The Painful Adult Shoulder: evidence based history, exam and approach
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The Painful Adult Shoulder: evidence based history, exam and approach

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The Painful Adult Shoulder: evidence based history, exam and approach

The Painful Adult Shoulder: evidence based history, exam and approach

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  • Palm placed on the opposite <br /> shoulder and fingers extended Examner pulls the patient’s hand from the shoulder <br />
  • Poor likelihood ratios that were weak and contained the null value <br />
  • Usually rotator cuff problems in older patients <br />
  • US equivalent to MRI in eval of Rotator cuff tears. <br />

The Painful Adult Shoulder: evidence based history, exam and approach The Painful Adult Shoulder: evidence based history, exam and approach Presentation Transcript

  • Aaron Gray, MD Departments of Family Medicine and Orthopaedics University of Missouri
  • Lecture Objectives  Discuss history and examination of the shoulder and review evidence  Identify evidence based indications for diagnostic imaging tests for shoulder pain
  • Overview  Taking a History of a Painful Shoulder  Review of Shoulder Anatomy  Physical Exam of the Shoulder  Imaging of the Shoulder  Diagnosis and Treatment of Specific Shoulder Injuries
  • History  Age Less than 35 – Impingement, tendonitis, instability Over 50 – Glenohumeral arthritis, adhesive capsulitis, rotator cuff tear  Onset and Duration of Symptoms Acute vs Gradual  Mechanism of Injury Trauma – fall Repetitive activities such as an overhead motion  Recent increase in activity?  Pain at night?
  • History  Location of Pain Often unhelpful  Radiation of pain?  Weakness or Stiffness?  Activities that worsen pain? Fixing hair, snapping bra, pulling out a wallet, reaching overhead  Sports, Hobbies, Occupation that involve the shoulder
  • Shoulder Anatomy 3 Bones Humerus Scapula Clavicle 3 Joints Glenohumeral Acromioclavicular Sternoclavicular 1 Articulation Scapular
  • Golf Ball on a Golf Tee
  • Bony Anatomy - Scapula Acromion Coracoid Glenoid Subscapular fossa Supraspinatus fossa Scapular spine Infraspinatus fossa
  • Glenoid Labrum
  • Subacromial Space The area under the acromion and above the glenohumeral joint Structures • Supraspinatus muscle • Subacromial/subdeltoid bursa Subacromial Bursa Supraspinatus Sobotta (2002) Small Space • Impingement
  • Rotator Cuff Muscle Actions • Supraspinatus o Abduction • Infraspinatus o External rotation • Teres Minor o External rotation Infraspinatus Teres minor Supraspinatus Posterior View
  • Rotator Cuff Muscle Actions • Subscapularis: o Internal rotation o Adduction Subscapularis Anterior View
  • Research on Diagnostic Accuracy of Shoulder Exam Is A Common Story…
  • Cochrane Database Review 2013 – Hanchard, et al.  Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement.  33 studies involving 4002 shoulders
  • Cochrane Database Review 2013 – Hanchard, et al.  There is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.
  • Physical Exam of the Shoulder • Inspection • Palpation • Range of Motion • Strength • Neurovascular status • Provocative Shoulder Testing • The joint above and below (i.e. neck and elbow)
  • Inspection and Examination of Posterior Shoulder
  • Physical Exam of the Shoulder • Inspection • Palpation • Range of Motion • Strength • Neurovascular status • Provocative Shoulder Testing • The joint above and below (i.e. neck and elbow)
  • ABduction: 180° ADduction: 0° Movements at the Shoulder Joint
  • Rotation InternalExternal (Mid thoracic)(60-80°) Movements at the Shoulder Joint
  • Forward Flexion: 180° Extension: 60° Movements at the Shoulder Joint
  • Physical Exam of the Shoulder • Inspection • Palpation • Range of Motion • Strength • Neurovascular status • Provocative Shoulder Testing • The joint above and below (i.e. neck and elbow)
  • Strength Testing Basics • Compare to unaffected side • Differentiate between true weakness and weakness secondary to pain
  • Muscle Testing Infraspinatus/Teres Minor • Patient’s arms adducted at sides • Elbows flexed to 90° • Patient attempts external rotation against examiner’s resistance
  • Muscle Testing Subscapularis Lift-off test o Internally rotate shoulder o Dorsum of hand against lower back o Patient attempts to push away examiner’s hand Belly Press Test Bear Hug Test
