Doctor, What’s Wrong with My Shoulder? A Pragmatic Approach to Evaluation of the Shoulder Tad Funahashi. MD KP National Primary Care Conference May 18, 2013

Evaluation of the Shoulder Who has Shoulder Pain? Evaluation of shoulder patients can be remarkably simple . . . this morning, we’ll take you through our simple “ACT” . . . and provide you with a take-home, survival guide to evaluation of the shoulder patient . . .

Good News . . . Essentially, All Shoulder Problems Present as Either . . .

Pain or

Instability

First, Anatomy for Pain & Instability Just so we are all talking the same language . . .

Bone Anatomy

Capsular Anatomy

Rotator Cuff Anatomy

Bursa Anatomy

Interactive Anatomy Building the Shoulder . . . (Interactive Shoulder)

Now that you understand the anatomy behind the pathology . . .

Let’s look at Pain & Instability as they present clinically. Starting with the much more common problem:

“Pain”

First, Make Sure It is Shoulder Pain! • R/O Extrinsic (Referred) Sources: – C Spine: neck position & neurologic sx – Chest: you know better – Cardiac: you know better – Abdominal / Diaphragmatic: you know better

Second, Triage & Treat the Urgent Stuff . . . • AC Separations • Clavicular Fractures

• Proximal Humerus Fractures • Infection

AC Separations: • Grade I, II: – Injury to AC Joint Capsule:

• Grade III: – Injury to ACj Capsule & Coraco-Clavicular ligaments

• Return to function better with conservative tx • Grade IV - VI: – Injury to both + more

• Unless wildly displaced, sling & send to PT

Clavicular Fractures: • Mid 1/3 clavicular fractures: – treatment in a figure 8 harness or sling and rest for 6 - 8 weeks – better than surgical intervention (2004?)

• Distal Clavicle fractures: – Send to Ortho for Evaluation

Proximal Humerus Fractures: • Often seen in elderly osteoporotic bone • Most Important: start osteoporosis intervention: – Bisphosphonates & prevent of Hip Fractures

• Check NV Status: – Axillary nerve (deltoid & sensation to lateral aspect of shoulder)

• Sling, & refer to Ortho

Infection • • • • • • •

History of injection Immune compromised Usually very painful Constitutional signs: fever, sweating Asymmetric swelling and warmth Aspirate? Refer to ortho . . .

Now what you’ll see most commonly. . .

Pain in “Older” Patients • Approximately > 44 y.o. (?!) –“ACT” your age • Sources of Pain: –Arthritis: Joints –Capsulitis: Capsule –Tendonitis: Rotator Cuff

Pain: Arthritis Glenohumeral vs. Acromioclavicular • AC Joint: – – – – – –

may have history of trauma bench pressing, push ups localized to AC joint pain on compression usually normal ROM positive cross arm test

– Diagnostic Key: X ray: abnormal – ACj Arthrosis

Pain: Arthritis Glenohumeral vs. Acromioclavicular • Glenohumeral: – – – – – –

may have history of trauma gradual onset dull achy, deeper pain may c/o crepitous often decreased ROM pain with motion

– Diagnostic Key: X ray: abnormal – G-Hj Arthrosis

Pain: Capsule • Arthritis

• Capsulitis: – Adhesive Capsulitis – Frozen Shoulder

• Tendonitis

Pain: Capsulitis “Adhesive Capsulitis” or “Frozen Shoulder” • • • •

Idiopathic, Diabetes, Post Traumatic, RTC, Iatrogenic Unrelenting, unresponsive, progressive pain Night pain, keeps people awake; changes personality Hallmark: Progressive loss of motion, including loss of

external rotation • Usually runs a 6 - 18 month course: 4 Phases – Inflammatory - Progressive - Maturation - Resolution

• Diagnostic Key: Global Restriction of ROM with

normal X rays (sometimes mild osteopenia)

Pain: Tendons • Arthritis • Capsulitis

•Tendonitis: – Rotator Cuff – Bicipital Tendon

Pain: Tendonitis: The Most Common Diagnosis • Spectrum from Impingement to Rotator Cuff Tear • Natural progression of rotator cuff degeneration – Stage 1: Mild Inflammation – Stage 2: Degeneration of Tendon – Stage 3: Rotator Cuff Tear

• By 65 y.o. 30 - 50% of patients have a rotator cuff tear.

Pain:

Tendonitis:

Impingement?

Pain:

Tendonitis:

Impingement?

Pain: Tendonitis: Evaluation • History: – often insidious onset – pain with reaching or overhead activities – occasional history injury leading to pain

• Exam: – Impingement Signs 1 & 2 – Impingement Test • Diagnostic Key: combination Hx & Exam

Pain: Tendonitis Evaluation • Impingement Sign’s 1 .

.

. and 2:

Pain: Tendonitis Evaluation Impingement Test • Inject cortisone and lidocaine combo • Posterior approach: arthroscopists • Both diagnostic and therapeutic

Pain: Tendonitis Treatment: My preferred approach . . . • First Visit: (symptoms < 2 -3 weeks) – Eliminate inciting activity – Start NSAID’s (try 3 week trial of each type) – Start Exercises: ROM and Rotator Cuff strengthening, PT?

