COURSE B AAEM 51St Annual Scientific Meeting Savannah, Georgia Painful Shoulder

Home , Radicular pain

Painful Shoulder

American Association of Electrodiagnostic Medicine

Michael T. Andary, MD, MS Kerry H. Levin, MD Marko V. Bodor, MD John L. Andary, MD, MBA

2004 AAEM COURSE B AAEM 51st Annual Scientific Meeting Savannah, Georgia Painful Shoulder

Michael T. Andary, MD, MS Kerry H. Levin, MD Marko V. Bodor, MD John L. Andary, MD, MBA

2004 COURSE B AAEM 51st Annual Scientific Meeting Savannah, Georgia

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Painful Shoulder

Faculty

Michael T. Andary, MD, MS Marko V. Bodor, MD Associate Professor Physical Medicine and Rehabilitation Department of Physical Medicine and Rehabilitation Queen of the Valley Hospital Michigan State University Napa, California East Lansing, Michigan Dr. Bodor is a physiatrist in private practice in Napa, California, where his Dr. Andary earned his medical degree from Wayne State University practice consists of electrodiagnosis, sports medicine, spine interventional Medical School in Detroit and his MS degree in rehabilitation medicine procedures, and diagnostic ultrasound. He is a fellow of the American from the University of Washington. He is board-certified in physical med- Association of Physical Medicine and Rehabilitation, the AAEM, and the icine and rehabilitation, electrodiagnostic medicine, and pain management Physiatric Association of Spine, Sports, and Occupational Rehabilitation, (subspecialty of physical medicine and rehabilitation). Dr. Andary is a and is also a member of the American College of Sports Medicine, and the member of several medical societies, including the American Academy of International Spinal Injection Society. Dr. Bodor has been a reviewer for Physical Medicine and Rehabilitation, the AAEM, the International the Archives of Physical Medicine and Rehabilitation, Muscle & Association for the Study of Pain, and the Association of Academic Nerve, and the Journal of Biomechanics. He has also been the director Physiatrists, and has also served on several committees of these associations. of the West Coast Resources Pain Management Program in Napa, and the In addition, Dr. Andary has been a reviewer for the journals Clinical director of the Acute Rehabilitation Unit of Queen of the Valley Hospital Neurophysiology, Muscle & Nerve, Archives of Physical Medicine in Napa. Dr. Bodor’s research interests include topics in biomechanics, ex- and Rehabilitation, the Journal of Neurosurgery, and the Clinical ercise physiology, electromyography, and orthopedics. Journal of Pain, among others. John L. Andary, MD, MBA Kerry H. Levin, MD Shoulder & Knee Center Head, Section of Neuromuscular Disease/EMG Idaho Falls, Idaho Department of Neurology Dr. John Andary received his undergraduate degree from Michigan State Cleveland Clinic University and attended medical school at Wayne State University. During his orthopaedic residency at Wayne State, he also earned his master’s degree Cleveland, Ohio in business administration from Michigan State. Dr. Andary is fellowship Dr. Levin received his BA and his medical degree from Johns Hopkins trained in orthopaedic sports medicine. He has experience as a team doctor University in Baltimore, Maryland. He then performed a residency in in- for the Tampa Bay Buccaneers and for the University of Miami ternal medicine at the University Hospitals of Cleveland and a residency in Hurricanes. He is board certified by the American Board of Orthopaedic neurology at the University of Chicago Hospitals, where he later become Surgery and is a member of the American Academy of Orthopaedic the chief resident in neurology. Dr. Levin is involved in several professional Surgeons, American Orthopaedic Society for Sports Medicine, and organizations, including the AAEM, the American Board of Arthroscopy Association of North America. Dr. Andary received several re- Electrodiagnostic Medicine, the American Academy of Neurology, and the search awards for his anatomical work on the shoulder which was pub- American Board of Psychiatry and Neurology. He is on the editorial board lished in The Journal of Bone and Joint Surgery. of Muscle & Nerve, and is an ad-hoc reviewer for Neurology, the Journal of Clinical Neurophysiology, Pediatric Neurology, Muscle & Nerve, and the Journal of Neuroimmunology. He is currently the program director of both the Cleveland Clinic’s Clinical Neurophysiology ACGME Fellowship program and the Neurology ACGME Residency program, as well as the head of the neuromuscular disease/EMG section of the Cleveland Clinic’s Department of Neurology.

