FOR PRACTITIONERS IN STUDENT HEALTH SETTINGS

Matthew Lunser, DO Team Physician University of Vermont 11.2.17 Objectives

Learning Objective #1: Identify etiologies of problems in college health. Learning Objective #2: List the elements of and perform a systematic examination of the shoulder. Learning Objective #3: Explain management plans for common shoulder conditions in college students. Disclosures

I have no financial disclosures Thank you

Michele Bliss, MS, ATC Eugene Santos, MS, ATC Lisa Hardy, MS, ATC

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Anatomy Review

Bones Ligaments Muscles Neurovascular Anatomy

Anatomy

Anatomy

Ligaments Muscles

Infraspinatus

Shoulder Examination - History

Dominant arm Sports participation Prior injuries along kinetic chain Discoloration or swelling of arm Night pain Neck problems Shoulder Examination - Referred pain patterns

Supraspinatus Infraspinatus Shoulder Examination - Referred pain patterns

Subscapularis

Inspection Posture Deformity (dislocation, fractures)

Fractures swell, dislocations don’t Scapulothoracic motion

A special test?

Physical Examination

Palpation Sternoclavicular Clavicle Acromioclavicular joint (springy) Long head biceps tendon Physical Examination

Range of Motion Flexion (180˚) Abduction (180˚) External rotation (90˚) Cervical spine motion Physical Examination

Strength Testing Flexion Abduction External rotation Internal rotation flexion Practice!

History Inspection Strength Testing

Sternoclavicular Dominant arm Shoulder height Flexion Flexion joint

Sports Posture Clavicle Abduction Abduction

Acromioclavicular Arm swelling Musculature External rotation External rotation joint

Scapulothoracic Long head biceps Prior injuries Internal rotation Internal rotation motion tendon Physical Examination

Special Tests Provocative maneuvers Lack sensitivity and specificity Multiple named tests for each structure 140 named shoulder tests Neer’s Test

Supraspinatus Impingement Arm internally rotated and passively moved into maximal flexion “neer - pinky to ear” Abnormal is reproducible pain Sensitivity: 64-80% Specificty: 30-53% Hawkin’s Test

Supraspinatus Impingement Patient standing, shoulder flexed to 90 degrees and then passively internally rotated “hawk wing” Abnormal is reproducible pain Sensitivity: 55-80% Specificity: 38-59%

AKA Hawkins-Kennedy Test Empty Can Test

Supraspinatus strain/tear Arm flexed to 90 degrees, horizontal adducted to 30 degrees, extended and thumbs down ---> Resisted flexion Abnormal is pain or weakness Sensitivity: 64-74% Specificity: 29-65%

“Full Can test” is also valid (1996) AKA: Jobe’s Test, Scaption Test External Rotation Test

Infraspinatus strain/tear Elbow at side and flexed 90˚, resist examiner’s internal rotation force Abnormal is pain or weakness Lift Off Test

Subscapularis strain/tear Dorsum of hand on back, lift off back against examiner’s resistance Abnormal is pain/weakness Sensitivity: 17.6% Specificity: 100%

Lower portion of subscapularis Bear Hug Test

Subscapularis strain/tear Arm across body with fingers flat and pushing down onto top of the contralateral shoulder, resist examiner’s external rotation pressure Abnormal is weakness/pain Sensitivity: 60% Specificity: 91.7%

Upper portion of subscapularis O’Brien’s Test

Labrum tear – SLAP lesion Shoulder flexed to 90˚ and horizontal adduction to 15-20˚, point thumb down and resist examiner’s downward force. Compare with palm up. Abnormal is pain with thumb down, pain relieved with palm up. Sensitivity: 63-94% Specificity: 28-53% Biceps Load II Test

Labral Tear Arm abducted 120˚, full external rotation, resist the patient’s elbow flexion Abnormal is pain at the labrum Sensitivity: 89.7% Specificity: 96.9% Cross Arm Test

Acromioclavicular joint sprain Shoulder at 90 degrees, passive full adduction across chest Abnormal is pain at the acromioclavicular joint Sensitivity: 77% Speed’s Test

Biceps tendon pathology Shoulder flexed to 90˚, elbow fully extended, arm supinated ---> resisted shoulder flexion Abnormal with pain in bicipital groove Sensitivity: 32-60% Specificity: 38-67% Apprehension Test

Anterior instability/dislocation Shoulder at 90˚ abduction, and 90˚ external rotation, apply a gentle external rotation force Abnormal is sensation of instability, apprehension” Sensitivity: 40-100% Specificity: 42-96% Relocation Test

Anterior instability/dislocation Apply a posterior force on the humeral head while performing the apprehension test Reduced sense of apprehension confirms instability Sulcus Sign

Multidirectional instability Arm at side, examiner pulls inferiorly on humerus Abnormal is formation of a “sulcus” superior to the humeral head Thoracic Outlet Syndrome Tests

Allen Test – Wright Test Adson Maneuver Halstead Maneuver Military Brace Position Roos Test

ALL HAVE POOR RELIABILITY

Spurling’s Test

Cervical With the neck extended, sidebent ipsilateral, and rotated contralateral, examiner applies a downward pressure to the head Abnormal is pain radiating to the involved shoulder Sensitivity: 30% Specificity: 93% Practice

Impingement Labrum Stability Other

Neer’s test Empty can O’Brien’s test Apprehension test Cross arm test

External rotation Hawkin’s test Biceps load II test Relocation test Speed’s test test

