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The Painful Shoulder Part II: Common Acute & Chronic Disorders

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The Painful Shoulder Part II: Common Acute & Chronic Disorders The Painful Shoulder Part II: Common Acute & Chronic Disorders © Jackson Orthopaedic Foundation www.jacksonortho.org Presenters AJ Benham, DNP, FNP, ONC Kathleen Geier, DNP, FNP, ONC Jackson Orthopedic Foundation 3317 Elm Street - Suite 102 Oakland, CA 94609 [email protected] [email protected] http://www.orthoprimarycare.info/ Conflict Of Interest Disclosures We hereby certify that, to the best of our knowledge, no aspect of our current personal or professional situation might reasonably be expected to affect significantly our views on the subject on which we are presenting. Objectives • 1. Differentiate among common conditions associated with shoulder pain based on history and physical exam • 2. Formulate plans for imaging and treatment of specific shoulder conditions according to evidence based guidelines. • 3. Discuss indications & appropriate communication techniques for referral of patients with shoulder conditions to services including PT, surgery, etc. Common Sites of Shoulder Pain A A good place for a chart ACUTE CHRONIC • Fractures • Impingement Syndrome Humerus • Frozen Shoulder Clavicle Adhesive capsulitis Scapula • Biceps Tendonitis • *Dislocations • Labral Injury Humerus SLAP Tear AC Joint • Osteoarthritis SC Joint Glenohumeral • *Rotator Cuff Tear Acromioclavicular S.I.T.S. Muscles • Osteolysis Distal clavicle Shoulder Landmarks A A good place for a chart More Shoulder Landmarks A A good place for a chart Musculoskeletal Exam • Inspection • Palpation * • Range of Motion • Resisted Strength • Sensation • Provocative Testing * One joint above; one below www.jacksonortho.org ACUTE CHRONIC • Fractures • Impingement Syndrome Clavicle • Frozen Shoulder Humerus Adhesive capsulitis Scapula • Biceps Tendonitis • *Dislocations • Labral Injury Humerus SLAP Tear AC Joint • Osteoarthritis SC Joint Glenohumeral • *Rotator Cuff Tear Acromioclavicular S.I.T.S. Muscles • Osteolysis Distal clavicle Clavicle Fracture Onset: FOOSH or blow to shoulder Location: Middle third clavicle most frequent +/- Posterior dislocation SC joint Observation: “ Obvious” deformity Palpation: Point Tenderness NeuroVasc: R/o brachial plexus or vascular injury Xray: A/P & Cephalic tilt views *Chest film r/o pneumo or rib fx TX: Refer displaced fx to ortho Figure of 8 sling x 2-4 weeks F/u Xray 4-6 weeks Clavicle Imaging A/P Cephalic Tilt Proximal Humerus Fx Onset: Direct blow or FOOSH Observation: Ecchymosis 24-48 hours Palpation: TTP NeuroVasc: R/o brachial plexus/vascular damage Xray: A/P & lateral; axillary( if possible)or Y view for subtle scap/coracoid fx; TX: <1 cm displacement: immobilizer f/u Xray early Refer: 3-4 part fx; anatomic neck; >1 cm. displaced; n/v compromise www.jacksonortho.org Y-View Left Shoulder Axillary View Shoulder Immobilizers •painful Scapular Fracture Onset: Rare. High force direct blow Location: TTP at fracture site Abduction painful Observation: +/- ecchymosis NeuroVasc: R/o brachial plexus or vascular injury Xray: A/P & axillary or lateral for scapula *Chest film: trauma series for humerus TX: Sling for comfort ROM when tolerable 2-4 weeks Refer if unstable or involves joint Scapula Fracture ACUTE CHRONIC • Fractures • Impingement Syndrome Humerus • Frozen Shoulder Clavicle Adhesive capsulitis Scapula • Biceps Tendonitis • *Dislocations • Labral Injury Glenohumeral SLAP Tear AC Joint • Osteoarthritis SC Joint Glenohumeral • *Rotator Cuff Tear Acromioclavicular S.I.T.S. Muscles • Osteolysis Distal clavicle Glenohumeral Dislocation Anterior: More frequent Arm held in external rotation, abducted Humeral head palpable anteriorly Dimple below acromion (Sulcus sign) Posterior: Uncommon; dx usually delayed Arm close to body, adducted, internally rotated Painful external rotation and forward elevation Phys. Exam: TTP over anterior/ posterior aspect Swelling Apprehension test: pain > apprehension Glenohumeral Dislocation XRAY: Anterior: AP view Posterior: Axillary or Y Bankhart lesion 50% Hill-Sachs lesion Treatment: Relocation Immobilization for capsular healing Mobilization 7-10 days post injury ROM to prevent adhesive capsulitis 90% recurrence in athletes who throw overhead Surgery to repair Bankhart 95% successful Hill Sachs Defect – Anterior Dislocation www.jacksonortho.org Hill-Sachs – Posterior Dislocation A A good place for a chart www.jacksonortho.org Bony Bankhart Lesion – Anterior Dislocation Dislocation Tests Sulcus Sign – Inferior Dislocation With patient’s arm in neutral, pull downward on elbow or wrist while observing shoulder area for a depression lateral or inferior to the acromion. Many asymptomatic patients, especially adolescents normally have some degree of instability. ACUTE CHRONIC • Fractures • Impingement Syndrome Humerus • Frozen Shoulder Clavicle Adhesive capsulitis Scapula • Biceps Tendonitis • *Dislocations • Labral Injury Humerus SLAP Tear AC Joint • Osteoarthritis SC Joint Glenohumeral • *Rotator Cuff Tear Acromioclavicular S.I.T.S. Muscles • Osteolysis Distal clavicle AC Joint Sprain/Separation “Shoulder Separation” Onset: Direct blow to top of shoulder or deltoid; (Fall from horse; knock down in football; Occasionally FOOSH) Location: AC joint Observation: Localized swelling; stepped deformity Palpation: Stepped deformity; TTP NeuroVasc: R/o brachial plexus or vascular injury Xray: A/P confirms diagnosis Axillary view if *Grade 4-6 suspected TX: Grade 1-2: Sling & analgesia x 3 weeks ROM when tolerable Refer if unstable or involves joint Grade > 3: refer for ortho eval AC Joint Separation Classification Shoulder Separation Treatment ACUTE CHRONIC • Fractures • Impingement Syndrome Humerus • Frozen Shoulder Clavicle Adhesive capsulitis Scapula • Biceps Tendonitis • *Dislocations • Labral Injury Humerus SLAP Tear AC Joint • Osteoarthritis SC Joint Glenohumeral • *Rotator Cuff Tear Acromioclavicular S.I.T.S. Muscles • Osteolysis Distal clavicle Sternoclavicular Joint Sprain & Separation Onset: MVA most frequent cause Location: Medial clavicle displaced from sternal border Observation: Head tilts to affected side; pain w abduct; deformity; pain worse supine; can’t place shoulder flat on table Palpation: Localized NeuroVasc: Posterior dislocation can be life threatening compression trachea & greater neck vessels Xray: Difficult to see on plain films; cephalic tilt CT scan provides more detail TX: Mild: sling or Figure 8; progressive ROM Acute: refer for closed or open reduction Anterior Dislocations SternoClavicular Dislocations ACUTE CHRONIC • Fractures • Impingement Syndrome • *Rotator Cuff Tendiinopathy Humerus S.I.T.S. Muscles Clavicle • Frozen Shoulder Scapula Adhesive capsulitis • *Dislocations • Biceps Tendonitis • Labral Injury Humerus SLAP Tear AC Joint • Osteoarthritis SC Joint Glenohumeral Rotator Cuff Tear Acromioclavicular • Osteolysis Distal clavicle Rotator Cuff Tear Onset: Rare r/t trauma in younger patients >40 r/t chronic impingement syndrome Location: S.I.T.S muscles Observation: +/- Swelling; + painful ROM Palpation: TTP at RC insertion NeuroVasc: Normal Xray: AP view may reveal calcific tendonitis; MRI; Arthrography; Ultrasound TX: Surgery for younger & select older patients Rehab for older patients or poor candidates Repair within 3 weeks to avoid retraction, re-injury, tendon degeneration, and atrophy Rotator Cuff Muscles PRINT THIS SLIDE! Supraspinatus Testing A A good place for a chart Infraspinatus Testing Patient has pain when externally rotating the shoulder against resistance with elbow flexed to 90 degrees. Subscapularis Injury • Lift-Off Test: Position patient’s hand behind the back at waist level with palm facing out. Ask patient to move arm away from body against examiner resistance. Impingement A A good place for a chart Impingement Syndrome Neer: A series of pathological changes in the supraspinatus tendon: – Stage 1: Hemorrhage and edema – Stage 2: Tendonitis and fibrosis – Stage 3: Tendon degeneration of the RC & biceps; Bony changes & tendon rupture Impingement Syndrome Onset: Primary (aging) vs Secondary (athletes) Location: RC tendons impinged between humerus and coracoacromial arch. Anterolateral pain w occasional radiation to elbow Observation: Worse with OH movement & at night Clicking, popping; ROM painful 90°- 130° Palpation: Diffuse TTP NeuroVasc: Mild local erythema; normal neuro Xray: AP and Zanca (AP w 10° cephalic tilt) Hooked acromion; spurring; tendon/ligament sclerosis TX: Rest, NSAIDs, ice , modified activity Strength program when tolerated Surgery: 1° decompression; 2° stabilization Impingement Syndrome • Primary • Secondary – Older age – Younger age – Repetitive use – Athletes – Overhead reaching – Overhead throwing – AC spurring – Humeral stabilizer fatigue – Tendon degeneration – Tendon degeneration – Rest, ice, NSAIDs – Rest, ice, NSAIDs – Injection* – Injection* – RC strengthening – Humeral & scapular – Surgery stabilization exercises • SA decompression – Surgery • Bankhart repair Impingement Syndrome • Neer Test: With the arm fully pronated, raise the patient’s arm fully overhead in full flexion. Stabilize the scapula to prevent scapulo-thoracic motion. • Positive test = pain 90° - 130° ACUTE CHRONIC • Fractures • Impingement Syndrome Humerus • Frozen Shoulder Clavicle Adhesive capsulitis Scapula • Biceps Tendonitis • *Dislocations • Labral Injury Humerus SLAP Tear AC Joint • Osteoarthritis SC Joint Glenohumeral • *Rotator Cuff Tear Acromioclavicular S.I.T.S. Muscles • Osteolysis Distal clavicle Adhesive Capsulitis Onset: Slow onset, immobility after injury (RCT) Location: Thickening & contraction of capsule around glenohumeral
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