• Second Visit: (or symptoms > 3 - 6 weeks) – same as above – Start Injections series: up to 3 injections Q4-6wks

Pain: Tendonitis Treatment

Pain: Tendonitis: Rotator Cuff Tear • Sometimes, history of fall onto shoulder or sudden jerk to shoulder with a “pop” or “tear” • More often, recalcitrant, gradually progressive shoulder pain, unresponsive to rest, NSAID, and Physical Therapy • Weakness ? • No improvement for minimum 8 - 12 weeks, then . . . Consider checking MRI: r/o Rotator Cuff Tear

• Diagnostic Key: MRI or Ortho Referral

Pain: Proximal Biceps Rupture • Hx: – c/o “pop” in shoulder area – now has “popeye” arm with pain

• Tx: – conservative/PT – sx improve in 6 - 8 wks

• Caveat: look for RTC pathology

Pain: Tendonitis My approach from Impingement to Tear . . . • Initial Eval: – minimum 4 - 6 weeks of conservative therapy – Cessation of irritating activity, NSAID’s, Physical Therapy (ROM & Strengthening)

• F/U: If no improvement: try Injection Series • F/U: If no improvement: – Ortho Referral, • ?? with MRI to evaluate for possible RTC tear

Pain: Tendonitis Pearl: Staying Out of Trouble . . . • Avoid progression or missing to Massive Rotator Cuff Tears • Cuff Tear Arthropathy

• “Lift Off” Test

Shoulder Pain Evaluation . . . 5 Minute ACT: • Imaging: Normal

• Imaging: Abnormal

• Pain History:

• X ray:

– Unremitting vs. Activity related (Capsulitis vs Cuff) – Any position vs. Overhead/reaching (Capsulitis vs. Cuff)

– AC j Arthritis – GH j Arthritis

• MRI ?: – Rotator Cuff Tear

• Pain Exam: – Globally limited ROM including ER: Capsulitis – Impingement signs: Tendinitis

Then . . .

in “Older” Patients, you “ACT” on Pains . . .

• Arthritis: – Dx: X ray – Tx: NSAID, glucosamine/CS, rest, NSAID, PT to maintain motion – Surgery, if pain disabling and unremitting, rarely TSR

• Capsulitis: – Dx: ROM, ER – Tx: rest/time, pain control, PT to maintain or improve ROM – Surgery: rarely

• Tendonitis – Dx: Impingement signs & test – Tx: rest, NSAID, PT for ROM and muscle strengthening – Surgery: only if fails complete conservative management

Pain & Instability: So, What about Instability in the “Older” Patient? Recurrent Instability: very uncommon in “older” patients . . .

Pearl: But Keep Me Out of Trouble . . . • If “older” patient presents after a traumatic shoulder dislocation . . . • R/O Rotator Cuff Injury . . . Especially Subscapularis

Good News #2: We’ve already covered 90+ % of patients that present in the clinic with shoulder symptoms . . .

Any Questions Thus Far?

What about Shoulder Problems in Younger Patients? • Potential Causes: – – – – – – – –

Atraumatic Dislocations Traumatic Dislocations Subtle Subluxation Internal Impingment GIRD SLAP Lesions Labral Flaps & Tears Nerve Entrapment Syndromes

Good News #3 . . . The “Younger” Patients with Shoulder Problems usually related to:

Instability

Traumatic Instability • • • • •

Usually anterior or anterior-inferior dislocations > 80% recurrence in patients under 20 y.o. Low recurrence rate in older patients, but r/o RTC tear Pathology: Tear or detachment of capsule from glenoid History: – shoulder aBducted and externally rotated – “came out and had to be relocated on field or ER” – now keeps coming out with activity or ADL’s

• Diagnostic Key: the History + Exam

Traumatic Dislocation • History is Key • . . . could try

Apprehension Test for confirmation

• Tx: – observation – surgery only if recurrent dislocations problematic

Atraumatic Instability • The “loosey goosey” shoulder . . . and patient • “Spandex Capsule instead of Denim” • History: – – – –

Cheerleader, gymnast, swimmer, water polo minimal or no trauma dislocates in many directions often bilateral

• Exam: – hyperlaxity of MCP, thumb to forearm – sulcus sign

• Diagnostic Key: History + Exam

Atraumatic Dislocation • History is Key • Confirmatory Examination: – Sulcus Sign – Hyperlaxity

• Tx: – Physical Therapy

The Young Shoulder Pain

• Arthritis: rare • Capsulitis: rare • Tendinosis – related to instability of the shoulder – the pathology: instability . . . causes tendinosis . . . which manifests as pain

Young Shoulder Pain: Tendonitis • Repetitive overhead athletes:

– throwers – swimmers – volleyball – tennis players

Young Shoulder Pain • Essentially, most diagnosis related to underlying subtle instability & overuse: – – – – – –

Subtle subluxation with impingement Internal impingement SLAP lesions GIRD Labral flaps & tears Nerve entrapment syndromes

Good News #4 . . . All Shoulder Pain in the Young Initially Treated by: • Cessation or Alteration of Underlying Activity: Cross Training • NSAID’s • Physical Therapy for Stretching, Muscle Strengthening & Scapular Balancing exercises • Impress the patient, parent, trainer, coach, and orthopedist:

“Appears that your pain is related to tendonitis exacerbated by your participation in _______ with some underlying component of subtle instability.”

So, in a NutShell . . . • Older Patients: • Younger Patients: ACT on their pain: Instability: – Arthritis – Capsulitis – Tendonitis

– Dislocations – Subtle Instability . . . leading to Tendonitis/Pain

Thank You . . .