Shoulder Pain: Evidence Based Evaluation & Management

1. Shoulder Pain:Evidence Based Evaluation & Management Frank J. Domino, M.D. Professor Department Family Medicine & Community Health University of Massachusetts Medical School

2. Disclosure • Editor in Chief: 5 Minute Clinical Consult • Author and Editor for Up To Date • Pri Med Curriculum Committee • Author/Editor: • www.Epocrates.com, Rxpalm, Inc., • www.Familydoctor.org

3. By the end of this session, you will: 1  Understand the normal and abnormal anatomy of the shoulder 2.  Learn to use the history and physical examination to narrow the differential diagnosis 3.  Develop an evidence based diagnostic and treatment algorithm for use

4. Causes of Shoulder Pain in the Primary Care Setting: Impingement Syndrome >70% Adhesive Capsulitis 12% Bicipital Tendonitis 4% A/C Joint OA 7% Other (Instability, Infection) 7% Smith, J Gen Intern Med 1992

5. Stats 101 • Sensitivity: % of People with Disease who Test + • (TP / (TP + FN)) = a/(a+c) • Specificity: % of People without Disease who test Negative (TN/(TN+FN) = b/(b+d) • PPV: Percent of + Test Results that are truly positive • TP/(TP+FP) = a/(a+b) Disease + - T E + a b S T - c d

6. 1. Impingement Syndromeaka Rotator Cuff Tendonitis 1. Impingement Syndrome • Typically Age > 25 Years • Supraspinatous Tendon • Insidious Onset 2. Adhesive Capsulitisaka: “Frozen Shoulder” RCT Pain -> ↓ ROM ---> Contracture of joint capsule

7. 3. Biceps Tendonitis • Inflammation of long head of biceps tendon • Repetitive lifting, overhead reaching or supination • Anterior humeral pain; tenderness bicipital groove Tear of Biceps Tendon: • Chronically inflamed tendon • Loss of flexion/supination • “Popeye Sign”—proximal to antecubitalfossa Long Short Holtby, Arthroscopy 2004

8. Instability (Laxity) 4. INSTABILITY • Age < 25 & Trauma • Derangement of G/H Joint Capsule  • Dysfunction of Shoulder Stabilizers  • Pain, subluxation or dislocation. • Labral Tear:SLAP: Superior Labrum from Anterior to Posterior; --damage to superior labrum --deep pain; clunking with overhead

9. 7% Other • Cervical Radiculopathy (neck pain, pain that radiates to the elbow) • Infection (G/N, Lyme) • Left Sided: CVD/Anginal Equivalent

10. Introduction to Examination • The shoulder is a multiaxial ball-and-socket synovial joint • Depends on muscles and ligaments rather than bones for support and stability • Easily forgettable terms/anatomy

11. Supination & Pronation

12. Shoulder Flexion & Extension • Flexion is moving the arm FORWARD • Extension (like reaching for you wallet) extending behind you

13. The Rotator Cuff Muscles • Rotator Cuff • Supraspinatus: Abduction • Infraspinatus: External rotation • Teres Minor: External rotation • Subscapularis: Internal rotation UpToDate, 2006

14. Approach to Exam 1. Observe 2. Palpate

15. 3. Range of Motion • Active and Passive • Abduction • Internal Rotation • External Rotation • Impingement: Pain w/ active Abduction (Supraspinatus Tendon) • Adhesive Capsulitis: Pain w: both active & passive ROM

16. 4. Provocative Testing • Thanks: • J. Herb Stevenson, M.D. • Lee Mancini, M.D. • Impingement:+ Empty Can, Neer, Hawkin’s • Adhesive Capsulitis Loss of ROM • Instability ”Laxity”: Apprehension Testing • Biceps Tendonitis: Speed’s

17. Testing/Provocation Impingement: Empty Can • Resist Forward Flexion & Internal Rotation • Test of SupraspinatusImpingement

