Shoulder Pain

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Shoulder Pain

• Marzena Slater, M.D.
• PGY 2
• Emory Family Medicine

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Objectives

• To provide a background of shoulder anatomy
• Provide an overview of shoulder pain evaluation
• Discuss provocative testing used in the
  evaluation of shoulder pain
• Summarize key history and physical findings that
  will aid in diagnosing common shoulder problems
• Discuss common shoulder pathologies, their
  treatment and when to refer

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Shoulder Anatomy
Reference 1
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Shoulder Anatomy

• The shoulder is one of the most complex joints in
  the body.
• Composed of
• 1.Bony structures
• Humerus
• Glenoid
• Acromion
• Clavicle
• 2. Soft tissue structures
• The rotator cuff muscles and supporting elements
• 4 surrounding joints
• Glenohumeral joint
• Acromioclavicular joint
• Sternoclavicular joint
• Scapulothoracic joint/pseudoarticulation

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The Glenohumeral Joint

• Most commonly dislocated major joint in the body
• Basic principles
• GH joint a ball and socket joint
• The glenoid fossa is flat and much smaller than
  the contacting humeral head (25-30)
• Cartilaginous labrum provides much of the socket
  function- but not much stability
• Stability is achieved stabilizing structures

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Static Stabilizers

• Consist of
• Bony structures
• Labrum
• GH ligaments (superior, middle, inferior)
• Joint capsule
• Help maintain harmony
• Continue to function in the presence of
  neurologic or intrinsic muscle pathology

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Dynamic Stabilizers

• Include
• Rotator cuff
• Scapular stabilizers (teres major, rhomboids,
  serratus anterior,trapezius and levator scapula)
• Cannot function in the presence of neuromuscular
  injury or intrinsic muscle damage
• Their malfunctioning leads to GH laxity and
  shoulder pain

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The Rotator Cuff

• Main function- depress the humeral head against
  the glenoid stabilize
• Composed of 4 muscles
• Supraspinatus- abduction helper to deltoid, pulls
  humeral head towards glenoid
• Infraspinatus- external rotation helper, pulls
  humeral head inferiorly
• Teres minor-external rotation helper, pulls
  humeral head inferiorly
• Subscapularis-internal rotation helper to
  pectoralis and latismus dorsi
• When damaged, humeral had can move upward within
  the joint 2/2 to unopposed deltoid action

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History

• Always begin with the patients age, dominant
  hand and sport or work activity
• Determine patients chief symptom (ex pain,
  weakness, instability, limited ROM)
• How and when did the problem begin
• Are patients sx related to specific injury/event
  or are the more insidious in onset
• Do specific activities/arm movements exacerbate
  or alleviate the sx

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History Cont.

• Associated sx
• Instability/laxity (ex. Multidirectional GH
  instability)
• Weakness (ex. Impingment, rotator cuff
  pathology)
• Swelling (ex. Acute trauma/fx/rotator cuff tear)
• Numbness (ex. C spine dz)
• Loss of Motion/stiffness (ex. Adhesive
  capsulitis, dislocation or GH instability)
• Catching (ex. Labral disorder)
• Popping (ex. Labral disorder)
• What previous treatments have been tried ice,
  heat, medications (NSAIDS, Tylenol, ASA)
• Previous medical interventions physical therapy,
  injections, surgical interventions

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Physical Exam

• Approach it systematically
• Dont ignore the good shoulder- it can give you
  a reference for whats normal in your patient
• Expose both shoulders and perform
• Inspection
• Palpation
• ROM passive and active in all planes
• Strength testing- isolate relevant muscle groups
  individually
• Special tests as indicated

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Inspection

• Look for
• Swelling
• Asymmetry (ex. Squaring)
• Muscle atrophy
• Scars
• Ecchymosis
• Venous Distention

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Inspection

• Look for
• Swelling
• Asymmetry (ex. Squaring)
• Muscle atrophy
• Scars
• Ecchymosis
• Venous Distention

Ant. Shoulder Dislocation
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Inspection

• Look for
• Swelling
• Asymmetry (ex. Squaring)
• Muscle atrophy
• Scars
• Ecchymosis
• Venous Distention

Ant. Shoulder Dislocation
AC joint separation
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Inspection

• Look for
• Swelling
• Asymmetry (ex. Squaring)
• Muscle atrophy
• Scars
• Ecchymosis
• Venous Distention

Ant. Shoulder Dislocation
AC joint separation
Supraspinatus and infraspinatus atrophy
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Palpation

