The Sore Shoulder: How To Evaluate, When To Scan, When To Refer

1. The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets

2. Case 1

3. History • 25 yo right-handed female presents with pain and weakness in her left shoulder • She works in an office but is involved in several recreational sports including volleyball, water-skiing and snow skiing • She has had problems with her shoulder since high school but symptoms have worsened in the last few months

4. Her pain is anterior, posterior, and lateral • She denies any specific injury but notes that her arm would feel momentarily weak at various times with her athletic activities • She has had similar but milder symptoms in her opposite shoulder • She was treated in high school with an exercise program but no supervised therapy. This seemed to relieve her symptoms

5. She has never had an x-ray or MRI • Occasionally she describes tingling in her whole arm • She takes oral contraceptives but is otherwise healthy. She had knee arthroscopy for a “patella problem” 4 years ago

6. What Are the Key Points Learned From the History?

7. What Is Your Differential Diagnosis?

8. Exam • No significant tenderness • ROM –full • Impingement tests – negative • Instability tests • Positive load-shift and drawer tests • Equivocal sulcus sign & relocation test

9. Apprehension tests produce discomfort only • Strength full in all muscle groups • No crepitus, no atrophy or swelling • Neurocirculatory exam – normal • Cervical spine exam - normal

10. Demonstration • Apprehension tests • Relocation test • Load-shift • Drawer test • Sulcus sign

11. On Physical Exam, How Do You Tell Apart Uni- Versus Multi-directional Instability and Why Is That Important?

12. When Do You Order X-rays and What Views?

13. Imaging - X-rays • Possible positive findings • Bony Bankart lesion • Hill-Sachs lesion

14. Hill-Sachs Lesion

15. When Do You Order an MRI?

16. MRI • Possible positive findings • Labrum tears • Capsular abnormalities – increased volume, avulsions

17. Normal Labrum

18. Bankart Lesion

19. Enlarged Capsule

20. Describe Your Initial Treatment

21. How Long Should You Continue Non-operative Treatment?

22. Initial Treatment • No labrum tear • Physical therapy – supervised TIW – 6 weeks minimum • Strengthening • Neuromuscular control • Scapular stabilization • Core stabilization

23. Labrum Tear Present • Referral for surgical consultation

24. Results • Multidirectional instability without labrum tear • Very high success rate with non-operative management • May require prolonged and specialized therapy program

25. Instability With Labrum Tear • Very high rate of unsatisfactory results without surgery • Early referral

26. What Is the Surgical Decision-making Process in This Case?

27. Case 2

28. Patient History • 47 yo female complains of pain in her dominant right shoulder. Onset was about 3 months ago. • She thought her pain may have started after she caught herself from falling in the shower, but the incident was so mild she quickly had forgotten about it. Since that time, she has steadily worsened.

29. She feels weak and has a lot of pain when she lifts her arm overhead. She describes the pain as being deep within the shoulder. • Some ADLS have become difficult, including fastening her bra. • She has no paresthesias or neck pain.

30. She went to an urgent care facility and had x-rays. She was told these were normal. An NSAID was given at that time and it helped “a little”. • She takes Lipitor, Wellbutrin, and Glucophage.

31. What Are the Key Points Learned From the History?

32. What Is Your Differential Diagnosis?

33. Exam • Tenderness anteriorly and posteriorly around the acromion • ROM – FF 90 degrees, ER – 20 degrees with arm at the side, IR – to about the SI joint • Impingement tests – all cause pain at end range of motion • Strength near normal in all groups

34. Mild crepitus • No atrophy or swelling • Neurocirculatory exam – normal • Instability tests – negative • Cervical spine exam – normal

35. Demonstration • ROM testing • C-spine and other ancillary testing

36. How Does Your Exam Eliminate Rotator Cuff Problems From the Differential?

37. When Do You Order X-rays and What Views?

38. Imaging - X-rays • Possible positive findings • Generally normal x-rays • Osteopenia?

39. When Do You Order an MRI?

40. MRI • Possible positive findings • Need to know cuff and labrum status • Many false positives in older age group

41. Describe Your Initial Treatment

42. What Is the Role of Corticosteroid Injections?

43. How Long Should You Continue Non-operative Treatment?

44. Initial Treatment • Always non-operative • Unless history of contralateral frozen shoulder unresponsive to therapy • Get control of pain • NSAIDs • Supplemental non-narcotic analgesics • TENS

45. Physical therapy – supervised TIW • Specify aggressive ROM/stretching • Myofascial/trigger point approach • Aquatic program • Combine with home program • Reassess in 4 weeks • Insurance often limits visits – “save” visits for post-op PT • Referral if no progress

46. What Is the Surgical Decision-making Process in This Case?

47. Results • Majority respond to PT • First operative intervention is manipulation under anesthesia

48. Case 3

49. Patient History • 54 yo male maintenance supervisor and recreational softball player complains of a 6 month history of dominant shoulder pain • Pain is localized to the anterior aspect of the shoulder with radiation to the deltoid insertion • He recalls no specific injury but has had several similar bouts of pain over the last 5 or 6 years. Each of these episodes resolved with activity modification alone

50. His current pain is worse with overhead activities and with reaching. He is occasionally wakened from sleep by his shoulder pain • He notes no numbness, tingling, or neck pain • He has mild treated hypertension but has no other significant medical history