Assessment of Shoulder Pain

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Assessment of Shoulder Pain

• A Physiotherapy approach for General Practitioners

Presenters Jaquie Goldsack and Linda Gomercic
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Introduction

• Anatomy
• Review of movement terminology
• Subjective Examination
• Objective Examination
• Practical component
• Differential Diagnosis
• When is Physio Indicated
• When is a specialist referral required
• Case Scenarios
• Questions

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Anatomy- Bone/Joint

• Articulations
• Glenohumeral
• Acromioclavicular
• Sternoclavicular
• functional articulation of thorax and scapula
• Shallow joint- deepened by labrum
• Lots of degrees of freedom
• Large HoH, small fossa
• Stability dependant on non bony connections

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Ligaments

• Major Ligaments
• Anterior GHLs
• Coracohumeral Ligament
• Superior GHL
• Middle GHL
• Inferior GHL
• Labrum
• Narrow, wedged shaped structure
• Intimately associated with the shld capsule
• Blends with origin of LHB
• Pain sensitive structure
• Roles deepens fossa, controls translational
  movement of the shld in mid range movements,
  draws HoH into glenoid fossa.

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Muscles

• Rotator Cuff
• Made up of
• SS
• IF
• Sub scap
• Teres minor
• Other stabilisers
• Upper, Middle and Lower traps
• Post Deltoid
• Other muscles that impact on shoulder Position
  (global)
• LS
• Rhomboids
• Pec Minor

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Bursae

• Subacromial
• Decreases friction
• Thickens with degeneration and wear and tear
• Can be site of acute irritation or secondary
  inflammatory response to primary degenerative
  pathology
• Sub acromial space- true site of classic
  impingement

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Innervation of the RC

• Supraspinatus suprascapula nerve C4, C5, C6
• Infraspinatus suprascapula nerve C5, C6
• Subscapularis Upper and lower subscapula nerve
  C5, C6, C7
• Teres Minor Axillary nerve C5, C6

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Quick Review of Terminology

• Flexion/extension
• IR/ER
• HF/HE

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• Abduction/ Adduction
• Protraction/Retraction

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Subjective Examination

• Mechanism of injury
• Pain area
• Duration of pain (date of onset)
• Irritability
• 24hr behaviour
• Agg/easing factors
• Previous History of shoulder problems (esp if
  gradual onset)
• Occupation
• Sports, exercise, hobbies
• Red flags (Hx cancer, bilateral PN, pain levels
  exceeding those expected, systemic SS, non
  mechanical MOI)

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Objective

• Observation (scap levels, protraction, downward
  tilt, depression, clavicle levels)
• Normal resting position of the Scapula
• superior angle T2/3
• inferior angle T6/7
• upward rotation average 10 degrees
• Anterior tilt 8 degrees
• Internal Rotation 33-35 degrees
• 2-3 fingers off of the spinous process ??

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Scapular Movements
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Depressed Scapula
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Protracted/Winging scap
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Anterior Tilt
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Kyphotic tx, Ant sitting HoH
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Posture
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Objective Examination cont

• 4 finger position of scap- superior and inferior
  angles of the scapula, acromion and coracoid.
• The claw position of HoH- Anterior and
  posterior acromion compared to anterior and
  posterior HoH (HoH sitting 1/3 anterior to
  acromion).
• AROM
• With scap repositioning
• PROM

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Repositioning of scap and Re-Ax ROM
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Special Tests- Hawkins and Kennedy

• Impingement testing

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Full Can/Empty Can

• Rotator cuff tear/inflammation

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Subscap lift off and Press Belly Tests
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Speeds
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Apprehension
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Sulcus
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Neural Tension tests

• Median
• shoulder depression
• 90 deg shoulder abduction
• Wrist, finger, thumb Extension
• Supination
• ER of shoulder
• Elbow extension

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Neural Tension Tests

• Ulnar
• Wrist extension/ 4th and 5th finger ext
• Pronation/ supination
• Elbow flexion
• ER of shoulder
• Shoulder Abduction

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Neural Tension Tests

• Radial
• Shoulder Depression
• Elbow extension
• Whole arm IR
• Wrist flexion/ thumb flexion
• Shoulder abduction

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Practical- Groups

• Observation
• AROM
• Scap repositioning
• Hawkins Kennedy
• Full can/ Empty Can
• Lift Off / press belly
• Speeds
• Apprehension Test
• Sulcus

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ImagingWhen is it warranted?