Authors had nothing to disclose.

Course Chair: Michael T. Andary, MD, MS

The ideas and opinions expressed in this publication are solely those of the specific authors and do not necessarily represent those of the AAEM. iii Painful Shoulder

Contents

Faculty ii Objectives iii Course Committee iv

The Use of History and Physical Examination to Diagnose Shoulder Pain 1 Michael T. Andary, MD, MS

Peripheral Nerve Disorders in the Shoulder Region: Mechanisms and Differential Diagnosis 11 Kerry H. Levin, MD

Shoulder Pathokinesiology and Rehabilitation 21 Marko V. Bodor, MD

Looking at the Surgical Options for Shoulder Pain 29 John L. Andary, MD, MBA CME Self-Assessment Test 43 Evaluation 47 Future Meeting Recommendations 49

Please be aware that some of the medical devices or pharmaceuticals discussed in this handout may not be cleared by the FDA or cleared by the FDA for the specific use described by the authors and are “off-label” (i.e., a use not described on the product’s label). “Off-label” devices or pharmaceuticals may be used if, in the judgement of the treating physician, such use is medically indicated to treat a patient’s condition. Information regarding the FDA clearance status of a particular device or pharmaceutical may be obtained by reading the product’s package labeling, by contacting a sales representative or legal counsel of the manufacturer of the device or pharmaceutical, or by contacting the FDA at 1-800-638-2041.

O BJECTIVES—After attending this seminar, participants will learn (1) the history and physical techniques to assist in the diagnosis of specific shoulder disorders, (2) electrodiagnostic techniques used to distinguish peripheral nerve etiologies for shoulder pain, (3) how pathokinesiology affects treatment and exercise prescriptions in the treatment of shoulder pain, and (4) surgical indications and approach to common shoulder problems. P REREQUISITE—This course is designed as an educational opportunity for residents, fellows, and practicing clinical EDX consultants at an early point in their career, or for more senior EDX practitioners who are seeking a pragmatic review of basic clinical and EDX principles. It is open only to persons with an MD, DO, DVM, DDS, or foreign equivalent degree. A CCREDITATION S TATEMENT—The AAEM is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. CME CREDIT—The AAEM designates attendance at this course for a maximum of 4.0 hours in category 1 credit towards the AMA Physician’s Recognition Award. This educational event is approved as an Accredited Group Learning Activity under Section 1 of the Framework of Continuing Professional Development (CPD) options for the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. Each physician should claim only those hours of credit he/she actually spent in the activity. The American Medical Association has determined that non-US licensed physicians who participate in this CME activity are eligible for AMA PMR category 1 credit. iv

2003-2004 AAEM COURSE COMMITTEE

Kathleen D. Kennelly, MD, PhD Jacksonville, Florida

Thomas Hyatt Brannagan, III, MD Dale J. Lange, MD T. Darrell Thomas, MD New York, New York New York, New York Knoxville, Tennessee

Kimberly S. Kenton, MD Andrew Mazur, MD Bryan Tsao, MD Maywood, Illinois Portsmouth, Rhode Island Shaker Heights, Ohio

Christopher J. Standaert, MD Seattle, Washington

2003-2004 AAEM PRESIDENT

Lois Margaret Nora, MD, JD Rootstown, Ohio The Use of History and Physical Examination to Diagnose Shoulder Pain

Michael T. Andary, MD, MS Associate Professor Michigan State University College of Osteopathic Medicine Department of Physical Medicine and Rehabilitation East Lansing, Michigan

