and peripelvic apophyseal avulsion fractures

Multidirectional instability

Stability Tests Sulcus sign (MDI) No Sens / Spec Data

Subtalar Tilt test

Posture Lines: ear lobeacromion-iliac crest Lordosis, kyphosis Pelvic inclination - ASIS lower than PSIS

Rehab, rehab, rehab Strengthening Core stability Postural exercises Upper Back Proprioception exercises Endurance / conditioning Ergonomic assessment at work? Chronic pain

Take Home Points Always think about Posture Check for flexibility Consider hypermobility syndrome Use physical therapy

You may not have seen it, but it has seen you. Problem with Look, Feel, Move? Worry especially if problems greater than 6 months No relief or worse with physiotherapy Internal derangement symptoms