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NINAD KARANDIKAR, MD

ASSISTANT PROFESSOR

DEPT OF PM&R

UNIVERSITY OF KY

Understand the normal anatomy and bio-mechanics of the shoulder

Perform a good history and physical exam in a patient with c/o shoulder pain

Formulate a differential diagnosis

Obtain appropriate work-up to confirm diagnosis

Discuss treatment algorithms for appropriate management

An estimated 20 percent of the population will

suffer shoulder pain during their lifetime1

Shoulder pain is second only to low back pain

in patients seeking care for musculoskeletal

ailments in the primary care setting2

Shoulder pain is defined as “chronic” when

it has been present for longer than six

th dl f h th th ti tmonths, regardless of whether the patient

has previously sought treatment

WHAT IS THE INVOLVED

STRUCTURE ?STRUCTURE ?

WHAT IS THE MECHANISM ?

ANATOMY OF THE SHOULDER COMPLEX

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Anatomy of the Shoulder Joint “Shoulder” Joint: 4 different articulations

Gleno-humeral

Acromio-clavicular

Sterno-clavicular

Scapulo-thoracic

SPACE: Sub-acromial

BURSA: Sub-acromial (and sub-deltoid)

“Shoulder” Joint Articulations

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Sacrifices stability to improve mobility

Stability:

Bony (Intrinsic): glenoid fossa articulating with the

humeral head & negative intra-articular pressureg p

Soft tissue (extrinsic):

○ Capsule with ligaments (Primary STATIC stabilizer)

○ Labrum

ROTATOR CUFF (Primary DYNAMIC

stabilizer)

ANTERIOR VIEW POSTERIOR VIEW

LATERAL VIEWLATERAL VIEW

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1. Serves as a base for muscle attachment The musculature controls scapular motion mainly

through synergistic co-contractions and force couples

M i f d i bili i h2. Maintenance of dynamic stability with controlled mobility at the glenohumeraljoint The scapula moves in a coordinated fashion with

the moving humerus, so that the humeral head is constrained within the glenoid fossa throughout the full range of shoulder motion

The maintenance of proper alignment of the glenoid fossa

○ Allows for optimal bony constraint

○ Facilitates muscular constraint by maintaining proper length tension relationships of the rotator c ff m scleslength-tension relationships of the rotator cuff muscles

○ This in turn allows efficient contraction of the rotator cuff muscles, thereby compressing the humeral head into the fossa

○ The scapula rotates upward with overhead activities to clear the acromion from the rotator cuff decreasing the likelihood of “physiologic” impingement

3 The third role of the scapula is best3. The third role of the scapula is best represented as the link in the proximal-to-distal transfer of energy that allows the most appropriate shoulder positioning for optimal function of the arm

The scapula is pivotal in transferring the large forces and high energy from the major sources for force and energy—the legs and trunk—to the actual delivery mechanism of the energy and force the arms andmechanism of the energy and force—the arms and hands

These actions can be accomplished most effectively through the stable and controlled platform of the scapula, so that the entire arm rotates as a unit around the stable base provided by the scapulothoracic and the glenohumeral joints

The muscles primarily responsible for scapular stability and motion are: Trapezius

Serratus anterior

Rhomboids

Levator scapulae

Weakness of these muscles predisposes to scapular malposition, malfunction and consequently impingement syndrome

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COMMON CAUSES OF SHOULDER PAINSHOULDER PAIN

INTRINSIC CAUSES3

Rotator cuff disorders

Acromio-clavicular joint disorders

Gleno-humeral disordersAdhesive capsulitisAdhesive capsulitis

Osteoarthritis

Instability

Other chronic pain: including less common, non-shoulder problems

Extrinsic Causes Neurologic

Cervical nerve root compression (C5, C6)

Brachial plexus lesions

Herpes zoster

Cardiovascular Myocardial ischemia

Axillary vein thrombosis

Thoracic outlet syndrome

Thoracic Spinal cord lesion

Cervical spine disease

Abdominal Hepatobiliary disease

Diaphragmatic irritation (eg, splenic injury, ruptured ectopic pregnancy, perforated viscus)

Thoracic Upper lobe pneumonia

Apical lung tumor

Pulmonary embolus

MOST COMMON CAUSES Impingement Syndrome

Adhesive Capsulitis These 2 causes account for the majority j y

of primary care office visits for “Shoulder Pain”

