The Shoulder:
Complex Joint
Simplified
51st OCFP ASA
November 30th, 2013
Marie-Josée Klett, MD CCFP Dip Sport Med
Louise Walker, MD CCFP FCFP Dip Sport Med
Department of Family Medicine
University of Ottawa
Faculty/Presenter Disclosure
• Faculty: Dr Louise Walker
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
– NONE
Faculty/Presenter Disclosure
• Faculty: Dr Marie-Josée Klett
• Program: 51st Annual Scientific Assembly
• Relationships with commercial interests:
– NONE
Disclosure of Commercial
Support: Dr Louise Walker
• This program has received NO financial support
• This program has received NO in-kind support
• Potential for conflict(s) of interest:
– NONE
Disclosure of Commercial
Support: Dr Marie-Josée Klett
• This program has received NO financial support
• This program has received NO in-kind support
• Potential for conflict(s) of interest:
– NONE
Mitigating Potential Bias: Dr
Louise Walker
• 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
Sore - most problems have pain so ask for
details to identify pattern of the pain
Stability - Subluxation or Dislocation
- AMBRI or TUBS
Stiff
- frozen shoulder
- stiffness from injury (RCT, fracture)
- GH joint osteoarthritis
Shoulder History














Nature of the problem – pain, instability, stiffness
Duration
How did it onset
Location of pain
Radiation of the pain
Aggravating factors
Relieving factors
Pain during and/or after activity
Pain at night
Neurological symptoms
Handedness
Occupation – “WHACS” questions
Rx to date; Past Hx; ROS; FHx; Meds; Allergies;
“Other”-reason for visit at this time; sporting history; legal
WHACS
• What work do you do?
• How do you do it?
• Are you concerned about any exposures on or off the
job?
• Co-workers or others with similar symptoms?
• Satisfied with your job?
LOOK
• 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
AC Joint
Separation
Ant. Shoulder
Dislocation
Supraspinatus and
infraspinatus atrophy
FEEL
• Ask patient to point to area of maximal pain
• Trapezius area = think c-spine
• Upper humerus = think shoulder
• Top of shoulder = think AC joint
• Locate the point of maximal tenderness if possible
Shoulder Surface Anatomy
Practice
AC joint
GH joint
Suprapinatous
insertion
MOVE: Active – Passive - Resisted
• Active followed by passive with slight overpressure to
assess pain and end feel
• 6 Planes of Motion: Forward Flexion, Extension,
Abduction, Adduction, External Rotation, Internal
Rotation
• Forward Flexion 1800
• Abduction 1800 (to ear without head tilt)
• Internal Rotation – Thumb at T3 to T7
• External Rotation – 450 to 900
• Resisted tests overlap with special tests
Shoulder Range of Motion
Active FF and ABD – Also
Painful Arc of Abduction
Passive – Also Neer’s
Impingement Sign
Shoulder Range of Motion
Internal Rotation
External Rotation
Scapulothoracic Movement
• Observe active forward flexion and abduction from
behind patient
• Watch for scapular winging on descent
• Dysfunction common with rotator cuff tears and
instability
• Wall push up – for more pronounced winging seen
with LTN injury (serratus anterior palsy)
Scapular Winging
Scapulothoracic Movement
Wall Push Up
Special Tests
•
•
•
•
•
•
•
•
Rotator Cuff
Impingement
Biceps
AC joint
GH joint
Laxity
Instability
Labrum
Rotator Cuff: Anatomy
Rotator Cuff: History
•
•
•
•
•
Pain often in deltoid area
Pain with overhead activity
Achy pain, present at night
Mechanism: For tendinopathy/partial tears often insidious onset
For acute tears fall on outstretched arm or other trauma (ex:
dislocation)
• Age greater than 60 and night pain often indicates rotator cuff
tear (88% sensitivity but only 20% specificity)
Rotator Cuff: Physical Exam
Supraspinatus:
• Empty can (Jobe’s) – (sensitivity 89% if pain and weakness;
specificity 50%, for tear)
• Full can (less painful therefore stronger predictor of tear if
positive for weakness)
• 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:
• Resisted ER weakness or pain (LR+ 2.6; LR- 0.49)
• ER lag sign -(sensitivity 68% ; specificity 100% for full tear)
-(LR+ 7.2 ; LR- 0.57)
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Rotator Cuff: Physical Exam
Subscapularis:
• resisted IR (lift-off) weakness/pain
• IR lag sign – (sensitivity 62% ; specificity 100% for tear)
- (LR+ 5.6; LR- 0.04)
Combine Strength and Pain ProvocationTests
