Injuries/Ailments of the Shoulder

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Injuries/Ailments of the Shoulder

• Allyson Howe, M.D.
• Capt, USAF, MC
• Primary Care Sports Medicine Fellow

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SHOULDER

• Incidence
• Review pertinent anatomy
• History and physical exam
• Cases with expected exam findings

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Incidence

• Second most common musculoskeletal complaint
• Difficult joint to examine
• Multidirectional range of motion- UNIQUE!
• Shoulder injury can affect nearly every sport as
  well as impede many daily activities

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Bony AnatomyAnterior

• Bones

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Bony AnatomyPosterior
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Bony AnatomyJoints and Articulations

STATIC STABILIZERS
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LABRUM
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Clinical Anatomy

• Deltoid
• Rotator cuff
• Teres major

• Latissimus dorsi
• Biceps
• Pectoralis muscles

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Clinical Anatomy

• Rotator Cuff
• Supraspinatus
• Infraspinatus

• teres minor
• Supscapularis

POSTERIOR
ANTERIOR
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Clinical Anatomy

• Rotator Cuff
• Supraspinatus Abd
• Infraspinatus ER

• teres minor ER
• Supscapularis IR

Depress humeral head against glenoid to allow
full abduction
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Muscular AnatomyPosterior
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Clinical Anatomy

• Bursae
• subacromial
• subdeltoid
• subscapular

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Functional anatomy

• Glenohumeral ball and socket joint
• Very shallow (golf ball sitting on a tee)
• Inherently unstable
• Static stabilizers
• glenohumeral ligaments, glenoid labrum and
  capsule
• Dynamic stabilizers
• Predominantly rotator cuff muscles
• Also scapular rotators (trapezius, levator
  scapulae, serratus anterior, rhomboids)

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Clinical ExamHistory

• Pain
• Acute
• Chronic
• Weakness
• Deformity

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Clinical ExamHistory

• Single event
• Repetitive overload
• Instability
• Does it feel like its going to come out?
• Catching/Locking
• Disability

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Clinical ExamHistory

• Sport/occupation
• Frequency
• Duration
• Previous injury
• Previous treatment
• Systemic illness
• Other joints involved

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Physical Exam

• Inspection
• Note deformity, swelling, color changes
• Palpation
• Bony structures, soft tissue anatomy
• Range of Motion
• Flexion, Abduction, Internal and External
  rotation

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Physical Exam

• Strength testing
• Internal/External rotation, Abduction
• Rotator cuff muscles

• Special Tests
• Isolate anatomy

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Physical ExamInspection

• Front back
• Height of shoulder and scapulae
• Muscle atrophy, asymmetry

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Physical Exam Palpation

• At rest with movement
• ie. can feel supraspinatus, AC joint
• Bony structures
• Joints
• Soft tissues

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Physical Exam Range of Motion

• Abduction 0-180o

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Physical Exam Range of Motion

• Forward flexion
• 0o 180o

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Physical Exam Range of Motion

• Extension
• 0o 40 to 60o

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Physical Exam Range of Motion

• Internal rotation
• T5 segment

• External rotation
• 80-90o

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Physical Exam Strength

• Resisted external rotation
• Tests infraspinatus, teres minor strength

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Physical Exam Strength

• Resisted internal rotation
• Tests subscapularis strength

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Physical Exam Strength

• Empty can test
• 45o angle
• Steady downward pressure
• Tests supraspinatus strength

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Radiographs
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Radiographic Anatomy
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Radiographic Anatomy
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Case 1

• 22-year-old male rugby player falls onto right
  shoulder while being tackled
• Severe pain on top of right shoulder

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Case 1

• Notable deformity over superior shoulder
• Painful range of motion
• Unable to lift right arm above waist
• Diagnosis??

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Acromioclavicular (A-C) Sprain

• Damage to A-C joint ligaments
• Pain and/or deformity over A-C joint
• Graded I-VI
• I-III usually treated non-operatively
• IV-VI referred to orthopedic surgery

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Cross-Arm Adduction Test

• AC joint pathology
• Arm flexed to 90
• Hyperadduct arm across body as far as possible
• Pain in AC () test

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A-C Shear Test

• Interlock fingers with hand on distal clavicle
  and spine of scapula
• Pain in A-C joint when hands squeezed together
  () test

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Case 2

• 24-year-old male handball player
• Fell onto shoulder after being pushed
• Intense pain
• Hand is tingling and arm feels like its hanging
• xrays

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X RAYS
DIAGNOSIS???
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Shoulder Dislocation/Anterior Instability

• Humeral head dislocates from glenoid fossa
• Almost always anterior
• Usually traumatic mechanism with injury to
  capsule-labrum complex

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SHOULDER INSTABILITYClassification

• AMBRI
• Atraumatic
• Multidirectional
• Bilateral
• Rehab
• Inferior capsular shift

• TUBS
• Traumatic
• Unilateral
• Bankart
• Surgery

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Shoulder Dislocation/Anterior Instability

• Treatment
• Reduction of dislocation
• Protection rehab, rehab, rehab
• Most will have future dislocations and/or
  instability
• At least 70!!! (young)
• May require surgical tightening/repair of the
  capsule/labrum complex

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Sulcus Sign

• Inferior instability
• Arm relaxed in neutral position, pull downward at
  elbow
• () test sulcus at infra-acromial area
• compare to unaffected side

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Apprehension Test

• Anterior and Posterior instability
• Shoulder at 90 abducted, slight anterior
  pressure External rotation
• () test dislocation apprehension
• some false ()

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Relocation Test

• Perform after positive apprehension test
• Apply post force over humeral head during
  external rotation (ER)
• () test increased ER tolerance

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Load Shift Test

• Test for multidirectional instability
• Grasp humeral head, slide anteriorly and
  posteriorly while securing rest of shoulder
• () if greater than 50 displacement (graded 1-3)

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Case 3

• 35-year-old male tennis player
• Shoulder pain exacerbated by practicing serves
• Develops dull, aching pain in right shoulder
• Exam?

