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Shoulder Problem Evaluation

. Second most common musculoskeletal complaintDifficult joint to examineMultidirectional range of motion- UNIQUE!Shoulder injury can affect nearly every sport and many daily activities. Objectives. Review pertinent anatomyDiscuss common pathologyDiscuss historical clues to diagnosisSelect casesPhysical exam in small group discussions.

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Shoulder Problem Evaluation

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    1. Shoulder Problem Evaluation MS3 Family Medicine

    2. Second most common musculoskeletal complaint Difficult joint to examine Multidirectional range of motion- UNIQUE! Shoulder injury can affect nearly every sport and many daily activities

    3. Objectives Review pertinent anatomy Discuss common pathology Discuss historical clues to diagnosis Select cases Physical exam in small group discussions

    4. Bony Anatomy Anterior

    5. Bony Anatomy Anterior and Posterior

    6. Radiographic Anatomy

    7. Where do things go wrong?? Fractures

    8. Where do things go wrong?? Dislocations and Separations Dislocations and separations are protected by both “static” and “dynamic” stabilizers…

    9. Where do things go wrong?? Dislocations and Separations Oh, yeah…Arthritis can happen at these joints, too…

    10. Glenohumeral Joint Shallow (“golf ball sitting on a tee”) Inherently unstable (maximizes ROM) Static stabilizers glenohumeral ligaments, glenoid labrum and capsule Dynamic stabilizers Predominantly rotator cuff muscles Also scapular stabilizers Trapezius, leavator scapulae, serratus anterior, rhomboids

    11. Bony Anatomy “Static Stabilizers”

    12. What goes wrong… Besides separations and dislocations?? Instability!!!

    13. LABRUM

    14. What goes wrong? Tears and tendonopathies

    15. The Rotator Cuff Muscles “dynamic stabilizers”

    16. The Rotator Cuff Muscles Supraspinatus Infraspinatus Teres minor Supscapularis

    17. The Rotator Cuff Muscles: SITS Supraspinatus ABD Infraspinatus ER Teres minor ER Supscapularis IR

    18. Finally…the subacromial space

    19. What can go wrong???

    20. Impingement

    21. Other Anatomy Deltoid Rotator cuff Teres major Latissimus dorsi Biceps Pectoralis muscles 17 muscles create the movement of the shoulder17 muscles create the movement of the shoulder

    22. Shoulder Anatomy

    24. So…what causes shoulder pain? Impingement Labrum and biceps pathology A-C joint pathology Rotator Cuff Injury Instability Among other things…

    25. Clinical Exam History Pain Acute Chronic Weakness Deformity

    26. Clinical Exam History Single event Repetitive overload Instability Does it feel like it’s going to come out? Catching/Locking

    27. Clinical Exam History Sport / Occupation Previous injury Previous treatment Other joints involved Disability

    28. Physical Exam: Big 6 Inspection Palpation Range of Motion Strength Neurovascular Special Tests

    29. Special Tests Impingement Rotator Cuff Integrity Labrum and Biceps AC (SC) Joints Instability

    30. Physical Exam The physical exam will be demonstrated during small group discussions…

    31. Which rotator cuff muscle(s) are responsible for external rotation Supraspinatus Infraspinatus Subscapularis Teres Minor Both 2 and 4

    32. The apex (bottom) of the scapula is at what level of the spine? C7 T3 T7 T12 L4

    33. Case #1 22-year-old male rugby player falls onto his right shoulder while being tackled Severe pain on top of his right shoulder

    34. Case #1 Notable deformity over superior shoulder Painful range of motion Unable to lift right arm above waist Special Tests?? Diagnosis???

    35. Acromioclavicular (A-C) Sprain Special Tests Shear Test Cross Arm Test A-C Palpation Resisted Extension Active compression test

    36. 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

    37. AC Joint Sprain Treatment Analgesics, ice prn Sling for as long as needed Physical Therapy ROM restoration Gradual strength exercise Return to sport activity as tolerated

    38. Case #2 24-year-old male handball player Fell onto his shoulder after being pushed Intense pain Hand is tingling and arm feels like it’s hanging X-rays

    39. X RAYS

    40. Shoulder Dislocation/Anterior Instability Humeral head dislocates from glenoid fossa Almost always anterior (95%) Usually traumatic with injury to capsule-labrum complex

    41. 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

    42. Special Tests Glenoid Labrum and Instability Biceps Load I and II Kim Test Jerk Test Active-Compression Test (O’Brien) Crank Test Apprehension Test Relocation Test Load and Shift Sulcas Sign

    43. Which of the following structures can be “impinged”? Biceps tendon Subacromial Bursa Rotator Cuff Tendons All of the above

