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THE SHOULDER: Evaluation and Treatment of Common Injuries. Brandon Mines, MD Emory Sports Medicine Center March 18 th , 2010. The Shoulder. Anatomy History Physical Examination Common shoulder injuries Acromioclavicular joint sprain Impingement Rotator Cuff Tear Adhesive Capsulitis

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the shoulder evaluation and treatment of common injuries

THE SHOULDER: Evaluation and Treatment of Common Injuries

Brandon Mines, MD

Emory Sports Medicine Center

March 18th, 2010

the shoulder
The Shoulder
  • Anatomy
  • History
  • Physical Examination
  • Common shoulder injuries
    • Acromioclavicular joint sprain
    • Impingement
    • Rotator Cuff Tear
    • Adhesive Capsulitis
    • Clavicle Fractures
    • Shoulder Subluxation/Dislocation
shoulder pain
Shoulder Pain
  • Very common problem in sports medicine
  • Unique anatomy & range of motion make diagnoses challenging
  • Thorough understanding of anatomy & biomechanics is important to helpful
  • Bony, soft tissues & nerve injuries
  • Acute or chronic pain
shoulder anatomy bony anatomy
Shoulder Anatomy:Bony Anatomy
  • Humerus
  • Scapula
    • Glenoid
    • Acromion
    • Coracoid
    • Scapular body
  • Clavicle
  • Sternum
shoulder anatomy joints
Shoulder Anatomy:Joints
  • Glenohumeral
  • Acromioclavicular
  • Sternoclavicular
  • Scapulothoracic articulation
glenohumeral joint
Glenohumeral Joint
  • Most common dislocated joint
  • Lacks bony stability
  • Composed of:
    • Fibrous capsule
    • Ligaments
    • Surrounding muscles
    • Glenoid labrum
shoulder anatomy rotator cuff muscles
Shoulder Anatomy:Rotator Cuff Muscles
  • Depress humeral head against glenoid
shoulder anatomy rotator cuff muscles1
Shoulder anatomy:Rotator cuff muscles
  • Supraspinatus:
    • Abduction
  • Infraspinatus:
    • External rotation
  • Teres Minor:
    • External rotation
  • Subscapularis:
    • Internal rotation
shoulder anatomy other musculature
Shoulder Anatomy:Other Musculature
  • Pectoralis major, deltoid, latissimus dorsi, biceps
  • Rhomboids, trapezius, levator scapulae, serratus anterior
history
History
  • Mechanism of injury
  • Specific sport/activity when injury occurred
  • Duration of symptoms
  • Acute event or chronic
  • Aggravating/alleviating factors
  • Pain (Location/Character/Night pain)
history1
History
  • Sensation of instability
  • Weakness
  • Popping/Crepitus: painful/non-painful
  • Stiffness
  • Numbness/Tingling
  • Shoulder activities involved in patients occupation
history2
History
  • Past medical history of shoulder injury/surgery
  • Previous history of injections
  • Hand dominance
physical examination
Physical Examination
  • Inspection
  • Palpation
  • Range of Motion
  • Strength
  • Provocative shoulder testing
  • Neurovascular status
  • Neck & elbow exam
pe inspection
PE: Inspection
  • Compare to normal shoulder for obvious deformities
  • Abnormalities of:
    • Humeral head
    • Clavicle
    • AC joint
    • SC joint
pe inspection1
PE: Inspection
  • Muscle atrophy
    • May indicate nerve damage or disuse atrophy 2° to rotator cuff pain/tear
  • Appearance of skin:
    • Swelling
    • Ecchymosis
    • Erythema
    • Venous distention
pe inspection2
PE: Inspection
  • Scapulothoracic motion
  • Dyskinesia or winging
pe palpation
PE: Palpation
  • Bony structures:
    • SC joint
    • Clavicle
    • AC joint
    • Acromion
    • Greater tuberosity
    • Coracoid process
