Approach To Overuse Related Shoulder Injuries

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  • Approach To Overuse Related Shoulder Injuries

    1. 1. Approach to overuse related shoulder injuries Dausen Harker MD Family Medicine
    2. 2. Objectives <ul><li>Epidemiology Review </li></ul><ul><li>Shoulder anatomy review </li></ul><ul><li>Common causes of shoulder pain </li></ul><ul><li>General approach to exam </li></ul><ul><li>Special tests </li></ul>
    3. 3. Epidemiology <ul><li>2 nd most common orthopedic problem in primary care sports medicine (second to knee injury) </li></ul><ul><li>Young athletes with overuse injuries is increasing </li></ul><ul><li>Overuse injuries common in military population </li></ul><ul><li>Most common overuse injuries </li></ul><ul><ul><li>Rotator Cuff Pathology </li></ul></ul><ul><ul><li>Impingement </li></ul></ul><ul><ul><li>Glenohumeral Instability/Labrum Tears </li></ul></ul><ul><ul><li>Biceps Tendonitis </li></ul></ul><ul><ul><li>AC Joint Pathology </li></ul></ul>
    4. 4. Anatomical structures <ul><li>Please review images of shoulder anatomy prior to or while viewing slides </li></ul><ul><li>Major anatomical components involved in shoulder pain </li></ul><ul><ul><li>Rotator cuff muscles and tendons </li></ul></ul><ul><ul><li>AC joint </li></ul></ul><ul><ul><li>Glenoid and labrum </li></ul></ul><ul><ul><li>Biceps tendon </li></ul></ul><ul><ul><li>Skeletal components of shoulder </li></ul></ul><ul><ul><li>Shoulder related bursa </li></ul></ul>
    5. 5. Evaluation <ul><li>Every shoulder exam should include: </li></ul><ul><ul><li>Appearance </li></ul></ul><ul><ul><li>Range of Motion </li></ul></ul><ul><ul><ul><li>Active vs Passive </li></ul></ul></ul><ul><ul><li>Palpation </li></ul></ul><ul><ul><li>Neurological testing </li></ul></ul><ul><ul><li>Special tests </li></ul></ul>
    6. 6. Rotator Cuff Injury <ul><li>One of the most common causes of shoulder pain </li></ul><ul><li>Involves “ SITS minor ” muscles </li></ul><ul><li>Includes tendonitis and tears </li></ul>
    7. 7. Rotator Cuff Injury <ul><ul><li>Tendonitis : </li></ul></ul><ul><ul><ul><li>Most common condition among pt’s with shoulder complaints—especially >30 y/o </li></ul></ul></ul><ul><ul><ul><li>Supraspinatous or infraspinatous </li></ul></ul></ul><ul><ul><ul><li>Repetitive over head activity most common cause </li></ul></ul></ul><ul><ul><ul><li>Pain </li></ul></ul></ul><ul><ul><ul><ul><li>Worse with reaching and over head activity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>May awaken pt at night </li></ul></ul></ul></ul><ul><ul><ul><li>Associated with increased risk of tear </li></ul></ul></ul>
    8. 8. Rotator Cuff Injury <ul><ul><li>Tears : </li></ul></ul><ul><ul><ul><li><30 y/o: <1% of shoulder injury are complete tears </li></ul></ul></ul><ul><ul><ul><li>>45 y/o: ~35% of shoulder injury are tears </li></ul></ul></ul><ul><ul><ul><li>Supraspinatous and Infraspinatous </li></ul></ul></ul><ul><ul><ul><li>Common mechanisms of injury </li></ul></ul></ul><ul><ul><ul><ul><li>Fall on an outstretched arm </li></ul></ul></ul></ul><ul><ul><ul><ul><li>direct blow to shoulder </li></ul></ul></ul></ul><ul><ul><ul><ul><li>rapid acceleration </li></ul></ul></ul></ul><ul><ul><ul><li>Associated with chronic impingement, tendon degeneration or trauma </li></ul></ul></ul><ul><ul><ul><li>Clinical signs: Weakness, loss of shoulder function, and symptoms of tendonitis </li></ul></ul></ul>
    9. 9. Special Tests <ul><li>Drop Arm Test </li></ul><ul><li>Supraspinatous Strength Test </li></ul><ul><li>Lift Off Test </li></ul><ul><li>90 0 elbow flexion with external arm rotation and resistance </li></ul>
    10. 10. Drop Arm Test <ul><li>Slowly lower fully ABducted arm </li></ul><ul><li>Active pressure may be applied at 90 0 ABduction </li></ul><ul><li>Positive test indicated by inability to keep arm ABducted at 90 0 </li></ul><ul><li>Indicates rotator cuff tear </li></ul>
    11. 11. Supraspinatous Strength Test <ul><li>Shoulder ABducted to 90 0 with 30 0 of forward flexion and arm pronation (thumb down) </li></ul><ul><li>Isolates supraspinatous </li></ul><ul><li>Positive test if asymmetric weakness or inability to maintain arm position </li></ul>