18. Impingement: Neer • Neer Impingement Test • Passive forward flexion of the forearm resulting in pain

19. Impingement:Hawkins’ Test Hawkins, Am J Sports Med 1980 Woodward, Am Fam Phys 2000

20. Instability Testing Apprehension • Apprehension Test • laxity most common source shoulder pain <25 • Passive external rotation that results in discomfort and the feeling “that the shoulder will pop out” • Indicative of glenohumeral laxity

21. Biceps Tendonitis Speed’s Test With elbow extended and hand supinated, palpate bicipital groove while patient attempts to forward flex shoulder 30 degrees against resistance Siegel, Am Fam Phys 1999

22. Spurling’s ManeuverCervical Radiculopathy • Extend Neck • Rotate toward Side with Pain • Axial Load

23. DemonstrationObserve, Palpate, ROM, Provocation

24. Plain X-RaysImpingement: AP, Int/Ext RotationLaxity: “Y” view Acromion Clavicle Glenoid Fossa Humerus

25. Basic Approach to Treatment • Eliminate Cause • Pain Control NSAIDs/Acetaminophen Corticosteroid Injection • Stretching • Rehabilitation Don’t Do it

26. Case 1. Doc, why does my shoulder hurt? • 55 year old carpenter presents with 3 month history of right shoulder pain. • Gradual onset without h/o trauma. • Pain at night when he lies on affected side • Pain with overhead activity Pain w/AROM, + Empty Can, Hawkins

27. Rotator Cuff Tendonitis: Treatment • Reduce offending activities • Physical Therapy • NSAIDs or subacromial steroid injection • Each is better than placebo • Little long term difference • No benefit in combination treatment • Obtain X-rays: AP w/Internal & External Rotation

28. Materials for Glenohumeral Joint injection • 5-10 cc Syringe • 22 or 25 g 1 ½ needle • 3-5 ml of 1% or 2% Lidocaine w/o Epi. • 1-2 ml of • 1 to 2 mLTriamcinolone (Kenalog) 40 mg/mL or • betamethasone sodium phosphate and acetate (CelestoneSoluspan)

29. Subacromial Bursa Injection

30. http://familydoctor.org/268.xml; http://www.orthoassociates.com/shoulder1.htm

31. DemonstrationPhysical Therapy/Rehab

32. Adhesive Capsulitis: Treatment Pain w/ AROM & PROM: • Reduce offending activities • Physical Therapy • NSAIDs or subacromial steroid injection • Most resolve with conservative treatment: Stretching/Exercises x 18 months; • Orthopedic Referral

33. Case 2: “What happened to my arm?” • Just started working out again • Lifting weights; curls with free weights • Went to driving range, felt a sharp pain and pop in arm. • Now “lump” in middle of forearm.

34. Biceps Tendonitis • Eliminate Offending Activity • NSAIDs/Steroid Injection (Subacromial after age 50 – tendon rupture) • Ice/Physical Therapy/Exercises • Biceps Tendon Rupture; ? surgical repair. Orthopedic referral.

35. Biceps Tendonitis Exercise 5 to 10 pounds; Arm kept vertical and close to the body Swing arm back and forth or in a small diameter circle (no greater than one foot in any direction). 20 biceps curls 1-2 x/day Increase weight every 5 days as tolerated

36. Case 3: Doc, my shoulder and arm hurts • 45 year old transcriptionist • Now needs reading glasses to see computer screen • No pain with ROM of shoulder • + Spurling’s

37. Spurling’s ManeuverCervical Radiculopathy • Extend Neck • Rotate toward Side with Pain • Axial Load

38. Cervical RadiculopathyTreatment • Change Work Environment • X-Rays • NSAID’s • Physical Therapy • ? Meditation

39. 48 Year Old Painter falls off ladder • “My Shoulder is killing me” • “Feels like it is going to pop out” • No pain at rest • DX: Instability: + Apprehension

40. Instability/Laxity • NSAIDs • Aggressive strengthening and neuro- muscular rehab • Surgery if fails conservative care

41. Shoulder Summary

42. Thank you Frank.domino@umassmemorial.org