Clinical tests & treatment of shoulder pain & injury
Dr Law KY, Billy MBChB (CUHK), MRCS (Ed), MScSMHS (CUHK), FRCSEd (Orth) FHKAM (Orth Surg), FHKCOS Resident specialist Sports team, Department of Orthopaedics and Traumatology Prince of Wales Hospital The Chinese University of Hong Kong
A very common scene….. An ultrasound request form 60/F Left shoulder pain x 6 months Please arrange an early US shoulder
60/F Left shoulder pain / weakness Approach Treatment Let’s start in the consultation room History Physical exam Investigations
Impingement syndrome Rotator cuff tendon pinched between Greater tuberosity Undersurface of acromion
Rotator cuff tendon tendinitis Subacromial bursitis
Impingement syndrome Symptoms
Shoulder pain upon abduction Overhead activities e.g. lifting, painting Site of pain Anterolateral asepct of shoulder
Initial stage Pain
As condition progress
Weakness Partial/complete rotator cuff tear Stiffness
How to make the diagnosis? Physical exam Look Muscle wasting Feel Pain over subacromial area, ACJ Move Painful arc Special test Impingement sign Hawkin sign Test of rotator cuff power
Cuff power
Supraspinatous Infraspinatous Teres minor Subscapularis Belly Push Lift off test
Biceps tendinitis Biceps tendon rupture Speed test Yergason test
ACJ arthritis Cross adduction test
Shoulder impingement, Cuff tear
Treatment Activity modification Analgesic/NSAID Physiotherapy Subacromial steroid injection Surgery Acromioplasty Rotator cuff debridement/repair
Another patient comes in….
Frozen shoulder Idiopathic adhesive capsulitis Typical presentation
Insidiously onset shoulder pain/stiffness Ages 40 - 60 years, female more common Three phases: freezing, frozen, thawing Association DM, Thyroid disease, hyperlipidaemia
Painful phase (Freezing) Initial inflammatory phase Severe shoulder pain
Difficult to lie on affected side Limitation in range of motion Patient tends to avoid motion due to pain Duration 2-9 months
Progressive stiffness phase (Frozen) Pain improves but shoulder stiffness increased Difficulty in putting up bra, tucking shirt, reaching opposite axilla, back Duration 3-12 months
Resolution phase (Thawing) Slow regain of motion Motion, function restoration may not be complete On/off vague shoulder pain
Classically, frozen shoulder has been described as self-limiting benign condition lasting from 10 to 18 months.
Many studies show that significant percentage of patients had residual loss of shoulder motion many years after the onset of initial symptoms
Clinical hallmark
Limitation of active and passive range of glenohumeral motion in all planes of motion XR normal
Treatment Analgesic/NSAID Physiotherapy Surgery Manipulation under anesthesia Surgical release Arthroscopic Open
Let’s go to the 3rd patient….
22/M Right shoulder injury during Rugby Game
Fall on right shoulder Severe pain Not able to move his right shoulder
What is the approach? Differential diagnosis Assessment Treatment
Differential diagnosis What is the problem? Bone Joint Soft tissue Associated neurovascular injury
Bone problem
Clavicle fracture Clavicle + scapular fracture
Joint problem
Anterior shoulder dislocation
ACJ dislocation
Soft tissue problem Rotator cuff tear Associated neurovascular injury Axillary nerve Brachial plexus injury
On field assessment Look, Feel, Move Deformity ACJ dislocation
Shoulder dislocation
Mid clavicle fracture
Feel
Move + special test Poor active ROM in most of the patients Examine for neurovascular injury
Axillary nerve Radial nerve Median nerve Ulnar nerve
Radial, brachial pulse
Don’t miss chest wall, neck injury
If you suspect dislocation…. Don’t attempt on field close reduction No XR taken before reduction Uncertain type of dislocation Tx of anterior vs posterior dislocation different May convert undisplaced fracture to displaced fracture
No sedation Strong muscle pull make reduction difficult, painful
What will be done in AED? History, physical exam Document neurovascular status XR
Management of shoulder dislocation
Close reduction Sedation Oxygen monitoring Resuscitation equipment standby
Neurological exam after CR
XR before & after CR
After discharge….. Patient given shoulder immobilizer in AED Referral to sports clinic
Physical sign for anterior instability
Apprehension test
Relocation test
Management of shoulder dislocation
Shoulder immobilizer
Why ?
subscapularis subscapularis
IR
ER
198 patients, RCT Inclusion criteria 1st time anterior dislocation, post traumatic Presentation within 3 days No associated fractures
Immobilize ER vs IR x 3 wks Minimal fu 2 yrs, Mean fu 25.6 months
IR
ER
FU
79%
82%
Compliance
53%
72%
Recurrence
42%
26%
Complications 7% had temporary stiffness after immobilization in ER Problem resolved within month or 2 with self directed ROM exercise No other complications
Usual indications of surgery Recurrent dislocation 1st time dislocation in selected patients
If surgery is planned MRI & CT would be arranged
The 4th patient….
