Assessment of Shoulder Pain

1. Assessment of Shoulder Pain A Physiotherapy approach for General Practitioners Presenters: Jaquie Goldsack and Linda Gomercic

2. Introduction • Anatomy • Review of movement terminology • Subjective Examination • Objective Examination • Practical component • Differential Diagnosis • When is Physio Indicated • When is a specialist referral required • Case Scenarios • Questions

3. Anatomy- Bone/Joint • Articulations: • Glenohumeral • Acromioclavicular • Sternoclavicular • ‘functional’ articulation of thorax and scapula • Shallow joint- deepened by labrum • Lots of degrees of freedom • Large HoH, small fossa • Stability dependant on non bony connections

4. Ligaments • Major Ligaments • Anterior GHL’s • Coracohumeral Ligament • Superior GHL • Middle GHL • Inferior GHL • Labrum • Narrow, wedged shaped structure • Intimately associated with the shld capsule • Blends with origin of LHB • Pain sensitive structure • Roles: deepens fossa, controls translational movement of the shld in mid range movements, draws HoH into glenoid fossa.

5. Muscles • Rotator Cuff • Made up of: • SS • IF • Sub scap • Teres minor • Other stabilisers • Upper, Middle and Lower traps • Post Deltoid • Other muscles that impact on shoulder Position (global) • LS • Rhomboids • Pec Minor

6. Bursae • Subacromial • Decreases friction • Thickens with degeneration and wear and tear • Can be site of acute irritation or secondary inflammatory response to primary degenerative pathology • Sub acromial space- true site of classic impingement

7. Innervation of the RC • Supraspinatus: suprascapula nerve C4, C5, C6 • Infraspinatus: suprascapula nerve C5, C6 • Subscapularis: Upper and lower subscapula nerve C5, C6, C7 • Teres Minor: Axillary nerve C5, C6

8. Quick Review of Terminology • Flexion/extension • IR/ER • HF/HE

9. Abduction/ Adduction • Protraction/Retraction

10. Subjective Examination • Mechanism of injury • Pain area • Duration of pain (date of onset) • Irritability • 24hr behaviour • Agg/easing factors • Previous History of shoulder problems (esp if gradual onset) • Occupation • Sports, exercise, hobbies • Red flags (Hx cancer, bilateral P&N, pain levels exceeding those expected, systemic S&S, non mechanical MOI)

11. Objective • Observation (scap levels, protraction, downward tilt, depression, clavicle levels) • Normal resting position of the Scapula: • superior angle – T2/3 • inferior angle – T6/7 • upward rotation – average 10 degrees • Anterior tilt – 8 degrees • Internal Rotation – 33-35 degrees • 2-3 fingers off of the spinous process ??

12. Scapular Movements

13. Depressed Scapula

14. Protracted/Winging scap

15. Anterior Tilt

16. Kyphotic tx, Ant sitting HoH

17. Posture

18. Objective Examination cont • 4 finger position of scap- superior and inferior angles of the scapula, acromion and coracoid. • The ‘claw’ position of HoH- Anterior and posterior acromion compared to anterior and posterior HoH (HoH sitting 1/3 anterior to acromion). • AROM • With scap repositioning • PROM

19. Repositioning of scap and Re-Ax ROM

20. Special Tests- Hawkins and Kennedy • Impingement testing

21. Full Can/Empty Can • Rotator cuff tear/inflammation

22. Subscap lift off and Press Belly Tests

23. Speeds

24. Apprehension

25. Sulcus

26. Neural Tension tests • Median: • shoulder depression • 90 deg shoulder abduction • Wrist, finger, thumb Extension • Supination • ER of shoulder • Elbow extension

27. Neural Tension Tests • Ulnar: • Wrist extension/ 4th and 5th finger ext • Pronation/ supination • Elbow flexion • ER of shoulder • Shoulder Abduction

28. Neural Tension Tests • Radial – • Shoulder Depression • Elbow extension • Whole arm IR • Wrist flexion/ thumb flexion • Shoulder abduction