“Impingement syndrome” is the term used to

describe symptoms and signs that result from

compression of the rotator cuff tendons and the

s bacromial b rsa bet een the greater t bercle ofsubacromial bursa between the greater tubercle of

the humeral head and the lateral edge of the

acromion process

Overhead repetitive activity is important in

pathophysiology

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Repetitive Impingement

Rotator cuff tendon inflammation (tendinitis)

Rotator Cuff degeneration (also called tendinosis / tendinopathy)

Rotator cuff tears (partial or complete)

Adhesive capsulitis refers to a stiffened glenohumeral joint that has lost significant range of motion (abduction and rotation)

Pathology: Pathology: It is a reversible contraction of the joint capsule in

almost all cases

Most common causes: Rotator cuff problems

Stroke

DM / Thyroid problems

Patients with adhesive capsulitis complain primarily of stiffness, although they may have

pain

l d t t di i i h d i f ti always demonstrate diminished passive range of motion

Patients with rotator cuff tendinopathy typically complain of pain with active motion

passive motion remains normal (in the absence of guarding)

HISTORY TAKING

Detailed History of “Pain” Location / Character / radiation

Onset / duration / progress

Participation in sports

H/O trauma / infection / CA / Sz disorder

H/O DM / thyroid disorders

Associated loss in ROM & weakness

Night pain +/- fever and constitutional symptoms

Any unexplained significant sensory or motor deficit

Occupational & recreational history

PHYSICAL EXAMINATION

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Look: Atrophy / erythema Feel: TTP / warmth / swelling / trigger points Move

Active + Passive Resisted Resisted

Special (Provocative)Tests Impingement Labral Tear Instability Thoracic outlet

Neurological exam, if necessary

Movement Muscles

Fwd Flex Deltoid, Pec major, Long head of Biceps

Extension Deltoid, Teres major, Lat dorsi, Pecmajor, Triceps (Long Head)j , p ( g )

Abduction Deltoid, Supraspinatus

Adduction Pec major, Lat dorsi, Teres major

Int rotation Pec major, Deltoid, Lat dorsi, Teresmajor, Subscapularis

Ext Rotation Infraspinatus, Deltoid, Teres minor

Apley’s scratch test

EXAMINE SCAPULO-THORACIC RHYTHM Stand behind the patient

Place a thumb on or to hold the inferior tip of each scapula

Have the patient abduct and / or forward flex the arm

Assess for scapular asymmetry

Always perform an exam in a gown to assess for scapular rhythm

1 deg of movement at the scapula for every 2 degrees of gleno-humeral abduction

PROVOCATIVE TESTSTESTS

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PATHOLOGY PROVOCATIVETESTS

STRUCTUREINVOLVED

Impingement 1. Neer’s2. Hawkins3. Arc of Pain

Rotator Cuff 1. Drop arm test2. Empty can test3. Lift off test4. External rotation

1. Supraspinatus2. Supraspinatus

3. Subscapularis4. Infraspinatus

and Teres Minor

Biceps Tendinitis 1. Speeds2. Yergasons

Long Head Biceps

AC arthritis Cross arm test AC arthritis

Instability Apprehension testSulcus sign

Labral tear O’Brien’s sign

Arm at 90° FF and their elbow flexed to 90°

Quickly move the arm into internal rotation

Shoulder pain elicited by internal rotation represents a positive test

Examiner performs maximal passive forward flexion with internal rotation whilst stabilising the scapula

Reproduction of pain is a ++ test Pain at 90 degrees is consistent with g

mild impingement

Pain at 60 to 70 degrees is consistent with moderate impingement

Pain at 45 degrees or below is consistent with severe impingement

First 0-30 deg: no

pain

30-120 deg: pain ++

> 120 deg: no pain

Performed by having the patient place a straight arm in about 90 degrees of abduction and 30 degrees of forward flexion, then internally rotating the shoulder completelyp y

The patient then resists the clinician's attempts to adduct the arm

Pain without weakness is consistent with tendinopathy

Pain with weakness is consistent with tendon tear

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Lift off test

The patient attempts to externally rotate the arms against resistance while the arms are at the sides and the elbows are flexed to 90 degrees

Speed’s and Yergason’s Test The patient

elevates the affected arm to 90 degrees, then actively adducts it

Reproduction of pain: ++ test

Apprehension Test The patient is instructed to flex their

arm to 90° with the elbow fully extended and then adduct the arm 10-15°medial to sagittal plane

The arm is then maximally internally rotated and the patient resists the pexaminer's downward force

