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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 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

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  1. THE SHOULDER: Evaluation and Treatment of Common Injuries Brandon Mines, MD Emory Sports Medicine Center March 18th, 2010

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

  3. 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

  4. Shoulder Anatomy:Bony Anatomy • Humerus • Scapula • Glenoid • Acromion • Coracoid • Scapular body • Clavicle • Sternum

  5. Shoulder Anatomy:Joints • Glenohumeral • Acromioclavicular • Sternoclavicular • Scapulothoracic articulation

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

  7. Shoulder Anatomy:Rotator Cuff Muscles • Depress humeral head against glenoid

  8. Shoulder anatomy:Rotator cuff muscles • Supraspinatus: • Abduction • Infraspinatus: • External rotation • Teres Minor: • External rotation • Subscapularis: • Internal rotation

  9. Shoulder Anatomy:Other Musculature • Pectoralis major, deltoid, latissimus dorsi, biceps • Rhomboids, trapezius, levator scapulae, serratus anterior

  10. 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)

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

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

  13. Shoulder Pain:Physical Examination

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

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

  16. 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

  17. PE: Inspection • Scapulothoracic motion • Dyskinesia or winging

  18. 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

  19. 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

  20. PE: Range of Motion • Forward Flexion • Abduction • Adduction • Internal Rotation • External Rotation

  21. PE: Muscle testing • Compare to unaffected side • Differentiate between true weakness & weakness 2° to pain

  22. PE: Muscle TestingSupraspinatus • Empty Can Test • 90° abduction • 30° forward flexion • Thumbs pointing downward • Patient attempts elevation against examiner’s resistance

  23. 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

  24. PE: Muscle TestingInfraspinatus/Teres Minor • Patient’s arms adducted @ sides • Elbows flexed to 90° • Patient attempts external rotation against examiner’s resistance

  25. Provocative Tests • Impingement signs • AC Joint • Biceps tendon • Glenohumeral joint stability • Labral signs • Cervical spine signs

  26. Impingement Signs:Neer’s Test • Scapula stabilized • Arm fully pronated • Examiner brings shoulder into maximal forward flexion • Pain  subacromial impingement

  27. 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

  28. 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

  29. 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

  30. Biceps Tendon:Speed’s Test • Elbow flexed 20°-30° • Forearm supinated • Arm in 60° flexion • Patient forward flexes arm against examiner’s resistance

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. Shoulder Pain:Common Injuries

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

  38. AC Joint Sprain • Six classifications of injury:

  39. 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

  40. 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

  41. Rotator Cuff Impingement/Tendinitis • Rotator cuff muscles, (especially supraspinatus) & biceps tendon • Impinge against undersurface of acromion & coracoacromial ligament

  42. 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

  43. 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

  44. 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

  45. 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

  46. Rotator Cuff Impingement/Tendinitis • Radiographs: • Standard AP & axillary • Suprascapular outlet view • May show undersurface AC joint spurring or glenohumeral degenerative changes

  47. Rotator Cuff Impingement/Tendinitis • Treatment: • Conservative • Temporary avoidance of aggravating factors • Ice • NSAIDS • Physical Therapy

  48. Rotator CuffImpingement/Tendinitis Strengthening Exercises

  49. Rotator Cuff Impingement/Tendinitis • Corticosteroid injection • If not improving w/ PT • May allow more effective participation in PT

  50. 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

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