INTRODUCTION report pain in both places if their dominant arm was involved. As with all pain problems, the influence of the central nervous Physicians commonly have patients present with neck and upper system and psychological issues cloud an already confusing limb pain. A survey of over 9000 working-age adults found that picture.40 Thus, deciding if shoulder symptoms are actually 24% of people report shoulder pain in the previous 7 days. This related to shoulder pathology is difficult and at times impossible. pain interfered with normal activity in 14% of the entire sample. Adding neck, elbow, and wrist/hand pain to these numbers If the decision has been made that there is actually a shoulder almost doubles the prevalence. This is consistent with other pop- problem, a new set of problems opens up. There is little agree- ulation-based studies.40 ment on exactly how to make a specific shoulder-related diagnosis or what is the “gold standard” for each diagnosis. Many Classification of shoulder pain is challenging for numerous patients with shoulder pain present with signs and symptoms reasons. One of the most basic issues is to define exactly what consistent with multiple problems. For example, they may have “shoulder pain” means. There is considerable overlap between shoulder instability signs, superior labrum anterior to posterior neck, shoulder, and arm complaints. These symptoms are inter- (SLAP) lesions, and rotator cuff signs. Thus, it is difficult to de- related in most written articles as well as in patient complaints. termine if there is one cause or multiple causes for the pain. This Thus, in reviewing literature and examining patients, it is im- makes the diagnosis based only on a history and physical unreli- possible and medically misleading to artificially separate shoul- able and risky. Much of the diagnostic accuracy relies on surgi- der pain from neck and upper limb pain. Some studies have cal inspection which has its own set of bias, reliability, and focused on pain directly in the shoulders; other studies have clas- standardization issues. Even then, it is not clear that lesions seen sified symptoms in a regional pain distribution (neck/arm, at surgery are definitely the cause for pain. neck/shoulder, cervicobrachial, and neck/upper arm pain). Other reviews of the available literature have attempted to clas- Studies that describe the use of history and physical to diagnose sify the problem based on the pathoanatomic origins and not shoulder disorders are frequently as confusing as might be ex- just symptoms alone.40 This is mirrored by the clinical problems pected, given the multiple potential diagnoses, poor ability to of diffuse symptoms that include the shoulder with combina- make definitive diagnoses, and difficult treatment options. There tions of neck and arm symptoms. Many neck problems can refer are scores of reported physical examination tests evaluating the pain into the shoulder and vice versa. In an epidemiological neck and shoulder. The science and reproducibility of these tests study, if patients reported neck or shoulder pain, 46% would is variable. There are physicians’ names associated with some 2 The Use of History and Physical AAEM Course maneuvers, while at other times the same or similar maneuver is to radiate down the arm is unclear, but pain referral to below the described with a different name. This makes variability of tech- shoulder and to the elbow was required in at least one study.35 nique inevitable. This author prefers to hold the Spurling’s position and wait 30- 60 seconds for symptoms to develop. An initial negative test will This manuscript will focus primarily on the physical examina- turn positive after 30-60 seconds in many patients. tion and will organize some of the more common techniques for shoulder pain assessment. Unfortunately, not all of the tests will Validity of Spurling’s Sign not be covered. There will be some descriptions and names of the physical examination maneuvers to attempt to clarify the One study, using needle electromyography (EMG) as the refer- techniques and diagnoses they should yield. When possible, ev- ence standard, reported a sensitivity of 30% and a specificity of idence for accuracy and reliability will be given. These include 93%.35 This is consistent with another study using a combina- primarily the acromioclavicular (AC) joint, glenohumeral joint, tion of myelography, symptoms, and neurologic signs as the ref- and the muscles and tendons that surround these joints. erence standard.39

Shoulder Impingement Causing Neck Pain LOCALIZATION OF SYMPTOMS The overlap between shoulder symptoms and neck pain was il- Asking the patient for the exact site of symptoms or using a pain lustrated in a recent paper reporting on a retrospective review of diagram can be helpful in making a diagnosis. Patients who 34 patients with chronic neck pain along the medial border of report pain in one localized site may be easier to diagnose than the scapula coming from shoulder impingement.6 These 34 pa- those patients who report diffuse pain. Patients who report tients were selected out of a potential referral population of 972 diffuse pain in the neck, shoulders, elbows, wrists and hands patients with neck or shoulder pain. Patients were identified as have a strong association with psychological ill health. those who reported neck pain in the area of the superior medial Additionally, the same study reported other historical traits: border of the scapula during shoulder impingement signs, which being a “blue collar worker,” unemployed, female, and an active was called a positive “referred” shoulder impingement sign. smoker, were independently associated with diffuse pain in a These 34 patients met the following four criteria: (1) no pain in survey of over 9000 working adults in Britain.41 the shoulder during a negative shoulder impingement sign; (2) pain in the neck during the shoulder impingement maneuver; (3) abnormal radiographs of the shoulder including trabecular NECK PAIN atrophy (pseudocyst formation) under the greater tuberosity, and sclerosis either on the under side of the surface of the Referral of symptoms into the shoulder from neck problems is acromion or cortex of the greater tuberosity; and (4) the referred common. Periscapular pain is the norm with neck disease, either neck pain was relieved by injection of lidocaine and steroid into from radiculopathy, facet arthropathy, disc disease, or myofascial the subacromial space. This makes the case that these patients pain. There is little clear evidence to help physicians differentiate had neck pain referred from impingement syndrome in the one type of pain from another. Pain in the neck coupled with shoulder.6 Although there are methodological issues with this symptoms made worse by neck movement strongly suggest a paper there is good documentation of the referral of shoulder problem in the neck. pathology to the neck.

