The Painful Shoulder Part II: Common Acute & Chronic Disorders

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 good place for a chart ACUTE CHRONIC

Shoulder Landmarks

A good place for a chart More Shoulder Landmarks

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

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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

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 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 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

Onset: Slow onset, immobility after injury (RCT) Location: Thickening & contraction of capsule around glenohumeral joint at deltoid insertion Observation: Loss of ROM: elevation and external rotation Unable to sleep on affected side Palpation: Deltoid insertion NeuroVasc: Normal Xray: A/P normal w poss disuse osteopenia Arthrography – joint capsule constriction with loss of normal axillary & subscapularis spac TX: NSAIDs, PT, intra-articular injection Dilation during arthrography Surgery if conservative care fails

Tendonitis

A good place for a chart Biceps Tendonitis

Cause: Inflammation of the sheath around the long head of the biceps Onset: Gradual or acute Location: Discrete pain at lateral shoulder, bicipital groove Observation: Mild swelling Palpation: TTP over lateral shoulder & bicipital groove NeuroVasc: Normal Xray: Only if unresolved or chronic to rule out impingement TX: Rest, ice, NSAIDs, corticosteroid injections TENS, weighted pendulum swings Surgery: transfer of biceps tendon Biceps Tendon – Long Head

• SPEED’S Maneuver Flex patient’s elbow 20-30 degrees with forearm supinated and shoulder in 60 degrees flexion. Resist forward flexion of the arm while palpating biceps tendon at anterior shoulder. Labral (SLAP) Injury

Onset: Gradual or acute; throwers Location: Superior Labrum Anterior & Posterior; deep pain at glenohumeral joint Observation: Normal appearance; clicks, pops, clunks especially in overhead position; catching sensation; “coming out of socket” Palpation: TTP deep palpation anterior GH joint; Signs of laxity or instability NeuroVasc: Normal Xray: Normal; may need MRI to confirm dx TX: Rest, ice, NSAIDs, PT ( ROM, RC strength, Scap stabilizers, proprioception; 6-8 weeks) Arthroscopy Labral Tear – Crank (Clunk) Test

• Position patient’s arm in 90 degree flexion and external rotation. Push humerus into glenohumeral joint while internally and externally rotating. ACUTE CHRONIC

Onset: Gradual. Overuse. Previous trauma; RC Tear Lyme disease; RA if multiple joints Location: Glenohumeral joint Observation: Stiffness; mild edema and erythema; loss PROM

Palpation: GH TTP, warmth, swelling NeuroVasc: Normal Xray: AP of glenohumeral joint; joint space loss; DJD

TX: Ice, heat, NSAIDs, ROM, corticosteroid injections Surgery: Arthroscopic debridement Arthroplasty: Hemi, Total, Reverse, Glenohumeral Osteoarthritic Changes Glenohumeral Rheumatoid Arthritis Changes Osteolysis Distal Clavicle

Onset: Gradual. Most often in weight lifters. Likely begins w stresss fx. Bone resorption > cystic & erosive changes. Poor bone remodelling r/t chronic stress. Location: AC joint Observation: Swelling; painful abduction Palpation: TTP over AC NeuroVasc: Normal Xray: AC; ostepenia & lucency at distal clavicle TX: D/C weight loading; NSAIDs, PT Surgery: resection distal clavicle

AC Joint Dysfunction

• The patient actively flexes the shoulder to 90 degrees then actively adducts it. • AC joint dysfunction (arthritis, spurring, etc.,) indicated by pain AC Joint DJD/Rotator Cuff Tear

A good place for a chart REFERENCES

• Woodward, T. W., & Best, T. M. (2000). The painful shoulder: part I. Clinical evaluation. American family physician, 61(10), 3079-3089. • Woodward, T. W., & Best, T. M. (2000). The painful shoulder: part II. Acute and chronic disorders. American family physician, 61(11), 3291-3300. • Zuckerman, J. D., Mirabello, S. C., Newman, D., Gallagher, M., & Cuomo, F. (1991). The painful shoulder: Part II. Intrinsic disorders and impingement syndrome. American family physician, 43(2), 497.

www.jacksonortho.og Contact Information

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/ www.jacksonortho.org www.jacksonortho.org Headline

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