The Shoulder: Complex Joint

Simplified

51st OCFP ASANovember 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 Mitigating Potential Bias: Dr Louise WalkerWalker

• Not applicable

Mitigating Potential Bias: Dr Marie-Mitigating Potential Bias: Dr Marie-Josée KlettJosée 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

Ant. Shoulder Dislocation

AC Joint Separation

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 ExamSupraspinatus:

• 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 instabilityB - frequently BilateralR - responds to RehabilitationI - rarely requires an Inferior capsular

shift surgery

T – TraumaticU – UnilateralB – Bankart lesionS – usually requires Surgery

Laxity/Instability: Physical Exam

Laxity: • often increased ROM • sulcus test

Instability: • Apprehension/relocation test

Shoulder Laxity Test: Sulcus test

Shoulder Instability TestsApprehension 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 Sulcus7) 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-TestQuestion 1

How sensitive is night pain as a predictor of rotator cuff tear in a 65 yo?

A 88%

B 66%

C 44%

D 22%

Pre-TestQuestion 2

There is good correlation between structural pathology of the rotator cuff seen on MRI and clinical symptoms

A True

B False

Pre-TestQuestion 3

The management of a partial thickness supraspinatus tear includes:

A NSAIDs, physiotherapy and surgical referral

B NSAIDS, physiotherapy and cortisone injection

C NSAIDS and cortisone injection

D rest, physiotherapy and surgical referral

Pre-TestQuestion 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 sling and relative rest for 6 weeks

B referral for possible surgery

C physiotherapy

D all of the above

Pre-TestQuestion 5

Which of the following conditions is least suitable for corticosteroid injection?

A subacromial bursitis

B multidirectional laxity

C rotator cuff tear

D 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 1

B 2

C 3

D 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 30-50 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 refer to a surgeon

B investigate with ultrasound or MRI

C inject with corticosteroid

D 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 rotator cuff tendinopathy

B adhesive capsulitis

C glenohumeral osteoarthritis

D 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 recurrent shoulder subluxations

B recurrent shoulder dislocations

C rotator cuff tendinopathy

D 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 MRI

B Ultrasound

C MRI Arthrogram

D 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

A position he plays

B direction he shoots

C degree of the sprain

D when the play-offs start

What is important to know about this injury before you give return-to-play advice?

AC Separation Types

partial partial

completecomplete

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-TestQuestion 1

How sensitive is night pain as a predictor of rotator cuff tear in a 65 yo?

A 88%

B 66%

C 44%

D 22%

Post-TestQuestion 2

There is good correlation between structural pathology of the rotator cuff seen on MRI and clinical symptoms

A True

B False

Post-TestQuestion 3

The management of a partial thickness supraspinatus tear includes:

A NSAIDs, physiotherapy and surgical referral

B NSAIDS, physiotherapy and cortisone injection

C NSAIDS and cortisone injection

D rest, physiotherapy and surgical referral

Post-TestQuestion 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 sling and relative rest for 6 weeks

B referral for possible surgery

C physiotherapy

D all of the above

Post-TestQuestion 5

Which of the following conditions is least suitable for corticosteroid injection?

A subacromial bursitis

B multidirectional laxity

C rotator cuff tear

D 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.com/

library/adult_health/sma_rotator_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 tearsMultidirectional instability persisting despite 6 months of

physiotherapyRecurrent anterior dislocation (or young active first-time dislocator)Grade 4-6 AC joint separation, Grade 3 not responding to

conservative measuresSymptomatic AC joint OA if impingement on rotator cuff and failure

of conservative measuresDistal 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=shoulder• http://www.summitmedicalgroup.com/library/adult_health/

sma_frozen_shoulder_exercises/• http://www.summitmedicalgroup.com/library/adult_health/

sma_rotator_cuff_injury_exercises/

Thanks to ASA Organizing Committee and Staff