• Sternoclavicular joint
• Clavicle
• Coracoid process
• Acromion
• Acromioclavicular joint
• Scapula

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Palpation

• Bicipital Groove of biceps tendon
• Subacromial Bursa
• Cervical Spine

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Range of Motion- Active

• Apley Scratch Test is the quickest way to
  evaluate
• External rotation/ abduction (Fig 1)
• Internal rotation/ adduction (Fig 2)
• Internal rotation/ adduction (Fig 3)

Fig 1
Fig 2
Fig 3
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Range of Motion- Passive

• If patient is unable to perform fully any of the
  active testing, passive testing should be
  conducted
• If Passive ROM normal but active ROM restricted,
  muscle weakness is a likely cause of restriction.
• If passive and active ROM affected, bony
  (intra-articular) or soft tissue
  (extra-articular) blockage most likely- ex.
  Adhesive capsulitis

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Range of Motion- Passive

• Abduction- 180 degrees
• Isolate the GH joint
• 1st 20-30 degrees of abduction dont require ST
  motion.
• Arm internally rotated 1st 120 degrees (palm
  down)
• Arm externally rotated (palm up) gt120 degrees
• Adduction- 45 degrees
• Flexion- 90 degrees
• Extension- 45 degrees
• Internal Rotation- 55 deg
• External Rotation- 40-45 deg.

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Strength Testing- Rotator Cuff Evaluation

• Always compare the 2 upper extremities
• Isolate the rotator cuff muscle groups
• Key finding with rotator cuff problems is pain
  accompanied by weakness.
• True weakness should be distinguished from
  weakness due to pain

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Supraspinatus

• The Empty can test
• abduct shoulders to 90 degrees in forward
  flexion, with thumbs pointing down
• The patient attempts to elevate arms against
  examiner resistance

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Infraspinatus and Teres Minor

• With patients arms at the sides, the patient
  flexes both elbows to 90 degrees while the
  examiner provides resistance against external
  rotation

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Subscapularis

• Lift off test
• Patient rests dorsum of the hand on the back in
  the lumbar area.
• Inability to move hand off the back by further
  internal rotation of the arm, suggests injury to
  subscapularis muscle

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Provocative Testing

• Provide more focused evaluation for specific
  problems that you are suspecting from your
  initial HP
• Include
• Impingment signs
• Neers Sign, Hawkins Test
• Rotator cuff tear
• Drop Arm Test
• AC joint Arthritis
• Cross-arm test
• Cervical Nerve disorder
• Spurlings Maneuver
• GH instability
• Apprehension test, Relocation (Jobe), Sulcus Sign
• Biceps Tendon instabillity/tendonitis
• Yergason test, Speeds maneuver
• Labral Disorders
• Clunk Test, O Briens

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Impingement Signs

• Neer Sign
• Arm in full flexion with arm fully pronated
• Stabilize scapula
• Pain subacromial impingment-Rotator cuff tendons
  pinched under coracoacromial arch
• Hawkins Test
• Forward Flex shoulder to 90 deg., elbow_at_ 90 deg.,
  then IR
• Pain suprapinatus tendon impingement or
  tendonitis
• ? More sensitive for impingement than Neers

Neer
Neer
Hawkins
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Rotator Cuff Tear

• Drop Arm Test
• Passively abduct patients shoulder to 90 degrees
  have patient lower slowly to waist
• Weakness or arm drop indicates rotator cuff
  tear/dysfunction
• Note the patient may be able to lower the arm
  slowly to 90 degrees (deltoid fxn) but will be
  unable to do so as far as the waist

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AC joint pathology

• Cross Arm Test
• Shoulder in 90 degrees forward flexion, then
  abduct arm across body
• Pain indicates AC joint pathology
• Decreased ROM indicates tight posterior capsule
• AC Shear
• Cup hands over clavicle/scapula then squeeze
• Pain/movement AC pathology

Cross Arm Test
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Cervical Nerve Pathology

• Pain that originates from the neck or radiates
  past elbow, is suspicious for neck disorder
• Spurling Maneuver
• Extend neck and rotate head of patient to
  affected shoulder. Then apply axial load.
• Reproduction of sx indicates cervical disk
  pathology

