CAFC Chronicles: Costly Tales of Claim Construction Fails
Evaluation of the Painful Shoulder Jacklyn Lindsay Quade_0.ppt
1. Evaluation of the Painful Shoulder
J. Lindsay Quade, MD
Clinical Instructor
Internal Medicine/Pediatrics, Sports Medicine
University of Michigan Health System
2. Objectives
• To improve physician comfort with obtaining relevant history in the evaluation
of the painful shoulder
• To improve physician comfort with physical examination of the shoulder,
including special testing
• To improve physician comfort with diagnosis and management of common
causes of shoulder pain
3. The Shoulder
• Shoulder pain is common in the primary care setting, responsible for 16% of all
musculoskeletal complaints.
• Taking a good history, paying special attention to the age of the patient and
location of the pain, can help tailor the physical exam and narrow the diagnosis.
• Knowledge of common shoulder disorders is important as they can often be
treated with conservative measures and without referral to a subspecialist.
8. MSK Shoulder Pain Differential
• Articular Causes
• Glenohumeral (GH) and acromoclavicular
(AC) arthritis
• Ligamentous and labral lesions
• GH and AC joint instability
• Osseus: fracture, osteonecrosis, neoplasm,
infection
• Periarticular Causes
• Chronic impingement and rotator cuff
tendinitis
• Bicep tendinitis
• Rotator cuff and long biceps tendon tears
• Subacromial bursitis
• Adhesive capsulitis
9. Taking Your History
• Age
• Hand dominance
• Occupation
• Sports/physical activities
• Trauma
• Onset
• Location
• Character
• Duration
• Radiation
• Aggravating/relieving
factors
• Night pain
• Effect on shoulder
function
• Stiffness/restriction of
movement
• Grinding or clicking
• Weakness
• Numbness/tingling
• Pain
10. The Physical Exam
• Inspection
• Asymmetry
• Bony deformity or abnormal contour
• Muscle atrophy or bulge
• Scapular winging
11. The Physical Exam
• Range of Motion
• Active
• Passive
• Apley’s “scratch” test
• Scapular movement
•Strength Testing
18. Specific Examples
• Rotator Cuff Pathology
• “Frozen Shoulder”
• Shoulder Instability
• AC Joint Separation
• Arthritis
• Labral Tear
• “SICK Scapula”
Main points:
Presenting symptoms
PE findings
Diagnosis
Conservative treatment or refer?
19. Rotator Cuff Pathology
• Presentation & symptoms:
• PAIN
• +/- weakness
• Age? trauma vs chronic
• Physical exam findings:
• Pain with ROM & resistance testing (+empty can, +push-off)
• + drop arm if full-thickness tear
• + Neer’s and Hawkins if impingement
20. Rotator Cuff Pathology
• Diagnosis:
• Xray – often negative
• Ultrasound
• Consider MRI if planning for surgery
• Management:
• Tendinopathy or impingement – conservative treatment, PT, subacromial GC injection
• Partial-thickness tear – PT (up to 12 weeks), possibly subacromial GC injection
• Full-thickness tear – Ortho referral
21. “Frozen Shoulder” (Adhesive Capsulitis)
• Presentation & symptoms:
• Pain, often >3 months
• Progressive loss of ROM
• Age >40yo
• Risk factors: immobility, DM, hypothyroidism
• Physical exam findings:
• Limited active ROM, external rotation often 50% normal
• Endpoint with passive ROM
22. “Frozen Shoulder” (Adhesive Capsulitis)
• Diagnosis:
• CLINICAL!
