8/8/2013
Diagnosis and Management of At the end of this hour you will know Common Shoulder and Hip Complaints 1. The differential diagnosis for patients with decreased AROM and PROM of shoulder. 2. The key difference between impingement syndrome and rotator cuff tear. 3. How to diagnose a shoulder labral tear. 4. The key exam finding in hip OA. 5. The 2 exam maneuvers to bring out hip
UCSF Essentials of Primary Care impingement and/or labral tear. August 8, 2013 Carlin Senter, M.D.
Musculoskeletal work-up Shoulder Problems • History
• Inspection
• Other Tests
1 8/8/2013
Shoulder keys Shoulder examination
• History • Inspection • – Hand dominance Palpation • ROM – Occupation – Abduction – H/o dislocation – Forward flexion – – ER Pain that wakes patient from sleep – IR • Exam • Strength – Always perform neck exam with shoulder – Supra – Infra and teres minor – Inspection: gown tied under arms or shirt off – Subscapularis – Always examine unaffected side first • Other tests http://www.aafp.org/afp/20000515/3079.html
Shoulder: diagnosis driven exam Case #1
Active ROM • 50 y/o RHD woman with DM2 and hypothyroidism presenting with R shoulder Normal Decreased pain. No injury. Waking up at night during Impingement sleep. Shoulder feels very stiff, having trouble RC tear Labral tear Passive ROM reaching behind and raising above head. Biceps tendinitis Normal AC joint OA Decreased
Frozen Xray GH joint shoulder OA Normal Abnormal
2 8/8/2013
Range of motion Range of motion
Internal rotation
Abduction External rotation Flexion
Supine shoulder PROM Physical exam: AROM
External Internal Unable to lift rotation rotation the shoulder so uses entire shoulder girdle to abduct and FF.
http://www.belmarpt.com/newwordpress/wp-content/uploads/2009/03/img_0294.jpg
3 8/8/2013
Physical examination: PROM Shoulder: diagnosis driven exam
Active ROM
Normal Decreased
Impingement RC tear Labral tear Passive ROM Biceps tendinitis Normal AC joint OA Decreased Forward flexion Abduction Frozen Xray GH joint shoulder OA Normal Abnormal http://www.youtube.com/watch?v=p52IdSVqvjo
Weighted abduction: diagnose Shoulder xrays glenohumeral joint OA • Evaluate etiology of decreased passive and active ROM
1# weight No weight AP Glenohumeral joint Scapular Y view Xrays courtesy of Ben Ma.
4 8/8/2013
Case #1: decreased AROM, PROM, but Shoulder: diagnosis driven exam normal xrays A. Adhesive capsulitis Active ROM
B. Rotator cuff tear Normal Decreased 71% C. Impingement syndrome Impingement D. Glenohumeral joint osteoarthritis RC tear Labral tear Passive ROM Biceps tendinitis Normal AC joint OA 19% Decreased 8% 2%
Frozen Xray GH joint . . j ... shoulder s y . l OA p s u . . . a n t r e m h u m e Abnormal o Normal h e s i v e c a Rotator cuff t... m p i n g e A d I G l e n
Adhesive capsulitis Associated with
• Diabetes • Hyper and hypothyroidism • Hypoadrenalism • Parkinson’s disease • Cardiac disease • Pulmonary disease • Stroke • Surgery (cardiac, cardiac cath, neurosurgery, radical neck dissection)
http://www.aurorahealthcare.org/healthgate/images/si55551230.jpg
5 8/8/2013
Adhesive capsulitis is a clinical Active ER key finding diagnosis • No need for MRI • Xrays helpful to r/o GH joint OA
3 stages of adhesive capsulitis Treatment for adhesive capsulitis
• Pain control: NSAIDs, oral or injected corticosteroids (either in GH joint or subacromial bursa) Freezing Frozen Thawing • Does not change disease course • +/- physical therapy to help restore ROM Resolution • Capsular distention injections 3-9 months 4-12 months 12-42 months Average time ↑ pain ↓ pain Gradual ↑ ROM • Surgery to resolution: ↓ ROM Stable, • Manipulation under anesthesia 1-3 years Pain at rest, decreased ROM • Arthroscopic release and repair sleep
Manske and Prohaska, Curr Rev Musculoskeletal Med, 2008.
6 8/8/2013
Case #2 Case #2 Exam
• 57 y/o RHD man presents with R shoulder pain • I: no atrophy that started after he fell 3 months ago. Pain at • P: mild ttp deltoid, nontender biceps and AC R deltoid. He tried physical therapy without joint benefit. Waking at night from sleep due to • ROM: Unable to actively abduct past 120 pain. degrees 2/2 pain. Full PROM.
