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. Second most common musculoskeletal complaintDifficult joint to examineMultidirectional range of motion- UNIQUE!Shoulder injury can affect nearly every sport and many daily activities. Objectives. Review pertinent anatomyDiscuss common pathologyDiscuss historical clues to diagnosisSelect casesPhysical exam in small group discussions.
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1. Shoulder Problem Evaluation MS3 Family Medicine
2. Second most common musculoskeletal complaint
Difficult joint to examine
Multidirectional range of motion- UNIQUE!
Shoulder injury can affect nearly every sport and many daily activities
3. Objectives
Review pertinent anatomy
Discuss common pathology
Discuss historical clues to diagnosis
Select cases
Physical exam in small group discussions
4. Bony AnatomyAnterior
5. Bony AnatomyAnterior and Posterior
6. Radiographic Anatomy
7. Where do things go wrong??Fractures
8. Where do things go wrong??Dislocations and Separations Dislocations and separations are protected by both “static” and “dynamic” stabilizers…
9. Where do things go wrong??Dislocations and Separations Oh, yeah…Arthritis can happen at these joints, too…
10. Glenohumeral Joint Shallow (“golf ball sitting on a tee”)
Inherently unstable (maximizes ROM)
Static stabilizers
glenohumeral ligaments, glenoid labrum and capsule
Dynamic stabilizers
Predominantly rotator cuff muscles
Also scapular stabilizers
Trapezius, leavator scapulae, serratus anterior, rhomboids
11. Bony Anatomy“Static Stabilizers”
12. What goes wrong…Besides separations and dislocations?? Instability!!!
13. LABRUM
14. What goes wrong?Tears and tendonopathies
15. The Rotator Cuff Muscles“dynamic stabilizers”
16. The Rotator Cuff Muscles Supraspinatus Infraspinatus Teres minor Supscapularis
17. The Rotator Cuff Muscles: SITS Supraspinatus ABD
Infraspinatus ER
Teres minor ER
Supscapularis IR
18. Finally…the subacromial space
19. What can go wrong???
20. Impingement
21. Other Anatomy
Deltoid
Rotator cuff
Teres major
Latissimus dorsi
Biceps
Pectoralis muscles 17 muscles create the movement of the shoulder17 muscles create the movement of the shoulder
22. Shoulder Anatomy
24. So…what causes shoulder pain? Impingement
Labrum and biceps pathology
A-C joint pathology
Rotator Cuff Injury
Instability
Among other things…
25. Clinical ExamHistory
Pain
Acute
Chronic
Weakness
Deformity
26. Clinical ExamHistory Single event
Repetitive overload
Instability
Does it feel like it’s going to come out?
Catching/Locking
27. Clinical ExamHistory Sport / Occupation
Previous injury
Previous treatment
Other joints involved
Disability
28. Physical Exam: Big 6 Inspection
Palpation
Range of Motion
Strength
Neurovascular
Special Tests
29. Special Tests Impingement
Rotator Cuff Integrity
Labrum and Biceps
AC (SC) Joints
Instability
30. Physical Exam
The physical exam will be demonstrated during small group discussions…
31. Which rotator cuff muscle(s) are responsible for external rotation Supraspinatus
Infraspinatus
Subscapularis
Teres Minor
Both 2 and 4
32. The apex (bottom) of the scapula is at what level of the spine? C7
T3
T7
T12
L4
33. Case #1 22-year-old male rugby player falls onto his right shoulder while being tackled
Severe pain on top of his right shoulder
34. Case #1 Notable deformity over superior shoulder
Painful range of motion
Unable to lift right arm above waist
Special Tests??
Diagnosis???
35. Acromioclavicular (A-C) Sprain Special Tests
Shear Test
Cross Arm Test
A-C Palpation
Resisted Extension
Active compression test
36. Acromioclavicular (A-C) Sprain Damage to A-C joint ligaments
Pain and/or deformity over A-C joint
Graded I-VI
I-III usually treated non-operatively
IV-VI referred to orthopedic surgery
37. AC Joint Sprain Treatment Analgesics, ice prn
Sling for as long as needed
Physical Therapy
ROM restoration
Gradual strength exercise
Return to sport activity as tolerated
38. Case #2 24-year-old male handball player
Fell onto his shoulder after being pushed
Intense pain
Hand is tingling and arm feels like it’s hanging
X-rays
39. X RAYS
40. Shoulder Dislocation/Anterior Instability Humeral head dislocates from glenoid fossa
Almost always anterior (95%)
Usually traumatic with injury to capsule-labrum complex
41. Shoulder Dislocation/Anterior Instability Treatment
Reduction of dislocation
Protection & rehab, rehab, rehab
Most will have future dislocations and/or instability
At least 70%!!! (young)
May require surgical tightening/repair of the capsule/labrum complex
42. Special TestsGlenoid Labrum and Instability Biceps Load I and II
Kim Test
Jerk Test
Active-Compression Test (O’Brien)
Crank Test
Apprehension Test
Relocation Test
Load and Shift
Sulcas Sign
43. Which of the following structures can be “impinged”? Biceps tendon
Subacromial Bursa
Rotator Cuff Tendons
All of the above
44. Case #3 35-year-old male tennis player
Shoulder pain exacerbated by practicing serves
Develops dull, aching pain in right shoulder
45. SHOULDER PAINPhysical Exam Tenderness to palpation anterior shoulder
Pain with abduction starting around 90 degrees
Unable to lift arm past 120 degrees
Pain with forward flexion at 90-120 degrees
Special Tests??? Diagnosis???
