presentation for md orthopedic

1. “My Sore Shoulder!”
Guide to Diagnosis and
Conservative Treatment

2. Shoulder Anatomy
 Acromioclavicular
(AC) joint
 Glenohumeral joint
 Glenoid labrum
 Humerus
 Rotator cuff
 Biceps muscle/tendon
 Deltoid muscle

3. Common Shoulder Conditions
 Rotator cuff injuries
 Impingement
 Instability
 Labral tears
 Bicipital tendonitis
 AC joint disorders
 Suprascapular nerve entrapment

4. Rotator Cuff Injuries
 Rotator cuff serves as a stabilizer for the
shoulder
 Cuff is comprised of the supraspinatus,
infraspinatus, subscapularis and teres
minor muscles
 Common rotator cuff injuries occur to the
underside of the supraspinatus tendon
 Increase in risk of tear at age 40

5. Impingement
(Bursitis/Tendonitis)
 Can include inflammation of the bursa
overlying the rotator cuff, inflammation
within the rotator cuff tendons, or calcium
deposits within the rotator cuff tendons
caused by wear and tear
 Can be caused by frequent extension of
the arm at high speed under high load
(i.e. throwing a baseball)
 Potential outcome is a rotator cuff tear

6. Instability
 Shoulder laxity needs to be differentiated from
frank instability
 Laxity is common in the swimmer and
throwing athlete, as the shoulder must be
loose enough to allow excessive external
rotation
 Instability is unwanted translation of the
humeral head on the glenoid, and
compromises the comfort and function of the
shoulder

7. Labral Tears
 Frequently seen in
throwing athletes
 Glenohumeral joint
receives compressive
and shearing forces
during the movement
of the humeral head,
anteriorly to
posteriorly

8. Bicipital Tendonitis
 Inflammation of the biceps tendon
 Diagnosis made principally by palpation
of the tendon during clinical examination
 Occurs frequently in the throwing athlete:
• Modest biceps activity during cocking and
acceleration phase
• High level of biceps activity during follow-
through phase

9. AC Joint Disorders
 Most sprains to the
AC joint occur as the
result of a fall or a
blow to the lateral
acromion
 Symptoms of a
separation may
range from pain over
the AC joint to a
frank deformity

10. Suprascapular Nerve
Entrapment
 Suprascapular nerve supplies the
supraspinatus and infraspinatus muscles
of the rotator cuff
 The nerve can be compromised by
traction injuries or compression injuries
 Athlete may present with subtle
weakness and vague complaints of
posterior shoulder girdle pain

11. The Subjective Evaluation
 What?
 How?
 When?
 Where?
 Pain?
 Instability?
 Weakness?
 Deformity?

12. The Clinical Examination
 Inspection
 Examination of the cervical spine
 Palpation
 Range of motion assessment
 Strength assessment
 Glenohumeral stability assessment
 Neurovascular examination
 Special tests

13. Inspection
 Should be performed from different
perspectives (front, side, back, top)
 Should assess for symmetry, atrophy,
hypertrophy, deformities, bruising and
swelling
 Note scars as evidence of prior surgical
procedures

14. Examination of the Cervical
Spine
 Have the patient look up at the ceiling,
touch his chin to his chest, look over
each shoulder
 Any numbness, tingling or pain referred
to the affected shoulder points to the
cervical spine as the etiology of the
shoulder pain

15. Palpation
Bony Landmarks:
 SC joint
 Clavicle
 AC joint
 Acromion
 Bicipital groove
 Scapula
Soft Tissue:
 Biceps tendon
 Supraspinatus
insertion to the
proximal humerus
 Deltoid
 Posterior capsule

16. Range of Motion
 Includes testing of both active and
passive range of motion
 For example, in the setting of a rotator
cuff tear, passive range of motion will be
normal but active range of motion will be
diminished due to the tear in the muscle

17. Range of Motion (norms)
 External rotation in a 0° plane (90°)
 External rotation in a 90° plane (90°)
 Abduction (150°)
 Internal rotation (90°)
 Forward flexion (180°)
 ALWAYS compare both shoulders!

18. Range of Motion
 During range of motion assessment is a
reasonable time to test for impingement
 Impingement sign: with the arm abducted to
90° and the elbow flexed to 90°, externally
rotate the patient’s arm
 Impingement test: forward flex the patient’s
arm to 180°
• Pain signifies a positive test

19. Strength Assessment
 Strength is easy to assess by standing behind
the patient who is seated on the exam table
 Strength is graded 0 to 5 over 5:
• 0/5 = total paralysis
• 1/5 = palpable or visible contraction
• 2/5 = full ROM with gravity eliminated
• 3/5 = full ROM against gravity
• 4/5 = full ROM with decreased strength
• 5/5 = normal strength