    • Spine of scapula
  • Soft tissue structures
    • Short & long heads of biceps
    • Subacromial bursa
    • Musculature of shoulder
    • Anterior capsule
    • Posterior capsule
    • Pericapsular musculature
pe range of motion
PE: Range of Motion
  • Passive & Active
  • Compare to unaffected side
  • Pain w/ movement?
  • Dominant shoulder (“Overhead athletes”)
    • 5° to 10° more external rotation
    • 5° to 10° less internal rotation
pe range of motion1
PE: Range of Motion
  • Forward Flexion
  • Abduction
  • Adduction
  • Internal Rotation
  • External Rotation
pe muscle testing
PE: Muscle testing
  • Compare to unaffected side
  • Differentiate between true weakness & weakness 2° to pain
pe muscle testing supraspinatus
PE: Muscle TestingSupraspinatus
  • Empty Can Test
  • 90° abduction
  • 30° forward flexion
  • Thumbs pointing downward
  • Patient attempts elevation against examiner’s resistance
pe muscle testing subscapularis
PE: Muscle testingSubscapularis
  • “Lift-off test”
  • Internally rotate shoulder
  • Dorsum of hand against lower back
  • Patient attempts to push away examiner’s hand
  • Modified: Place hand on abdomen and resist internal rotation
pe muscle testing infraspinatus teres minor
PE: Muscle TestingInfraspinatus/Teres Minor
  • Patient’s arms adducted @ sides
  • Elbows flexed to 90°
  • Patient attempts external rotation against examiner’s resistance
provocative tests
Provocative Tests
  • Impingement signs
  • AC Joint
  • Biceps tendon
  • Glenohumeral joint stability
  • Labral signs
  • Cervical spine signs
impingement signs neer s test
Impingement Signs:Neer’s Test
  • Scapula stabilized
  • Arm fully pronated
  • Examiner brings shoulder into maximal forward flexion
  • Pain  subacromial impingement
impingement signs hawkins test
Impingement Signs:Hawkins’ Test
  • Patient’s arm forward flexed to 90°
  • Elbow flexed to 90°
  • Shoulder forcibly internally rotated by examiner
  • Pain  subacromial impingement or rotator cuff tendinitis
rotator cuff sign drop arm test
Rotator Cuff sign:Drop Arm Test
  • Passively abduct patient’s shoulder
  • Observe as patient slowly lowers arm to waist
  • If arm drops to patient’s side, suggests rotator cuff tear &/or supraspinatus dysfunction
ac joint crossover test
AC joint:Crossover Test
  • Patient raises affected arm to 90°
  • Actively adducts arm across body
  • Forces acromion into distal end of clavicle
  • Isolates AC joint & painful if positive
biceps tendon speed s test
Biceps Tendon:Speed’s Test
  • Elbow flexed 20°-30°
  • Forearm supinated
  • Arm in 60° flexion
  • Patient forward flexes arm against examiner’s resistance
anterior instability testing apprehension test
Anterior Instability Testing:Apprehension Test
  • Supine, sitting or standing
  • Arm abducted to 90°
  • Apply slight anterior pressure & slowly externally rotate
  • Apprehension may indicate anterior instability
  • Pain w/out apprehension is more likely impingement
inferior instability testing sulcus sign
Inferior Instability Testing:Sulcus Sign
  • Arm in neutral position
  • Pull downward on elbow or wrist
  • Observe for depression lateral or inferior to acromion
  • Positive if > 1 cm
  • Indicates inferior instability
  • Compare to other side
posterior instability testing posterior apprehension test
Posterior Instability Testing:Posterior Apprehension Test
  • Supine or sitting
  • Arm in 90° abduction, 90° elbow flexion
  • Apply posteriorly directed force in attempt to displace humeral head posteriorly
