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Complex Joint
Simplified
• Not applicable
Mitigating Potential Bias: Dr
Marie-Josée Klett
• Not applicable
Objectives
• Distinguish most common shoulder conditions
• Extrapolate how the anatomy of the shoulder relates to the injury
and pain pattern
• List the key points in taking the shoulder history
• Carry out a focused physical examination of the shoulder and
perform it by practice in pairs
• Order appropriate investigations for diagnosis of shoulder problems
• Interpret investigations based upon history and physical examination
• Formulate a management plan for common shoulder problems
• Propose home exercises for certain shoulder conditions
• Determine when a referral is required
• Evaluate the scientific evidence for tests and treatments where it is
available
Outline of Workshop
• First half:
– History – review key points
– SYSTEMATIC approach to exam – BOTH shoulders
– Review of pertinent anatomy
– Review Inspection – LOOK
– Review Palpation – FEEL
– Review Resisted and Special Tests based on evidence – MOVE
– Observe - then practice in pairs
– 5 minute exam
Outline of Workshop
• Second half:
– Case-based, practice dx based on history and exam
– Investigations: when to order what
– Management of most common conditions
– When to refer
– Review home exercises
History: 3 “S” Symptoms
• Anterior
– Deformity
– Swelling
– Symmetry
– Downsloping
– Deltoid Atrophy
LOOK
• Side
-Posture (protraction,
kyphosis, neck
position)
-Swelling
LOOK
• Posterior
-Atrophy Rotator
Cuff
-Scapular Winging
- Scapulohumeral
Rhythm
Abnormalities
Ant. Shoulder
Dislocation
AC Joint
Separation
Supraspinatus and
infraspinatus atrophy
FEEL
AC joint
GH joint
Suprapinatous
insertion
MOVE: Active – Passive - Resisted
Wall Push Up
Special Tests
• Rotator Cuff
• Impingement
• Biceps
• AC joint
• GH joint
• Laxity
• Instability
• Labrum
Rotator Cuff: Anatomy
Rotator Cuff: History
• Drop Arm Test – positive test (LR + 3.3) might help identify
RCD
Empty Can (Jobe’s)
Patient resists
abduction in the plane
of the scapula
Rotator Cuff: Physical Exam
Infraspinatus:
Subscapularis:
• Painful Arc (positive has LR+ 3.7, normal has LR- 0.36)
• Hawkins (sensitivity 60-90% specificity 25 -70%)
• Neers sign (sensitivity 88% specificity 30%)
• Neers Impingement test: inject 5-10 ml xylocaine in subacromial
space then repeat impingement signs
Hawkin’s
Flexion Adduction
Internal Rotation
(FAIR)
Practice
• Rotator Cuff:
– Supraspinatus: empty can, full can, drop arm
– Infraspinatus: resisted ER, ER lag
– Subscapularis: lift-off, IR lag
• Impingement:
– Neer’s
– Hawkin’s
– Painful arc
Biceps: Anatomy
•Examiner resists
forward flexion – ask
about pain
Biceps Physical Exam:
Yergason’s
Passive adduction
across body with
overpressure
Practice
• Biceps:
Proximal
– Speed’s
– Yergason’s
Distal
– Hook (100% no cord-like structure for complete distal tear;
75% just painful if partial)
• AC joint:
– Scarf
– palpation
Glenohumeral Joint: Anatomy
Glenohumeral Joint: History
• Osteoarthritis
– Gradual onset
– Age: 50 and older
– Morning Stiffness
– Better with moderate activity
Superior
Middle
Inferior
Laxity/Instability: History
Laxity:
• clinically loose shoulder, often increased ROM (these patients
do well in sports where this is an advantage such as swimming);
predisposed to RCD
Instability:
• may report episode of subluxations or “dead arm” followed by a
few days of pain
• actual episodes of dislocation often requiring ER visits, can
become more and more frequent with less and less trauma
Instability – 2 types
T – Traumatic
U – Unilateral
B – Bankart lesion
S – usually requires Surgery
Laxity/Instability: Physical Exam
Laxity:
• often increased ROM
• sulcus test
Instability:
• Apprehension/relocation test
Shoulder Laxity Test: Sulcus
test
Shoulder Instability Tests
Apprehension and Relocation Tests
• O’Briens: for SLAP tears – GH in 900 FF, 150 Horiz Flex, Full
IR/pronation - apply downward pressure and have patient resist.