Spurling’s Sign RANGE OF MOTION OF THE SHOULDER Spurling’s sign tests for cervical radiculopathy. There are a couple of ways that this sign has been described. In Spurling’s original Apley Scratch Test paper he describes assessment of cervical radiculopathy when “the head and neck are tilted toward the painful side and pres- The Apley scratch test assesses range of motion (ROM) of the sure is applied to the top of the head, the whole radicular pattern shoulder complex. The patient is asked to reach behind their may be reproduced.”30 Some authors like to add neck extension head and touch the superior medial angle of the contralateral to this position. This theoretically should bulge the cervical disc, scapula.11 Internal rotation of the shoulder is also tested when put more pressure on the nerve root, and cause symptoms to the patient tries to reach behind their back to touch as high as radiate down the arm in a radicular pattern. Spurling’s sign is they can on their thoracic spine from the inferior portion of the positive if dysesthesias radiate down the arm. Pain in the neck back.17 This test assesses the ROM of both the glenohumeral only is not a positive test.35 Exactly how far the symptoms need joint and scapulothoracic motion. AAEM Course Painful Shoulder 3

Accuracy and Significance of Range of Motion Testing in the soft tissues. The pain is usually in the subacromial region. Injection of local anesthetic to relieve the pain is supportive of There is a loss of ROM in many painful shoulder problems. It is the diagnosis of impingement syndrome.3,38 useful to separate glenohumeral ROM deficits from scapulothoracic problems. There is little literature focusing on specific Accuracy of Neer and Hawkins Impingement Signs ROM maneuvers correlating with specific diagnoses. Decreased ROM—especially loss of external rotation of the glenohumeral Clinical signs were prospectively compared to the “gold stan- joint—is highly suspicious of either adhesive capsulitis or de- dard” of findings at arthroscopy in 85 patients who underwent generative arthritis of the glenohumeral joint. Loss of internal ro- shoulder arthroscopy by a Canadian surgeon. When looking for tation is suggestive of glenohumeral internal rotation deficit subacromial bursitis (but not rotator cuff tear) the Neer sign had (GIRD) in competitive overhead athletes. a sensitivity of 75%, compared to 92% sensitivity for the Hawkins sign. When looking for a rotator cuff tear, the sensitivity of the Neer sign was 85% and the Hawkins sign was 88%. IMPINGEMENT SYNDROME AND ROTATOR CUFF TEARS The specificity and positive predictive values for the Hawkins and Neer tests were much lower—in the range of 35-55%. The Clinical Presentation Neer sign was also positive in 46% of patients with Bankart lesions, 46% of patients with SLAP lesions, and 68% of arthri- Patients usually present with pain in the affected shoulder with tis patients. The Hawkins sign had similar findings for SLAP overhead activity. Shoulder and arm pain at night are common, and AC joint arthritis. Both tests had a high negative predictive especially if patients sleep on the affected side. This pain fre- value, over 90% for bursitis and rotator cuff tearing when they quently refers into the arm. There may be an “arc of pain” within were combined. Overall, their sensitivity appears to be quite approximately 60-120° of abduction of the arms.3 Patients fre- good, but specificity is limited.19 This study has some strengths quently complain of weakness of shoulder movements either due because it includes multiple diagnoses, which is frequently seen to pain or rotator cuff tears. in clinical practice, and was prospectively and systematically completed by one person. However, the obvious limitations re- Neer Impingement Test garding the limited number of patients and physicians make generalization problematic. First described in 1972, the Neer impingement test is performed with the patient seated and the examiner standing. The elbow is Internal Rotation Resistance Stress Test straight, and the arm is passively elevated in the plane some- where between flexion and abduction. The humerus may also be The internal rotation resistance stress test is used to help differ- internally rotated. The scapula should be depressed and stabi- entiate between intraarticular and outlet impingement syn- lized by the examiner’s other hand. The arm may be elevated as drome. This test has been described in patients who already have far as 180°. The internal rotation of the humerus forces the a positive Neer impingement sign. The arm (shoulder) is posi- greater tuberosity of the humerus to compress soft tissue struc- tioned in 90° of abduction and 80° of external rotation. The rel- tures (supraspinatus tendon, subacromial bursa, and biceps ative isometric strength of internal and external rotation is tested tendon) against the acromion, superior glenoid, and at times the and compared to each other. The test is considered positive if the coracoacromial ligament and AC joint.32 If subacromial injec- internal rotation strength is relatively weaker than the external tion of local anesthetic relieves the pain, this is strongly support- rotation strength. The strength is not compared to the con- ive of impingement problems.3,38 tralateral arm. A positive test (weak internal rotation) is suggestive of internal impingement. If the test is negative (stronger Hawkins Impingement Test internal rotation) the impingement is considered classic outlet impingement.32 In 1980, Hawkins and Kennedy described another provocative test for impingement syndrome. The humerus is forward flexed Gerber’s Subcoracoid Impingement Test to 90°, the elbow is flexed to 90°, and then forcibly internally rotated, again driving the greater tuberosity towards the anterior In the Gerber’s subcoracoid impingement test, the arm (shoul- acromion, coracoacromial ligament, and AC joint causing pain der) is abducted to 90° and internally rotated. If there is pain and 4 The Use of History and Physical AAEM Course restriction of motion, this is a positive test and suggests entrap- The authors concluded that for extensive rotator cuff pathology, ment of the rotator cuff between the humeral head and coracoid testing the supraspinatus would be helpful. The drop arm test process.32 Validity studies on this test were not found. and empty can test were not reported in this study.10