• Trauma
• Very large loss in range of motion/severe
  shoulder pathology
• Red flags ie history of cancer, unexplained
  weight loss
• Failed conservative management
• Dislocation- can still be managed conservatively
• Unclear diagnosis

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Differential DiagnosisOther Causes of pain in
the shoulder

• Referral from the neck
• Thoracic outlet Syndrome
• Peripheral nerve sensitisation
• Thoracic spine pain
• SLAP lesions
• Refer to table

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When are anti inflammatories/Cortisone Warranted

• Moderate-severe pain thats not improving (acute
  rotator cuff tears)
• Difficulties with sleep
• Failure of over the counter anti inflammatorys
  to provide relief
• Frozen shoulder stage I and possibly II (pain
  relief)
• Slow progress with conservative management

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When is Physio Indicated

• Rotator cuff pathology and impingement.
• Dysfunctional scapula position
• Significant symptom relief and improvement of
  range of motion from scap repositioning
• Post cortisone
• Stiff shoulder
• ?Frozen shoulder. Especially stages II and III
  when pain has decreased and shoulder is stiff.
  Physio essential to restore ROM and function.
  There is also a role for physio with education
  and prevention of secondary problems in stage I.
  Research also shows gains in the first 2 months
  of stage 1.
• Hypermobile/unstable shoulder
• Pre and post shoulder surgery
• Unclear diagnosis for example pins and needles,
  multiple pathology, referring pain into arm,
  headaches etc

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Treatment Approach

• Muscle release
• Heat/ ice/ ultrasound/ tens/ acupuncture
• Tape to offload structures/ promote optimal
  position
• Mobilisations shoulder, cervical, thoracic or
  nerve
• Stability exercises
• Motor control exercises
• Global muscle strengthening

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Specialist Referral

• Recurrent dislocations/subluxations
• Rotator cuff tears gt2cm, massive tears, full
  thickness tears, partial thickness tears gt50
• Frozen shoulder stage 1
• If conservative management is not working
• Unsure diagnosis

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Case Study 1/Discussion

• 45y/o Female presents with acute onset right
  shoulder pain after spending the weekend
  painting. She is unable to lift her arm
  gt90degrees due to pain.
• Pain is at the deltoid insertion with some
  radiation down to elbow when she uses her arm (ie
  brushing teeth, doing hair)
• Agg activities include lifting arm, brushing
  hair, reaching, doing up bra, lying on her right
  side
• Easing activities include supporting arm, rest,
  heat to shoulder
• Special Qs nil Hx of cancer, no neural Sx,
• What is your differential Dx?
• What tests would you perform?

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Case Study 2/Discussion

• 30 y/o male presents with right sided pain in his
  biceps and PN numbness in his palm, onset 6
  weeks ago, gradually worsening. Gets pain at
  night time.
• Works as a labourer. Hx of carrying a large sheet
  of metal. The other person carrying dropped one
  side of it, causing a traction force through his
  right arm.
• Agg activities include arm hanging by side,
  carrying objects, lying on right side. Gets
  headaches with prolonged sitting and driving
• Ease activities putting arm on head or resting
  thumb in belt, resting arm on object
• Mild decrease in range of motion. Catch at
  90degrees of abduction but can continue through
  ROM.
• Observation Depressed and protracted right
  scapula
• Differential Dx?
• What tests would you perform?

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Case Study 3/Discussion

• 40 year old diabetic female presenting with
  gradual onset of pain and restriction of the
  right GH joint over the last 3 months.
• Constant ache with sharp pain upon movement
• Agg all shoulder movements, sleeping, dressing
  herself
• Worse at night sleeps only 3-4 hours per day
• Ease nothing at the moment
• Works full time as a secretary
• Unaware of any previous injuries to the shoulder
• Observation Rounded shoulders and kyphotic
  shoulder hike on affected side
• AROM 40deg flxn abduction 10 deg ER HBB
  iliac crest
• Differential Diagnosis ?
• What tests would you perform?
• Any imaging?
• Physio approach

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Questions

• Thank you for attending