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….. ƒ An ultrasound request form ƒ 60/F ƒ Left shoulder pain x 6 months ƒ Please arrange an early US shoulder

60/F Left shoulder pain / weakness ƒ Approach ƒ Treatment ƒ Let’s start in the consultation room ƒ History ƒ Physical exam ƒ Investigations

Impingement syndrome ƒ Rotator cuff tendon pinched between ƒ Greater tuberosity ƒ Undersurface of acromion

ƒ Rotator cuff tendon tendinitis ƒ Subacromial bursitis

Impingement syndrome ƒ Symptoms

ƒ Shoulder pain upon abduction ƒ Overhead activities e.g. lifting, painting ƒ Site of pain ƒ Anterolateral asepct of shoulder

ƒ Initial stage ƒ Pain

ƒ As condition progress

ƒ Weakness ƒ Partial/complete rotator cuff tear ƒ Stiffness

How to make the diagnosis? ƒ Physical exam ƒ Look ƒ Muscle wasting ƒ Feel ƒ Pain over subacromial area, ACJ ƒ Move ƒ Painful arc ƒ Special test ƒ Impingement sign ƒ Hawkin sign ƒ Test of rotator cuff power

ƒ Cuff power ƒ ƒ ƒ ƒ

Supraspinatous Infraspinatous Teres minor Subscapularis ƒ Belly Push ƒ Lift off test

ƒ Biceps tendinitis ƒ Biceps tendon rupture ƒ Speed test ƒ Yergason test

ƒ ACJ arthritis ƒ Cross adduction test

Shoulder impingement, Cuff tear

Treatment ƒ Activity modification ƒ Analgesic/NSAID ƒ Physiotherapy ƒ Subacromial steroid injection ƒ Surgery ƒ Acromioplasty ƒ Rotator cuff debridement/repair

Another patient comes in….

Frozen shoulder ƒ Idiopathic adhesive capsulitis ƒ Typical presentation ƒ ƒ ƒ ƒ

Insidiously onset shoulder pain/stiffness Ages 40 - 60 years, female more common Three phases: freezing, frozen, thawing Association ƒ DM, Thyroid disease, hyperlipidaemia

Painful phase (Freezing) ƒ Initial inflammatory phase ƒ Severe shoulder pain ƒ ƒ ƒ ƒ

Difficult to lie on affected side Limitation in range of motion Patient tends to avoid motion due to pain Duration ƒ 2-9 months

Progressive stiffness phase (Frozen) ƒ Pain improves but shoulder stiffness increased ƒ Difficulty in putting up bra, tucking shirt, reaching opposite axilla, back ƒ Duration ƒ 3-12 months

Resolution phase (Thawing) ƒ Slow regain of motion ƒ Motion, function restoration may not be complete ƒ On/off vague shoulder pain

ƒ Classically, frozen shoulder has been described as self-limiting benign condition lasting from 10 to 18 months.

ƒ Many studies show that significant percentage of patients had residual loss of shoulder motion many years after the onset of initial symptoms

Clinical hallmark

ƒ Limitation of active and passive range of glenohumeral motion in all planes of motion ƒ XR normal

Treatment ƒ Analgesic/NSAID ƒ Physiotherapy ƒ Surgery ƒ Manipulation under anesthesia ƒ Surgical release ƒ Arthroscopic ƒ Open

Let’s go to the 3rd patient….

22/M Right shoulder injury during Rugby Game

ƒ ƒ ƒ

Fall on right shoulder Severe pain Not able to move his right shoulder

What is the approach? ƒ Differential diagnosis ƒ Assessment ƒ Treatment

Differential diagnosis ƒ What is the problem? ƒ Bone ƒ Joint ƒ Soft tissue ƒ Associated neurovascular injury

Bone problem

Clavicle fracture Clavicle + scapular fracture

Joint problem

Anterior shoulder dislocation

ACJ dislocation

Soft tissue problem ƒ Rotator cuff tear ƒ Associated neurovascular injury ƒ Axillary nerve ƒ Brachial plexus injury

On field assessment ƒ Look, Feel, Move ƒ Deformity ACJ dislocation

Shoulder dislocation

Mid clavicle fracture

Feel

Move + special test ƒ Poor active ROM in most of the patients ƒ Examine for neurovascular injury ƒ ƒ ƒ ƒ

Axillary nerve Radial nerve Median nerve Ulnar nerve

ƒ Radial, brachial pulse

ƒ Don’t miss chest wall, neck injury

If you suspect dislocation…. ƒ Don’t attempt on field close reduction ƒ No XR taken before reduction ƒ Uncertain type of dislocation ƒ Tx of anterior vs posterior dislocation different ƒ May convert undisplaced fracture to displaced fracture

ƒ No sedation ƒ Strong muscle pull make reduction difficult, painful

What will be done in AED? ƒ History, physical exam ƒ Document neurovascular status ƒ XR

