“My Sore Shoulder!”

1. “My Sore Shoulder!” Guide to Diagnosis and Conservative Treatment

2. Shoulder Anatomy • Acromioclavicular (AC) joint • Glenohumeral joint • Glenoid labrum • Humerus • Rotator cuff • Biceps muscle/tendon • Deltoid muscle

3. Common Shoulder Conditions • Rotator cuff injuries • Impingement • Instability • Labral tears • Bicipital tendonitis • AC joint disorders • Suprascapular nerve entrapment

4. Rotator Cuff Injuries • Rotator cuff serves as a stabilizer for the shoulder • Cuff is comprised of the supraspinatus, infraspinatus, subscapularis and teres minor muscles • Common rotator cuff injuries occur to the underside of the supraspinatus tendon • Increase in risk of tear at age 40

5. Impingement (Bursitis/Tendonitis) • Can include inflammation of the bursa overlying the rotator cuff, inflammation within the rotator cuff tendons, or calcium deposits within the rotator cuff tendons caused by wear and tear • Can be caused by frequent extension of the arm at high speed under high load (i.e. throwing a baseball) • Potential outcome is a rotator cuff tear

6. Instability • Shoulder laxity needs to be differentiated from frank instability • Laxity is common in the swimmer and throwing athlete, as the shoulder must be loose enough to allow excessive external rotation • Instability is unwanted translation of the humeral head on the glenoid, and compromises the comfort and function of the shoulder

7. Labral Tears • Frequently seen in throwing athletes • Glenohumeral joint receives compressive and shearing forces during the movement of the humeral head, anteriorly to posteriorly

8. Bicipital Tendonitis • Inflammation of the biceps tendon • Diagnosis made principally by palpation of the tendon during clinical examination • Occurs frequently in the throwing athlete: • Modest biceps activity during cocking and acceleration phase • High level of biceps activity during follow-through phase

9. AC Joint Disorders • Most sprains to the AC joint occur as the result of a fall or a blow to the lateral acromion • Symptoms of a separation may range from pain over the AC joint to a frank deformity

10. Suprascapular Nerve Entrapment • Suprascapular nerve supplies the supraspinatus and infraspinatus muscles of the rotator cuff • The nerve can be compromised by traction injuries or compression injuries • Athlete may present with subtle weakness and vague complaints of posterior shoulder girdle pain

11. What? How? When? Where? Pain? Instability? Weakness? Deformity? The Subjective Evaluation

12. The Clinical Examination • Inspection • Examination of the cervical spine • Palpation • Range of motion assessment • Strength assessment • Glenohumeral stability assessment • Neurovascular examination • Special tests

13. Inspection • Should be performed from different perspectives (front, side, back, top) • Should assess for symmetry, atrophy, hypertrophy, deformities, bruising and swelling • Note scars as evidence of prior surgical procedures

14. Examination of the Cervical Spine • Have the patient look up at the ceiling, touch his chin to his chest, look over each shoulder • Any numbness, tingling or pain referred to the affected shoulder points to the cervical spine as the etiology of the shoulder pain

15. Bony Landmarks: SC joint Clavicle AC joint Acromion Bicipital groove Scapula Soft Tissue: Biceps tendon Supraspinatus insertion to the proximal humerus Deltoid Posterior capsule Palpation

16. Range of Motion • Includes testing of both active and passive range of motion • For example, in the setting of a rotator cuff tear, passive range of motion will be normal but active range of motion will be diminished due to the tear in the muscle

17. Range of Motion (norms) • External rotation in a 0° plane (90°) • External rotation in a 90° plane (90°) • Abduction (150°) • Internal rotation (90°) • Forward flexion (180°) • ALWAYS compare both shoulders!

18. Range of Motion • During range of motion assessment is a reasonable time to test for impingement • Impingement sign: with the arm abducted to 90° and the elbow flexed to 90°, externally rotate the patient’s arm • Impingement test: forward flex the patient’s arm to 180° • Pain signifies a positive test

19. Strength Assessment • Strength is easy to assess by standing behind the patient who is seated on the exam table • Strength is graded 0 to 5 over 5: • 0/5 = total paralysis • 1/5 = palpable or visible contraction • 2/5 = full ROM with gravity eliminated • 3/5 = full ROM against gravity • 4/5 = full ROM with decreased strength • 5/5 = normal strength

