The Shoulder: Complex Joint Simplified

1. The Shoulder: Complex Joint Simplified 51st OCFP ASA November 30th, 2013 Marie-Josée Klett, MD CCFP Dip Sport Med Louise Walker, MD CCFP FCFP Dip Sport Med Department of Family Medicine University of Ottawa

2. Faculty/Presenter Disclosure • Faculty: Dr Louise Walker • Program: 51st Annual Scientific Assembly • Relationships with commercial interests: • NONE

3. Faculty/Presenter Disclosure • Faculty: Dr Marie-Josée Klett • Program: 51st Annual Scientific Assembly • Relationships with commercial interests: • NONE

4. Disclosure of Commercial Support: Dr Louise Walker • This program has received NO financial support • This program has received NO in-kind support • Potential for conflict(s) of interest: • NONE

5. Disclosure of Commercial Support: Dr Marie-Josée Klett • This program has received NO financial support • This program has received NO in-kind support • Potential for conflict(s) of interest: • NONE

6. Mitigating Potential Bias: Dr Louise Walker • Not applicable

7. Mitigating Potential Bias: Dr Marie-Josée Klett • Not applicable

8. Objectives • Distinguish most common shoulder conditions • Extrapolate how the anatomy of the shoulder relates to the injury and pain pattern • List the key points in taking the shoulder history • Carry out a focused physical examination of the shoulder and perform it by practice in pairs • Order appropriate investigations for diagnosis of shoulder problems • Interpret investigations based upon history and physical examination • Formulate a management plan for common shoulder problems • Propose home exercises for certain shoulder conditions • Determine when a referral is required • Evaluate the scientific evidence for tests and treatments where it is available

9. Outline of Workshop • First half: • History – review key points • SYSTEMATIC approach to exam – BOTH shoulders • Review of pertinent anatomy • Review Inspection – LOOK • Review Palpation – FEEL • Review Resisted and Special Tests based on evidence – MOVE • Observe - then practice in pairs • 5 minute exam

10. Outline of Workshop • Second half: • Case-based, practice dx based on history and exam • Investigations: when to order what • Management of most common conditions • When to refer • Review home exercises

11. History: 3 “S” Symptoms Sore - most problems have pain so ask for details to identify pattern of the pain Stability - Subluxation or Dislocation - AMBRI or TUBS Stiff - frozen shoulder - stiffness from injury (RCT, fracture) - GH joint osteoarthritis

12. Shoulder History • Nature of the problem – pain, instability, stiffness • Duration • How did it onset • Location of pain • Radiation of the pain • Aggravating factors • Relieving factors • Pain during and/or after activity • Pain at night • Neurological symptoms • Handedness • Occupation – “WHACS” questions • Rx to date; Past Hx; ROS; FHx; Meds; Allergies; • “Other”-reason for visit at this time; sporting history; legal

13. WHACS • What work do you do? • How do you do it? • Are you concerned about any exposures on or off the job? • Co-workers or others with similar symptoms? • Satisfied with your job?

14. LOOK • Anterior • Deformity • Swelling • Symmetry • Downsloping • Deltoid Atrophy

15. LOOK • Side • Posture (protraction, kyphosis, neck position) • Swelling

16. LOOK • Posterior • Atrophy Rotator Cuff • Scapular Winging • Scapulohumeral Rhythm

17. Abnormalities Ant. Shoulder Dislocation AC Joint Separation Supraspinatus and infraspinatus atrophy

18. FEEL • Ask patient to point to area of maximal pain • Trapezius area = think c-spine • Upper humerus = think shoulder • Top of shoulder = think AC joint • Locate the point of maximal tenderness if possible

19. Shoulder Surface Anatomy Practice AC joint GH joint Suprapinatous insertion

20. MOVE: Active – Passive - Resisted • Active followed by passive with slight overpressure to assess pain and end feel • 6 Planes of Motion: Forward Flexion, Extension, Abduction, Adduction, External Rotation, Internal Rotation • Forward Flexion 1800 • Abduction 1800 (to ear without head tilt) • Internal Rotation – Thumb at T3 to T7 • External Rotation – 450 to 900 • Resisted tests overlap with special tests

21. Shoulder Range of Motion Passive – Also Neer’s Impingement Sign Active FF and ABD – Also Painful Arc of Abduction

22. Shoulder Range of Motion Internal Rotation External Rotation

23. Scapulothoracic Movement • Observe active forward flexion and abduction from behind patient • Watch for scapular winging on descent • Dysfunction common with rotator cuff tears and instability • Wall push up – for more pronounced winging seen with LTN injury (serratus anterior palsy)

24. Scapular Winging

25. Scapulothoracic Movement Wall Push Up

26. Special Tests • Rotator Cuff • Impingement • Biceps • AC joint • GH joint • Laxity • Instability • Labrum

27. Rotator Cuff: Anatomy

28. Rotator Cuff: History • Pain often in deltoid area • Pain with overhead activity • Achy pain, present at night • Mechanism: For tendinopathy/partial tears often insidious onset • For acute tears fall on outstretched arm or other trauma (ex: dislocation) • Age greater than 60 and night pain often indicates rotator cuff tear (88% sensitivity but only 20% specificity)