• Xray if need to rule-out fracture or OA
• US later if concerned for RC pathology
• Management:
• Set expectations
• Pain control, gentle ROM exercises/PT
• If severe, intra-articular GC injection under fluoroscopy
24. Shoulder (GH) Instability
• Diagnosis:
• Clinical
• Xrays often normal
• MR arthrogram if no improvement
• Management:
• Activity modification
• PT focused on aggressive strengthening
• Refer to Ortho if no improvement with PT or if recurrent dislocation
25. Acute Shoulder Dislocation
• Physical Exam:
• External rotation & abduction, palpable humeral head
• Check innervation of skin over lateral deltoid! (Axillary nerve)
• Diagnosis:
• Clinical
• Xray
• Management:
• Relocate & immobilize
• ROM exercises within 7-10 days aggressive rehab program
26. AC Joint Separation
• Presentation & symptoms:
• Direct blow to shoulder or FOOSH
• Male contact sport athlete, ~20yo
• Pain/swelling
• Physical exam findings:
• Pain and swelling over AC joint
• “Stepped” deformity if more severe
• + cross-arm test
• + painful arc
27. AC Joint Separation
• Diagnosis:
• Clinical +
• Xray
• Management:
• Types I-III: Non-operative (rest, ice, analgesics, sling for immobilization, PT)
• Types IV+: Ortho referral for surgery
28. Shoulder Arthritis
• Presentation & symptoms:
• Age >50
• Progressive pain with activity
• Decreased ROM
• Impingement symptoms
• History of rotator cuff injury, previous trauma, or shoulder surgery
• Physical exam findings:
• AC joint: tenderness over AC joint, pain at extreme internal rotation, + cross-arm test
• GH joint: decreased ROM, pain and crepitus at extremes of motion
29. Shoulder Arthritis
• Diagnosis:
• Clinical +
• Xray
• Management:
• AC joint:
• Activity modification, NSAIDs, GC injection
• GH joint:
• Goal = maintain function with adequate pain control
• PT, glucosamine & chondroitin, intra-articular GC injection
• Referral to Ortho if conservative treatment fails
30. Labral Tear
• Presentation & Symptoms:
• Pain +/- instability
• Clicking/popping
• Overhead athlete, history of dislocation, history of trauma
• Physical Exam:
• Pain with passive external rotation
• Pain with palpation of bicipital groove
• + Apprehension/relocation, O’Brien’s, SLAPprehension, crank tests
• Can also have + biceps testing
31. Labral Tear
• Diagnosis:
• Xrays usually normal but may show Hills-Sach lesion
• MRI or MR arthrogram
• Management:
• Conservative: rest, NSAIDs PT
• Operative: Ortho referral
• If conservative measures fail, larger tears, concomitant RC tear
32. “SICK Scapula”
• Presentation & Symptoms:
• Pain
• Repetitive overhead activity
• Drooping shoulder on dominant side
• Physical Exam:
• Scapular malposition
• Inferior medial border prominence
• Coracoid pain and malposition
• Kinesis abnormalities of scapula
34. Take-Home Points
• Shoulder pain is common
• Taking a good history can help narrow both your differential and your physical exam
• Having a good grasp of shoulder anatomy is necessary for interpreting physical exam
findings
• Develop your own shoulder exam approach and follow it consistently
• Aim to know at least one special test for each category of shoulder pain
35. Take-Home Points
• Rotator cuff pathology can often be diagnosed with US
• Frozen shoulder is a clinical diagnosis
• To be diagnosed with arthritis, there should be pain on exam and an abnormal xray
• If you are concerned about a labral tear, consider referral +/- an MR arthrogram
• Most chronic shoulder pain can be treated conservatively
• If patient is not improving clinically, refer to Sports Medicine
38. References
• Beuerlein MJS, McKee MD, Fam, AG. (2010). The shoulder. In Lawry GV (2nd.), Fam’s musculoskeletal examination and joint injection
techniques, (pp. 7-19). Philadelphia: Mosby.
• Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008 Feb
15; 77 (4): 453-60.
• Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part II. Treatment. Am Fam Physician. 2008 Feb 15; 77 (4):
493-7.
• Dodson CC, Altchek DW. SLAP lesions: an update on recognition and treatment. J Orthop Sports Phys Ther. 2009 Feb; 39 (2): 71-80.
• Edmonds EW, Denerink DD. Common conditions in the overhead athlete. Am Fam Physician. 2014 Apr 1; 89 (7): 537-41.
• Ewald, A. Adhesive capsulitis: a review. Am Fam Physician. 2011 Feb 15; 83 (4): 417-22.
• O’Connor, F, et al. (2013). ACSM’s Sports Medicine: A comprehensive review. Musculoskeletal injuries in the tennis player, (pp. 717).
Philadelphia: Lippincott.
• Woodward TW, Best TM. The painful shoulder: part I. Clinical evaluation. Am Fam Physician. 2000 May 15; 61 (10): 3079-88.
• Woodward TW, Best TM. The painful shoulder: part II. Acute and chr onic disorders. Am Fam Physician. 2000 Jun 1; 61 (11): 3291-300.