  • Muscle Testing Supraspinatus “Jobe’s Test” or “Empty Can Test” • 90° abduction • 30° forward flexion • Thumbs pointing downward • Patient attempts elevation against examiner’s resistance
  • Physical Exam of the Shoulder • Inspection • Palpation • Range of Motion • Strength • Neurovascular status • Provocative Shoulder Testing • The joint above and below (i.e. neck and elbow)
  • Neurovascular Testing • Distal pulses • Capillary refill • Sensation www.swipnet.se, accessed 10/2005
  • Physical Exam of the Shoulder • Inspection • Palpation • Range of Motion • Strength • Neurovascular status • Provocative Shoulder Testing • The joint above and below (i.e. neck and elbow)
  • Impingement Signs Neer Test • Scapula stabilized • Arm fully pronated • Examiner brings shoulder into maximal forward flexion • Pain suggests Subacromial Impingement
  • Impingement Signs Hawkins Test • Patient’s arm forward flexed to 90° • Elbow flexed to 90° • Shoulder forcibly internally rotated by examiner • Pain suggests Subacromial Impingement
  • AC joint Crossover Test • Patient forward flexes affected arm to 90° • Actively adducts arm across body • Forces acromion into distal end of clavicle • Suggests AC joint pathology if painful
  • Sensitivity/Specificity  Neer Impingement Sensitivity: 72% Specificity: 60%  Hawkins-Kennedy Impingement Sensitivity: 79% Specificity: 59% Hegedus. British J Sports Med, 2012.
  • Biceps Tendon/Labrum Speed’s Test • Elbow flexed 20°- 30° • Forearm supinated • Arm in 60° flexion • Patient forward flexes arm against examiner’s resistance
  • Biceps Tendon/Labrum Yergason’s Test • Elbow flexed to 90° with thumb up • Grasp hand (hand shake) • Patient supinates against resistance
  • Labral signs O’Brien Test • Arm forward flexed to 90° • Elbow fully extended • Arm adducted 10° across body with thumb down • Apply downward pressure against patient resistance • Repeat with thumb up • Suggestive of labral tear if more pain with thumb down
  • Sensitivity/Specificity for SLAP Tear  Speeds Test Sensitivity: 20% Specificity: 78%  Yergason’s Test Sensitivity: 12% Specificity: 95%  O’Brien’s Test Sensitivity: 67% Specificity: 37% Hegedus. British J Sports Med, 2012.
  • • Arm abducted to 90° • Apply slight anterior pressure and slowly externally rotate • Apprehension may indicate anterior instability • High Diagnostic Odds Ratio of 53.6
  • • Supine • Shoulder abducted and externally rotated • Posteriorly directed force applied to shoulder • Positive if apprehension decreases and indicates anterior instability
  • Physical Exam of the Shoulder • Inspection • Palpation • Range of Motion • Strength • Neurovascular status • Provocative Shoulder Testing • The joint above and below (i.e. neck and elbow)
  • Cervical Spine Spurling’s Maneuver • Neck extended • Head rotated toward affected shoulder • Axial load placed on the cervical spine • Reproduction of patient’s shoulder/arm pain indicates possible nerve root compression
  • Hegedus. British J Sports Med, 2012.
  • Indications and Guidelines for Diagnostic Imaging
  • Be Wise When Ordering Imaging  Analysis of 459 elective outpatient CT and MRIs from PCPs  37% of shoulder MRIs were considered inappropriate  Examples of inappropriate indications Shoulder pain with no conservative therapy Osteoarthritis in older patients Lehnert & Bruce. J Am Coll Radiol , 2010.
  • Asymptomatic Rotator Cuff Tears Increase with Age Tempelhof et al. J Shoulder Elbow Surg, 1999.
  • American College of Radiology Appropriateness Criteria  Evidence based guidelines developed by a multidisciplinary panel  Reviewed every two years Wise et al. J Am Coll Radiol 2011.
  • ACR Appropriateness Criteria Wise et al. J Am Coll Radiol 2011.
  • MRI  Superior for most soft tissues in shoulder Rotator Cuff Tear Cartilage Bursae  Identifies tendon retraction, muscle atrophy and fatty infiltration Suggests chronic tear & poor prognosis
  • MR Arthrogram  Main use – instability in those <35 y/o  Injection of gadolinium enhances view of labrum  Typical History of Shoulder Instability or Labral Tear
  • Glenoid Labrum
  • CT Scan  Useful for characterizing fractures  Consider CT arthrography in evaluation of rotator cuff in setting of previous shoulder replacement  Otherwise… not many uses