• If all 3 tests are positive: Hawkins/Neer (impingement tests) +
supraspinatus weakness (full can test) + weakness in ER = 98%
chance of RC tear
• Age > 60 yrs, if any 2 tests positive = 98% chance of RC tear
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Subscapularis:
Lift-off and IR Lag Sign
Patient pushes back
Impingement Syndrome
• Mechanism:
Rotator cuff tendons get
impinged between
coracoacromial arch and the
humerus on abduction
• Multiple etiologies: osteophyte,
inflamed/injured tendon, inflamed
bursa, poor scapular stabilisation…
• Supraspinatus most commonly
involved
Impingement Syndrome: History
• Associated with underlying condition
• Pain with overhead activity, sometimes describe catching of
shoulder
• In younger patients most often associated with instability, in
older patients with osteoarthritis
• Athletes in overhead sports or patients who do a lot of overhead
work are most at risk
Impingement: Physical Exam
PAIN Provocation Tests
•
•
•
•
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
• Origin of long head on superior glenoid and
short head on corocoid process; both insert
on radial tubercle
• Flexion and supination of elbow
• Long head tendon travels under the RC
tendons through the biceps groove
Biceps: History
• Pain front of shoulder
• Long Head tendinosis 95% associated with RCT , Impingement
or SLAP
• Acute injuries:
– Proximal tears of long head common in elderly = “popeye”
muscle, may not have dramatic injury
– Distal tears – usually more dramatic, forced straightening of
elbow with biceps loaded
Biceps: Physical Exam
• LOOK - swelling, bruising, deformity
• FEEL - tenderness and distal defect (Hook test)
• SPECIAL TESTS – Speed’s and Yergason’s
Biceps Physical Exam:
Speed’s Test
•Examiner resists
forward flexion – ask
about pain
Biceps Physical Exam:
Yergason’s
• Patient’s elbow flexed
at 90° with thumb up
• Examiner grasps
wrist, & resists patient
attempt to supinate
• Ask about pain (at
bicipital groove)
Acromio-clavicular Joint
Acromioclavicular Joint: History
• Shoulder separation: 3 mechanisms
 direct blow to superior aspect of shoulder
 lateral blow to deltoid area
 Fall on outstretched hand
• AC OA: insidious onset pain
• Pain top of shoulder, usually well localised
• Pain with reaching across body
Acromioclavicular Joint: Exam
• Look for step deformity, bruising
• Tenderness to palpation (96% sensitive but not as specific)
• Scarf test
Scarf Test
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
• Frozen shoulder (adhesive capsulitis)
– Spontaneous or unrelated UE injury
– Gradual onset
– Age: 40-60 women> men
– Non-dominant > dominant or bilateral
– Associated with Diabetes (15-20%) and thyroid disorders
– Constant pain – worse with movement
– Significant night pain
– Progressive stiffness
Glenohumeral Joint: History
• Osteoarthritis
– Gradual onset
– Age: 50 and older
– Morning Stiffness
– Better with moderate activity
• Other causes of a stiff shoulder: Injury (post-traumatic after
fracture, dislocation etc), surgery (post-operative rotator cuff
repair)
Glenohumeral Joint: Physical Exam
• Painful with active ROMs at end ranges
• Decrease in ALL passive ROM (starts with ER > ABD/IR) and
ALL active ROM
• Resisted ROM not painful in mid range position and full
strength
• With OA may have crepitus
Laxity/Instability: Anatomy
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
A – Atraumatic congenital/acquired (microtrauma)
M – Multdirectional laxity or instability
B - frequently Bilateral
R - responds to Rehabilitation
I - rarely requires an Inferior
capsular shift surgery
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
Apprehension – positive if
maneuver
recreates symptoms
Relocation - positive if pain and
concern disappear on
“relocation” of the humeral head
Labral Injuries: Anatomy
Labral Injuries: History
• Mechanism: fall on outstretched arm, impaction injury,
weightlifters, pitchers, also from instability
• May complain of deep pain, clicking/clunking sensation in the
shoulder
Labral Injuries: 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%
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Practice
• 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
How sensitive is night pain as a predictor of rotator cuff tear in a 65 yo?