41. Photo References
19. Slide 28: http://grutter.us/ShoulderArm/AC%20arthritis.html
20. Slide 29: http://www.orthoinfo.org/topic.cfm?topic=A00222
21. Slide 30: http://josephhechtmd.com/slap-legion-surgery/
22. Slide 31: http://www.appliedradiology.com/articles/mr-arthrography
23. Slide 32: http://www.sportsandortho.com/UserFiles/sick2.png
24. Slide 33: https://acewebcontent.azureedge.net/blogs/blog-examprep-091313-2.jpg
25. Slide 37: http://galleryhip.com/michigan-football-logo-go-blue.html
All photos obtained through Yahoo! or Google image search
Editor's Notes
Comfort with recommednations until imaging comes back or seen by specialist
Acromion in greek – highest; together with coracoid extends laterally over shoulder joint
Glenoid labrum – the meniscus of the knee
Supraspinatus/infra/teres– inserts on GT (origin on scapula); subscap – inserts on lesser tub; biceps – originates on superior glenoid tubercle (short head on coracoid)
Narrow based on location of pain and age of patient, sport, trauma, etc
Neurologic causes, referred pain are other examples on the diff
empty can – bring in like 30 degrees
Impingment – RC not intact, can’t prevent cephalad migration of humeral head; narrowing of space b/t acromion and RC; acromion impinges on RC and bursa causing pain
Sulcus - inferior; apprehension – anterior; load and shift – A/P
Release is return of pain or apprehension with release
Speeds and yergason’s can also be positive
– obrien
Speeds and yergason’s can also be positive
https://www.youtube.com/watch?v=3G6mb1QQ90I – obrien
https://www.youtube.com/watch?v=JQI_om7b_JM - crank
http://ameblo.jp/g-money0229/entry-11512342937.html - crank
Pain anywhere, often worse at night and with overhead activities
Age:
Less often <40yo – trauma, competitive athlete with overuse (overhead sports)
Usually >40yo – chronic impingement, degeneration, occupation-related
RC is dynamic stabilizer; if probs, can have cephalid migration of humeral head -> impingement; other causes include anatomy of acromion, AC joint arthritis, enlarged bursa, frozen shoulder, calcification of coracoclavicular ligament
PE: could also have atrophy, biceps tests positive
MRI – if planning surgery
Xray – may show superior migration of humeral head with large cuff tear, if need to r/o fracture; could show type 2 of 3 acromion which predisposes
Conservative treatment – avoid agg factors, NSAIDs, ice
Tendinopathy – if PT fails, consider subacromial injection
Full thickness tear:
If healthy, surgery in 3-6 weeks
If elderly, comorbidities, non-compliant, then likely nonoperative treatment
Contraction of GH joint capsule and adherence to the humeral head
Pain with ROM
Expectations: risk to c/l side, 90% recover in 12-18 months
May never fully resolve
Add lidocaine or saline to injection, sometime prior to PT if severe enough
Or subacromial injection
Pain – often anterolateral
Transient neuro syxs – weakness, tingling, numbness
Trauma or overhead sport
Not laxity! Instabilty may have laxity, but laxity is asxic…
Xray could show Hill Sach’s lesion – indentation of posterior aspect of humeral head when should dislocates anteriorly and back of humeral head contacts anterior edge of glenoid OR may see avulsion fracture
MR if no improvement or concern for labrum
Activity modification – no overhead, bench press, etc
Xray could show Hill Sach’s lesion – indentation of posterior aspect of humeral head when should dislocates anteriorly and back of humeral head contacts anterior edge of glenoid OR may see avulsion fracture
Activity modification – no overhead, bench press, etc
Stepped deformity b/t acromion and clavicle
Xray – single AP with both joints or 2 AP views
Zanca view –allows AC to be seen without overlapping bone; AP with 10-15 degree cephalic tilt)
Types i-iii – 2 to 12 weeks
Impingement sxs with AC joint arthritis
Xrays – typical are AP, scapular Y, and axillary, and stryker notch (4 view); loss of joint space, osteophyte
Activity modification – overhead activities; golf for AC joint
Click/pop with movement
Physical exam: can have positive biceps tests!
Superior labrum anterior posterior = SLAP & Bankart lesion (lower) – associated with dislocation
-pain where biceps tendon anchors to the labrum
- Concomitant RC injury also common
Slap tear
MRI – better for anterior tears
Risk factors: trauma, other shoulder injury, muscle strain, unbalanced weight training
Loss of muscle coordination
Trapezius, rhomboid and serratus anterior must be synchronized
