Evaluation & Treatment of Disclaimer Shoulder and Pain in I, William T Crowe, have relevant financial relationships to be the Adult Patient© discussed, directly or indirectly, William T. Crowe, RN-C, FNP, referred to or illustrated with or MSN, MBA without recognition within the presentation as follows:

– None

Objectives Anatomy Review anatomy of the shoulder and elbow Bony structures – Clavicle Define elements of subjective history – Scapula – Humerus Discuss basic exam of the shoulder and elbow

Discuss current treatment regimens for common problems

Anatomy - clavicle Anatomy - Scapula

1 Anatomy Anatomy

Connective tissue Joint capsule – Ligaments Acromioclavicular – Hyaline cartilage – Fibrocartilage (labrum)

Anatomy Anatomy Passive stabilizers Active stabilizers (muscles) – Ligaments – Glenohumeral (aka Rotator Cuff) – Joint capsule (supraspinatus, subscapularis, infraspinatus, teres minor) – Thoracohumeral (pectoralis major, latissimus dorsi) – Biceps brachii (crosses both shoulder & elbow)

Anatomy Anatomy * 4 separate joints – Glenohumeral – Acromioclavicular – Sternoclavicular – Scapulothoracic

2 Anatomy Anatomy Planes of motion Normal ROM – Flexion & extension – 180 degrees flexion – Internal & external rotation – 45 - 60 degrees extension – Abduction/adduction – 150 degrees abduction – Circumduction (combination of above) – 90 degrees external rotation – 70-90 degrees internal rotation

Anatomy Anatomy Bony structures Connective tissue – Humerus – Ligaments (4 – Radius primary) – Ulna UCL*, RCL, Annular, Quadrate

Anatomy Anatomy Passive stabilizers Active stabilizers – Ligaments (UCL, RCL, Annular, Quadrate) – Flexors (biceps brachii, brachioradialis, – Joint capsule brachialis) – Extensors (triceps, anconeus) – Supinators (supinator, biceps brachii) – Pronators (pronator quadratus, pronator teres, flexor carpi radialis)

3 Anatomy* Anatomy 3 separate joints Planes of motion – Humeroulnar – Flexion & extension – Humeroradial – Internal & external rotation (radiocapitellar) – Proximal radioulnar

Anatomy Subjective/History Normal ROM Where does it – 140 - 150 degrees flexion hurt? – 0 - 10 degrees extension – 90 degrees supination (forearm) – 80 – 90 degrees pronation (forearm)

Location of pain* Location of Pain Anterior – superior shoulder Lateral/medial elbow – Pathology of AC joint – Tendonitis – Ligamental injury Lateral deltoid Olecranon – RC, adhesive capsulitis, OA of glenohumeral –

4 Subjective/History Subjective/History Where does it hurt? Severity – rest & activity When did it start? Instability What happened? Alleviating/Aggravating factors If injury, ROM? Treatment to date Previous injury Review of PMH/PSH/MEDS/DA

RECONSTRUCT THE STORY

Objective/Exam Objective/Exam Always begin by assessing: Observation – cervical spine – “can’t see, can’t treat” – BOTH shoulders – shoulder – general neurovascular examination

Objective/Exam* Objective/Exam Observation Inspection – Deformity – Swelling – Swelling – Ecchymosis – Atrophy – Deformity – Atrophy

5 Objective/Exam Objective/Exam Palpation Palpation – AC & SC joints – Bones – Cervical spine Epicondyles – Biceps tendon Supracondylar lines Olecranon and fossa – Anterior glenohumeral joint Radial head – Coracoid process

– Acromion – Scapula

Objective/Exam Objective/Exam Maneuvers Maneuver – ROM (active & passive) – Spurling’s Test

Objective/Exam Objective/Exam* Maneuvers Maneuvers – Wall pushup – Empty can – supraspinatus

2012, “Fingers to Toes”, UTSW, Chris Espinoza, MD

6 Objective/Exam Objective/Exam Maneuvers Maneuvers – Resisted external – Neer’s test – rotation – impingement of the infraspinatus/teres RC under minor coracoacromial arch

Objective/Exam Objective/Exam Maneuvers Maneuvers – Hawkins’ test – – Subscapularis subacromial Liftoff impingement or RC tendonitis Belly press

Objective/Exam Objective/Exam Maneuvers Maneuvers – Cross arm test – AC – Long head of Biceps joint disorder Speed test – outstretched arm, palm up

7 Objective/Exam Objective/Imaging Maneuvers Radiographs – Lateral epicondylitis CT scan – Medial epicondylitis MRI – UCL stability – MCL stability

