COMMON SHOULDER PROBLEMS

1. COMMON SHOULDER PROBLEMS Kevin deWeber, MD, FAAFP, FACSM Director, Sports Medicine Fellowship USUHS

2. Objectives • Review anatomy • Makes for better diagnoses • Discuss common shoulder problems • Describe current treatments

3. Anatomy • Scapula • Glenoid • Acromion • Coracoid • Subscapular fossa • Scapular spine • Supraspinous fossa • Infraspinous fossa

4. Anatomy • Bursae • Subacromial (Subdeltoid) • Subscapular

5. Joints of the Shoulder • Acromioclavicular • Glenohumeral • Sternoclavicular • Scapulothoracic • Not a “true” joint

6. Movement control • Flexion: Pectoralis Major, Deltoid (Anterior), Coracobrachialis • Extension: Deltoid (Posterior), Teres Major • Abduction: Deltoid, Supraspinatus • Adduction: Pectoralis Major, Latissimus, Subscapularis, Infrapspinatus, Teres Minor • Internal Rotation: Subscapularis, Pectoralis Major, Deltoid (A), Latissimus • External Rotation: Infraspinatus, Teres Minor, Deltoid

7. Inspection Palpation Range of Motion Strength Neuro-Vascular Special Tests Shoulder: Physical Exam

8. Range of Motion • Forward flexion: 160 - 180° • Extension: 40 - 60° • Abduction: 180◦ • Adduction: 45 ° • External rotation: 80 - 90 ° • Internal rotation: 60 - 90 °

9. Strength Testing • Rotator Cuff Muscles • S – Supraspinatus • I – Infraspinatus • t - Teres minor • S- Supscapularis • Abduction: Supra • IR: subscap • ER: infra, TM • Other muscles • Deltoid • Biceps • Pecs • Scapular stabilizers

10. Anatomy • Muscles • Deltoid • Trapezius * • Rhomboids * • Levator scapulae * • Rotator cuff • Teres major • Biceps • Pectoralis muscles * • Serratus anterior * • * Scapular stabilizers

11. Radiographic Anatomy

12. Common Shoulder Problems Instability Impingement Rotator cuff tears AC joint sprains and degeneration Adhesive capsulitis Labral tears Biceps tendinopathy Clavicle fractures

13. Glenohumeral Instability • DEFINITION: painful feeling of slippage, looseness, “going in and out”

14. Instability Eval: “FEDS” • Frequency • 1-times • 2-5 • “frequent” >5 • Etiology: Traumatic vs. Atraumatic • Direction (predominant) • anterior • posterior • inferior • Severity: Dislocation vs. Subluxation

15. Dislocation: impact to externally rotated, abducted arm Acute findings: prominent acromion, anterior fullness Special Tests: Apprehension, Relocation Anterior Instability

16. Bankart Lesion Anterior capsule torn Anteroinferior labrum torn Recurrent dislocations likely Hill-Sachs Lesion Humeral compression fracture Anterior Dislocation Injuries

17. Dislocations: Electrocutions, Seizures Acute findings: internal rotation, adduction Special tests: Posterior drawer Load-shift Posterior Instability

18. Usually atraumatic Special tests: Sulcus sign Inferior Instability

19. 4-view Radiographs: AP Axillary scapular “Y” AC joint MRI Instability Imaging

20. Anterior Dislocation

21. Posterior Dislocation

22. Attempt ASAP Intra-articularLidocaine HELPS! Use 2-3 techniques until successful Failure: to ER sedation Anterior Dislocation Reduction

23. Anterior Dislocation Treatment • Referral to Ortho & PhTh • Surgery for younger/athletic patients • Rehabilitation for others • Immobilization • Sling

24. Definition: compression of the rotator cuff in the subacromial space Symptoms: Pain with Overhead position or flexion/Internal Rotation Anterior, lateral shoulder pain Night Pain Risk Factors: Overhead activities Micotrauma GH Instability Shape of Acromion DJD Impingement

25. Impingement

26. Neer: full Flexion “Neer to the Ear” Hawkins: Internal Rotation Impingement screening tests

27. Full Can Test: Resistance applied in forward flexion and abduction (SCAPULAR PLANE) Impingement confirmatory test

28. 5cc 1% lidocaine 25-27g needle Postero-laterally Wait 10 minutes for result >50% pain reduction confirms Neer test: Subacromial Injection relieves pain

29. Impingement • Imaging not initially needed • 4-view shoulder series • MRI if considering surgery • Failed rehab • Pain with ADLs

