COMMON SHOULDER PROBLEMS

1
COMMON SHOULDER PROBLEMS

• Kevin deWeber, MD, FAAFP, FACSM
• Director, Sports Medicine Fellowship
• USUHS

2
Objectives

• Review anatomy
• Makes for better diagnoses
• Discuss common shoulder problems
• Describe current treatments

3
Anatomy

• Scapula
• Glenoid
• Acromion
• Coracoid
• Subscapular fossa
• Scapular spine
• Supraspinous fossa
• Infraspinous fossa

4
Anatomy

• Bursae
• Subacromial
• (Subdeltoid)
• Subscapular

5
Joints of the Shoulder

• Acromioclavicular
• Glenohumeral
• Sternoclavicular
• Scapulothoracic
• Not a true joint

6
Movement control

• Flexion Pectoralis Major, Deltoid (Anterior),
  Coracobrachialis
• Extension Deltoid (Posterior), Teres Major
• Abduction Deltoid, Supraspinatus
• Adduction Pectoralis Major, Latissimus,
  Subscapularis, Infrapspinatus, Teres Minor
• Internal Rotation Subscapularis, Pectoralis
  Major, Deltoid (A), Latissimus
• External Rotation Infraspinatus, Teres Minor,
  Deltoid

7
Shoulder Physical Exam

• Inspection
• Palpation
• Range of Motion
• Strength
• Neuro-Vascular
• Special Tests

8
Range of Motion

• Forward flexion
• 160 - 180
• Extension 40 - 60
• Abduction 180?
• Adduction 45
• External rotation
• 80 - 90
• Internal rotation
• 60 - 90

9
Strength Testing

• Rotator Cuff Muscles
• S Supraspinatus
• I Infraspinatus
• t - Teres minor
• S- Supscapularis
• Abduction Supra
• IR subscap
• ER infra, TM
• Other muscles
• Deltoid
• Biceps
• Pecs
• Scapular stabilizers

10
Anatomy

• Muscles
• Deltoid
• Trapezius
• Rhomboids
• Levator scapulae
• Rotator cuff
• Teres major
• Biceps
• Pectoralis muscles
• Serratus anterior

Scapular stabilizers
11
Radiographic Anatomy
12
Common Shoulder Problems

• Instability
• Impingement
• Rotator cuff tears
• AC joint sprains and degeneration
• Adhesive capsulitis
• Labral tears
• Biceps tendinopathy
• Clavicle fractures

13
Glenohumeral Instability

• DEFINITION painful feeling of slippage,
  looseness, going in and out

14
Instability Eval FEDS

• Frequency
• 1-times
• 2-5
• frequent gt5
• Etiology Traumatic vs. Atraumatic
• Direction (predominant)
• anterior
• posterior
• inferior
• Severity Dislocation vs. Subluxation

15
Anterior Instability

• Dislocation impact to externally rotated,
  abducted arm
• Acute findings prominent acromion, anterior
  fullness
• Special Tests Apprehension, Relocation

16
Anterior Dislocation Injuries

• Bankart Lesion
• Anterior capsule torn
• Anteroinferior labrum torn
• Recurrent dislocations likely
• Hill-Sachs Lesion
• Humeral compression fracture

17
Posterior Instability

• Dislocations Electrocutions, Seizures
• Acute findings internal rotation, adduction
• Special tests
• Posterior drawer
• Load-shift

18
Inferior Instability

• Usually atraumatic
• Special tests
• Sulcus sign

19
Instability Imaging

• 4-view Radiographs
• AP
• Axillary
• scapular Y
• AC joint
• MRI

20
Anterior Dislocation
21
Posterior Dislocation
22
Anterior Dislocation Reduction

• Attempt ASAP
• Intra-articular Lidocaine HELPS!
• Use 2-3 techniques until successful
• Failure to ER
• sedation

23
Anterior Dislocation Treatment

• Referral to Ortho PhTh
• Surgery for younger/athletic patients
• Rehabilitation for others
• Immobilization
• Sling

24
Impingement

• Definition compression of the rotator cuff in
  the subacromial space
• Symptoms
• Pain with Overhead position or flexion/Internal
  Rotation
• Anterior, lateral shoulder pain
• Night Pain
• Risk Factors
• Overhead activities
• Micotrauma
• GH Instability
• Shape of Acromion
• DJD

25
Impingement
26
Impingement screening tests

• Neer full Flexion
• Neer to the Ear
• Hawkins Internal Rotation

27
Impingement confirmatory test

• Full Can Test Resistance applied in forward
  flexion and abduction (SCAPULAR PLANE)

28
Neer test Subacromial Injection relieves pain

• 5cc 1 lidocaine
• 25-27g needle
• Postero-laterally
• Wait 10 minutes for result
• gt50 pain reduction confirms

29
Impingement

• Imaging not initially needed
• 4-view shoulder series
• MRI if considering surgery
• Failed rehab
• Pain with ADLs

30
Impingement Treatment

• Acute Phase
• Avoid Exacerbating Factors
• Control Pain/Inflammation
• Physical Therapy
• Corticosteroid Injection
• Recovery Phase ROM, Strength, Proprioception
• Maintenance Phase Longer, Intense Workouts
• Surgical Intervention Failed Conservative
  Measures, Signifcant Disability

31
Rotator Cuff Tears

• Similar presentation as Impingement
• Failed rehab for impingement
• Persistent pain/weakness after Neer injection
  test
• Imaging x-rays, MRI

