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Shoulder Problem Evaluation

Shoulder Problem Evaluation. MS3 Family Medicine. 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. Objectives. Review pertinent anatomy

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Shoulder Problem Evaluation

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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. SupraspinatusABD InfraspinatusER Teres minor ER Supscapularis IR The Rotator Cuff Muscles: SITS Depress humeral head against glenoid to allow full abduction

  17. Finally…the subacromial space

  18. What can go wrong??? Impingement!!!!!!!

  19. Impingement

  20. Deltoid Rotator cuff Teres major Latissimus dorsi Biceps Pectoralis muscles Other Anatomy

  21. Shoulder Anatomy

  22. Don’t forget the scapular stabilizer muscles

  23. So…what causes shoulder pain? • Impingement • Labrum and biceps pathology • A-C joint pathology • Rotator Cuff Injury • Instability Among other things…

  24. Clinical ExamHistory • Pain • Acute • Chronic • Weakness • Deformity

  25. Clinical ExamHistory • Single event • Repetitive overload • Instability • Does it feel like it’s going to come out? • Catching/Locking

  26. Clinical ExamHistory • Sport / Occupation • Previous injury • Previous treatment • Other joints involved • Disability

  27. Physical Exam: Big 6 • Inspection • Palpation • Range of Motion • Strength • Neurovascular • Special Tests

  28. Special Tests Impingement Rotator Cuff Integrity Labrum and Biceps AC (SC) Joints Instability

  29. Physical Exam • The physical exam will be demonstrated during small group discussions…

  30. 0 Which rotator cuff muscle(s) are responsible for external rotation • Supraspinatus • Infraspinatus • Subscapularis • Teres Minor • Both 2 and 4

  31. :00 The apex (bottom) of the scapula is at what level of the spine? • C7 • T3 • T7 • T12 • L4

  32. Case #1 • 22-year-old male rugby player falls onto his right shoulder while being tackled • Severe pain on top of his right shoulder

  33. Case #1 • Notable deformity over superior shoulder • Painful range of motion • Unable to lift right arm above waist • Special Tests?? • Diagnosis???

  34. Acromioclavicular (A-C) Sprain • Special Tests • Shear Test • Cross Arm Test • A-C Palpation • Resisted Extension • Active compression test

  35. 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

  36. 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

  37. 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

  38. X RAYS DIAGNOSIS???

  39. Shoulder Dislocation/Anterior Instability • Humeral head dislocates from glenoid fossa • Almost always anterior (95%) • Usually traumatic with injury to capsule-labrum complex

  40. 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

  41. 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

  42. 30 10 0 0 Which of the following structures can be “impinged”? • Biceps tendon • Subacromial Bursa • Rotator Cuff Tendons • All of the above

  43. Case #3 • 35-year-old male tennis player • Shoulder pain exacerbated by practicing serves • Develops dull, aching pain in right shoulder

  44. 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???

  45. Shoulder PainPhysical Exam Hawkin’s positive Neer’s positive IMPINGEMENT???

  46. Impingement as a Clinical Sign • Repetitive overhead activities • Subacromial bursa and/or rotator cuff impinged between acromion & humerus • Physical therapy, activity modification +/- medications

  47. 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

  48. 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?

  49. Case #4 Drop Arm Test Positive External Rotation Lag Sign positive Weakness with Empty Can Sign Normal bear hug and belly press tests… Diagnosis?????

  50. 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

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