The procedure is repeated in supination

+ test: Pain elicited by the fIrst manoeuvre (pronation) is reduced or eliminated by the second maneuvre (supination)

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3,4,5 Clinical Rules regarding tests for Shoulder Pain

1. A prospective analysis of 400 patients found that

the triad of weakness found with the empty-can

supraspinatus and external rotation tests, along

with a positive impingement test (e.g., Hawkins'

impingement test), had a 98 percent probability

of being a rotator cuff tear (partial or complete)4

Clinical Rules regarding tests for Shoulder Pain2. A retrospective analysis of 191 persons found that the

combination of being older than 65 years, having weakness on

external rotation testing and experiencing night pain resultedexternal rotation testing, and experiencing night pain resulted

in a 91 percent probability of having a rotator cuff tear

(partial or complete)5

3. However, 54 percent of asymptomatic persons older than 60

years have been shown to have a partial or full thickness

rotator cuff tear by MRI6

DIAGNOSING S OSHOULDER PAIN

Chronic Shoulder Pain: Part I. Evaluation and Diagnosis AAFP Vol. 77 / No. 4. February 2008

Clinical review of Shoulder pain: diagnosis and management in primary care. Mitchell, C. et al. BMJ 2005;331:1124-1128

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1. Xrays

2. Ultrasound

3 MRI scan3. MRI scan

4. Arthrogram

5. MR arthrogram

6. Labs: rarely required

Xrays

AP view

Axillary view

S l i

Fracture

Dislocation

Sh f i

Views Demonstrate

Scapular Y view Shape of acromion

Acromio-humeral interval

Hill-Sach lesion

Bankart lesion

DJD

Calcific tendinitis

Used in assessing rotator cuff tears (specially full thickness tears), labral tears, and biceps tendon tears

Less expensive than MRI

Accuracy with operator experience is close to that of MRI scan: 86 % vs 93 %*

*Accuracy of office-based ultrasonography of the shoulder for the diagnosis of rotator cuff tears. Iannotti JP. J Bone Joint Surg Am. 2005 Jun;87(6):1305-11.

Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess. 2003;7(29):iii, 1-166

Best modality for imaging the soft tissues of the shoulder

Preferred modality for imaging rotator cuff tears, both full-thickness and partial with a sensitivity of 92% and specificity of 88 100%7of 92% and specificity of 88-100%7

Also used to evaluate labral lesions and so may be helpful in the diagnosis of instability

MR Arthrogram is the test of choice for diagnosing labral tears

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1. Activity Modification

2. Medications (NSAIDs, topicals, judicious

use of opioids)p )

3. Physical therapy (including modalities)

4. Injections

5. Surgery

Reduction or avoidance of overhead activity is the mainstay of treatment for impingement and rotator cuff pathology

Avoiding heavy loading / lifting on the Avoiding heavy loading / lifting on the affected shoulder

Avoid Cross-body shoulder adduction activities (e.g. golf swing, weight lifting)

Vocational Counseling

Pain control is imperative to allow for the progression of treatment

Use of nonsteroidal anti-inflammatory drugs (NSAIDs) nonsteroidal anti inflammatory drugs (NSAIDs)

Acetaminophen

Judicious short-term opiate medication

may help achieve this goal

Risks and benefits of each class should be considered before use

Mainstay of therapy: Scapular stabilization

Stretching / strengthening / ROM

Modalities

A recent Cochrane review showed that A recent Cochrane review showed that stretching and strengthening provide improved short-term recovery and long-term function in patients with rotator cuff disease*

*Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev. 2003;(2):CD004258

Steroid Injections Indicated if poor response to activity

modification, medication and physical therapy

Directed towards the affected area

Subacromial Subacromial

AC joint

Gleno-humeral

Efficacy and accuracy of injection is extremely controversial

Accuracy of Steroid Injections done without guidance Sethi et al (Arthroscopy January 2005)

Based on our cadaveric study, we believe that without some form of radiologic guidance, it is unlikely that an anteriorly placed intra-articular glenohumeral injection will be accurately placed in awake patients, and we do not recommend this technique. Level IV.