Repeat with arm fully supinated. Positive test is pain in pronated
position but not in supinated.
• May also have positive apprehension and/or bicipital tests
• By combining all 3 tests
Sensitivity 75% Specificity 90%
• Laxity:
– Inferior Sulcus
• Instability:
– Apprehension/relocation
• Labrum:
– O’Brien’s
Summary of Tests for Specific
Shoulder Conditions
1) RC Tear: Resisted IR + ER, ER Lag, IR Lag, Lift-Off, Empty Can, Full Can,
Dropped Arm: (all for pain +/or especially weakness ), Positive Impingement
signs : (for pain)
2) Impingement : 3 Signs cause pain: Hawkin’s, Neer’s, Painful Arc
Neer’s Impingement Test : (injection lidocaine into subacromial space
relieves pain)
3) Frozen Shoulder or OA : passive ROM reduced in all planes (ER decreases
before ABD/IR)
4) Biceps: Speed’s, Yergason’s (pain+/or weakness)
5) AC Joint: Palpation, Scarf
6) Laxity: Inferior Sulcus
7) Instability: Apprehension/Relocation (causes/relieves apprehension)
8) Labral Tear: O’Brien’s (pain or pop)
9) Scapulohumeral Rhythm: Observe FF, Abd, Wall-push up (scapular
winging)
10)Referred Pain/Neurovascular: Radial pulse, TO tests, sensation (e.g.
sargeant’s patch), arm/hand strength, Spurling’s
5 Minute Shoulder Exam
• Neck Screen – ROM
• Look – front – side – back
• Feel - front - side – back
• Move - Active to Passive then Resisted
• Special Tests: Rotator Cuff (supraspinatus, infraspinatus,
scubscapularis)
Impingement
Biceps
AC Joint
Laxity
Instability
Labral
Neurovascular
Second Half Outline
• Pre-test
• Cases (interactive)
• Post-test
• Exercises
• Summary
Pre-Test
Question 1
A 88%
B 66%
C 44%
D 22%
Pre-Test
Question 2
There is good correlation between structural pathology of the
rotator cuff seen on MRI and clinical symptoms
A True
B False
Pre-Test
Question 3
The management of a partial thickness supraspinatus tear
includes:
A subacromial bursitis
B multidirectional laxity
C rotator cuff tear
D adhesive capsulitis
Case 1
A 1
B 2
C 3
D 4
Grades of Overuse Injury
• Non-specific symptoms
• Age greater than 60 and night pain often indicates rotator cuff
tear (88% sensitivity but only 20% specificity)
“Tendinopathy”
• Examination of affected tendons show absence of neutrophils,
lymphocytes or plasma cells as expected in acute and chronic
inflammation
• Hence the shift in terminology toward using “tendinopathy” as
the diagnosis or “rotator cuff disease”
• Changes in tissue collagen content and ground substance
during middle age predispose these tendons to injury when they
are repeatedly stressed. There is increased occurrence in 30-
50 year age group.
• The purpose of treatment is to up-regulate protein (collagen in
particular) production in the tenocytes and there are many ways
to do this.
How would you manage this
patient?