34/M Fireman Right shoulder injury after fall on out stretched hand Pain and clicking
External rotation, abduction Shoulder Power affected by pain
6/$3/HVLRQ (Superior Labrum Anterior Posterior)
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Synder etal. SLAP lesion of the shoulder. Arthroscopy 1990;6(4):274-9 Describe more extensive injury pattern involve superior labrum
Extend from anterior to posterior
in relation to biceps tendon anchor
Retrospective study 27 patients Most common mechanism of injury
Compression loading with shoulder in flexion & abduction
Anatomy Glenoid labrum Superior labrum Meniscus appearance with loose attachment to glenoid
12 o clock, supraglenoid tubercle ~ 5mm medial to superior rim of glenoid
Long head of biceps originate from Supraglenoid tubercle Superior labrum
Biomechanics Function of labrum Provide GHJ stability by increase glenoid depth
Long head of biceps Humeral head depressor Dynamic stabilizer to anterior stability of GHJ
Mechanism of injury Traction injury
Inferior Throwing Sudden pull when losing hold of heavy object Anterior Water skiing
Compression injury FOOSH
Direct blow
Difficulties in Diagnosis of SLAP ်ឰेԲᙰۜ९ᙰᆧַរჾ႞ऱܺᣄ
Controversy in symptoms Variable mechanism of injury Multiple co-existing pathology
Diagnosis: History Vague shoulder pain Exaggerate by overhead activity Popping, locking, snapping Unstable fragment trapped between glenoid, humerus
Instability Tear extend into anterior labrum Æ Bankart lesion
Weakness Rotator cuff compressed between tuberosity attachment and superior glenoid Æ PT/ FT tear
Physical exam No single or combination of tests could
conclusively and reliably predict when and what type of lesion found at scope
SLAP commonly associate with instability, cuff pathology, impingement
Sensitivity, Specificity in various series
different Î Heterogenous gp of patients
Examination maneuvers
Sensitivity
O’Brien’s
90%
Mayo Shear
80%
Neer’s
41%
Hawkin’s
31%
•Sensitivities of Examination maneuvers in SLAP Preop Exam Correlation with Arthroscopy confirmed SLAP in 51 patients Nirav K Pandya et al Arthroscopy vol 24, No2, 2008; 311-317
O’Brien’s Test (Active Biceps Compression Test)
10-15 adduction 90 forward flexion Thumb point downward Resist the downward force applied
Repeat examination with an ER arm, supinated forearm
Positive Test:
Pain / clicking with thumb point downwards, relief in supinated position
How does O’Brien’s test work?
Mayo Shear Test (Dynamic Labral Shear Test)
Passively ER in neutral position Stabilize scapula Passively abduct in scapular plane Positive Test: Reproduction of pain +/- Click from 60-120 abduction
Co-existing Pathology 544 shoulder arthroscopies 139 had SLAP lesions 123 had associated intraarticular pathologies Clinical features & pathological findings a/w different types of SLAP overlaps
Features of Different Types of SLAP Lesion TK Kim, W Queale, A Cosgarea & E McFarland JBJS (Am) Jan 2003, p.66-71
Diagnosis MR-arthrography
Bencardino Sensitivity 89%, Specificity 91% Coronal oblique sequence Deep cleft between superior labrum & glenoid extend well around & below biceps anchor
Management Initial Treatment Rest Anti-inflammatory medication Stretching, Strengthening exercise Consider operative treatment Symptomatic after 3/12 of non-operative treatment Stretching to attain full motion (IR) prior to OT
How does the surgery done?
16 patients, Isolated Type II SLAP Arthroscopic repair
Conclusion
SLAP lesion Uncommon shoulder injury Suspicious overhead athletes Vague shoulder pain, popping Physical exam Obrien, Mayo Shear
MRI arthrogram Treatment
Conservative Arthroscopic repair / debridement Satisfactory outcome
Definitive care
Clavicle fracture Clavicle + scapular fracture
Clavicle fracture
ACJ dislocation – non operative care
Shoulder problems Pain/stiffness Shoulder impingement, rotator cuff problems Frozen shoulder
Trauma
Shoulder dislocation SLAP lesion Fracture clavicle ACJ dislocation