Manchester Rheumatology Service (BMJ 1993) inaccurate placement of medication in 65% of the 108 joints

injected

Eustace's (1997) study 68% of shoulder injections performed by specialist physicians

without radiological guidance failed to hit their targets

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Steroid Injections: AAOS recommendations (OKU) Rotator cuff disease:

Subacromial injections are a treatment option currently supported by the American Academy of Orthopedic Surgeons (AAOS), although this may change with further review

Acromioclavicular joint for osteoarthritis: Subacromial injections are endorsed by the AAOS, despite

few studies demonstrating its effectiveness

Adhesive capsulitis: respond to intra-articular injections with decreased pain and

increased function, particularly in combination with physical therapy for stretching

Steroid Injections: AAOS recommendations Glenohumeral osteoarthritis:

Intra-articular steroid injections are not recommended by the AAOS

Intra articular hyaluronic acid injections have shown Intra-articular hyaluronic acid injections have shown promise in several studies, but the AAOS has no recommendation for this treatment to date

Self EB. Clinical guidelines for shoulder pain. In: Norris TR, ed. Orthopaedic Knowledge Update. Shoulder and Elbow 2. 2nd ed. Rosemont, Ill.: American Academy of Orthopaedic Surgeons, 2002:443-467

CLINICAL RECOMMENDATIONS

Clinical recommendation Evidence rating ReferencesMost patients with chronic shoulder pain

improve with nonoperative treatment. Worse outcomes are associated with severe pain,

prolonged symptoms, or gradual onset.

B 4, 5

There is little evidence for or against the use of medication for chronic shoulder pain.

B 10

Physical therapy can provide improved short-term recovery and long-term function

for rotator cuff disorders.

B 11

Although subacromial corticosteroid injections for rotator cuff disorders are very

B 12-16injections for rotator cuff disorders are very common in clinical practice, there is little

evidence to support or refute its use.

Glenohumeral joint injection has been shown to hasten the resolution of symptoms

in patients with adhesive capsulitis, but most patients resolve without intervention, and interventions have not been shown to

improve long-term outcomes.

B 16, 19

Chronic Shoulder Pain: Part II. Evaluation and Diagnosis AAFP Vol. 77 / No. 4. February 2008

Most patients with a chronic shoulder disorder can initially be treated conservatively with some combination ofA ti it difi tiActivity modification

Physical therapy

Medications and

Corticosteroid injections, if necessary, with no improvement after trying the above

Chronic Shoulder Pain: Part II. Evaluation and Diagnosis AAFP Vol. 77 / No. 4. February 2008

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1. No relief of pain and improvement in function, with an adequate trial of conservative therapy for 6 weeks to 3 months

2. Gleno-humeral instability (early referral)

3 Uncertainty of diagnosis (early referral)3. Uncertainty of diagnosis (early referral)

4. DJD of AC joint or GH joint

5. First dislocation – occupation/sport/active

6. Individualize on age, co-morbidities and activity level Labral tear or a rotator cuff tear in an active individual

Surgical Options Arthroscopic and open, based on indication

Impingement: Subacromial decompression

Excision of distal end of clavicle

Rotator cuff tears: Repair +/- decompression

Instability +/- labral tear: Repair +/- soft tissue tightening

Adhesive capsulitis: Adhesiolysis:

DJD Partial or complete joint replacement

MY ALGORITHMGO

Algorithm for chronic shoulder pain

Diagnosis and treatment of chronic painful shoulder: review of nonsurgical interventions. Andrews JR Arthroscopy. 2005 Mar;21(3):333-47

“The role of the Physician is to entertain the Patient whilst his disease runs itswhilst his disease runs its usual course."Molière 17th century

1. Pope DP, Croft PR, Pritchard CM, Silman AJ. Prevalence of shoulder pain in the community: the influence of case definition. Ann Rheum Dis. 1997;56(5):308-312.

2. Steinfeld R, Valente RM, Stuart MJ. A common sense approach to shoulder problems. Mayo Clin Proc. 1999;74(8):785-794.

3. Self EB. Clinical guidelines for shoulder pain. In: Norris TR, ed. Orthopaedic Knowledge Update: Shoulder and Elbow 2. 2nd ed. Rosemont, Ill.: American Academy of Orthopaedic Surgeons, 2002:443-467

4. Murrell GA, Walton JR. Diagnosis of rotator cuff tears Lancet. 2001; 357(9258):769-770

5. Litaker D, Pioro M, El Bilbeisi H, Brems J. Returning to the bedside:using the history and physical exam to identify rotator cuff tears. J Am Geriatr Soc. 2000;48(12):1633-1637

6 Sher JS Uribe JW Posada A Murphy BJ Zlatkin MB Abnormal findings on magnetic resonance images6. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77(1):10-15

7. Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value Iannotti JP J Bone Joint Surg Am 1991 Jan;73(1):17-29