1 / 87

Shoulder 101 …and Then Some

Shoulder 101 …and Then Some. Evan D. Ellis MD Rebound Orthopaedics and Sports Medicine. Why Shoulder 101?. Multiple studies: High percentage of visits to see PCP are for musculoskeletal pain 2 studies * : Large gap in PCP confidence in evaluating and treating musculoskeletal injuries

darice
Download Presentation

Shoulder 101 …and Then Some

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Shoulder 101 …and Then Some Evan D. Ellis MD Rebound Orthopaedics and Sports Medicine

  2. Why Shoulder 101? • Multiple studies: High percentage of visits to see PCP are for musculoskeletal pain • 2 studies*: Large gap in PCP confidence in evaluating and treating musculoskeletal injuries • Studies in both a rural and tertiary academic setting *Lynch et al JBJS AM 2006 and AJO 2005

  3. The Shoulder • ANATOMY • HISTORY • PHYSICAL EXAM • IMAGING • CASES/TREATMENT

  4. Anatomy • Not a ball and socket • More of a ball on a dish • Static Restraints • Dynamic Restraints

  5. Anatomy • Glenoid Concavity: • Bone • Cartilage • Labrum

  6. Anatomy • Labrum: • Deepens glenoid by 50% • 9 mm superoinferior* • 5 mm anteroposterior* • Contributes to 20% of stability in A-P direction • Loss of labral integrity may result in instability *McMahon et al. JSES. 2004. Jan-Feb;13(1):39-44. *Howell SM, Galinat BJ. The glenoid-labral socket: a constrained articular surface. Clin Orthop. 1989

  7. Static Restraints Glenohumeral Ligaments Superior: Prevents inferior translation with arm at side Middle: Important for mid-range abduction Inferior: Critical for ABD/ER Anterior band prevents anterior inferior translation Anatomy

  8. Anatomy • Ligaments do not center the head. • Limit its translation and rotation. • Think Check-Rains

  9. Anatomy Dynamic Restraints • Muscular Stabilizers • Anterior: Subscapularis • Superior: Supraspinatus • Posterior: Teres minor and Infraspinatus • Lateral: Deltoid • Scapular stabilizers

  10. History Basics • Painful shoulders can be: • Unstable • Stiff • Weak • Rough/Pain “What bothers you about your shoulder?”

  11. History • Age • Gender • Was there an injury? • Injury mechanism • Prior problem • Dominant arm

  12. History • Chronicity • Location of Pain • Pain at night • Stiffness/Unstable • Prior treatment

  13. Physical Exam • Goal: Reproduce Symptoms • Inspection, Palpation, ROM, neurovascular exam, special tests • Compare to contralateral side • Cervical spine • Note provocative positions

  14. Physical Exam • EXPOSE: • Neck • Shoulders • Arms

  15. Physical Exam • EXPOSE: • Neck • Shoulders • Arms • Women need gown or tank top!

  16. Physical Exam Motion: Active/Passive • Forward Elevation • External Rotation • ER in Abduction • Internal Rotation • IR in Abduction • X-Body

  17. Range of Motion • FE: 180 • ERS: 60 • ERA: 90 • IRA: 70 • IRB: T-spine • X-Body: 60

  18. Range of Motion • FE: 180 • ERS: 60 • ERA: 90 • IRA: 70 • IRB: T-spine • X-Body: 60

  19. Range of Motion • FE: 180 • ERS: 60 • ERA: 90 • IRA: 70 • IRB: T-spine • X-Body: 60

  20. Range of Motion • FE: 180 • ERS: 60 • ERA: 90 • IRA: 70 • IRB: T-spine • X-Body: 60

  21. Range of Motion • FE: 180 • ERS: 60 • ERA: 90 • IRA: 70 • IRB: T-spine • X-Body: 60

  22. Range of Motion • FE: 180 • ERS: 60 • ERA: 90 • IRA: 70 • IRB: T-spine • X-Body: 60

  23. Rotator Cuff Exam • MOTOR • Subscapularis • Supraspinatus • Infraspinatus • Teres Minor

  24. Rotator Cuff Exam • MOTOR • Subscapularis • Supraspinatus • Infraspinatus • Teres Minor

  25. Rotator Cuff Exam • MOTOR • Subscapularis • Supraspinatus • Infraspinatus • Teres Minor

  26. Rotator Cuff Exam • MOTOR • Subscapularis • Supraspinatus • Infraspinatus • Teres Minor

  27. Rotator Cuff Exam • MOTOR • Subscapularis • Supraspinatus • Infraspinatus • Teres Minor

  28. Neurologic Exam • NEURO • Sensation • Motor • Reflexes • Spurling’s

  29. Neurologic Exam • NEURO • Sensation • Motor • Reflexes • Spurling’s

  30. Special Tests - Cuff • CUFF • Neer Impingement Sign • Neer Impingement Test • Subacromial injection • Hawkins Test

  31. Special Tests - Cuff • CUFF • Neer Impingement Sign • Neer Impingement Test • Subacromial injection • Hawkins Test

  32. Special Tests - Cuff • CUFF • Neer Impingement Sign • Neer Impingement Test • Subacromial injection • Hawkins Test

  33. Apprehension/Relocation Supine position Stabilizes scapula Abduct to 90° Increase ER gradually Positive: Apprehension w/ increasing amounts of ER Apprehension relieved by posterior force on the humerus Special Tests - Instability

  34. Seated Load & Shift Assess A & P translation Grade 1+: to rim 2+: over rim w/reduction 3+: over rim & locked Compare to other side Assess for pain, click, & instability Special Tests - Instability

  35. Supine Load & Shift Arm position: 45-60° abduction Ant/Post directed force applied to humerus Assess Stability Pain Palpable click Special Tests - Instability

  36. Sulcus Sign: Arm at side To look for multi-directional instability Grade 1+ = 1 cm 2+ = 1-2 cm 3+ = > 2 cm Look for generalized hypermobility Special Tests - Instability

  37. Radiographs • Never order an MRI before X-Rays • Everyone deserves a normal set of X-Rays! • Most important X-Rays: True AP (Grashey) and Axillary Lateral • These two X-Rays are almost always omitted from a “shoulder series”!

  38. Radiographs • True AP or Grashey View: • Arthritis • Fracture • Massive Rotator Cuff tear

  39. Radiographs • True AP

  40. Radiographs • Axillary Lateral • Arthritis • Instability • Fracture

  41. Radiographs • Axillary Lateral

  42. Radiographs • Additional Views • Outlet • Internal/External • Stryker Notch • West Point View

  43. The Shoulder • Diagnosable & Treatable • Rotator cuff tears • Shoulder instability • Arthritis • SLAP tear • Diagnosable & Untreatable • Brachial neuritis • Voluntary instability/MDI • Rib fractures

  44. Age is Key

  45. Age is Key

  46. Case #1 History: • 16 year old RHD male football player • Shoulder “popped” out of place while getting tackled • To ER for reduction • Has happened 2 previous times

  47. Case #1 Physical Exam: • Full Range of Motion • Full rotator cuff strength • + Apprehension Test • + Relocation Test • + Anterior Load & Shift

  48. Case #1

  49. Case #1 • What do you do? • Place him in a sling • Refer to Ortho • If first time dislocater – Physical Therapy • If 2 or more dislocations – MRI and surgery

  50. Regular Sling vs. External Rotation Which is better? Itoi, JBJS 2007 159 patients Avg follow up of 25.6 months 74 immobilized in IR 31 recurred (42%) 85 immobilized in ER 22 recurred (26%) *Effect on labral position for healing Sling

More Related