COMMON SHOULDER PROBLEMS Kevin deWeber, MD, FAAFP, FACSM Director, Sports Medicine Fellowship USUHS Objectives Review anatomy – Makes for better diagnoses Discuss common shoulder problems Describe current treatments Anatomy Scapula – – – – – – – Glenoid Acromion Coracoid Subscapular fossa Scapular spine Supraspinous fossa Infraspinous fossa Anatomy Bursae – Subacromial (Subdeltoid) – Subscapular Joints of the Shoulder Acromioclavicular Glenohumeral Sternoclavicular Scapulothoracic – Not a “true” joint Movement control Flexion: Pectoralis Major, Deltoid (Anterior), Coracobrachialis Extension: Deltoid (Posterior), Teres Major Abduction: Deltoid, Supraspinatus Adduction: Pectoralis Major, Latissimus, Subscapularis, Infrapspinatus, Teres Minor Internal Rotation: Subscapularis, Pectoralis Major, Deltoid (A), Latissimus External Rotation: Infraspinatus, Teres Minor, Deltoid Shoulder: Physical Exam Inspection Palpation Range of Motion Strength Neuro-Vascular Special Tests Range of Motion Forward flexion: 160 - 180° Extension: 40 - 60° Abduction: 180◦ Adduction: 45 ° External rotation: 80 - 90 ° Internal rotation: 60 - 90 ° Strength Testing Rotator Cuff Muscles – – – – – – – S – Supraspinatus I – Infraspinatus t - Teres minor S- Supscapularis Abduction: Supra IR: subscap ER: infra, TM Other muscles – – – – Deltoid Biceps Pecs Scapular stabilizers Anatomy Muscles – – – – – – – – – Deltoid Trapezius * Rhomboids * Levator scapulae * Rotator cuff Teres major Biceps Pectoralis muscles * Serratus anterior * * Scapular stabilizers Radiographic Anatomy Common Shoulder Problems •Instability •Impingement •Rotator cuff tears •AC joint sprains and degeneration •Adhesive capsulitis •Labral tears •Biceps tendinopathy •Clavicle fractures Glenohumeral Instability – DEFINITION: painful feeling of slippage, looseness, “going in and out” Instability Eval: “FEDS” Frequency – 1-times – 2-5 – “frequent” >5 Etiology: Traumatic vs. Atraumatic Direction (predominant) – anterior – posterior – inferior Severity: Dislocation vs. Subluxation Anterior Instability Dislocation: impact to externally rotated, abducted arm Acute findings: prominent acromion, anterior fullness Special Tests: Apprehension, Relocation Anterior Dislocation Injuries Bankart Lesion – Anterior capsule torn – Anteroinferior labrum torn – Recurrent dislocations likely Hill-Sachs Lesion – Humeral compression fracture Posterior Instability Dislocations: Electrocutions, Seizures Acute findings: internal rotation, adduction Special tests: – Posterior drawer – Load-shift Inferior Instability Usually atraumatic Special tests: – Sulcus sign Instability Imaging 4-view Radiographs: – – – – AP Axillary scapular “Y” AC joint MRI Anterior Dislocation Posterior Dislocation Anterior Dislocation Reduction Attempt ASAP Intra-articular Lidocaine HELPS! Use 2-3 techniques until successful Failure: to ER – sedation Anterior Dislocation Treatment – Referral to Ortho & PhTh Surgery for younger/athletic patients Rehabilitation for others – Immobilization Sling Impingement Definition: compression of the rotator cuff in the subacromial space Symptoms: – Pain with Overhead position or flexion/Internal Rotation – Anterior, lateral shoulder pain – Night Pain Risk Factors: – – – – – Overhead activities Micotrauma GH Instability Shape of Acromion DJD Impingement Impingement screening tests Neer: full Flexion – “Neer to the Ear” Hawkins: Internal Rotation Impingement confirmatory test Full Can Test: Resistance applied in forward flexion and abduction (SCAPULAR PLANE) Neer test: Subacromial Injection relieves pain 5cc 1% lidocaine 25-27g needle Postero-laterally Wait 10 minutes for result >50% pain reduction confirms Impingement Imaging not initially needed – 4-view shoulder series – MRI if considering surgery Failed rehab Pain with ADLs Impingement Treatment Acute Phase: – – – – Avoid Exacerbating Factors Control Pain/Inflammation Physical Therapy Corticosteroid Injection Recovery Phase: ROM, Strength, Proprioception Maintenance Phase: Longer, Intense Workouts Surgical Intervention: Failed Conservative Measures, Signifcant Disability Rotator Cuff Tears Similar presentation as Impingement Failed rehab for impingement Persistent pain/weakness after Neer injection test Imaging: x-rays, MRI Rotator Cuff Tear Exam Supraspinatus: – drop-arm test Infraspinatus or Teres Minor – External rotation lag sign Subscapularis – Belly press test Rotator Cuff Tears Treatment – Conservative: Similar to Impingement – Surgical: Young patient, large tears, dominant arm Failed Conservative Therapy High-Level Athlete Unable to perform vocational activities Success depends upon degree of tendon damage and degeneration Ultrasound of RC tear Prolotherapy for RCTs – 25% Dextrose – Platelet-Rich Plasma (PRP) Concentration of platelets and their growth factors Process: (30 minutes) – 20-60cc blood is drawn, then centrifuged to produce 3-6ml of PRP – Ultrasound-guided injection AC Joint Sprain Mechanism: Fall on shoulder Presentation: superior shoulder pain Exam: – AC jt TTP – +/- deformity or swelling – Cross-chest (“scarf”) test AC Joint Sprain Cross Chest (“scarf”) Test Active Compression (“AC) test AC Joint Sprain AC Joint Sprain AC Joint Sprain Imaging – Bilateral AP – Zanca View 10-15 degrees of cephalic tilt – Axillary View Evaluates clavicular displacement AC Joint Sprain: Treatment Grade I and II: Conservative – – – – Grade III: Controversial; refer to Ortho for counseling – – – – Immobilization Ice, Analgesics ROM, Strengthening Anesthetic injection if rapid RTP needed Immobilization for up to 4 weeks Most studies indicate conservative treatment is better Surgical management with higher rate of complications1 Conservative management with mean time of 2.1 weeks to return to work2 Grade IV-VI: Surgical 1. Taft TN, et al. Dislocation of the acromioclavicular joint. An end-result study. J Bone Joint Surg Am 1987 2. Sep;69(7):1045-51. Auwojtys EM; Nelson G. Conservative treatment of Grade III acromioclavicular dislocations. SOClin Orthop Relat Res. 1991 Jul;(268):112-9. AC Joint Arthritis Chronic pain at AC joint Exam: ACJ ttp, + scarf test, + active compression test X-rays: narrowed AC jt, +/- osteophytes Tx: – Avoid painful activities – Steroid injections – Surgical removal of distal clavicle (Mumford) Adhesive Capsulitis Painful restriction of active and passive GH ROM Risk Factors – – – – – – – Idiopathic Diabetes Mellitus Female Gender Ages 40-60 Immobilization Inflammation Stroke Adhesive Capsulitis Stage I – 1-3 months – Pain with normal ROM Stage II: “Freezing” – 3-9 months – Pain and progressive ROM restriction Stage III: “Frozen” – 9-15 months – Severe ROM restriction with decreased pain Stage IV: “Thawing” – 15-24 months – Progressive restoration of ROM Adhesive Capsulitis: Treatment Anti-Inflammatories ROM, Stretching Steroid injection into subacromial space or GH jt Surgical – Dilatation – Manipulation Labral Tears Causes: Traction Injuries, FOOSH, Overhead motion overuse, MVA Trauma Locations: – Superior Labral AnteriorPosterior (SLAP) tear – Posterior – Anterior (from dislocation) Labral Tears History: – Pain with overhead or cross-body activity – Popping, clicking, catching – 85% incidence of coexisting pathology Physical (none diagnostic): – Crank Test – Anterior Slide Test – Yegason Test SLAP Tears Type 1: Fraying Injury Type 2: Biceps tendon detached Type 3: “Buckethandle” tear Type 4: “Buckethandle” with Biceps detached Labral Tears Diagnostic: Radiograph, MR arthrogram Treatment: – Physical Therapy for > 3 months – Usually don’t heal. Aim for PAIN CONTROL – Surgery: Types I and III: Debridement Types II and IV: Debridement and Reattachment – Post-Op Rehabilitation Immobilize for 3 weeks Progress with AROM Return to full activity after 12-14 weeks Biceps Tendinopathy Rarely seen in isolation – Labral tears – Rotator cuff tears – Impingement Exam findings non-specific Biceps Tendinopathy Speed’s Test: Resistance against Shoulder Flexion Yergason’s Test: Resistance against Supination Biceps Tendinopathy Treatment: – Rehab exercise – Sports Medicine referral if fails Prolotherapy injection – Refractory: MRI, surgery Clavicle Fractures Clinical Features – Clear Painful event – Pain with arm motion – Lump and possible tenting of the skin Clavicle Fractures Diagnosis – History & physical – X-ray – AP & axillary views, AP with 45° tilt – CT for proximal & distal clavicle fractures Clavicle Fractures Surgery indications: – – – – Open fracture Neurovascular compromise Displacement > shaft width Healed clavicle lump not desirable – Floating shoulder (concurrent scapular neck fracture) Clavicle Fractures Conservative tx: – Rest – Immobilization – – – – – sling proven BETTER than fig-8 Pain control, NO NSAIDs No overhead activity for 4-6 wks F/U 2-4 wks; x-rays for healing PhTh referral for rehab Surgery if fails Questions?