A
B
C
D
88%
66%
44%
22%
Pre-Test
Question 2
There is good correlation between structural pathology of the
rotator cuff seen on MRI and clinical symptoms
A
B
True
False
Pre-Test
Question 3
The management of a partial thickness supraspinatus tear
includes:
A
B
C
D
NSAIDs, physiotherapy and surgical referral
NSAIDS, physiotherapy and cortisone injection
NSAIDS and cortisone injection
rest, physiotherapy and surgical referral
Pre-Test
Question 4
A hockey player who sustains a grade 3 acromioclavicular joint
separation asks you for advice about treatment. Which one of
the following is the best advice?
A
B
C
D
sling and relative rest for 6 weeks
referral for possible surgery
physiotherapy
all of the above
Pre-Test
Question 5
Which of the following conditions is least suitable for corticosteroid
injection?
A
B
C
D
subacromial bursitis
multidirectional laxity
rotator cuff tear
adhesive capsulitis
Case 1
Bob is a 50 yo RHD accountant who plays beer-league softball.
Over the last 2 months he has noticed increasing pain in his
right shoulder, especially with throwing. This started after a
particularly hard throw to first base. He is now having to sit out a
few innings in order to get through a game. He feels the pain
mostly in his right deltoid.
From history alone, what is the grade
of this injury?
A
B
C
D
1
2
3
4
Grades of Overuse Injury
• Grade 1: No pain with activity, but discomfort afterward (either
immediately or during the evening or the following day)
• Grade 2: Some pain during activity but does not yet interfere
with performance
• Grade 3: Pain with activity that interferes with performance
• Grade 4: Pain so intense that activity cannot be performed at all
Why Grade the Injury?
• Grade based on the symptoms and impact on the participant’s
performance
• This grading helps guide the treatment and rehabilitation
process and return-to-play
• Grade 1 injuries – often can still train
• Grade 2 -3 – need relative rest (25 -75% decrease)
• Grade 4- often complete rest of injured part
Exam
• Pain with empty can test
• Painful arc
• Pain with Hawkin’s and Neer’s
• What is the most likely diagnosis?
Rotator cuff injuries
• Most common shoulder pathology
• Non-specific symptoms
• Range from mild tendinopathy to chronic/acute tears
• 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 3050 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
B
C
D
refer to a surgeon
investigate with ultrasound or MRI
inject with corticosteroid
xray and refer to physiotherapy
Shoulder xrays
• AP in internal and external rotation
• Axillary view
AP in Internal Rotation
Greater tuberosity
AP in External Rotation
AP in ER radiograph of the
right shoulder showing calcific
tendinosis
Axillary View
 Corocoid
Lesser
tuberosity
Glenoid
Greater
tuberosity
 Acromion
Rotator Cuff-Chronic
Imaging for Rotator Cuff
• No good correlation between structural pathology of the rotator
cuff (seen on MRI imaging) and clinical symptoms and
functional loss
• >50% of asymptomatic patients over 60 have RC tear, 1/3 of
patients 40-60
• Correlation with Clinical Findings!
Rotator Cuff Tears
• Structural overlap between all 4 RC tendons = challenge in
diagnosis from physical exam
• Lack of correlation between size of tendon tears (seen on imaging)
and symptoms
• Absence of inflammatory cells and extent of degeneration in larger
tears suggests that they may never heal…yet patients get clinically
better…
Ultrasound of Shoulder
• Especially useful to evaluate rotator cuff tears and subacromial
bursitis
• More specific for full-thickness tear, 88-100% than partial
thickness tear, 68-99%
• Better than MRI to assess for microscopic calcifications
• Not useful for glenohumeral joint evaluation
• Not much different than xray for AC joint
• Technician and radiologist expertise dependent.
