THE SHOULDER: Evaluation and Treatment of Common Injuries - PowerPoint PPT Presentation

THE SHOULDER: Evaluation and Treatment of Common Injuries

Brandon Mines, MD

Emory Sports Medicine Center

March 18th, 2010

• Anatomy
• History
• Physical Examination
• Common shoulder injuries
• Acromioclavicular joint sprain
• Impingement
• Rotator Cuff Tear
• Adhesive Capsulitis
• Clavicle Fractures
• Shoulder Subluxation/Dislocation

• 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

• Humerus
• Scapula
• Glenoid
• Acromion
• Coracoid
• Scapular body
• Clavicle
• Sternum

• Glenohumeral
• Acromioclavicular

• Sternoclavicular
• Scapulothoracic articulation

• Most common dislocated joint
• Lacks bony stability
• Composed of:
• Fibrous capsule
• Ligaments
• Surrounding muscles
• Glenoid labrum

• Depress humeral head against glenoid

• Supraspinatus:
• Abduction
• Infraspinatus:
• External rotation
• Teres Minor:
• External rotation
• Subscapularis:
• Internal rotation

• Pectoralis major, deltoid, latissimus dorsi, biceps
• Rhomboids, trapezius, levator scapulae, serratus anterior

• Mechanism of injury
• Specific sport/activity when injury occurred
• Duration of symptoms
• Acute event or chronic
• Aggravating/alleviating factors
• Pain (Location/Character/Night pain)

• Sensation of instability
• Weakness
• Popping/Crepitus: painful/non-painful
• Stiffness
• Numbness/Tingling
• Shoulder activities involved in patients occupation

• Past medical history of shoulder injury/surgery
• Previous history of injections
• Hand dominance

Shoulder Pain:Physical Examination

• Inspection
• Palpation
• Range of Motion
• Strength
• Provocative shoulder testing
• Neurovascular status
• Neck & elbow exam

• Compare to normal shoulder for obvious deformities
• Abnormalities of:
• Humeral head
• Clavicle
• AC joint
• SC joint

• Muscle atrophy
• May indicate nerve damage or disuse atrophy 2° to rotator cuff pain/tear
• Appearance of skin:
• Swelling
• Ecchymosis
• Erythema
• Venous distention

• Scapulothoracic motion
• Dyskinesia or winging

• 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

• 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

• Forward Flexion
• Abduction
• Adduction
• Internal Rotation
• External Rotation

• Compare to unaffected side
• Differentiate between true weakness & weakness 2° to pain

• Empty Can Test
• 90° abduction
• 30° forward flexion
• Thumbs pointing downward
• Patient attempts elevation against examiner’s resistance

• “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

• Patient’s arms adducted @ sides
• Elbows flexed to 90°
• Patient attempts external rotation against examiner’s resistance

• Impingement signs
• AC Joint
• Biceps tendon
• Glenohumeral joint stability
• Labral signs
• Cervical spine signs

• Scapula stabilized
• Arm fully pronated
• Examiner brings shoulder into maximal forward flexion
• Pain  subacromial impingement

• Patient’s arm forward flexed to 90°
• Elbow flexed to 90°
• Shoulder forcibly internally rotated by examiner
• Pain  subacromial impingement or rotator cuff tendinitis

• 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

• Patient raises affected arm to 90°
• Actively adducts arm across body
• Forces acromion into distal end of clavicle
• Isolates AC joint & painful if positive

• Elbow flexed 20°-30°
• Forearm supinated
• Arm in 60° flexion
• Patient forward flexes arm against examiner’s resistance

• 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

• 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

• Supine or sitting
• Arm in 90° abduction, 90° elbow flexion
• Apply posteriorly directed force in attempt to displace humeral head posteriorly

• 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

• 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

Shoulder Pain:Common Injuries

• Common
• “Shoulder separation”
• Mechanism:
• Fall landing on “point” or lateral aspect of shoulder
• Occasionally from fall on outstretched hand

• Six classifications of injury:

• 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

• 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 muscles, (especially supraspinatus) & biceps tendon
• Impinge against undersurface of acromion & coracoacromial ligament

• 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

• 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

• History:
• Pain referred to anterolateral aspect of shoulder w/ some radiation (not beyond elbow)
• Aggravated w/ overhead activities
• Night pain
• Clicking or popping sensation

• 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

• Radiographs:
• Standard AP & axillary
• Suprascapular outlet view
• May show undersurface AC joint spurring or glenohumeral degenerative changes

• Treatment:
• Conservative
• Temporary avoidance of aggravating factors
• Ice
• NSAIDS
• Physical Therapy

Strengthening Exercises

• Corticosteroid injection
• If not improving w/ PT
• May allow more effective participation in PT

• 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

• “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

• History:
• Slow onset of shoulder pain (pain  as motion progressively )
• Limited range of motion
• Night pain

• 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

• Treatment:
• Physical therapy:
• Work on gentle range of motion
• NSAIDS
• Ice
• Corticosteroid injections
• Manipulation under anesthesia

• 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

• Physical Exam:
• Visible & palpable deformity
• Local pain & swelling
• Pain may radiate into trapezius & neck
• Complete neuro exam important to detect brachial plexus injury

• Radiographs:
• AP and axillary view
• AP view w/ 45° cephalic tilt
• (Chest film if substantial trauma)

• Treatment:
• Conservative
• Sling for 2 to 4 weeks
• Displaced fractures may need referral for further evaluation

• 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

• Mechanism:
• Forced extension, abduction, external rotation
• Direct blow to posterior or posterolateral shoulder
• Repeated episodes of overuse (subluxation)

• 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)

• Radiographs:

Axillary View

True AP

Y view

• Radiographs:
• Helps to determine or confirm position
• If dislocated, obtain post-reduction films as well

Anterior dislocation

• Prompt reduction
• Many different methods of reduction

Traction-countertraction

• Stimson maneuver

• Treatment:
• Sling
• Ice
• NSAIDS
• Protected range of motion
• Rotator cuff strengthening after acute pain resolves
• Return to sport when normal strength & motion regained

• Develop systematic approach to examination
• Make sure to evaluate above & below shoulder joint
• Thorough neuro examination
• Address potential causes of injury
• Physical therapy !!!

THANK YOU!

• 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.