20. Strength Assessment • Supraspinatus: assessed at 90° of forward flexion in the scapular plane with the thumbs pointed to the floor; downward pressure is resisted by the patient • Test is specific for supraspinatus function, and evaluates cuff strength and integrity

21. Strength Assessment • External rotators: with the patient’s arm at his side and the elbow flexed to 90°, he will externally rotate as if hitting a tennis ball in a backhanded manner against resistance • Test is specific for the teres minor and infraspinatus muscles

22. Strength Assessment • Abduction: assessed in the coronal plane against resistance • May be suggestive of either deltoid or cuff deficiency • Subscapularis: with the dorsum of the patient’s hand on his ipsalateral back pocket, instruct him to push backward against resistance

23. Glenohumeral Stability Assessment • Subtle anterior instability is not uncommon in the throwing athlete • In addition, the hyperlax patient may have some element of multidirectional instability

24. Glenohumeral Stability Assessment • Sulcus sign: distraction force is placed on the elbow and the space created between the undersurface of the acromion and the apex of the humeral head is noted • This distance is recorded in centimeters, and indicates laxity in the joint

25. Glenohumeral Stability Assessment • “Load and shift” test: with the humeral head reduced (“loaded”) into the glenoid fossa, the examiner steadies the limb girdle with one hand and translates the humeral head both anteriorly and posteriorly with the opposite hand • The amount of translation is graded as 1+, 2+, or 3+ • This test is also repeated in the supine position • Glenohumeral translation depends upon the skill of the examiner as well as the patient’s ability to relax

26. Glenohumeral Stability Assessment • Apprehension test: evaluation of the patient’s sense of pending anterior subluxation or dislocation with the arm in stressed external rotation abduction • Can be performed sitting or supine, but works best with the patient supine • In order for a test to be positive, apprehension must be present – pain alone does not indicate a positive test

27. Glenohumeral Stability Assessment • Relocation test: following the supine apprehension test, apply posterior pressure to the proximal humerus at the same level of external rotation noted in the apprehension test • A positive relocation test is described when the patient’s apprehension disappears with the posterior stress

28. Neurovascular Examination • Dermatomal sensory examination • Deep tendon reflexes at the wrist and elbow • Cervical root testing – wrist extension, finger abduction and adduction, thumb abduction, elbow flexion • Palpation of the brachial and radial pulses

29. Special Tests • Drop arm test: the patient’s arm is abducted to 90° and released • A positive test is noted when the patient’s arm falls down from the position • Indicative of a rotator cuff tear

30. Special Tests • Speed’s test: with the shoulder in forward flexion, elbow extended, and hand supinated, resistance is applied • Pain in the location of the bicipital groove during resistance is indicative of bicipital tendonitis

31. Special Tests • O’Brien’s test: with the arm adducted across the midline, elbow extended and thumb down, the examiner applies downward pressure; the patient’s thumb is then turned up, and he again resists downward pressure • A positive test is indicative of a labral tear, and is described when greater pain occurs with the thumb pointed downward

32. Special Tests • Clunk test: while the patient lies supine the examiner abducts the arm past 90° with one hand while pressing the proximal humeral head anteriorly; the examiner then rotates the shoulder internally and externally • A positive test is elicited when the patient feels a deep “clunk” in the shoulder • Indicative of a labral tear

33. Radiographic findings • X-rays – what to look for: • Bony tumors • Fracture lines • Hook to the acromion • Degenerative changes • Dislocation

34. Radiographic findings • MRI • Good for ruling out bad things • Can be misleading • Must be correlated with clinical exam – the radiologist does not have the benefit of examining the patient

35. Conservative treatment • Physical therapy • Excellent form of strengthening and rehabilitating weak or injured muscles • Formal physical therapy will reassure you that the exercises are actually being done • The most successful conservative form of therapy for the musculoskeletal system

36. Conservative treatment • Oral anti-inflammatories • Sometimes just a short course of anti-inflammatories can provide permanent relief • Non-selective COX inhibitors still work great if the patient can tolerate them • COX-2 inhibitors: • Celebrex 200 mg daily • Vioxx 25 mg daily • Bextra 20 mg daily

37. Conservative treatment • Cortisone injection (short-acting + local) • Can be a permanent cure, but is frequently a short-term fix • Relief from the injection gives an excellent prognosis for surgical success • Should only be given every 3 months

38. If the above fail… • Refer to orthopedic surgeon • Surgery is a measure of last resort! • “There is no pain so terrible that surgery can’t make worse.”