My Sore Shoulder

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My Sore Shoulder!

• Guide to Diagnosis and Conservative Treatment

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Shoulder Anatomy

• Acromioclavicular (AC) joint
• Glenohumeral joint
• Glenoid labrum
• Humerus
• Rotator cuff
• Biceps muscle/tendon
• Deltoid muscle

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Common Shoulder Conditions

• Rotator cuff injuries
• Impingement
• Instability
• Labral tears
• Bicipital tendonitis
• AC joint disorders
• Suprascapular nerve entrapment

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Rotator Cuff Injuries

• Rotator cuff serves as a stabilizer for the
  shoulder
• Cuff is comprised of the supraspinatus,
  infraspinatus, subscapularis and teres minor
  muscles
• Common rotator cuff injuries occur to the
  underside of the supraspinatus tendon
• Increase in risk of tear at age 40

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Impingement (Bursitis/Tendonitis)

• Can include inflammation of the bursa overlying
  the rotator cuff, inflammation within the rotator
  cuff tendons, or calcium deposits within the
  rotator cuff tendons caused by wear and tear
• Can be caused by frequent extension of the arm at
  high speed under high load (i.e. throwing a
  baseball)
• Potential outcome is a rotator cuff tear

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Instability

• Shoulder laxity needs to be differentiated from
  frank instability
• Laxity is common in the swimmer and throwing
  athlete, as the shoulder must be loose enough to
  allow excessive external rotation
• Instability is unwanted translation of the
  humeral head on the glenoid, and compromises the
  comfort and function of the shoulder

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Labral Tears

• Frequently seen in throwing athletes
• Glenohumeral joint receives compressive and
  shearing forces during the movement of the
  humeral head, anteriorly to posteriorly

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Bicipital Tendonitis

• Inflammation of the biceps tendon
• Diagnosis made principally by palpation of the
  tendon during clinical examination
• Occurs frequently in the throwing athlete
• Modest biceps activity during cocking and
  acceleration phase
• High level of biceps activity during
  follow-through phase

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AC Joint Disorders

• Most sprains to the AC joint occur as the result
  of a fall or a blow to the lateral acromion
• Symptoms of a separation may range from pain over
  the AC joint to a frank deformity

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Suprascapular Nerve Entrapment

• Suprascapular nerve supplies the supraspinatus
  and infraspinatus muscles of the rotator cuff
• The nerve can be compromised by traction injuries
  or compression injuries
• Athlete may present with subtle weakness and
  vague complaints of posterior shoulder girdle
  pain

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The Subjective Evaluation

• What?
• How?
• When?
• Where?

• Pain?
• Instability?
• Weakness?
• Deformity?

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The Clinical Examination

• Inspection
• Examination of the cervical spine
• Palpation
• Range of motion assessment
• Strength assessment
• Glenohumeral stability assessment
• Neurovascular examination
• Special tests

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Inspection

• Should be performed from different perspectives
  (front, side, back, top)
• Should assess for symmetry, atrophy, hypertrophy,
  deformities, bruising and swelling
• Note scars as evidence of prior surgical
  procedures

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Examination of the Cervical Spine

• Have the patient look up at the ceiling, touch
  his chin to his chest, look over each shoulder
• Any numbness, tingling or pain referred to the
  affected shoulder points to the cervical spine as
  the etiology of the shoulder pain

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Palpation

• Bony Landmarks
• SC joint
• Clavicle
• AC joint
• Acromion
• Bicipital groove
• Scapula

• Soft Tissue
• Biceps tendon
• Supraspinatus insertion to the proximal humerus
• Deltoid
• Posterior capsule

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Range of Motion

• Includes testing of both active and passive range
  of motion
• For example, in the setting of a rotator cuff
  tear, passive range of motion will be normal but
  active range of motion will be diminished due to
  the tear in the muscle

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Range of Motion (norms)

• External rotation in a 0 plane (90)
• External rotation in a 90 plane (90)
• Abduction (150)
• Internal rotation (90)
• Forward flexion (180)
• ALWAYS compare both shoulders!