    12. 12. Lift Off Test <ul><li>Dorsum of hand on back and push outward against resistance (isolates internal rotation) </li></ul><ul><li>Isolates subscapularis </li></ul><ul><li>Positive test indicated by asymmetric inability to lift hand from back </li></ul>
    13. 13. External Rotation <ul><li>Elbow flexed to 90 0 with active resistance to external rotation </li></ul><ul><li>Isolates infraspinatous and teres minor </li></ul><ul><li>Positive test indicated by asymmetric weakness </li></ul>
    14. 14. Impingement <ul><li>Describes compression of rotator cuff tendons and subacromial bursa between bony structures </li></ul><ul><li>Mechanisms of injury: Rounded shoulders, poor muscle development, repetitive over head motion </li></ul><ul><li>Presentation nearly identical to rotator cuff injury </li></ul>
    15. 15. Special Tests <ul><li>Hawkins Test </li></ul><ul><li>Neers Test </li></ul>
    16. 16. Special Tests <ul><li>Hawkins Test </li></ul><ul><ul><li>90 0 forward flexion, 45-90 0 elbow flexion and passive internal rotation </li></ul></ul><ul><ul><li>Drives greater tuberosity into coracoacromial arch </li></ul></ul><ul><ul><li>Positive test indicated by pain </li></ul></ul><ul><ul><li>More sensitive than Neers test for impingement </li></ul></ul>
    17. 17. Special Tests <ul><li>Neer Test </li></ul><ul><ul><li>Arm internally rotated while fully extended and forward flexion to 180 0 </li></ul></ul><ul><ul><li>Positive test indicated by pain with motion </li></ul></ul>
    18. 18. Glenohumeral Instability/Labral tears <ul><li>GHI </li></ul><ul><ul><li>Characteristic group: Women, poor muscular development, large Rotator cuff tears, athletes < 40 (especially swimmers, throwers) </li></ul></ul><ul><ul><li>Clinical presentation: Vague symptoms, may see excessive ROM </li></ul></ul><ul><ul><li>TUBS: Traumatic, Unidirectional instability, Bankart lesion (glenoid labrum tear), frequently require Surgery </li></ul></ul><ul><ul><li>AMBRI: Atraumatic, Multidirectional shoulder laxity Bilaterally, usually responds to Rehabilitation, when sugery is necessary it involves tightening of Inferior capsule </li></ul></ul>
    19. 19. Glenohumeral Instability/Labral Tears <ul><li>LT </li></ul><ul><ul><li>Caused by similar mechanism as rotator cuff injuries </li></ul></ul><ul><ul><li>Greatest risk with repetitive overhead activities </li></ul></ul><ul><ul><li>Clinical presentation: Deep shoulder pain, catching sensation, instability </li></ul></ul>
    20. 20. Special Tests <ul><li>GHI </li></ul><ul><ul><li>Sulcus Sign </li></ul></ul><ul><ul><li>Apprehension Test </li></ul></ul><ul><ul><li>Anterior/Posterior Drawer Test </li></ul></ul><ul><li>LT </li></ul><ul><ul><li>Crank Test </li></ul></ul>
    21. 21. Special Tests <ul><li>Sulcus Sign </li></ul><ul><ul><li>Arm relaxed, neutral position with downward traction at wrist </li></ul></ul><ul><ul><li>Positive indicated by development of sulcus </li></ul></ul><ul><ul><li>Important to assess symmetry of test </li></ul></ul><ul><ul><li>Sulcus sign recorded as cm of sulcus </li></ul></ul>
    22. 22. Special Tests <ul><li>Apprehension Test </li></ul><ul><ul><li>Supine position, 90 0 ABduction, neutral rotation </li></ul></ul><ul><ul><li>Apply slight leverage at proximal humerus while externally rotating </li></ul></ul><ul><ul><li>Positive test indicated by pt apprehension that shoulder will give way </li></ul></ul>
    23. 23. Special Tests <ul><li>Anterior/Posterior Drawer Test </li></ul><ul><ul><li>Best to have patient in supine position </li></ul></ul><ul><ul><li>Humeral head slid anteriorly and posteriorly in glenoid while scapula is stabilized </li></ul></ul><ul><ul><li>Positive test with painful click/clunk, apprehension or increased movement compared to other shoulder </li></ul></ul>
    24. 24. Special Tests <ul><li>Crank Test </li></ul><ul><ul><li>Pt supine or seated with arm elevated to 160 0 </li></ul></ul><ul><ul><li>Force applied along axis with internal and external rotation </li></ul></ul><ul><ul><li>Drives humeral head against labrum </li></ul></ul><ul><ul><li>Positive test if pain is reproduced or catching +/- click is noted </li></ul></ul>