Shoulder: diagnosis driven exam Rotator cuff anatomy
Active ROM
Normal Decreased
Impingement RC tear Labral tear Passive ROM Biceps tendinitis Normal AC joint OA Decreased
Frozen Xray GH joint shoulder OA Normal Abnormal
7 8/8/2013
Rotator cuff anatomy Supraspinatus = abduction
Subscapularis Supraspinatus Supraspinatus Infraspinatus
Teres minor
Empty can
Photos from Dr. Christina Allen
Infraspinatus and teres minor = external rotation Subscapularis = internal rotation
Infraspinatus Teres minor Subscapularis Lift-Off
Photos from Dr. Christina Allen
8 8/8/2013
Subscapularis = internal rotation Impingement
Subacromial bursa Supraspinatus • Inflammation of the subacromial space – The area under the acromion and above the glenohumeral joint – Structures in this space • Supraspinatus • Subacromial/subdeltoid Subscapularis bursa
Impingement signs Case #2 exam, continued
• Other tests: – 4/5 supraspinatus strength due to pain. – 5/5 infra and teres minor with pain. – 4/5 subscapularis with pain. – (+) Neers, (+) Hawkins.
Hawkin’s Neer’s Photos from Dr. Christina Allen
9 8/8/2013
Diagnosis Rotator cuff tear more likely if…
A. Adhesive capsulitis • Older patient
B. Rotator cuff tear 60% • Traumatic mechanism C. Impingement syndrome • Weak on exam 40% D. Glenohumeral joint osteoarthritis
0% 0%
. .. t . . p s u . . . t s y . n c a r c u f f e o m h e s i v e d R o t a t A I m p i n g e G lenohum eral j...
Treatment Rotator cuff disease spectrum
A. Order MRI, confirm tear, refer for arthroscopic RCT • Stage I: < 25 y/o. Bursitis repair • Stage II: 25-40 y/o. Tendinitis and fibrosis of B. Repeat trial of physical therapy, f/u 3 months. rotator cuff C. NSAIDs and activity modification, f/u 3 months 34% • Stage III: > 40 y/o. Partial to complete tearing D. Subacromial injection, f/u 3 months 24% of rotator cuff 21% 21%
...... n . t o a l o . . l i n . . . , c i i a t r m a n d a c MRI c r o r I D s A b a R e p e a t u O r d e N S S
10 8/8/2013
AP shoulder Rotator cuff tear algorithm
• If weak on testing of rotator cuff order xrays and MRI if (+) rotator cuff tear refer. • Greater likelihood tear if >40 y/o • Surgical outcomes better if cuff tears fixed earlier than later – Smaller tear – Less fatty infiltration – Less muscle atrophy – Less retraction Reduced acromiohumeral interval
Saupe N, et al. AJR, 2006.
Differential diagnosis Case #3 traumatic shoulder injury • 30 y/o RHD man fell off bike 9 months ago, • AC joint separation injured R shoulder • Labral tear • Went to PT but continues to have pain • Rotator cuff tear • Anterior shoulder • Shoulder dislocation • Only feels pain if moves shoulder in certain • Fracture directions quickly – Humerus or clavicle • Does not wake him from sleep at night
11 8/8/2013
O’Brien’s Test Physical examination To r/o Labral Tear
• No atrophy • Arm forward flexed to 90° • Tender biceps tendon, nontender AC joint • Elbow fully extended • AROM R shoulder • Arm adducted 10°to – FF 0-170 with pain at top 15°with thumb down • Downward pressure – Abd 0-170 with pain at top • Repeat with thumb up – ER 45, IR L1 (Same as L shoulder) • Suggestive of labral • Strength 5/5 rotator cuff tear if more pain with • (-) Neers and Hawkins thumb down • • Sens = 59-94%, Spec (+) O’Brien’s test = 28-92%
Glenoid labrum SLAP tears
• Superior Labrum Anterior to Posterior – Many different types, classifications • Diagnosis: MR arthrogram • Treatment: surgery – Debridement – Repair • NOT a disease of older people (do not consider as etiology for shoulder pain in most >50 y/o as labrum degenerates naturally)
12 8/8/2013
Locate the hip pain
• Anterior groin = hip joint, hip flexor • Buttock = SI joint, Hip Problems lumbar spine • Lateral hip = greater trochanteric bursitis, gluteus tendinopathy • Radiating to thigh = could be hip joint
• Radiating to the foot = http://www.everydayhealth.com lumbar spine /hip-pain/hip-anatomy.aspx
Hip inspection Hip palpation
• Ecchymosis: fracture, • Abdomen hematoma • Pelvis • Leg shortened and – Iliac crest externally rotated: – ASIS – fracture Inguinal canal • Lymph nodes • Gait- unable to weight – Pubic tubercles http://www.emedx.com/emedx/diagnosis_information/hip bear or sig limp: _pelvis_disorders/hip_fracture_leg_external_rotation.htm • Hip fracture, inflammatory – Greater trochanter arthritis • Back: SI joints, LS
http://www.rush.edu/rumc/page- 1098987346941.html
13 8/8/2013
Hip passive range of motion: Hip passive range of motion internal and external rotation
Flexion External rotation Internal rotation normal 120 ° normal 40-60 ° normal 30-40 °
http://www.youtube.com/watch?v=5LNYdJIrWYo
Hip neurovascular exam Signs of intra-articular hip pathology
• Strength • Pain with passive ROM – Hip flexion (T12-L3) • Most pain with IR of – Knee extension (L2-4) affected hip – Plantar flexion (S1) – Narrows joint space – Foot dorsiflexion (L4) • Decreased IR of – Great toe extension (L5) affected compared to • Sensation to light touch unaffected side • Reflexes: patellar (L4) and achilles (S1) http://netterreference.com/ELSEVIER/netter_s_ Netter online anatomy atlas_of_human_anatomy/a/atlasbook/8 atlas, UCSF library.