20. Strength Assessment
 Supraspinatus: assessed at 90° of
forward flexion in the scapular plane with
the thumbs pointed to the floor;
downward pressure is resisted by the
patient
• Test is specific for supraspinatus function,
and evaluates cuff strength and integrity

21. Strength Assessment
 External rotators: with the patient’s arm
at his side and the elbow flexed to 90°,
he will externally rotate as if hitting a
tennis ball in a backhanded manner
against resistance
• Test is specific for the teres minor and
infraspinatus muscles

22. Strength Assessment
 Abduction: assessed in the coronal
plane against resistance
• May be suggestive of either deltoid or cuff
deficiency
 Subscapularis: with the dorsum of the
patient’s hand on his ipsalateral back
pocket, instruct him to push backward
against resistance

23. Glenohumeral Stability Assessment
 Subtle anterior
instability is not
uncommon in the
throwing athlete
 In addition, the
hyperlax patient may
have some element
of multidirectional
instability

24. Glenohumeral Stability Assessment
 Sulcus sign: distraction force is placed
on the elbow and the space created
between the undersurface of the
acromion and the apex of the humeral
head is noted
• This distance is recorded in centimeters, and
indicates laxity in the joint

25. Glenohumeral Stability Assessment
 “Load and shift” test: with the humeral head
reduced (“loaded”) into the glenoid fossa, the
examiner steadies the limb girdle with one hand
and translates the humeral head both anteriorly
and posteriorly with the opposite hand
• The amount of translation is graded as 1+, 2+, or 3+
• This test is also repeated in the supine position
• Glenohumeral translation depends upon the skill of the
examiner as well as the patient’s ability to relax

26. Glenohumeral Stability Assessment
 Apprehension test: evaluation of the
patient’s sense of pending anterior
subluxation or dislocation with the arm in
stressed external rotation abduction
• Can be performed sitting or supine, but works best
with the patient supine
• In order for a test to be positive, apprehension
must be present – pain alone does not indicate a
positive test

27. Glenohumeral Stability Assessment
 Relocation test: following the supine
apprehension test, apply posterior
pressure to the proximal humerus at the
same level of external rotation noted in
the apprehension test
• A positive relocation test is described when
the patient’s apprehension disappears with
the posterior stress

28. Neurovascular Examination
 Dermatomal sensory examination
 Deep tendon reflexes at the wrist and
elbow
 Cervical root testing – wrist extension,
finger abduction and adduction, thumb
abduction, elbow flexion
 Palpation of the brachial and radial pulses

29. Special Tests
 Drop arm test: the patient’s arm is
abducted to 90° and released
• A positive test is noted when the patient’s
arm falls down from the position
• Indicative of a rotator cuff tear

30. Special Tests
 Speed’s test: with the shoulder in
forward flexion, elbow extended, and
hand supinated, resistance is applied
• Pain in the location of the bicipital groove
during resistance is indicative of bicipital
tendonitis

31. Special Tests
 O’Brien’s test: with the arm adducted
across the midline, elbow extended and
thumb down, the examiner applies
downward pressure; the patient’s thumb
is then turned up, and he again resists
downward pressure
• A positive test is indicative of a labral tear, and
is described when greater pain occurs with the
thumb pointed downward

32. Special Tests
 Clunk test: while the patient lies supine
the examiner abducts the arm past 90° with
one hand while pressing the proximal
humeral head anteriorly; the examiner then
rotates the shoulder internally and
externally
• A positive test is elicited when the patient feels a
deep “clunk” in the shoulder
• Indicative of a labral tear

33. Radiographic findings
 X-rays – what to look
for:
• Bony tumors
• Fracture lines
• Hook to the acromion
• Degenerative changes
• Dislocation

34. Radiographic findings
 MRI
• Good for ruling out
bad things
• Can be misleading
• Must be correlated
with clinical exam –
the radiologist does
not have the benefit of
examining the patient

35. Conservative treatment
 Physical therapy
• Excellent form of strengthening and
rehabilitating weak or injured muscles
• Formal physical therapy will reassure you that
the exercises are actually being done
• The most successful conservative form of
therapy for the musculoskeletal system

36. Conservative treatment
 Oral anti-inflammatories
• Sometimes just a short course of anti-
inflammatories can provide permanent relief
• Non-selective COX inhibitors still work great if
the patient can tolerate them
• COX-2 inhibitors:
• Celebrex 200 mg daily
• Vioxx 25 mg daily
• Bextra 20 mg daily

37. Conservative treatment
 Cortisone injection (short-acting + local)
• Can be a permanent cure, but is frequently a
short-term fix
• Relief from the injection gives an excellent
prognosis for surgical success
• Should only be given every 3 months

38. If the above fail…
 Refer to orthopedic surgeon
 Surgery is a measure of last resort!
 “There is no pain so terrible that surgery can’t
make worse.”