Evaluation of the Injured Shoulder May 26, 2005

2. Evaluation of the Injured Shoulder May 26, 2005

3. Pretest: • What is a neurologic complication of posterior shoulder dislocation? • What population of patients are at risk for adhesive capsulitis? • What is the provocative test for impingement syndrome? • What is the most commonly torn rotator cuff muscle?

4. Most Common Diagnosis • Adhesive Capsulitis • Dislocation • Rotator cuff tear • Impingement syndrome

5. Common Missed Diagnosis • Posterior dislocation • axillary nerve damage in anterior dislocations

6. Red Flags • Significant trauma: determine mechanism of injury • fever • Weakness: cervical radiculopathy or neuritis. • Rule out referred pain: cervical, cardiac, pulmonary.

7. Basic Format for Joint Exam: “PORT” • Palpation – deformity or tenderness • Observation – position, color/perfusion, swelling • ROM – active and passive • Tests – joint specific provocative tests

8. Palpation (PORT) • Inspect for point of maximal tenderness: • palpate entire shoulder • touch the A-C joint • palpate the cervical spine

9. Observation (PORT) • Look for symmetry • Erythema

10. Observation: (PORT) • Look for symmetry • Erythema • Anterior and posterior humeral dislocation

11. Observation: (PORT) • Look for symmetry • Erythema • humeral dislocation • A-C joint step-off

12. Observation: NeuroVascular Lymphatic • Evaluate strength, sensation • Check reflexes • Check pulses • edema?

13. ROM (PORT) • Abduction • Flexion • Extension • Internal Rotation • External Rotation

14. ROM (PORT)

15. Basic Format for Joint Exam: “PORT” • Palpation – deformity or tenderness • Observation – position, color/perfusion, swelling • ROM – active and passive • Tests – joint specific provocative tests

16. Most Common Diagnosis • Adhesive Capsulitis • Dislocation • Rotator cuff tear • Impingement syndrome

17. Most Common Diagnosis • Range of Motion  Adhesive Capsulitis • Apprehension  Dislocation • Spill the can  Rotator cuff tear • Hawkin’s  Impingement syndrome

18. The Tof PORT joint specific tests: “Shoulder RASH”

19. Shoulder RASH • Range of MotionAdhesive Capsulitis • Apprehension Dislocation, subluxation • Spill the beer Torn rotator cuff. • Hawkin’s  impingement.

20. Shoulder RASH RASH Range of Motion Reduced think Adhesive Capsulitis

21. Adhesive Capsulitishttp://www.aafp.org/afp/990401ap/1843.html

22. ADHESIVE CAPSULITIS

23. ADHESIVE CAPSULITIS • Patient: diabetic women over 60yo.

24. ADHESIVE CAPSULITIS • Patient: diabetic women over 60yo. • Sx: Long (>6mo) of painful stiffness.

25. ADHESIVE CAPSULITIS • Patient: diabetic women over 60yo. • Sx: Long (>6mo) of painful stiffness. • Exam: painful loss of active/passive ROM.

26. ADHESIVE CAPSULITIS • Patient: diabetic women over 60yo. • Sx: Long (>6mo) of painful stiffness. • Exam: painful loss of active/passive ROM. • Cause: non-inflammatory fibroblastic proliferation, such as with Dupuytren’s.

27. ADHESIVE CAPSULITIS • Patient: diabetic women over 60yo. • Sx: Long (>6mo) of painful stiffness. • Exam: painful loss of active/passive ROM. • Cause: non-inflammatory fibroblastic proliferation, such as with Dupuytren’s. • Rx: analgesics and PT

28. ADHESIVE CAPSULITIS • Patient: diabetic women over 60yo. • Sx: Long (>6mo) of painful stiffness. • Exam: painful loss of active/passive ROM. • Cause: non-inflammatory fibroblastic proliferation, such as with Dupuytren’s. • Rx: analgesics and PT • 85% improve without referral.

29. Shoulder RASH RASH Apprehension Test: Subluxation and Dislocation

30. Apprehension Testhttp://www.aafp.org/afp/20000515/3079.html

31. Subluxation of Shoulder

32. Posterior subluxation

33. Subluxation of Shoulder • May follow traumatic event. • Symptoms: catching, “out of place,” or “going dead.” • With subluxation only: strengthen stabilizers. • With actual history of dislocation, consider referral.

34. Shoulder RASH RASH Spill the Beer: Torn Rotator Cuff (Supraspinatous)

35. Spill the Can http://www.aafp.org/afp/971101ap/salzman.html

36. Supraspinatus Muscle

37. Torn Rotator Cuff

38. Shoulder RASH RASH Hawkin’s Test for Impingement Syndrome

39. Hawkin’s Test for Impingement http://www.aafp.org/afp/971101ap/salzman.html

40. Impingement Syndrome: Sx • Most common cause of shoulder pain • Symptoms are chronic • anterior shoulder pain • night pain http://www.aafp.org/afp/980215ap/fongemie.html

41. Impingement Syndrome • Space between acromion and humeral head is narrow • especially with arm raised 60 to 120 degrees: “painful arc:” • Hx: pain with overhead activities

42. Impingement Syndrome • Impingement interval contains : • Subacromial Bursa • Long head of biceps • Rotator cuff

43. Impingement Syndrome • If Impingement interval is further narrowed by inflammation or excess acromion • Subacromial Bursitis • Long head of biceps tendonitis. • Rotator cuff tendonitis and tear.

44. http://www.aafp.org/afp/971101ap/salzman.html

47. Impingement Syndrome • Provocative test for Impingement Syndrome is Hawkin’s test. • Narrows the impingement interval and reproduces pain.

48. Hawkins Test: Abduction + Internal rotation = pain.

49. Impingement Syndrome • Three stages: • Stage I: ages less then 25 and inflammation only. • Stage II: ages 25-40; fibrosis and scarring of tissues. • Stage III: usually older than 40, and tears of rotator cuff or biceps tendon.

50. Impingement Syndrome Treatment • Stage I: Modify activities, NSAIDs, ice: expect rapid improvement. • Stage II: Injection, PT to increase ROM and strength: Expect slow recovery: 2-3 months. • Stage III: Consider referral to surgeon for possible repair.