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Range of Motion

• During range of motion assessment is a reasonable
  time to test for impingement
• Impingement sign with the arm abducted to 90
  and the elbow flexed to 90, externally rotate
  the patients arm
• Impingement test forward flex the patients arm
  to 180
• Pain signifies a positive test

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Strength Assessment

• Strength is easy to assess by standing behind the
  patient who is seated on the exam table
• Strength is graded 0 to 5 over 5
• 0/5 total paralysis
• 1/5 palpable or visible contraction
• 2/5 full ROM with gravity eliminated
• 3/5 full ROM against gravity
• 4/5 full ROM with decreased strength
• 5/5 normal strength

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Strength Assessment

• Supraspinatus assessed at 90 of forward flexion
  in the scapular plane with the thumbs pointed to
  the floor downward pressure is resisted by the
  patient
• Test is specific for supraspinatus function, and
  evaluates cuff strength and integrity

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Strength Assessment

• External rotators with the patients arm at his
  side and the elbow flexed to 90, he will
  externally rotate as if hitting a tennis ball in
  a backhanded manner against resistance
• Test is specific for the teres minor and
  infraspinatus muscles

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Strength Assessment

• Abduction assessed in the coronal plane against
  resistance
• May be suggestive of either deltoid or cuff
  deficiency
• Subscapularis with the dorsum of the patients
  hand on his ipsalateral back pocket, instruct him
  to push backward against resistance

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Glenohumeral Stability Assessment

• Subtle anterior instability is not uncommon in
  the throwing athlete
• In addition, the hyperlax patient may have some
  element of multidirectional instability

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Glenohumeral Stability Assessment

• Sulcus sign distraction force is placed on the
  elbow and the space created between the
  undersurface of the acromion and the apex of the
  humeral head is noted
• This distance is recorded in centimeters, and
  indicates laxity in the joint

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Glenohumeral Stability Assessment

• Load and shift test with the humeral head
  reduced (loaded) into the glenoid fossa, the
  examiner steadies the limb girdle with one hand
  and translates the humeral head both anteriorly
  and posteriorly with the opposite hand
• The amount of translation is graded as 1, 2, or
  3
• This test is also repeated in the supine position
• Glenohumeral translation depends upon the skill
  of the examiner as well as the patients ability
  to relax

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Glenohumeral Stability Assessment

• Apprehension test evaluation of the patients
  sense of pending anterior subluxation or
  dislocation with the arm in stressed external
  rotation abduction
• Can be performed sitting or supine, but works
  best with the patient supine
• In order for a test to be positive, apprehension
  must be present pain alone does not indicate a
  positive test

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Glenohumeral Stability Assessment

• Relocation test following the supine
  apprehension test, apply posterior pressure to
  the proximal humerus at the same level of
  external rotation noted in the apprehension test
• A positive relocation test is described when the
  patients apprehension disappears with the
  posterior stress

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Neurovascular Examination

• Dermatomal sensory examination
• Deep tendon reflexes at the wrist and elbow
• Cervical root testing wrist extension, finger
  abduction and adduction, thumb abduction, elbow
  flexion
• Palpation of the brachial and radial pulses

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Special Tests

• Drop arm test the patients arm is abducted to
  90 and released
• A positive test is noted when the patients arm
  falls down from the position
• Indicative of a rotator cuff tear

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Special Tests

• Speeds test with the shoulder in forward
  flexion, elbow extended, and hand supinated,
  resistance is applied
• Pain in the location of the bicipital groove
  during resistance is indicative of bicipital
  tendonitis

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Special Tests

• OBriens test with the arm adducted across the
  midline, elbow extended and thumb down, the
  examiner applies downward pressure the
  patients thumb is then turned up, and he again
  resists downward pressure
• A positive test is indicative of a labral tear,
  and is described when greater pain occurs with
  the thumb pointed downward

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Special Tests

• Clunk test while the patient lies supine the
  examiner abducts the arm past 90 with one hand
  while pressing the proximal humeral head
  anteriorly the examiner then rotates the
  shoulder internally and externally
• A positive test is elicited when the patient
  feels a deep clunk in the shoulder
• Indicative of a labral tear

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Radiographic findings

• X-rays what to look for
• Bony tumors
• Fracture lines
• Hook to the acromion
• Degenerative changes
• Dislocation

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Radiographic findings

• MRI
• Good for ruling out bad things
• Can be misleading
• Must be correlated with clinical exam the
  radiologist does not have the benefit of
  examining the patient

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Conservative treatment

• Physical therapy
• Excellent form of strengthening and
  rehabilitating weak or injured muscles
• Formal physical therapy will reassure you that
  the exercises are actually being done
• The most successful conservative form of therapy
  for the musculoskeletal system

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Conservative treatment

• Oral anti-inflammatories
• Sometimes just a short course of
  anti-inflammatories can provide permanent relief
• Non-selective COX inhibitors still work great if
  the patient can tolerate them
• COX-2 inhibitors
• Celebrex 200 mg daily
• Vioxx 25 mg daily
• Bextra 20 mg daily

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Conservative treatment

• Cortisone injection (short-acting local)
• Can be a permanent cure, but is frequently a
  short-term fix
• Relief from the injection gives an excellent
  prognosis for surgical success
• Should only be given every 3 months

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If the above fail

• Refer to orthopedic surgeon
• Surgery is a measure of last resort!
• There is no pain so terrible that surgery cant
  make worse.