32
Rotator Cuff Tear Exam

• Supraspinatus
• drop-arm test
• Infraspinatus or Teres Minor
• External rotation lag sign
• Subscapularis
• Belly press test

33
Rotator Cuff Tears

• Treatment
• Conservative Similar to Impingement
• Surgical
• Young patient, large tears, dominant arm
• Failed Conservative Therapy
• High-Level Athlete
• Unable to perform vocational activities
• Success depends upon degree of tendon damage and
  degeneration

34
Ultrasound of RC tear
35
Prolotherapy for RCTs

• 25 Dextrose
• Platelet-Rich Plasma (PRP)
• Concentration of platelets and their growth
  factors
• Process (30 minutes)
• 20-60cc blood is drawn, then centrifuged to
  produce 3-6ml of PRP
• Ultrasound-guided injection

36
AC Joint Sprain

• Mechanism Fall on shoulder
• Presentation superior shoulder pain
• Exam
• AC jt TTP
• /- deformity or swelling
• Cross-chest (scarf) test

37
AC Joint Sprain

• Cross Chest (scarf) Test
• Active Compression (AC) test

38
AC Joint Sprain
39
AC Joint Sprain
40
AC Joint Sprain

• Imaging
• Bilateral AP
• Zanca View
• 10-15 degrees of cephalic tilt
• Axillary View
• Evaluates clavicular displacement

41
AC Joint Sprain Treatment

• Grade I and II Conservative
• Immobilization
• Ice, Analgesics
• ROM, Strengthening
• Anesthetic injection if rapid RTP needed
• Grade III Controversial refer to Ortho for
  counseling
• Immobilization for up to 4 weeks
• Most studies indicate conservative treatment is
  better
• Surgical management with higher rate of
  complications1
• Conservative management with mean time of 2.1
  weeks to return to work2
• Grade IV-VI Surgical

1. Taft TN, et al. Dislocation of the
   acromioclavicular joint. An end-result study. J
   Bone Joint Surg Am 1987 Sep69(7)1045-51.
2. Auwojtys EM Nelson G. Conservative treatment of
   Grade III acromioclavicular dislocations. SOClin
   Orthop Relat Res. 1991 Jul(268)112-9.

42
AC Joint Arthritis

• Chronic pain at AC joint
• Exam ACJ ttp, scarf test, active compression
  test
• X-rays narrowed AC jt, /- osteophytes
• Tx
• Avoid painful activities
• Steroid injections
• Surgical removal of distal clavicle (Mumford)

43
Adhesive Capsulitis

• Painful restriction of active and passive GH ROM
• Risk Factors
• Idiopathic
• Diabetes Mellitus
• Female Gender
• Ages 40-60
• Immobilization
• Inflammation
• Stroke

44
Adhesive Capsulitis

• Stage I
• 1-3 months
• Pain with normal ROM
• Stage II Freezing
• 3-9 months
• Pain and progressive ROM restriction

• Stage III Frozen
• 9-15 months
• Severe ROM restriction with decreased pain
• Stage IV Thawing
• 15-24 months
• Progressive restoration of ROM

45
Adhesive Capsulitis Treatment

• Anti-Inflammatories
• ROM, Stretching
• Steroid injection into subacromial space or GH jt
• Surgical
• Dilatation
• Manipulation

46
Labral Tears

• Causes Traction Injuries, FOOSH, Overhead motion
  overuse, MVA Trauma
• Locations
• Superior Labral Anterior-Posterior (SLAP) tear
• Posterior
• Anterior (from dislocation)

47
Labral Tears

• History
• Pain with overhead or cross-body activity
• Popping, clicking, catching
• 85 incidence of coexisting pathology
• Physical (none diagnostic)
• Crank Test
• Anterior Slide Test
• Yegason Test

48
SLAP Tears

• Type 1 Fraying Injury
• Type 2 Biceps tendon detached
• Type 3 Bucket-handle tear
• Type 4 Bucket-handle with Biceps detached

49
Labral Tears

• Diagnostic Radiograph, MR arthrogram
• Treatment
• Physical Therapy for gt 3 months
• Usually dont heal. Aim for PAIN CONTROL
• Surgery
• Types I and III Debridement
• Types II and IV Debridement and Reattachment
• Post-Op Rehabilitation
• Immobilize for 3 weeks
• Progress with AROM
• Return to full activity after 12-14 weeks

50
Biceps Tendinopathy

• Rarely seen in isolation
• Labral tears
• Rotator cuff tears
• Impingement
• Exam findings non-specific

51
Biceps Tendinopathy

• Speeds Test Resistance against Shoulder Flexion
• Yergasons Test Resistance against Supination

52
Biceps Tendinopathy

• Treatment
• Rehab exercise
• Sports Medicine referral if fails
• Prolotherapy injection
• Refractory MRI, surgery

53
Clavicle Fractures

• Clinical Features
• Clear Painful event
• Pain with arm motion
• Lump and possible tenting of the skin

54
Clavicle Fractures

• Diagnosis
• History physical
• X-ray AP axillary views, AP with 45 tilt
• CT for proximal distal clavicle fractures

55
Clavicle Fractures

• Surgery indications
• Open fracture
• Neurovascular compromise
• Displacement gt shaft width
• Healed clavicle lump not desirable
• Floating shoulder (concurrent scapular neck
  fracture)

56
Clavicle Fractures

• Conservative tx
• Rest
• Immobilization
• sling proven BETTER than fig-8
• Pain control, NO NSAIDs
• No overhead activity for 4-6 wks
• F/U 2-4 wks x-rays for healing
• PhTh referral for rehab
• Surgery if fails

57
Questions?