Common Problems of the Shoulder

1. Common Problems of the Shoulder Part One Age >40

2. First, a little Anatomy

3. Shoulder Girdle Muscles

4. Shoulder Pain • Rule out Extrinsic Sources • Referred • Abdomen: subdiaphragmatic • Pulmonary disease: Pancoast tumor • Radicular • Cervical Spine

5. Cervicogenic Pain • Spondylosis: “degeneration” • Ache into shoulders • Pain reproduced with ROM • Radiculopathy (weakness) • C 4-5: 5 root, pain to shoulder, (deltoid) • C 5-6: 6 root, lat forearm, thumb (biceps, ECRL) • C 6-7: 7 root, middle finger (triceps) • C 7-8: 8 root, small finger (finger flexion) • C8-T1: T1 root, medial arm (finger abduction)

6. Common Diagnoses • Impingement • Rotator cuff tear • AC joint disease • Frozen shoulder • Rare: Glenohumeral arthritis, contusion, infection.

7. Shoulder Pain • Symptoms: • Pain overhead • Pain and weakness • Pain with anything • Duration of symptoms

8. Duration of Symptoms • If pain is acute (<12weeks), you can cure the patient with activity modification (no activity with elbow away from side), once a day stretch fully overhead, ice, and +/- NSAID or narcotic. • Pain > 12weeks is harder. • Pain > 6 months will need a miracle.

9. ImpingementThe most common diagnosis • Friction • Overuse--rare to get it in the history • Bursitis-->Tendinitis-->Rotator Cuff Tear

10. Impingement • Bursitis= pain but not when testing cuff • Tendinitis=hurts when cuff muscles are tested • Rotator cuff tear=weakness, frequently without pain

11. Impingement/BursitisPain with overhead activity • Pain felt at lateral shoulder • Pain at night • Can also be coming from the AC joint • EXAM: Impingement Sign vs AC joint tenderness and Cross Arm Adduction Test

12. TestsImpingement Sign

13. TestsCross Arm Adduction(pain must be at AC joint, not posterior capsule)

14. AC Joint • Tenderness directly over joint. • Pain increased with adduction, overhead activity • Treat like arthritis anywhere else. • Injections are frequently helpful diagnostically and therapeutically.

15. AC Joint Arthritis

16. Impingement Treatment • Activity modification: no activity with elbow away from side, in the gym, or at the computer. • Once a day stretch fully overhead. • NSAID and Ice • Injection in 3-6 wks prn. • Physical Therapy: After pain subsides: • Regain ROM, strengthen rotator cuff

17. Keeping shoulder healthy • Once pain subsides, start rotator cuff strengthening. • Continue cuff program at the gym and at home. • BOTH shoulders.

18. Pain and Weakness • Does this mean a Rotator Cuff Tear? • Can’t assess rotator cuff when there is pain • Treat pain first: NSAID, PT, ice, rest-4 wks • Cortisone shot (once) if above doesn’t work • Test cuff when pain subsides. • Refer after 6 weeks of treatment, not symptoms.

19. Rotator Cuff Tests • Best single test is External Rotation Strength (Infraspinatus and Teres Minor). • Can get extra credit testing Supraspinatus • Advanced placement if massive tear picked up testing Subscapularis (hand push off test with hand dorsum resting on low back)

20. TestsRotator CuffExternal Rotation

21. TestsRotator CuffSupraspinatus

22. Rotator Cuff Treatment • Cuff tear is rare in age<50. • Autopsy and MRI studies show most males over have RC tear and never had symptoms • Beware of the Repeat Injectee who has weakness. • Surgery decision is based on pain

23. Biceps Tendon RuptureProximal

24. Special Case: Rupture of long head of Biceps • Usually occurs without much trauma • Rupture of attrition (like a rope rubbing over a rock), remember long (lateral) head is intra-articular and part of the cuff. • Problem is the shoulder, not the tendon • Some supination power lost, not elbow flexion

25. Pain with Anything • Usually severe symptoms, not acute • Motion usually very restricted, passive and active (really can’t examine patient) • Frozen vs. “freezing” shoulder • PT, PT, PT (pain isn’t harmful) • Lots of support needed, injection might help.

26. Frozen Shoulder • Not an “-itis”, more like Dupuytrens contracture in the hand. • DDx: Shoulder joint infection (GH joint), Shoulder joint arthritis (DX with XR) • Best Dx test: no passive external rotation.

27. Frozen shoulder vs. Arthritis • Age • XR:

28. Shoulder Infection • Red, angry looking shoulder=septic arthritis of AC joint, not glenohumeral joint. • Aspirate point of maximal angriness (over superior AC joint), get labs, xray, and refer

29. Glenohumeral Joint Infection • Very rare • Increased incidence in diabetics, immuno-compromised patients. • Shoulder looks normal, just bigger. • SEVERE pain. Any motion hurts. • Often a fever. Get labs (CBC, blood cultures, ESR, CRP), XR, then: • Get a consult.

30. Who needs an Xray? • 1st visit, routine Hx/PE: No • No improvement after Tx: Yes • Odd Hx or PE, h/o fracture or injury: Yes • Pre-referral: Yes • Recommended XR: AP/outlet views

31. Shoulder Xrays

32. What about a MRI? • If it will change what you do, order it. • False positives • Helpful if cervical spine is bemuddling. • Some orthopedists like it prior to referral; doesn’t hurt to check for local customs.

33. Shoulder MRI