29. Rotator Cuff: Physical Exam Supraspinatus: • Empty can (Jobe’s) – (sensitivity 89% if pain and weakness; specificity 50%, for tear) • Full can (less painful therefore stronger predictor of tear if positive for weakness) • Drop Arm Test – positive test (LR + 3.3) might help identify RCD

30. Empty Can (Jobe’s) Patient resists abduction in the plane of the scapula

31. Rotator Cuff: Physical Exam Infraspinatus: • Resisted ER weakness or pain (LR+ 2.6; LR- 0.49) • ER lag sign -(sensitivity 68% ; specificity 100% for full tear) -(LR+ 7.2 ; LR- 0.57) Click View then Header and Footer to change this footer

32. Rotator Cuff: Physical Exam Subscapularis: • resisted IR (lift-off) weakness/pain • IR lag sign – (sensitivity 62% ; specificity 100% for tear) - (LR+ 5.6; LR- 0.04) Combine Strength and Pain ProvocationTests • If all 3 tests are positive: Hawkins/Neer (impingement tests) + supraspinatus weakness (full can test) + weakness in ER = 98% chance of RC tear • Age > 60 yrs, if any 2 tests positive = 98% chance of RC tear Click View then Header and Footer to change this footer

33. Subscapularis: Lift-off and IR Lag Sign Patient pushes back

34. Impingement Syndrome • Mechanism: Rotator cuff tendons get impinged between coracoacromial arch and the humerus on abduction • Multiple etiologies: osteophyte, inflamed/injured tendon, inflamed bursa, poor scapular stabilisation… • Supraspinatus most commonly involved

35. Impingement Syndrome: History • Associated with underlying condition • Pain with overhead activity, sometimes describe catching of shoulder • In younger patients most often associated with instability, in older patients with osteoarthritis • Athletes in overhead sports or patients who do a lot of overhead work are most at risk

36. Impingement: Physical Exam PAIN Provocation Tests • Painful Arc (positive has LR+ 3.7, normal has LR- 0.36) • Hawkins (sensitivity 60-90% specificity 25 -70%) • Neers sign (sensitivity 88% specificity 30%) • Neers Impingement test: inject 5-10 ml xylocaine in subacromial space then repeat impingement signs

37. Hawkin’s Flexion Adduction Internal Rotation (FAIR)

38. Practice • Rotator Cuff: • Supraspinatus: empty can, full can, drop arm • Infraspinatus: resisted ER, ER lag • Subscapularis: lift-off, IR lag • Impingement: • Neer’s • Hawkin’s • Painful arc

39. Biceps: Anatomy • Origin of long head on superior glenoid and short head on corocoid process; both insert on radial tubercle • Flexion and supination of elbow • Long head tendon travels under the RC tendons through the biceps groove

40. Biceps: History • Pain front of shoulder • Long Head tendinosis 95% associated with RCT , Impingement or SLAP • Acute injuries: • Proximal tears of long head common in elderly = “popeye” muscle, may not have dramatic injury • Distal tears – usually more dramatic, forced straightening of elbow with biceps loaded

41. Biceps: Physical Exam • LOOK - swelling, bruising, deformity • FEEL - tenderness and distal defect (Hook test) • SPECIAL TESTS – Speed’s and Yergason’s

42. Biceps Physical Exam:Speed’s Test • Examiner resists forward flexion – ask about pain

43. Biceps Physical Exam: Yergason’s • Patient’s elbow flexed at 90° with thumb up • Examiner grasps wrist, & resists patient attempt to supinate • Ask about pain (at bicipital groove)

44. Acromio-clavicular Joint

45. Acromioclavicular Joint: History • Shoulder separation: 3 mechanisms • direct blow to superior aspect of shoulder • lateral blow to deltoid area • Fall on outstretched hand • AC OA: insidious onset pain • Pain top of shoulder, usually well localised • Pain with reaching across body

46. Acromioclavicular Joint: Exam • Look for step deformity, bruising • Tenderness to palpation (96% sensitive but not as specific) • Scarf test

47. Scarf Test Passive adduction across body with overpressure

48. Practice • Biceps: Proximal • Speed’s • Yergason’s Distal • Hook (100% no cord-like structure for complete distal tear; 75% just painful if partial) • AC joint: • Scarf • palpation

49. Glenohumeral Joint: Anatomy

50. Glenohumeral Joint: History • Frozen shoulder (adhesive capsulitis) • Spontaneous or unrelated UE injury • Gradual onset • Age: 40-60 women> men • Non-dominant > dominant or bilateral • Associated with Diabetes (15-20%) and thyroid disorders • Constant pain – worse with movement • Significant night pain • Progressive stiffness