46. Shoulder PainPhysical Exam
Hawkin’s positive
Neer’s positive
IMPINGEMENT???
47. Impingement as a Clinical Sign Repetitive overhead activities
Subacromial bursa and/or rotator cuff impinged between acromion & humerus
Physical therapy, activity modification +/- medications
48. Diagnoses associated with clinical sign of Rotator Cuff Impingement: Subacromial bone spurs and / or bursal hypertrophy
AC joint arthrosis and /or bone spurs
Rotator cuff disease
Superior labral injury
Glenohumeral instability
Scapular dyskinesis
Biceps tendinopathy
A diagnostic injection sometimes helps to clarify the diagnosis
49. Case #4 45-year-old weight lifter
Caught bar as it was falling off his shoulder
Sudden pain
Severe weakness left shoulder
Worse with overhead activities; while sleeping at night
Pain in anterior lateral shoulder
Special tests?
50. Case #4 Drop Arm Test Positive
External Rotation Lag Sign positive
Weakness with Empty Can Sign
Normal bear hug and belly press tests…
Diagnosis?????
51. Rotator Cuff Tear Supraspinatus tendon most common
Acute trauma or chronic tendinopathy
Treatment dependent upon age/activity
Young, active usually require operative treatment
Older, low-activity usually respond to non-operative treatment
52. Case #5 42-year-old female with dull pain right shoulder
Pain is diffuse in nature
Sometimes spreads to between shoulder blades
Seems worse at night
53. Physical Exam Obese, pleasant female
Diffuse pain
Normal shoulder exam
Not able to reproduce pain during exam
What else do you want to do???
54. Shoulder pain isn’t always the shoulder!!Get more history…
Gall bladder disease
Peptic Ulcer Disease
Cervical radiculopathy
Cardiac ischemia
Pulmonary conditions
ie Pancoast’s tumor, Pneumonia
55. In the human body, which is the most incredible joint? PIP
Knee
Ankle
Shoulder
None of the above
56. Case #6 40-year-old male
Recently shoveled 16” of snow
Can hardly lift left arm due to pain
Special Tests? Diagnosis?
57. Biceps Tendonopathy Speed Test
Yergason Test
Direct palpation
58. Biceps Tendonopathies Repetitive overhead activity
Repetitive forearm flexion/supination
Difficult to discern from rotator cuff tendinopathy or impingement
59. Conclusion Shoulder injuries are common.
Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis.
Impingement is a clinical sign, not a diagnosis.
Don’t forget about medical causes.
60. QUESTIONS?
61. Physical ExamInspection Front & back
Height of shoulder and scapulae
Muscle atrophy, asymmetry
62. Physical Exam Range of Motion Abduction 0-180o
63. Physical Exam Range of Motion Forward flexion:
0o – 180o
64. Physical Exam Range of Motion Extension
0o – 40 to 60o
65. Physical Exam Range of Motion Internal rotation
T5 segment External rotation
80-90o
66. Physical Exam Strength Empty can test
30o angle
Steady downward pressure
Tests supraspinatus strength and pain
67. Physical Exam Strength Resisted external rotation
Tests infraspinatus, teres minor strength
68. Physical Exam Strength of Subscapularis Liftoff test Belly press test
69. Cross-Arm Adduction Test AC joint pathology
Arm flexed to 90°
Hyperadduct arm across body as far as possible
Pain in AC = (+) test
70. A-C Shear Test Interlock fingers with hand on distal clavicle and spine of scapula
Pain in A-C joint when hands squeezed together = (+) test
71. Sulcus Sign Inferior instability
Arm relaxed in neutral position, pull downward at elbow
(+) test = sulcus at infra-acromial area
compare to unaffected side
72. Apprehension Test Anterior instability
Shoulder at 90° abducted, slight anterior pressure & External rotation
(+) test = dislocation apprehension
some false (+)
73. Relocation Test Perform after positive apprehension test
Apply post force over humeral head during external rotation (ER)
(+) test = increased ER tolerance
74. Load & Shift Test Test for multidirectional instability
Grasp humeral head, slide anteriorly and posteriorly while securing rest of shoulder
(+) if greater than 50% displacement (graded 1-3)
75. Impingement Signs
76. Drop Arm TestSuggestive of Rotator Cuff Tear Passive abduction to 90°
Instruct patient to slowly lower arm
At 90° abducted arm will suddenly drop, may need to add slight pressure
(+) drop = (+) test
77. Speed’s TestBiceps Tendinopathy Long head of biceps tendonitis
Fwd flex to 90°, abd 10°, full supination
Apply downward force to distal arm
Pain = (+) test
weakness w/o pain = muscle weakness or rupture
78. O’Brien’s Active CompressionSLAP lesion (Superior Labrum Antero-Posterior) Labral/AC pathology
Arm flexed to 90°, elbow extended, adduct 10-15°, resist downward force
+ if AC pain or internal pain/click
79. O’Brien’s Active CompressionSLAP lesion Supination should be pain free (decreased pain)
80. Crank TestLabral injury Glenoid labrum tear
Abduct arm to 160°, pt is supine or upright, elbow secured with one hand axial load at shoulder with other
(+) if audible/painful catch/grind is noted