labral signs
Labral signs
  • O’Brien’s test
  • Arm forward flexed to 90°
  • Elbow fully extended
  • Arm adducted 10° - 15°, thumb down
  • Downward pressure
  • Repeat w/ palm up
  • Suggestive of labral tear if more pain w/ thumb down
cervical spine spurling s maneuver
Cervical Spine:Spurling’s Maneuver
  • Neck extended
  • Head rotated toward affected shoulder
  • Axial load placed on the spine
  • Reproduction of patient’s shoulder/arm pain indicate possible nerve root compression
acromioclavicular joint sprain
Acromioclavicular Joint Sprain
  • Common
  • “Shoulder separation”
  • Mechanism:
    • Fall landing on “point” or lateral aspect of shoulder
    • Occasionally from fall on outstretched hand
ac joint sprain
AC Joint Sprain
  • Six classifications of injury:
ac joint sprain1
AC Joint Sprain
  • Physical Exam:
    • Well-localized swelling & tenderness over AC joint
    • Painful active & passive range of motion
    • Crossover testing increases pain
    • Type II, III, V may have high riding clavicle
    • May have tenderness to palpation over clavicle shaft, SC joint & clavicular attachments of trapezius & deltoids
ac joint sprain2
AC Joint Sprain
  • Treatment:
    • Type I, II, III:
      • Conservative treatment
      • Ice, Rest, NSAIDS
      • Begin ROM exercise as soon as tolerated
    • Type IV and higher:
      • May require further intervention
rotator cuff impingement tendinitis
Rotator Cuff Impingement/Tendinitis
  • Rotator cuff muscles, (especially supraspinatus) & biceps tendon
    • Impinge against undersurface of acromion & coracoacromial ligament
rotator cuff impingement tendinitis1
Rotator Cuff Impingement/Tendinitis
  • Mechanism:
    • Subacromial bursa & rotator cuff tendon become inflamed secondary to friction against undersurface of acromion & coracoacromial ligament
    • May result from overuse, rotator cuff weakness, mild anterior instability, direct trauma
rotator cuff impingement tendinitis2
Rotator Cuff Impingement/Tendinitis
  • Predisposing factors:
    • Repetitive motion of shoulder above horizontal plane (swimming, throwing, golf, tennis, etc.)
    • Fatigue of rotator cuff  abnormal shoulder mechanics
    • Subtle instability resulting in 2° impingement
    • Upper extremity inflexibility, anterior sloped or hooked acromion, AC joint spurring/hypertrophy
rotator cuff impingement tendinitis3
Rotator Cuff Impingement/Tendinitis
  • History:
    • Pain referred to anterolateral aspect of shoulder w/ some radiation (not beyond elbow)
    • Aggravated w/ overhead activities
    • Night pain
    • Clicking or popping sensation
rotator cuff impingement tendinitis4
Rotator Cuff Impingement/Tendinitis
  • Physical Exam:
    • Possible atrophy of supra- & infraspinatus
    • Tenderness over greater tuberosity & long head of biceps
    •  range of motion 2° to pain
    • Painful arc within 70° to 120° abduction
    • + impingement signs (Neer’s, Hawkins’)
    • Crepitus/snapping w/ external to internal rotation
rotator cuff impingement tendinitis5
Rotator Cuff Impingement/Tendinitis
  • Radiographs:
    • Standard AP & axillary
    • Suprascapular outlet view
    • May show undersurface AC joint spurring or glenohumeral degenerative changes
rotator cuff impingement tendinitis6
Rotator Cuff Impingement/Tendinitis
  • Treatment:
    • Conservative
    • Temporary avoidance of aggravating factors
    • Ice
    • NSAIDS
    • Physical Therapy
rotator cuff impingement tendinitis7
Rotator CuffImpingement/Tendinitis

