Chronic Scapulothoracic Pain or Chronic Shoulder Pain

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Chronic Scapulothoracic Painor?? Chronic
Shoulder Pain ??

• Steve Moll, DO
• Senior Medical Officer
• USS SAIPAN (LHA-2)

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Chronic Scapulothoracic Pain

• At the conclusion of this activity, you
  should
• ? Appreciate the degree to which myofascial
  painsyndromes from the scapulothoracic region
  can cause shoulder pain.
• ? Understand the importance of treating
  predisposing factors in myofascial pain
  syndromes.
• ? Know that successful treatment requires a
  multi-factorial approach.

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The Shoulder...
Its not just a Joint, but a Complex.

• The shoulder consists of four joints
• Glenohumeral
• Acromioclavicular
• Sternoclavicular
• Scapulothoracic

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Differential Diagnosis

• Shoulder pain arising from problems
• Intrinsic to the A-C / glenohumeral joints, or
• Extrinsic (referred pain
  patterns)
• Somatic
• Visceral

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Differential Diagnosis

• acromioclavicular arthritis
• acromioclavicular separation
• adhesive capsulitis
• adhesive capsulitis
• apical lung tumors
• avascular necrosis
• axillary vein thrombosis
• bicipital tendonitis
• biliary tract disease
• brachial neuritis
• brachial plexopathy
• calcific tendonitis
• cephalobrachialgia
• cervical root compression (esp.C5)

cervicodorsal sympathalgia coronary artery
disease angina costoclavicular
syndrome dislocation fibromyalgia forward head
syndrome fractures clavicle, scapula,
humerus glenohumeral arthritis -
crystal-induced - osteoarthritis -
post-traumatic - rheumatoid - septic
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Differential Diagnosis
rotator cuff tear scapulocostal syndrome shoulder
instability snapping shoulder syndrome spinal
cord lesions splenic lesions subacromial
bursitis supraspinatus nerve compression supraspin
atus tendonitis swimmers shoulder thoracic
outlet syndrome tumor

• glenohumeral instability- AMBRI- TUBS
• impingement syndrome
• labral tears (SLAP tear)
• levator scapulae syndrome
• lumbar facet syndrome
• myofascial pain syndrome
• Parsonage-Turner syndrome
• pneumonia
• polymyalgia rheumatica
• reflex sympathetic dystrophy

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History Physical Exam
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History

• Whats new or different in the 6 months prior to
  the onset of pain?

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History

• Whats new or different in the 6 months prior to
  the onset of pain?
• - New job? Longer hours in front of the
  computer? - New car? Longer commute? - New
  duty station (shipboard)? Running shoes? -
  Raked leaves? - More stress? Less/poorer
  sleep? - Marital conflict? - Different
  pillow? - Pregnancy?

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History

• What occupies the majority of your day?
• How much time do you spend - sitting? - talking
  on the phone?
• - driving?, or - being driven nuts?

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History

• Is there a time of the day when your is pain
  better? Worse?
• How well do you sleep?

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Physical Exam

• - ROM (active passive)
• - Strength
• - Special tests (lift off Neer Hawkins
  cross-body adduction empty can)

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Physical Exam

• - ROM (active passive)
• - Strength
• - Special tests (e.g. lift off Neer Hawkins
  cross-body adduction empty can)
• - Palpate
• - Posture

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Travell Trigger Points (TrPs) Myofascial Pain
Syndrome

• TrP "a hyperirritable spot in skeletal muscle
  that is associated with a hypersensitive palpable
  nodule in a taut band. The spot is tender when
  pressed and can give rise to characteristic
  referred pain, motor dysfunction, and autonomic
  phenomena.
• Palpation is a reliable diagnostic criterion for
  locating TrPs.

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Travell Trigger Points (TrPs) Myofascial Pain
Syndrome

• Etiology of TrPs
• 1. Local myofascial tissues
• - Motor end plate dysfunction cascade5 - from
  genetic defects, or - acquired defects
  (nicotine, caffeine, psychological
  physiological stress
• 2. CNS factors (central sensitization)4,5
• 3. Biomechanical factors

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Referred pain patterns
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Treatment

• Direct Tx of TPs
• - pressure
• - injection
• - dry needling
• - massage
• Treatment of Perpetuating Factors

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Treatment of Perpetuating Factors

• ? Postural stresses
• Psychological stress
• Mechanical factors
• Constriction of muscles
• Social habits

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Treatment of Perpetuating Factors

• ? Postural stresses- poor posture - misfitting
  furniture- immobility - frequent repetitive
  movements

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Treatment of Perpetuating Factors

• ? Psychological stress
• - hopelessness
• - depression
• - anxiety tension

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Treatment of Perpetuating Factors

• ? Mechanical factors
• - SI dysfunctions
• - hemipelvic disparities
• - limb length discrepancy
• - Morton's foot (long second metatarsal)

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Treatment of Perpetuating Factors

• ? Social habits
• - nicotine
• - caffeine
• - alcohol abuse

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Conclusion

• The Family Practice Physician
• is eminently qualified to successfully manage
• the multifactorial problems which plague the
  chronic pain patient.

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Common Concomitants

• Forward Head Syndrome
• Myofascial Pain (Scapulothoracic) Syndrome
• Rotator Cuff Syndrome
• Thoracic facet syndrome (somatic dysfunction)

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Treatment (contd)

• Fix the SLEEP problem!
• No sleep. No relief. No hope.
• Raise SEROTONIN levels.
• Treat the depression /or anxiety.

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Treating Insomnia

• R/O Obstructive Sleep Apnea
• Trazodone (Desyrel)
• Allow self-titration
• Explicit verbal written instructions
• Treatment failures? Bipolar until proven
  otherwise.
• TCAs (nortriptylene amitriptyline)
• Gabapentin (Neurontin)
• Zolpidem (Ambien)
• SSRIs

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Boosting Serotonin Levels

• SSRIs
• Start early
• Escalate doses, as tolerated
• Yes this is an anti-depressant. No I
  dont think youre depressed.I am giving this
  to you as an adjunct