Objective/Imaging Objective/Imaging

2012, “Fingers to Toes”, UTSW, Chris Espinoza, MD

Objective/Imaging Missed diagnosis – Dislocation for several months

MUST get 2 views

2012, “Fingers to Toes”, UTSW, Chris Espinoza, MD

8 Objective/Imaging Objective/Imaging AP thorax True AP Axillary Lateral

2012, “Fingers to Toes”, UTSW, Chris Espinoza, MD 2012, “Fingers to Toes”, UTSW, Chris Espinoza, MD

Objective/Imaging Objective/Imaging

96 asymptomatic patients - 34% (33/96) with RC tear - 54% (25/46) > 60 y/o with RC tear Sher et al, JBJS 1995

Objective - Studies Shoulder pain* 3rd most common musculoskeletal complaint 2nd most common referral to ortho ~ 20% of all Americans will experience in their lifetime 8-13% of athletic injuries

9 Rotator Cuff pathology Impingement Syndrome* Impingement Syndrome Prevalence – As of 1/2010, no – documented studies for prevalence of – 5-40% – Rotator cuff tendonitis of general pop may – Rotator cuff tendon tear have but no pain Debaradino & Chang Causes – Acromial morphology (hooked) – – Trauma (macro & micro) – Repetitive overhead activity – Subacromial bursa

Impingement Syndrome Impingement Syndrome* Subjective Objective – Gradual increase in pain – Pain with abduction/flexion of the shoulder – Pain increases with overhead motions – Neer’s test + – Difficult to sleep, especially on affected – Hawkins’ test + shoulder

Subacromial bursitis / RC Impingement Syndrome tendonitis Treatment – Conservative Rest NSAIDs Physical Therapy Cortisone injection – Surgical Arthroscopic

10 RC tear* AC pathology Treatment Chronic – Conservative – Arthritis Rest NSAIDs Physical Therapy Acute Cortisone injection – AC separation – Surgical Arthroscopic Mini-open Open

AC pathology AC pathology Subjective Objective – Pain usually well localized, front of shoulder – Visible deformity – Pain with motion, esp cross body – Pain on palpation – Cross-body adduction

AC pathology AC pathology* Treatment – Conservative NSAIDs Cortisone injections – Surgical Distal clavicle excision ORIF

11 Osteoarthritis Osteoarthritis Subjective Objective – Gradual pain, usually centered in back of – Weakness in muscles, atrophy shoulder – Decreased ROM – Loss of motion – Age > 50

Osteoarthritis Osteoarthritis* Treatment – Conservative NSAIDs Physical therapy (with caution) Cortisone injection – controversial – Surgical Joint replacement

Instability Instability Causes Subjective – Repetitive trauma – “loose” – Recurrent dislocation – Hx of recurrent dislocations

12 Instability Instability Objective Treatment – Apprehension test + – REFER to Orthopedic specialist

Elbow pain Tendonitis (epicondylitis) No hard numbers Age – 30 – 50 years of age (most common)

Tendonitis (epicondylitis) Tendonitis (epicondylitis) Subjective Objective – Pain over epicondyle – POP over the lateral or medial epicondyle – Pain increases with grasping – Lateral epicondylitis test + – May have burning sensation – Medial epicondylitis test + – No radiographic studies indicated

13 Lateral epicondylitis Medial epicondylitis

Tendonitis (epicondylitis)* Sprain Treatment Subjective – Conservative (85-90%) – Hx of trauma – direct blow or twisting Rest – Throwing injury (UCL) NSAIDs – Pain Physical therapy – Joint instability Bracing Cortisone injection to site – Surgical (80%) Epicondylar release

Sprain Sprain* Objective Treatment – Swelling – Conservative – Decreased ROM REST – Ligamental laxity RICE – Surgical – Valgus stress (milking) REFER if conservative Tx fails

14 Olecranon Bursitis Olecranon Bursitis Causes Subjective – Trauma – Pain/ to posterior of elbow – Extended pressure – – Underlying medical conditions (RA, )

Olecranon Bursitis Olecranon Bursitis Objective Treatment – “Goose egg” to – Conservative posterior elbow RICE – Decreased ROM NSAIDs – Redness to (infectious) posterior elbow Aspirate (symptomatic relief) – XR ?? (injury, Cortisone injection to site infection) – Surgical

Cubital Tunnel Syndrome Cubital Tunnel Syndrome Ulnar Nerve Entrapment Ulnar Nerve Entrapment

Prevalence Subjective – 2nd most common compressive neuropathy – Hand (4th & 5th fingers) falls asleep when elbow – Males 3-8x > females flexed (sleeping, phone usage) Cause – Aching to the medial elbow – Weakened grip – ??? Risk factors – Previous elbow injury/fx – Bone spurs

15 Cubital Tunnel Syndrome Cubital Tunnel Syndrome Ulnar Nerve Entrapment Ulnar Nerve Entrapment

Objective Treatment – Tinel’s sign + – Conservative – Elbow flexion test + Soft splinting – EMG/NCV studies NSAIDs – Surgical Anterior transposition

Fractures Fractures

Fractures Fractures

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