Management of shoulder dislocation

ƒ Close reduction ƒ Sedation ƒ Oxygen monitoring ƒ Resuscitation equipment standby

ƒ Neurological exam after CR

XR before & after CR

After discharge….. ƒ Patient given shoulder immobilizer in AED ƒ Referral to sports clinic

Physical sign for anterior instability

Apprehension test

Relocation test

Management of shoulder dislocation

ƒ Shoulder immobilizer

Why ?

subscapularis subscapularis

IR

ER

ƒ 198 patients, RCT ƒ Inclusion criteria ƒ 1st time anterior dislocation, post traumatic ƒ Presentation within 3 days ƒ No associated fractures

ƒ Immobilize ER vs IR x 3 wks ƒ 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

ƒ Usual indications of surgery ƒ Recurrent dislocation ƒ 1st time dislocation in selected patients

ƒ If surgery is planned ƒ MRI & CT would be arranged

The 4th patient….

34/M Fireman ƒ Right shoulder injury after fall on out stretched hand ƒ Pain and clicking ƒ ƒ

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 ƒ Describe more extensive injury pattern involve superior labrum

ƒ Extend from anterior to posterior

in relation to biceps tendon anchor

ƒ Retrospective study 27 patients ƒ Most common mechanism of injury

ƒ Compression loading with shoulder in flexion & abduction

Anatomy ƒ Glenoid labrum ƒ Superior labrum ƒ Meniscus appearance with loose attachment to glenoid

ƒ 12 o clock, supraglenoid tubercle ~ 5mm medial to superior rim of glenoid

ƒ Long head of biceps originate from ƒ Supraglenoid tubercle ƒ Superior labrum

Biomechanics ƒ Function of labrum ƒ Provide GHJ stability by increase glenoid depth

ƒ Long head of biceps ƒ Humeral head depressor ƒ Dynamic stabilizer to anterior stability of GHJ

Mechanism of injury ƒ Traction injury

ƒ Inferior ƒ Throwing ƒ Sudden pull when losing hold of heavy object ƒ Anterior ƒ Water skiing

ƒ Compression injury ƒ FOOSH

ƒ Direct blow

Difficulties in Diagnosis of SLAP ်ឰेԲᙰۜ९ᙰᆧַរჾ႞ऱܺᣄ

ƒ Controversy in symptoms ƒ Variable mechanism of injury ƒ Multiple co-existing pathology

Diagnosis: History ƒ Vague shoulder pain ƒ Exaggerate by overhead activity ƒ Popping, locking, snapping ƒ Unstable fragment trapped between glenoid, humerus

ƒ Instability ƒ Tear extend into anterior labrum Æ Bankart lesion

ƒ Weakness ƒ Rotator cuff compressed between tuberosity attachment and superior glenoid Æ PT/ FT tear

Physical exam ƒ No single or combination of tests could

conclusively and reliably predict when and what type of lesion found at scope

ƒ SLAP commonly associate with instability, cuff pathology, impingement

ƒ 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)

ƒ ƒ ƒ ƒ

10-15 adduction 90 forward flexion Thumb point downward Resist the downward force applied

ƒ Repeat examination with an ER arm, supinated forearm

ƒ Positive Test:

ƒ Pain / clicking with thumb point downwards, relief in supinated position

How does O’Brien’s test work?

Mayo Shear Test (Dynamic Labral Shear Test) ƒ ƒ ƒ ƒ

Passively ER in neutral position Stabilize scapula Passively abduct in scapular plane Positive Test: ƒ Reproduction of pain ƒ +/- Click from 60-120 abduction

Co-existing Pathology 544 shoulder arthroscopies ƒ 139 had SLAP lesions ƒ 123 had associated intraarticular pathologies ƒ 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 ƒ Rest ƒ Anti-inflammatory medication ƒ Stretching, Strengthening exercise ƒ Consider operative treatment ƒ Symptomatic after 3/12 of non-operative treatment ƒ Stretching to attain full motion (IR) prior to OT

How does the surgery done?

ƒ 16 patients, Isolated Type II SLAP ƒ Arthroscopic repair

Conclusion ƒ ƒ ƒ ƒ ƒ

SLAP lesion Uncommon shoulder injury Suspicious overhead athletes Vague shoulder pain, popping Physical exam ƒ Obrien, Mayo Shear

ƒ MRI arthrogram ƒ Treatment

ƒ Conservative ƒ Arthroscopic repair / debridement ƒ Satisfactory outcome

Definitive care

Clavicle fracture Clavicle + scapular fracture

Clavicle fracture

ACJ dislocation – non operative care

Shoulder problems ƒ Pain/stiffness ƒ Shoulder impingement, rotator cuff problems ƒ Frozen shoulder

ƒ Trauma ƒ ƒ ƒ ƒ

Shoulder dislocation SLAP lesion Fracture clavicle ACJ dislocation