Lift off test Sulcus sign Spurling’s test

Bear hug test Common Shoulder Problems in College Students

Dislocation, subluxation, and instability Acromioclavicular joint sprain Labral tear Biceps tendonitis Impingement syndrome Clavicle fracture Thoracic outlet syndrome Shoulder Dislocation, Subluxation, Instability

First time dislocation/reduction Chronic subluxers Shoulder pain with underlying instability Shoulder Dislocation

Anterior most common Reduction with traction gentle external rotation Dislocation doesn’t swell Post reduction xrays Fractures swell Sling for comfort Physical therapy Shoulder Dislocation

Most first time dislocation/reduction can be treated conservatively Orthopedic referral First-time traumatic shoulder dislocation with Bankart lesion confirmed by MRI in athlete younger than 25 years of age “High demand athletes”

Orthobullets.com Chronic subluxation

Recurrent subluxation or dislocations Refer to orthopedics Physical therapy Multidirectional Instability

More common in athletic individuals Often treated adequately with physical therapy Acromioclavicular joint sprain

“Separated shoulder” Fall onto shoulder Palpation can make diagnosis Type I – II nonoperative

Sling for comfort, better in 3 – 6 weeks Type III controversial 25 – 100% increased Type III coracoclavicular distance Type IV – VI orthopedic referral Labral tear

Can be acute or chronic Types I – VIII Deep shoulder pain, clicking Physical exam special tests are helpful MRI increases visualization of the labrum Consider early referral Refer if no improvement Rotator cuff tear

Supraspinatus is most common Acute vs. chronic Partial vs. full thickness Acute tear with significant weakness consider MRI/referral repair within 6 weeks Consider short interval reevaluation Physical therapy, scapular stabilization Biceps tendonitis

Long head of the biceps Overuse injury Diagnose with palpation Differentiate from tendon subluxation Transverse view Usually conservative treatment Subluxation has lower threshold for referral Impingement Syndrome

Less common in college students Repetitive overhead activities lifting, tennis, climbing Almost always nonoperative Physical therapy and activity modification Clavicle fracture

75% occur at mid-clavicle Nonoperative if less than 100% displacement (> 1 width) Pain control, sling Elbow ROM several times daily within 3 days Shoulder use as tolerated Union ~6 weeks, xray

Distal and proximal third fracture requires referral Thoracic outlet syndrome

Beware of upper extremity DVT Weight lifters Shoulder pain case “A” Shoulder pain “A”

HPI: 20 y/o male two months intermittent lateral right shoulder pain likes lifting weights, overhead press, squats had self limited discoloration of the right arm question tingling elbow to hand Shoulder pain “A”

Exam: 138/75 101 F 105 bpm Normal inspection no palpable pain full shoulder and neck ROM 5/5 shoulder and elbow strength (-) neck axial compression (-) Spurling’s test (-) Holmstead maneuver (-) Allen test Shoulder pain “A”

Assessment: vascular thoracic outlet syndrome Plan: Stretching for pec minor, anterior scalene f/u 1 week lifting as tolerated Shoulder pain case “B” Shoulder pain “B”

HPI: 20 y/o male several falls snowboarding last week having right shoulder pain and neck pain enjoys lifting weights self limited arm discoloration after pushups yesterday question numbness right arm question right hand swelling Shoulder pain “B”

Exam: 130/74 97.4F 66 bpm Normal inspection 5/5 right upper extremity strength sensation normal (+) Allen test (+) Roos test Shoulder pain “B”

Assessment: thoracic outlet syndrome Plan: reviewed online exercises avoid weight lifting f/u PRN Shoulder pain “A” 1 week f/u

HPI: shoulder pain improved still having positional discoloration in hand/forearm no tingling trying home stretching exercises, not lifting Exam: 126/72 72 bpm slight darker color to right hand/forearm capillary refill <2 seconds (-) Allen’s test Shoulder pain “A” 1 week f/u

Assessment: thoracic outlet syndrome, r/o DVT Plan: upper extremity venous ultrasound complete today Shoulder pain “B” 3 day f/u

HPI: Right arm feels “full” Having discoloration No weakness Exam: increased redness of the right upper extremity also mild arm swelling (-) Allen test Dx: Arm swelling, discoloration of skin, r/o DVT Plan: stat upper extremity venous ultrasound cancel trip to Montreal this afternoon Shoulder pain “B”

Ultrasound shows right subclavian vein thrombosis Transferred to ED and started Xarelto (rivaroxaban) Xarelto 20mg daily for 3 months for provoked DVT

had rapid symptom improvement, continue despite limited evidence vs Coumadin No skateboarding, no overhead lifting Okay for other lifting with close monitoring Okay for pickup basketball Shoulder pain “A”

Right subclavian vein DVT Referred to E/D, Dx unprovoked DVT Lovenox and initiated warfarin given proven efficacy INR goal 2-3 for 6 months for unprovoked DVT Avoid heavy lifting Hypercoagulable workup and ECHO (heart murmur) to be completed Has returned back to gentle lifting INR q3-4 weeks, avoid EtOH Conclusions

Palpable pain of acromioclavicular joint and long head biceps can be diagnostic Special tests are imperfect, used to confirm what you are thinking Most shoulder problems can be managed conservatively Refer to orthopedics for acute rotator cuff tears, distal/proximal clavicle fractures, clavicle fractures and A/C sprains with more than 100% displacement, and recurrent dislocations Thoracic outlet syndrome differential includes deep vein thrombosis Thank you