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SHOULDER PAINPhysical Exam

• Tenderness to palpation anterior shoulder
• Pain with abduction starting around 90 degrees
• Unable to lift arm past 120 degrees
• Pain with forward flexion at 90-120 degrees

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SHOULDER PAINSPECIAL TESTS

• Hawkins
• Place arm in passive abduction to 90o
• Flex elbow
• Internally rotate shoulder

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SHOULDER PAINSPECIAL TESTS

• Neer
• PASSIVE
• Forced forward flexion of arm with internally
  rotated shoulder
• Test is positive if pain occurs at same point as
  with active forward flexion

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SHOULDER PAIN

• DIAGNOSIS ???

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Impingement(aggravated by overhead serving)
AND hair brushing!
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Impingement Syndrome

• Common problem with repetitive overhead
  activities
• Subacromial bursa and/or rotator cuff impinged
  between acromion humerus
• Rotator cuff strain vs bursitis
• Treatment usually physical therapy /-
  medications
• (Hair cut for those with mullets)

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Impingement
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Impingement Signs
Hawkins test
Neers test
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Diagnostic Injection

• 5 - 10 mL of 0.5 - 1 lidocaine injected into
  subacromial space
• 50 pain relief supports diagnosis of
  impingement syndrome

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Case 4

• 45-year-old male power lifter
• Caught bar as was falling off shoulder
• Sudden pain
• Severe weakness left shoulder
• Worse with overhead activities while sleeping at
  night
• Diagnosis?

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Rotator Cuff Tear

• Supraspinatus tendon most common
• Can be due to acute trauma or chronic
  tendinopathy or irritation
• Treatment dependent upon age/activity
• Young, active usually require operative treatment
• Older, low-activity usually respond to
  non-operative treatment
• Therapy, ice, activity modification

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Rotator Cuff Strength Testing
Supraspinatus testing

• Weakness on exam
• Grade strength on 0?5 scale
• Compare to other side

Subscapularis testing
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Drop Arm Test

• Slowly lower fully abducted arm
• At 90 abducted arm will suddenly drop, may need
  to add slight pressure
• () drop () test

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SHOULDER MRI
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Case 5

• 42-year-old female with dull pain right shoulder
• Pain is diffuse in nature
• Sometimes spreads to between shoulder blades
• Seems worse at night

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Physical Exam

• Obese, pleasant female
• Diffuse pain
• Normal shoulder exam
• Not able to reproduce pain during exam
• What else do you want to do???

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If at first you dont succeed

• On further history, pain sometimes associated
  with eating
• Has been having mid and right sided abdominal
  pain she attributes to eating large meals
• Exam of abdomen reveals tenderness in right upper
  quadrant when she takes a deep breath
• Thoughts??

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Shoulder pain isnt always the shoulder!!

• Gall bladder disease
• Peptic Ulcer Disease
• Cervical radiculopathy
• May refer pain to shoulder
• Cardiac ischemia
• Even right sided!! (rarely but possible)
• Pulmonary conditions
• ie Pancoasts tumor, Pneumonia

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Case 6

• 40-year-old fellowship director
• Spent yesterday morning shoveling 16 of snow
• Can hardly lift left arm due to pain
• Diagnosis?

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Biceps Tendinitis

• Caused by repetitive overhead activity, forearm
  flexion/supination
• Difficult to discern from rotator cuff
  tendinopathy, impingement
• Consider diagnostic injection into bicipital
  groove

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Speeds Test

• Long head of biceps tendinitis
• Fwd flex to 90, abd 10, full supination
• Apply downward force to distal arm
• Pain () test
• weakness w/o pain muscle weakness or rupture

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Yergasons Test

• Biceps tendonitis and/or subluxation
• Elbow flex to 90, thumb up, patient supinates
  flexes against resistance
• Pain/painful pop tendonitis/instability

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Conclusion

• Shoulder injuries are common
• Knowledge of the anatomy is crucial to correct
  pathoanatomic diagnosis
• History can point you in the right direction
• Dont forget about medical causes!
• Physical exam with specific testing confirms the
  diagnosis

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Special Tests

• A few more tests to finish up.

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OBriens Active CompressionSLAP lesion

• Labral/AC pathology
• arm flexed to 90, elbow extended, adduct 10-15,
  resist downward force
• if AC pain or internal pain/click

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LABRUM
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OBriens Active CompressionSLAP lesion

• Supination should be pain free

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Crank TestSLAP lesion

• Glenoid labrum tear
• Abduct arm to 90-120 pt is supine, elbow secured
  with one hand axial load at shoulder with other
• () if audible/painful catch/grind is noted

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Spurling TestCervical Radiculopathy

• Cervical nerve root irritation
• Axial load on cervical spine in extension and
  rotate to affected shoulder
• () if neck, shoulder, or arm pain
• Looks towards affected shoulder

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Diagnostic Injections of Shoulder

• Trigger points
• AC joint
• Subacromial space
• impingement
• 50 improvement
• Glenohumeral joint

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Adson TestNeurovascular compression

• Standing, arm at side, extend and Externally
  rotate arm, rotate head while holding breath,
  monitor radial pulse
• () if pain/paresthesia