A refer to a surgeon
B investigate with ultrasound or MRI
C inject with corticosteroid
D xray and refer to physiotherapy
Shoulder xrays
Corocoid
Lesser
tuberosity
Glenoid
Greater
tuberosity
Acromion
Rotator Cuff-Chronic
Imaging for Rotator Cuff
• For rotator cuff tears they are quite sensitive and specific, over
90% but like ultrasound are less accurate for partial thickness
tears
http://sitemaker.umich.edu/fm_gmeig_musculoskeletal_joint-inject-aspir/subacromial_injection
Rotator Cuff Tear - Management
• Ultrasound
• For partial thickness tears: treatment same as tendinopathy
• For full-thickness tears decision making for surgical candidates
based on symptoms, age, duration, size
• Consider surgical referral if
– symptoms persist beyond 3 months of conservative
treatment
– age <50
– acute tear
– size 1.5 to 5 cm (level B evidence)
– size >5cm (level C evidence)
• Consider MRI before surgical referral
Case 2
• GH Osteoarthritis
• Tumour
• Infection
Investigations
• Possibly x-ray to rule out some of the above (level I -
recommended but insufficient evidence)
Frozen Shoulder - Management
Best Practice & Research Clinical Rheumatology (April 2009), 23 (2), pg. 161-192
Case 3
http://www.eurorad.org/eurorad/case.php?id=2418
Anterior Dislocation - Management
http://www.91sqs.com/batch.download.php?aid=3669
ER brace (level C)
http://sportinjurysolutions.com/store/shoulder_braces.html
Case 4
A MRI
B Ultrasound
C MRI Arthrogram
D X-ray
Labral Tears - Management
A 35 year old physician plays hockey and slipped and hit the
boards with his non-dominant shoulder a few days ago. He
brings his x-rays from emergency where he was told he had an
AC sprain. He wants to know when he can go back to play.
Exam
• Inspection
• Palpation – AC and CC ligaments
• Scarf
What is important to know about
this injury before you give return-to-
play advice?
A position he plays
B direction he shoots
C degree of the sprain
D when the play-offs start
AC Separation Types
partial
partial
complete
complete
Xray AC Joint
Grade 2
Grade 3
http://lasantaferena.com/blog/2008/05/17/me-and-my-new-shadow/
http://blog.amal.net/?p=323
Management Type 1
• Return when ROM is full and pain free; full strength to protect
themselves and be effective in their sport; test ability to do a
push up in your office
• Type 4, 5, 6 - Refer
AC Joint OA
• Very common
Mrs. Smith is a 50yo lawyer who sees you in the ER for left
shoulder and arm pain. She was carrying a heavy file box
yesterday when she tripped and the box fell, hurting her arm in
the process. Her entire upper arm has been sore since and she
had trouble sleeping last night despite taking ibuprofen.
Exam
A 88%
B 66%
C 44%
D 22%
Post-Test
Question 2
A True
B False
Post-Test
Question 3
A subacromial bursitis
B multidirectional laxity
C rotator cuff tear
D adhesive capsulitis
Rehabilitation Exercises
• General principles:
– Decrease pain
– Restore ROM
– Increase strength
– Sport specific drills
• Exercises:
– ROM
– Strengthening
http://media.summitmedicalgroup.com/media/db/relayhealth-images/xfrozsho_2.jpg
Towel stretch (IR)
http://www.ucsfbreastcarecenter.org/reconst_latex_3weeks.html
Scapular Stabilization Exercises
http://www.summitmedicalgroup.com/library/adult_health/sma_upper_back_pain_exercises
http://www.summitmedicalgroup.c
om/library/adult_health/sma_rotat
or_cuff_injury_exercises
http://www.summitmedicalgroup.com/
library/adult_health/sma_rotator_cuff
_injury_exercises/
Summary - Imaging
• http://www.shoulderdoc.co.uk/article.asp?section=497
• Clinical Sports Medicine, Brukner & Khan – 4th Edition 2012
• Am Fam Physician. 2008 Feb 15;77(4):453-460.
• Am Fam Physician. 2008 Feb 15;77(4):493-497.
• The Sports Medicine Patient Advisor - book by Pierre Rouzier
http://www.sportsmedpress.com
• ACOEM Guidelines 2011 –Testing and Treatment:
http://www.guideline.gov/content.aspx?id=36626&search=shoul
der
• http://www.summitmedicalgroup.com/library/adult_health/sma_fr
ozen_shoulder_exercises/
• http://www.summitmedicalgroup.com/library/adult_health/sma_r
otator_cuff_injury_exercises/
Thanks to ASA Organizing
Committee and Staff