30. Acute Phase: Avoid Exacerbating Factors Control Pain/Inflammation Physical Therapy Corticosteroid Injection Recovery Phase: ROM, Strength, Proprioception Maintenance Phase: Longer, Intense Workouts Surgical Intervention: Failed Conservative Measures, Signifcant Disability Impingement Treatment

31. Similar presentation as Impingement Failed rehab for impingement Persistent pain/weakness after Neer injection test Imaging: x-rays, MRI Rotator Cuff Tears

32. Rotator Cuff Tear Exam • Supraspinatus: • drop-arm test • Infraspinatus or Teres Minor • External rotation lag sign • Subscapularis • Belly press test

33. Rotator Cuff Tears • Treatment • Conservative: Similar to Impingement • Surgical: • Young patient, large tears, dominant arm • Failed Conservative Therapy • High-Level Athlete • Unable to perform vocational activities • Success depends upon degree of tendon damage and degeneration

34. Ultrasound of RC tear

35. Prolotherapy for RCTs • 25% Dextrose • Platelet-Rich Plasma (PRP) • Concentration of platelets and their growth factors • Process: (30 minutes) • 20-60cc blood is drawn, then centrifuged to produce 3-6ml of PRP • Ultrasound-guided injection

36. Mechanism: Fall on shoulder Presentation: superior shoulder pain Exam: AC jt TTP +/- deformity or swelling Cross-chest (“scarf”) test AC Joint Sprain

37. Cross Chest (“scarf”) Test Active Compression (“AC) test AC Joint Sprain

38. AC Joint Sprain

39. AC Joint Sprain

40. Imaging Bilateral AP Zanca View 10-15 degrees of cephalic tilt Axillary View Evaluates clavicular displacement AC Joint Sprain

41. AC Joint Sprain: Treatment • Grade I and II: Conservative • Immobilization • Ice, Analgesics • ROM, Strengthening • Anesthetic injection if rapid RTP needed • Grade III: Controversial; refer to Ortho for counseling • Immobilization for up to 4 weeks • Most studies indicate conservative treatment is better • Surgical management with higher rate of complications1 • Conservative management with mean time of 2.1 weeks to return to work2 • Grade IV-VI: Surgical • Taft TN, et al. Dislocation of the acromioclavicular joint. An end-result study. J Bone Joint Surg Am 1987 Sep;69(7):1045-51. • Auwojtys EM; Nelson G. Conservative treatment of Grade III acromioclavicular dislocations. SOClin Orthop Relat Res. 1991 Jul;(268):112-9.

42. AC Joint Arthritis • Chronic pain at AC joint • Exam: ACJ ttp, + scarf test, + active compression test • X-rays: narrowed AC jt, +/- osteophytes • Tx: • Avoid painful activities • Steroid injections • Surgical removal of distal clavicle (Mumford)

43. Painful restriction of active and passive GH ROM Risk Factors Idiopathic Diabetes Mellitus Female Gender Ages 40-60 Immobilization Inflammation Stroke Adhesive Capsulitis

44. Stage I 1-3 months Pain with normal ROM Stage II: “Freezing” 3-9 months Pain and progressive ROM restriction Stage III: “Frozen” 9-15 months Severe ROM restriction with decreased pain Stage IV: “Thawing” 15-24 months Progressive restoration of ROM Adhesive Capsulitis

45. Adhesive Capsulitis: Treatment • Anti-Inflammatories • ROM, Stretching • Steroid injection into subacromial space or GH jt • Surgical • Dilatation • Manipulation

46. Causes: Traction Injuries, FOOSH, Overhead motion overuse, MVA Trauma Locations: Superior Labral Anterior-Posterior (SLAP) tear Posterior Anterior (from dislocation) Labral Tears

47. History: Pain with overhead or cross-body activity Popping, clicking, catching 85% incidence of coexisting pathology Physical (none diagnostic): Crank Test Anterior Slide Test Yegason Test Labral Tears

48. Type 1: Fraying Injury Type 2: Biceps tendon detached Type 3: “Bucket-handle” tear Type 4: “Bucket-handle” with Biceps detached SLAP Tears

49. Labral Tears • Diagnostic: Radiograph, MR arthrogram • Treatment: • Physical Therapy for > 3 months • Usually don’t heal. Aim for PAIN CONTROL • Surgery: • Types I and III: Debridement • Types II and IV: Debridement and Reattachment • Post-Op Rehabilitation • Immobilize for 3 weeks • Progress with AROM • Return to full activity after 12-14 weeks

50. Rarely seen in isolation Labral tears Rotator cuff tears Impingement Exam findings non-specific Biceps Tendinopathy