  • Ultrasound  Very operator dependent  Can be used to evaluate acromioclavicular joint, rotator cuff tendons, long head of bicep tendon  Increased accuracy of injections into glenohumeral joint/biceps tendon sheath
  • Diagnosis and Treatment of Selected Specific Conditions
  • Shoulder Impingement  Hx: Gradual onset of pain worsened with overhead activities. Often with night pain  PE: +impingement tests, weakness and pain with resisted supraspinatous testing, ROM usually NL  Imaging: Xray – usually NL. Can see acromion spurs.  Treatment: PT for strengthening of scapula stabilizers and rotator cuff, consider injection if severe pain  Referral - Consider if not improved after 6 months of adequate rehab
  • Rotator Cuff Injuries  Continuum of edema/hemorrhage > tendonitis and fibrosis > partial or complete tear  Rotator cuff tears are uncommon under the age of 40 but strains do occur  Hx: pain in lateral shoulder, night pain is common, +/- history of trauma  PE: pain and weakness of affected muscles.  Differentiating weakness because of pain versus a tear can be difficult. Consider diagnostic lidocaine injection.
  • Rotator Cuff Injuries  Imaging: Xray usually normal. Tears are best evaluated with U/S or MRI.  Treatment: Complete tears in an active person should be referred for surgical consult. Partial tears and strains can often successfully be rehabilitated. Consider injection if severe pain does not allow physical therapy.
  • Adhesive Capsulitis (Frozen Shoulder)  Hx: pain and decreased range of active and passive motion, night pain (early in condition)  At Risk: Diabetics, women, post surgical immobilization, 40-60 y/o  PE: decreased active and passive ROM  Imaging: Xrays- NL, used to differentiate glenohumeral arthritis  Treatment: NSAIDS and corticosteroid injections beneficial during painful stage. PT ROM and exercise. Increase aggressiveness as pain resolves  Refer when: conservative treatment has failed
  • Biceps Tendonitis  Often occurs in combination with rotator cuff pathology  Hx: Pain in anterior aspect of shoulder that radiates to biceps  PE: TTP in bicipital groove, +Speed’s & Yergason’s test  Imaging: Xrays – NL, US/MRI – fluid around tendon
  • Shoulder Dislocation  72-95% recurrence in <20 y/o patients  20-30% in 25-40 yo  10-15% in >40 yo  Shoulder dislocations in patients <25 y/o should have surgical stabilization
  • Glenoid Labral Tear  Hx: Multiple mechanisms Atraumatic Traction in overhead throwing athletes Sudden pull from catching oneself from falling Compression from falling onto outstretched arm  Hx: Pain with overhead activities; sometimes will have popping, clicking, or catching with motion. Often will have failed rehab with continued discomfort.
  • Glenoid Labral Tear  PE: All tests have poor +LR  Imaging: MR arthrogram  Treatment: start with PT, however, most patients will need surgical treatment to resume full function
  • 67 yo male w/ decreased ROM
  • Glenohumeral Arthritis  Hx: decreased and painful ROM, hx of previous injury or arthritis in other joints  PE: Decreased active and passive ROM  Imaging: degenerative changes of glenohumeral joint  Treatment: glenohumeral corticosteroid injection, shoulder replacement  Refer when: pain has become severe despite conservative treatment
  • Biceps Tendon Rupture
  • Biceps Tendon Rupture  Hx: forceful elbow extension against resistance, pain, ecchymosis  PE: “Popeye” deformity, decrease flexion and supination strength  Imaging: MRI will show rupture  Treatment: Quick referral to a surgeon in active patients. Pain control and PT in elderly
  • Take Home Pearls  Don’t order an MRI for an arthritic shoulder  ~50% of patients 80 years or older have asymptomatic rotator cuff tears  Glenohumeral arthritis is often rarely helped by physical therapy
  • Take Home Pearls  Refer all first time shoulder dislocations under age of 25 for surgical repair  Order an MR Arthrogram for a pt <35 y/o with shoulder instability when there is concern for labral tear
  • References  Madden, Chris, et al.  Netter’s Sports Medicine.  1st Ed. Saunders, 2009.   Puffer, James.  20 Common Problems in Sports Medicine. 1st Ed.  McGraw-Hill, 2001.   Esenyel CZ, et al. Arch Orthop Trauma Surg , 2010.  Mar;130(3):297-300.  Hegedus EJ, et al. British Journal of Sports Medicine 2008;42:80-92.  Sethi PM, Arthroscopy. 2005 Jan;21(1):77-80.  Tallia A & Cardone D. Diagnostic and Theraputic Injection of the Shoulder. Am Fam Physician. 2003 Mar 15;67(6):1271-1278.