Strengthening Exercises

rotator cuff impingement tendinitis8
Rotator Cuff Impingement/Tendinitis
  • Corticosteroid injection
      • If not improving w/ PT
      • May allow more effective participation in PT
rotator cuff tear
Rotator Cuff Tear
  • Full or partial thickness disruption of tendon fibers
  • PE:
    • + impingement signs (Neer’s, Hawkins’)
    • Drop arm test +
  • Diagnosis: MRI
  • Conservative treatment
  • Surgical evaluation if fail to improve
adhesive capsulitis
Adhesive Capsulitis
  • “Frozen shoulder”
  • Thickening & contraction of capsule around glenohumeral joint causing loss of motion & pain
  • Mechanism:
    • Unknown
    • Possibly 2° to pain & guarding of shoulder
    • Other: Trauma, rotator cuff tendinitis, RSD, CAD, DM, hormonal imbalance
adhesive capsulitis1
Adhesive Capsulitis
  • History:
    • Slow onset of shoulder pain (pain  as motion progressively )
    • Limited range of motion
    • Night pain
adhesive capsulitis2
Adhesive Capsulitis
  • Physical Exam:
    • Significant  range of motion w/ firm end point on motion testing
    • Internal & external motion most limited
  • Radiographs:
    • Routine x-rays usually normal
    • Arthrogram may show  joint volume
adhesive capsulitis3
Adhesive Capsulitis
  • Treatment:
    • Physical therapy:
      • Work on gentle range of motion
    • NSAIDS
    • Ice
    • Corticosteroid injections
    • Manipulation under anesthesia
clavicle fracture
Clavicle Fracture
  • Common
  • Most occur in middle one-third of clavicle
  • Mechanism:
    • Fall on outstretched arm or point of shoulder
    • Direct blow to midportion of clavicle less common
clavicle fracture2
Clavicle Fracture
  • Physical Exam:
    • Visible & palpable deformity
    • Local pain & swelling
    • Pain may radiate into trapezius & neck
    • Complete neuro exam important to detect brachial plexus injury
clavicle fracture3
Clavicle Fracture
  • Radiographs:
    • AP and axillary view
    • AP view w/ 45° cephalic tilt
    • (Chest film if substantial trauma)
clavicle fracture4
Clavicle Fracture
  • Treatment:
    • Conservative
    • Sling for 2 to 4 weeks
    • Displaced fractures may need referral for further evaluation
anterior shoulder subluxation dislocation
Anterior Shoulder Subluxation/Dislocation
  • Dislocation:
    • Complete separation of articular surfaces
  • Subluxation:
    • Abnormal translation of humeral head on glenoid without complete separation of articular surfaces
  • Humeral head can dislocate anteriorly, posteriorly or inferiorly
  • Anterior dislocation most common
anterior shoulder subluxation dislocation1
Anterior Shoulder Subluxation/Dislocation
  • Mechanism:
    • Forced extension, abduction, external rotation
    • Direct blow to posterior or posterolateral shoulder
    • Repeated episodes of overuse (subluxation)
anterior shoulder subluxation dislocation2
Anterior Shoulder Subluxation/Dislocation
  • Physical Exam:
    • Intense pain
    • Arm held in abduction & external rotation
    • Humeral head palpable anteriorly
    • Unable to completely internally rotate or abduct the shoulder
    • Thorough neuro exam (close relation of axillary nerve)
anterior shoulder subluxation dislocation3
Anterior Shoulder Subluxation/Dislocation
  • Radiographs:

Axillary View

True AP

Y view

anterior shoulder subluxation dislocation4
Anterior Shoulder Subluxation/Dislocation
  • Radiographs:
    • Helps to determine or confirm position
    • If dislocated, obtain post-reduction films as well

Anterior dislocation

anterior shoulder dislocation
Anterior Shoulder Dislocation
  • Prompt reduction
  • Many different methods of reduction

Traction-countertraction

anterior shoulder subluxation dislocation5
Anterior Shoulder Subluxation/Dislocation
  • Treatment:
    • Sling
    • Ice
    • NSAIDS
    • Protected range of motion
    • Rotator cuff strengthening after acute pain resolves
    • Return to sport when normal strength & motion regained
the shoulder1
The shoulder
  • Develop systematic approach to examination
  • Make sure to evaluate above & below shoulder joint
  • Thorough neuro examination
  • Address potential causes of injury
  • Physical therapy !!!
references
References:
  • Dunlap J: Shoulder dislocations, in Puffer JC: 20 Common Problems in Sports Medicine, McGraw-Hill, 2002; 29-43.
  • Kinderknecht JJ: Shoulder pain, in Puffer JC: 20 Common Problems in Sports Medicine, McGraw-Hill, 2002; 3-38.
  • Hutton KS, Julin MJ: Shoulder injuries, in Mellion MB: Team Physician’s Handbook, 3rd Ed, Hanley-Belfus, Inc, 2002; 397-418.
  • Woodard TW, Best TM. The painful shoulder: Part I. Clinical Evaluation. Am Fam Phys 2000; 61:3079-88.
  • Woodard TW, Best TM. The painful shoulder: Part II. Acute and chronic disorders. Am Fam Phys 2000; 61:3291-3000.