Ultrasound
Diagrammatic transverse view
of the supraspinatus tendon
Transverse ultrasonographic
view of the normal
supraspinatus tendon
Full Thickness RC Tear - Retraction
MRI of Shoulder Rotator Cuff Tears
• For rotator cuff tears they are quite sensitive and specific, over
90% but like ultrasound are less accurate for partial thickness
tears
• Provides information on rotator cuff muscle atrophy and fatty
infiltration as well as other pathology
• More expensive modality
RC Tendinopathy - Management
• Avoidance of aggravating activity with cross training to keep up
fitness. Rowing machine or cycling may be fine. Avoid overhead
use in ADLs
• Consider x-ray
• Physiotherapy (level B evidence) or home exercises
• Analgesia – oral NSAID ( A), acetaminophen (I), ice (I)
• Consider subacromial corticosteroid injection if not responding…but
intramuscular steroid may be just as effective ( level B)
• Extracorporeal Shock Wave Therapy (ESWT) if calcific tendinopathy
(level A)
Shoulder: Subacromial Injection
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
A 55 year old sedentary woman presents with insidious onset of
non dominant arm shoulder pain over the past month or so. It is
getting progressively worse. It is now difficult for her to wash
her hair and get dressed without pain. She has a feeling of
stiffness in the shoulder as well. She can’t sleep on the affected
side. She has had DM Type 2 for 5 years.
Exam
• Reduced ROM in all planes
• Unable to do many special tests due to pain
• Strength is normal
What is the most likely diagnosis?
A
B
C
D
rotator cuff tendinopathy
adhesive capsulitis
glenohumeral osteoarthritis
labral tear
Adhesive Capsulitis (frozen shoulder)
•
•
•
•
•
•
Generally age 40-60; atraumatic
Women > men (1.3:1) and non-dominant arm (1.3:1)
More common in diabetics and auto-immune disorders
Clinical diagnosis: loss of ROM in all planes
3 stages: freezing (most painful), frozen, thawing
May last 18 months or more
Differential Diagnosis
• GH Osteoarthritis
• Tumour
• Infection
Investigations
• Possibly x-ray to rule out some of the above (level I recommended but insufficient evidence)
Frozen Shoulder - Management
•
•
•
•
•
•
•
•
Education , home exercises (level C) and reassurance
Heat (usually better than ice) (level I)
Analgesia – oral NSAID, acetaminophen, narcotics (level I)
Physiotherapy with manual therapy (level B)
Corticosteroid injection – intra-articular (level A)
Arthrodistension (level I)
Arthroscopic release of adhesions (level I - rare)
Manipulation under anesthesia (level C -rare)
Shoulder: Intra-articular Injection
(posterior approach)
Best Practice & Research Clinical Rheumatology (April 2009), 23 (2), pg. 161-192
Case 3
A 26 year old RHD university drama student has an 8 year
history of her left shoulder “popping out”. She never had any
acute trauma. It started initially when doing a behind her back
type of stretching. With these episodes her arm goes
temporarily numb (“dead arm”) and there is shoulder pain that
can last a few hours to a few days. The same thing started
recently in the right arm while trying to take a self portrait
picture with her arm stretched out to the front. This prompted
her to come for advice since she is afraid it may affect her
drama career. She has not had any treatment to date.
Exam
• Laxity tests – positive sulcus sign (multidirectional)
• Instability tests – apprehension (anterior)/relocation
What is the most likely diagnosis?
A
B
C
D
recurrent shoulder subluxations
recurrent shoulder dislocations
rotator cuff tendinopathy
labral tear
Multidirectional Instability –
Management
•
Rehabilitation under physiotherapist direction
•
X-ray to look for Hill-Sachs lesion or bony Bankart lesion
because this may affect management
•
Surgical referral only if symptoms are not managed after 6
months of good conservative therapy
Hill-Sachs
Bankart
http://www.eurorad.org/eurorad/case.php?id=2418
Anterior Dislocation - Management
•
X-ray, MRI if suspect associated injury (rotator cuff, labrum)
•
For first time traumatic anterior dislocations (95% vs 5%
posterior) of the shoulder patients splinted for at least 3 weeks
(to 6 wks) in sling or ER brace (level C)
•
Physiotherapy for rotator cuff strengthening
•
? Surgical stabilisation for young active first-time dislocators
(level C)
•
Recurrences – refer to ortho
Anterior Dislocation
http://www.91sqs.com/batch.download.php?aid=3669
ER brace (level C)
http://sportinjurysolutions.com/store/shoulder_braces.html
Case 4
A 25 year old who lifts weights presents 3 weeks after an acute
injury to the dominant shoulder. The injury was sustained while
doing dumbbell bench presses at his maximum load. The
athlete felt something pop, which was painful deep in the
shoulder. There is now a nagging pain and a sense of
instability when he goes in the press position and sometimes a
clunking sensation.