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GH instability

• Apprehension test
• Shoulder in neutral position at 90 deg abduction.
• Apply slight ant pressure to humerus
• Pain/apprehension about impending subluxation GH
  instabiliy
• Relocation (Jobe)
• Perform if above positive
• With patient supine, apply posterior force on
  prox. Humerus while externally rotating patients
  arm.
• Decrease pain/apprehension GH instability
• Sulcus Sign
• Arm to side, downward traction
• Increased acromioclavicular sulcus inferior
  instability

Relocation
Apprehension
Sulcus
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Biceps Tendonitis

• Yergasons
• Patients elbow flexed at 90 deg with thumb up
• Examiner grasps wrist, resists patient attempt
  to supinate the arm and flex elbow
• Pain biceps tendonitis
• Speeds Maneuver
• Flex pts elbow to 20-30 degrees w/ forearm in
  supination and arm in 60 degrees of flexion
• Examiner resists forward flexion and palpates
  biceps tendon

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Labral Disorders

• Clunk Test
• Patient supine
• Patients arm is rotated loaded from extension
  thru forward flexion.
• clunk sound or clicking sensation, may indicate
  labral tear
• OBriens
• 90 deg FF, max IR, then adduct and flex

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Acute and Chronic Disorders of the Shoulder
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Clavicular Fractures

• Common, most in mid 1/3 clavicle
• Hx
• Fall on outstreched hand or direct blow
• PE
• Point tenderness /or a visible deformity
• Always do neurovascular exam
• Imaging
• Xray- AP and cephalic tilt views
• Rx figure of 8 sling for 2-4 wks
• F/U in 4-6 wks with Xray
• Refer to ortho
• If fx of distal clavicle- may disrupt ligaments
  of AC joint

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Proximal Humeral Fractures

• Hx
• Fall onto outstretched hand or direct blow
• PE
• Crepitus at fx site
• Ecchymosis within 24-48 hours of injury
• Imaging
• AP and Lateral Xray. Axillary view if pt able
• RX
• Shoulder immobilizer to prevent external rotation
  and abduction
• Refer to ortho if
• Complex fx
• Anatomic neck involvement
• Displaced gt1 cm
• Ass. Neurovascular injury

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Glenohumeral Dislocation

• Most dislocations are anterior
• Ant. Dislocation
• pt holds arm in external rotation/abduction
• Humeral head palpable anteriorly/ dimple below
  acromion
• Posterior Dislocation
• Arm in abduction/internal rotation
• Dx often delayed
• Imaging
• Need two views
• AP- can miss posterior dislocation
• Axillary or Y view

AP
Y view
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Glenohumeral Dislocation

• Complications
• Recurrent GH dislocations
• apprehension, relocation or sulcus
• Bony inury
• gt50 have Hill Sachs deformity- defect in
  posterolateral humeral head
• Rotator Cuff Tear
• 50 age lt40, 80 gt60
• RX
• Relocation
• ROM exercises early
• Recurrent- Bankart repair -surgical repair of
  detachement of labrum to glenoid

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AC joint sprain/separation

• Common injury among athletes and active patients
• Mechanism
• direct blow to superior aspect of shoulder
• lateral blow to deltoid area
• Fall on outstretched hand
• Exam
• Well localized swelling tenderness over AC
  joint
• Always examine pt in seated position
• Palpable stepped deformity between the acromion
  and clavicle may indicate more severe injury
• Imaging
• Xray
• AP- confirms dx
• Axillary- if suspect grade 4-6 injury

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Classification of AC injuries

• Grade 3 and greater refer to orthopedics for
  possible repair

Ligaments or joint Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6
Acromioclavicular Ligaments Sprained Disrupted Disrupted Disrupted Disrupted Disrupted
Acromioclavicular joint Intact Disrupted or slight vertical separation Disrupted Disrupted Separated Ruptured
Coracoclavicular Ligament Intact Sprained Disrupted or slight vertical separation Disrupted Disrupted Disrupted
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Rotator Cuff Tear

• Most common in greater than 40 yo.
• Hx
• Younger patients- trauma related
• Middle aged- chronic impingment leads to rupture
  of cuff
• Imaging
• AP view GH joint- may show calcific tendonitis of
  cuff /- superior migration of humeral head-?
  should be f/u with further imaging
• MRI gold standard
• RX
• Surgical repair in young and selected older
  patients within 3 weeks of injury preferably
• Rehab for patients that are not surgical
  candidates

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Impingement Syndrome

• Mechanism
• rotator cuff tendons get impinged between
  coracoacromial arch and the humerus on abduction
• Supraspinatus most commonly involved
• Two types
• Primary
• Older patient, chronic overuse and degeneration
• Secondary
• Younger, throwing athlete, GH instability leading
  to impingement