29. Practical- Groups • Observation • AROM • Scap repositioning • Hawkins + Kennedy • Full can/ Empty Can • Lift Off / press belly • Speeds • Apprehension Test • Sulcus

30. ImagingWhen is it warranted? • Trauma • Very large loss in range of motion/severe shoulder pathology • Red flags ie history of cancer, unexplained weight loss • Failed conservative management • Dislocation- can still be managed conservatively • Unclear diagnosis

31. Differential DiagnosisOther Causes of pain in the shoulder • Referral from the neck • Thoracic outlet Syndrome • Peripheral nerve sensitisation • Thoracic spine pain • SLAP lesions Refer to table

32. When are anti inflammatories/Cortisone Warranted • Moderate-severe pain that’s not improving (acute rotator cuff tears) • Difficulties with sleep • Failure of over the counter anti inflammatory’s to provide relief • Frozen shoulder stage I and possibly II (pain relief) • Slow progress with conservative management

33. When is Physio Indicated • Rotator cuff pathology and impingement. • Dysfunctional scapula position • Significant symptom relief and improvement of range of motion from scap repositioning • Post cortisone • Stiff shoulder • ?Frozen shoulder. Especially stages II and III when pain has decreased and shoulder is stiff. Physio essential to restore ROM and function. There is also a role for physio with education and prevention of secondary problems in stage I. Research also shows gains in the first 2 months of stage 1. • Hypermobile/unstable shoulder • Pre and post shoulder surgery • Unclear diagnosis for example pins and needles, multiple pathology, referring pain into arm, headaches etc

34. Treatment Approach • Muscle release • Heat/ ice/ ultrasound/ tens/ acupuncture • Tape to offload structures/ promote optimal position • Mobilisations – shoulder, cervical, thoracic or nerve • Stability exercises • Motor control exercises • Global muscle strengthening

35. Specialist Referral • Recurrent dislocations/subluxations • Rotator cuff tears >2cm, massive tears, full thickness tears, partial thickness tears >50% • Frozen shoulder stage 1 • If conservative management is not working • Unsure diagnosis

36. Case Study 1/Discussion • 45y/o Female presents with acute onset right shoulder pain after spending the weekend painting. She is unable to lift her arm >90degrees due to pain. • Pain is at the deltoid insertion with some radiation down to elbow when she uses her arm (ie brushing teeth, doing hair) • Agg activities include: lifting arm, brushing hair, reaching, doing up bra, lying on her right side • Easing activities include: supporting arm, rest, heat to shoulder • Special Q’s: nil Hx of cancer, no neural Sx, • What is your differential Dx? • What tests would you perform?

37. Case Study 2/Discussion • 30 y/o male presents with right sided pain in his biceps and P&N & numbness in his palm, onset 6 weeks ago, gradually worsening. Gets pain at night time. • Works as a labourer. Hx of carrying a large sheet of metal. The other person carrying dropped one side of it, causing a traction force through his right arm. • Agg activities include arm hanging by side, carrying objects, lying on right side. Gets headaches with prolonged sitting and driving • Ease activities: putting arm on head or resting thumb in belt, resting arm on object • Mild decrease in range of motion. Catch at 90degrees of abduction but can continue through ROM. • Observation: Depressed and protracted right scapula • Differential Dx? • What tests would you perform?

38. Case Study 3/Discussion • 40 year old diabetic female presenting with gradual onset of pain and restriction of the right GH joint over the last 3 months. • Constant ache with sharp pain upon movement • Agg – all shoulder movements, sleeping, dressing herself • Worse at night – sleeps only 3-4 hours per day • Ease – nothing at the moment • Works full time as a secretary • Unaware of any previous injuries to the shoulder • Observation: Rounded shoulders and kyphotic; shoulder hike on affected side • AROM: 40deg flxn+ abduction; 10 deg ER; HBB = iliac crest • Differential Diagnosis: ? • What tests would you perform? • Any imaging? • Physio approach

39. Questions Thank you for attending