Exam
•
•
•
•
O’Brien’s - positive
Apprehension – positive for pain
Relocation is still painful
Speeds is painful
What investigation is most useful to
make the diagnosis?
A
B
C
D
MRI
Ultrasound
MRI Arthrogram
X-ray
Labral Tears - Management
• Reminder: No one good physical exam finding…need to have
index of suspicion
• Diagnosis generally requires MRI arthrogram
• Small tears may be managed conservatively, most will require
surgical stabilisation
Case 5
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-toplay advice?
A
B
C
D
position he plays
direction he shoots
degree of the sprain
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
• As little as 14 days and as much as 6 weeks
• Custom padding (or shoulder pads) can be worn but cannot
prevent further A-C injury from the `ice hockey mechanism‘
• Permanent bump probable
Management Type 2 to 6
• Type 2 – Takes 6 weeks to 3 months recovery. Same treatment
as type 1
• Type 3 - Takes 3 months or more to settle. Surgery is
controversial. Consider orthopedic referral
• Type 4, 5, 6 - Refer
AC Joint OA
• Very common
• Symptomatic if painful to palpation, positive scarf sign
• Management as with any other OA, can inject AC joint with
cortisone, may require surgery if osteophytes causing
impingement
Case 6
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
•
•
•
•
•
Bruising upper arm
Distal bump
Tender at bicipital groove, no tenderness at elbow, Hook normal
Pain with forward flexion
Cannot do Speeds, pain with Yergason
Bicipital Tears - Management
• Confirm Diagnosis: U/S or MRI (U/S usually quicker)
• Proximal tears managed conservatively: pain management,
rehabilitation
• Full distal tears require urgent surgery-ortho on call (don’t wait
for imaging!)
Bicipital Tendinopathy
• Often co-exists with rotator cuff pathology
• Treatment is conservative, very similar to rotator cuff but no
injections
Post-Test
Question 1
How sensitive is night pain as a predictor of rotator cuff tear in a 65 yo?
A
B
C
D
88%
66%
44%
22%
Post-Test
Question 2
There is good correlation between structural pathology of the
rotator cuff seen on MRI and clinical symptoms
A
B
True
False
Post-Test
Question 3
The management of a partial thickness supraspinatus tear
includes:
A
B
C
D
NSAIDs, physiotherapy and surgical referral
NSAIDS, physiotherapy and cortisone injection
NSAIDS and cortisone injection
rest, physiotherapy and surgical referral
Post-Test
Question 4
A hockey player who sustains a grade 3 acromioclavicular joint
separation asks you for advice about treatment. Which one of
the following is the best advice?
A
B
C
D
sling and relative rest for 6 weeks
referral for possible surgery
physiotherapy
all of the above
Post-Test
Question 5
Which of the following conditions is least suitable for corticosteroid
injection?
A
B
C
D
subacromial bursitis
multidirectional laxity
rotator cuff tear
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
• Xrays: OA (and chronic RC), calcific tendinopathy, Hill Sachs,
Bankart, dislocation, AC separation/OA
• U/S: rotator cuff tear, calcification, bursitis
• MRI: rotator cuff tear, fatty infiltration and atrophy of RC
muscles, bursitis
• MRI arthrogram or 3T MRI: labral tear
Summary - when to refer to ortho
 Rotator Cuff tears: full-thickness tears when symptoms persist
beyond 3 months of conservative treatment, age <50; acute tear;
large (>1.5cm)
 Labral tears
 Multidirectional instability persisting despite 6 months of
physiotherapy
 Recurrent anterior dislocation (or young active first-time dislocator)
 Grade 4-6 AC joint separation, Grade 3 not responding to
conservative measures
 Symptomatic AC joint OA if impingement on rotator cuff and failure
of conservative measures
 Distal bicep tendon tears (at elbow)
Useful References
•
•
•
•
•
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