    44. Case #3 35-year-old male tennis player Shoulder pain exacerbated by practicing serves Develops dull, aching pain in right shoulder

    45. SHOULDER PAIN Physical 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 Special Tests??? Diagnosis???

    46. Shoulder Pain Physical Exam Hawkin’s positive Neer’s positive IMPINGEMENT???

    47. Impingement as a Clinical Sign Repetitive overhead activities Subacromial bursa and/or rotator cuff impinged between acromion & humerus Physical therapy, activity modification +/- medications

    48. Diagnoses associated with clinical sign of Rotator Cuff Impingement: Subacromial bone spurs and / or bursal hypertrophy AC joint arthrosis and /or bone spurs Rotator cuff disease Superior labral injury Glenohumeral instability Scapular dyskinesis Biceps tendinopathy A diagnostic injection sometimes helps to clarify the diagnosis

    49. Case #4 45-year-old weight lifter Caught bar as it was falling off his shoulder Sudden pain Severe weakness left shoulder Worse with overhead activities; while sleeping at night Pain in anterior lateral shoulder Special tests?

    50. Case #4 Drop Arm Test Positive External Rotation Lag Sign positive Weakness with Empty Can Sign Normal bear hug and belly press tests… Diagnosis?????

    51. Rotator Cuff Tear Supraspinatus tendon most common Acute trauma or chronic tendinopathy Treatment dependent upon age/activity Young, active usually require operative treatment Older, low-activity usually respond to non-operative treatment

    52. 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

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

    54. Shoulder pain isn’t always the shoulder!! Get more history… Gall bladder disease Peptic Ulcer Disease Cervical radiculopathy Cardiac ischemia Pulmonary conditions ie Pancoast’s tumor, Pneumonia

    55. In the human body, which is the most incredible joint? PIP Knee Ankle Shoulder None of the above

    56. Case #6 40-year-old male Recently shoveled 16” of snow Can hardly lift left arm due to pain Special Tests? Diagnosis?

    57. Biceps Tendonopathy Speed Test Yergason Test Direct palpation

    58. Biceps Tendonopathies Repetitive overhead activity Repetitive forearm flexion/supination Difficult to discern from rotator cuff tendinopathy or impingement

    59. Conclusion Shoulder injuries are common. Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis. Impingement is a clinical sign, not a diagnosis. Don’t forget about medical causes.

    60. QUESTIONS?

    61. Physical Exam Inspection Front & back Height of shoulder and scapulae Muscle atrophy, asymmetry

    62. Physical Exam Range of Motion Abduction 0-180o

    63. Physical Exam Range of Motion Forward flexion: 0o – 180o

    64. Physical Exam Range of Motion Extension 0o – 40 to 60o

    65. Physical Exam Range of Motion Internal rotation T5 segment External rotation 80-90o

    66. Physical Exam Strength Empty can test 30o angle Steady downward pressure Tests supraspinatus strength and pain

    67. Physical Exam Strength Resisted external rotation Tests infraspinatus, teres minor strength

    68. Physical Exam Strength of Subscapularis Liftoff test Belly press test

    69. Cross-Arm Adduction Test AC joint pathology Arm flexed to 90° Hyperadduct arm across body as far as possible Pain in AC = (+) test

    70. 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

    71. Sulcus Sign Inferior instability Arm relaxed in neutral position, pull downward at elbow (+) test = sulcus at infra-acromial area compare to unaffected side

    72. Apprehension Test Anterior instability Shoulder at 90° abducted, slight anterior pressure & External rotation (+) test = dislocation apprehension some false (+)

    73. Relocation Test Perform after positive apprehension test Apply post force over humeral head during external rotation (ER) (+) test = increased ER tolerance

    74. 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)

    75. Impingement Signs

    76. Drop Arm Test Suggestive of Rotator Cuff Tear Passive abduction to 90° Instruct patient to slowly lower arm At 90° abducted arm will suddenly drop, may need to add slight pressure (+) drop = (+) test

    77. Speed’s Test Biceps Tendinopathy Long head of biceps tendonitis Fwd flex to 90°, abd 10°, full supination Apply downward force to distal arm Pain = (+) test weakness w/o pain = muscle weakness or rupture

    78. O’Brien’s Active Compression SLAP lesion (Superior Labrum Antero-Posterior) Labral/AC pathology Arm flexed to 90°, elbow extended, adduct 10-15°, resist downward force + if AC pain or internal pain/click

    79. O’Brien’s Active Compression SLAP lesion Supination should be pain free (decreased pain)

    80. Crank Test Labral injury Glenoid labrum tear Abduct arm to 160°, pt is supine or upright, elbow secured with one hand axial load at shoulder with other (+) if audible/painful catch/grind is noted

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