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Impingement Syndrome

• Hx
• Pain over anterolateral shoulder /- radiation to
  elbow
• Aggravated by overhead activities and worst at
  night
• PE Hawkins, Neer
• RX
• Conservative
• Acute Phase NSAIDS, Injection, Icing, rest
• Pain resolving Rotator cuff strengthening
  exercises
• Xrays- get if 2-3 mo of conservative Rx fails-
  may show hooked acromion, AC spurring.
• MRI as indicated
• Surgery if conservative Rx fails

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Frozen Shoulder

• Mechanism thickening and contracture of capsule
  around GH joint
• Etiology
• Immobility (surgery, pain)
• ?Autoimmune
• Imaging
• X-rays- normal
• Arthography- constriction of joint capsule
• RX
• Physical therapy
• Pain medications (NSAIDS)
• Corticosteroids occasionally
• Surgical referral if conservative fails

The Origin of Acupuncture
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Biceps Tendonitis

• Inflammation of sheath around long head of biceps
• Hx
• Pain and tenderness in bicipital groove
• Often associated with impingement syndrome or
  rotator cuff tear
• PE Yergasons, Speeds
• Rx
• Conservative Rest, ice, NSAIDs, Injection
• Surgical Transfer of tendon

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Labral injury

• SLAP lesion (Superior Labrum Anterior Posterior)
  common in throwing athletes
• HX Painful shoulder that clicks or pops with
  motion
• PE clunk test, O'Brien's, /-laxity signs
• Rx
• Often will need surgical repair, especially if
  athlete.

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Osteolysis of Distal Clavicle

• If atraumatic, most common in weight lifters
• Begins as stress fx bone remodeling cannot
  occur due to continual stress on joint
• Hx
• Dull Pain over AC joint
• worst in beginning of exercise period
• Aggravated by abduction of shoulder
• Dx
• Xrays- osteopenia and lucency of distal clavicle
• RX
• D/C load-bearing activity
• Surgical Resection of distal clavicle

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Case 1

• 42 yo Male comes to your office complaining of Rt
  shoulder pain. He does not remember any specific
  injury, but has been playing tennis a lot over
  the past 4 months and tells you that opposing
  players no longer fear his serve. It is
  difficult and painful for him to reach overhead
  and behind him. Even rolling onto his shoulder
  in bed is painful.
• PE shows full ROM, but with discomfort at end
  ranges of Flexion, abduction and internal
  rotation. There is significant pain when you
  place the shoulder in position of 90 degrees of
  flexion and then internally rotate. There is
  also moderate weakness on abduction and external
  rotation. The rest of the MS exam is normal.

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• The most likely diagnosis is
• Acromioclavicular sprain
• Rotator Cuff tear
• Adhesive Capsulitis
• Rotator Cuff impingement
• Cervical Radiculopathy

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• The most likely diagnosis is
• Acromioclavicular sprain
• Rotator Cuff tear
• Adhesive Capsulitis
• Rotator Cuff impingement
• Cervical Radiculopathy

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• The best initial treatment is
• Corticosteroid injection
• Arthroscopic subacromial decompression
• Strengthening and ROM exercises
• Elbow sling
• Cervical collar

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• The best initial treatment is
• Corticosteroid injection
• Arthroscopic subacromial decompression
• Strengthening and ROM exercises
• Elbow sling
• Cervical collar

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• Predisposing factors for this problem include
• Repetitive motion of the shoulder above the
  horizontal plane
• Hooked acromion
• Acromioclavicular spurring
• Shoulder instability
• All of the above

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• Predisposing factors for this problem include
• Repetitive motion of the shoulder above the
  horizontal plane
• Hooked acromion
• Acromioclavicular spurring
• Shoulder instability
• All of the above

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References

• Woodward, T.W Best, T.M The Painful Shoulder
  Part I. Clinical Evaluation. American Family
  Physician. May, 15 2006603079-88.
• Woodward, T.W Best, T.M The Painful Shoulder
  Part II. Acute and Chronic Disorders. American
  Family Physcian. June 1, 2000 613291-300.
  http//www.aafp.org/afp/20000601/3291.html
• Hoppenfield, M. Physical Examination of the Spine
  and Extremities. New JerseyPrentice Hall 1976.
• Thompson, J.C. Netters Concise Atlas of
  Orthopedic Anatomy. PhiladelphiaElselvier Inc
  2002

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