    25. 25. Biceps Tendonitis <ul><li>Inflammation of long head of biceps as it passes through bicipital groove </li></ul><ul><li>Assoc with repetitive lifting or overhead activity that leads to inflammation </li></ul><ul><li>Can lead to spontaneous rupture (10%) </li></ul><ul><li>Pain aggravated by lifting, carrying bags or overhead reaching; </li></ul><ul><li>pt often localizes pain directly to bicipital groove </li></ul>
    26. 26. Special Tests <ul><li>Speed Test </li></ul><ul><li>Yergason Test </li></ul>
    27. 27. Special Tests <ul><li>Speed Test </li></ul><ul><ul><li>Shoulder forward flexed to 60 0, arm flexed to 30 0 and supinated </li></ul></ul><ul><ul><li>Downward force applied to distal forearm </li></ul></ul><ul><ul><li>Positive test indicated by pain or weakness </li></ul></ul>
    28. 28. Special Tests <ul><li>Yergason Test </li></ul><ul><ul><li>Arm neutral, elbow flexed to 90 0 </li></ul></ul><ul><ul><li>Pt attempts to supinate and flex elbow against resistance </li></ul></ul><ul><ul><li>Positive test indicated pain or a “painful pop” </li></ul></ul>
    29. 29. AC Joint Pathology <ul><li>Injury type: Sprain, partial or complete tear </li></ul><ul><li>Associated with overuse (reaching across chest or overhead) or trauma (especially falls on tip of shoulder) </li></ul><ul><li>Associated with anterior shoulder pain </li></ul><ul><li>Pt usually localize pain directly to AC joint (i.e. pt will point to AC joint) </li></ul>
    30. 30. Special Tests <ul><li>Cross Chest ADduction Test (Cross Arm Test) </li></ul><ul><ul><li>Forward flexed to 90 0 and hand to opposite shoulder </li></ul></ul><ul><ul><li>Examiner hyperADducts shoulder </li></ul></ul><ul><ul><li>Positive test indicated by pain at AC joint </li></ul></ul><ul><ul><li>May be false + with impingement </li></ul></ul>
    31. 31. Summary <ul><li>Shoulder injury common in primary care sports medicine </li></ul><ul><li>Difficult exam due to complexity of shoulder </li></ul><ul><ul><li>Made easier by following step wise approach </li></ul></ul><ul><li>The Big 5’s </li></ul><ul><ul><li>Overuse Injuries: Rotator cuff pathology, Impingement, GHI/LT, Biceps tendonitis, AC joint pathology </li></ul></ul><ul><ul><li>Physical Exam: Appearance, ROM, Palpation, Neurologic, Special Tests </li></ul></ul>
    32. 32. Summary Special Tests <ul><li>Rotator Cuff </li></ul><ul><ul><li>Drop Arm Test </li></ul></ul><ul><ul><li>Supraspinatous Strength Test </li></ul></ul><ul><ul><li>Lift Off Test </li></ul></ul><ul><ul><li>External Rotation </li></ul></ul><ul><li>Impingement </li></ul><ul><ul><li>Hawkins Test </li></ul></ul><ul><ul><li>Neer’s Test </li></ul></ul><ul><li>GHI </li></ul><ul><ul><li>Sulcus Sign </li></ul></ul><ul><ul><li>Apprehension Test </li></ul></ul><ul><ul><li>Anterior/Posterior Drawer Test </li></ul></ul><ul><li>LT </li></ul><ul><ul><li>Crank Test </li></ul></ul><ul><li>Biceps Tendonitis </li></ul><ul><ul><li>Speed Test </li></ul></ul><ul><ul><li>Yergason Test </li></ul></ul><ul><li>AC Joint </li></ul><ul><ul><li>Cross Arm Test </li></ul></ul>
    33. 33. Resources <ul><li>Anderson, Bruce. “Acromioclavicular Injury.” UpToDate®. www.uptodate.com . ©2006. Howard, </li></ul><ul><li>Anderson, Bruce. “Biceps Tendonitis and Rupture.” UpToDate®. www.uptodate.com . © 2006. </li></ul><ul><li>Anderson, Bruce. “Multidirectional Instability of the Shoulder.” UpToDate®. www.uptodate.com . ©2006. </li></ul><ul><li>Anderson, Bruce. “Rotator Cuff Tendonitis.” UpToDate®. www.uptodate.com . © 2006 </li></ul><ul><li>Anderson, Bruce and Michael Roberts. “Shoulder Impingement Syndrome.” UpToDate®. www.uptodate.com . ©2006. </li></ul><ul><li>Anderson, Bruce and Ronald Anderson. “Evaluation of the Patient with Shoulder Complaints.” UpToDate®. www.uptodate.com . © 2006. </li></ul><ul><li>Anderson, Bruce, et. al. “Rotator Cuff Tear.” UpToDate®. www.uptodate.com . © 2006. </li></ul><ul><li>Cassas, Kyle J. and Amelia Cassettari-Wayhs. “Childhood and Adolescent Sports-Related Overuse Injuries.” American Family Physician. March 2006. Vol 73, No. 6. pp 1014-1022. </li></ul><ul><li>Thomas M., Francis G. O’Conner. “The Injured Shoulder. Primary Care Assessment.” Archives of </li></ul><ul><li>Family Medicine July/August 1997, Vol. 6. pp 376-384 </li></ul>

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