14 8/8/2013
If pain with passive ROM be concerned about hip emergencies Non-emergent hip pathology • Septic arthritis • Osteoarthritis ( >50 y/o) – Xrays • Femoral acetabular impingement (< 50 y/o) – Hip aspiration • Orthopaedics • Labral tear (< 50 y/o) • Interventional radiology • • Do not delay Adductor strain (any age, active) – Confirmed: to OR for washout • Femoral neck fracture or stress fracture – Xrays – Make non weight bearing (crutches or wheelchair)
Case #1 Case #1 exam
69 y/o woman w/ L hip pain. • I: no ecchymosis Pain worse when trying to put shoes on, sitting, driving. • P: mild tenderness L inguinal canal Better if takes ibuprofen. • ROM Started a year ago, slowly – getting worse. Has noticed R hip flexion 130, IR 40, ER 60 that the left hip isn’t as – L hip flexion 100 (limited 2/2 groin pain), ER 30 flexible as the right hip in and IR 10 (limited 2/2 groin pain) yoga.
15 8/8/2013
Xrays Hip OA treatment
• Pain control – Tylenol – NSAIDs • Physical therapy – Gait training – Core strengthening • Activity modification: avoid pain Normal
Frontera: Essentials of Physical Hip osteoarthritis Medicine and Rehabilitation, 2nd ed.
Hip replacement Case #2
• 6-12 month recovery • 29 y/o woman with R hip pain • Excellent pain relief • Localizes to R groin starting POD 1 • Started when running on • 10-20 year minimum sand duration • Pain 2/10 sitting, 5/10 standing • Aleve helps • Groin pain can be sharp with certain movements • Did PT but didn’t help http://www.aafp.org/afp /2009/1215/p1429.html
16 8/8/2013
5 questions for every athlete with Case #2 exam hip pain 1. Training: increased mileage? • I: no ecchymosis 2. Nutrition: Calories in versus calories out? • P: ttp R inguinal canal History of eating d/o? Dietary restrictions? • ROM: bilateral flexion 130, IR 40 and ER 60 3. History of stress fractures? but R groin pain with flexion and IR. 4. Family history of osteoporosis? • OT: 5. Menstrual history? – FADIR and FABER R hip cause R groin pain – No pain with FADIR and FABER L hip
FADIR FABER
• Flexion • Flexion • Adduction • Abduction • Internal • External • Rotation • Rotation
http://kurumiyama.web.fc2.com/PT/orthopedic_test.htm
http://www.aafp.org/afp /2009/1215/p1429.html
17 8/8/2013
Case #2 differential diagnosis Femoroacetabular impingement (FAI)
1. Hip labral tear 2. Hip impingement 3. Labral tear and impingement 4. Femoral neck stress fracture
FAI imaging Hip labral tear
• Xrays to order – AP pelvis – Dunn view lateral • Hip flexed 90 and abducted 20 degrees – Lateral can miss impingement
http://www.aafp.org/afp/1999/1015/p1687.html http://www.aafp.org/afp/2009/1215/p1429.html
18 8/8/2013
Hip labral tear imaging Treatment FAI/labral tear
• Xrays: normal or impingement, r/o OA • Physical therapy • MR arthrogram – Core strengthening – Contrast injected into hip joint – Hip muscle strengthening
– 92% sensitivity (DeLee and Drez’s Orthpaedic Sports Medicine, 3 rd ed) • Activity modification • Corticosteroid injection – Short term pain relief – Confirm that provides pain relief (right diagnosis)
http://www.currentprotocols.com/Wi leyCDA/CPUnit/refId -mia2602.html
Surgery for FAI/labral tear At the end of this hour you will know
• Indications 1. The differential diagnosis for patients with decreased – Pain with flexion and IR AROM and PROM of shoulder. – Labral tear on MRI or MR arthrogram 1. Adhesive capsulitis and Glenohumeral joint OA – Relief of pain after injection 2. The key difference between impingement syndrome and – Failed physical therapy rotator cuff tear. • Arthroscopy 1. RCT is weak – Labral debridement or repair 3. How to diagnose a shoulder labral tear. – Osteoplasty of femoral neck and/or acetabulum to restore 1. O’Brien’s test normal bony alignment 4. The key exam finding in hip OA. – Higher pt satisfaction if no co-existing hip cartilage damage 1. Decreased hip PROM, particularly flexion and IR (chondropathy) – Impact of FAI and FAI surgery on development of hip OA is 5. The 2 exam maneuvers to bring out hip impingement unknown and/or labral tear. 1. FADIR and FABER cause groin pain
Kemp JL et al, Br J Sports Med 2012; 46:632-643.
19 8/8/2013
Thank you
Questions? [email protected]
20