TESTING STRENGTH AND INTEGRITY OF THE TESTING THE INTEGRITY OF THE INFRASPINATUS TENDON SUPRASPINATUS TENDON Drop Sign Supraspinatus Test The drop sign can be used to test the integrity of the infraspina- With the supraspinatus test (Jobe test) the patient abducts their tus tendon. With the patient in the seated position, the arm shoulder to 90° in the scapular plane (horizontally flexed to 30°) (shoulder) is abducted to 90° in the scapular plane. The elbow is with the thumb pointing inferiorly down to the floor (internally flexed to 90° and the shoulder is almost fully externally rotated rotating the humerus). The examiner resists the patient’s efforts (short by 5°). Full external rotation is avoided to prevent elastic to abduct their arm in the scapular plane. If this causes pain in recoil. The drop sign is positive if there is a “lag” and the patient the subacromial area, it is considered a positive test. Weakness cannot maintain the shoulder in full external rotation. The mag- compared to the contralateral side is also a positive test.10,32 nitude of the lag is recorded to the nearest 5°. A positive drop sign indicates a tear of the infraspinatus. The “external rotation Empty Can Test lag sign” is also performed in a similar position except the arm (shoulder) is only abducted to 20°. A positive drop sign in this The empty can test is a popular variation to the supraspinatus position has also been reported as highly suggestive of a complete test. This test is used primarily to assess the strength of the supraspinatus tear. Interpretation of these signs is complicated by supraspinatus. It should be noted that one fine-wire needle other pathology that affects ROM of the shoulder and neuro- EMG study shows the deltoid and infraspinatus are also active logic weakness.32 during this test, thus the supraspinatus is not purely isolated during this test.28 The shoulder is abducted to between 30-60° with the thumb pointed down (glenohumeral joint internally SUBSCAPULARIS TENDON TEAR rotated). The arm is usually flexed forward another 30°. The patient then attempts to abduct their glenohumeral joint, which Lift-Off Test is resisted by the examiner. Weakness with this test is indicative of supraspinatus tear; pain without weakness could suggest The lift-off test assesses the integrity of the subscapularis tendon. supraspinatus tendon pain from tendonitis or tendonosis.12,28 This is performed by placing the patient’s arm in full internal rotation and extension behind their back. The elbow is at 90°. The Drop Arm Test patient is asked to move their hand off their back, thus the maneuver attempts to maximize simultaneous internal rotation and The drop arm test is considered another variation of the extension. If the subscapularis muscle is weak from a tendon tear supraspinatus test and attempts to detect tears in the rotator cuff they are unable to lift their hand off their back. This is a positive (especially the supraspinatus). The patient is instructed to fully test for subscapularis tendon rupture.24 abduct their arm, and then slowly lower the arm to their side. In a positive test, at about 90° of abduction the patient will lose Belly-Press Test their strength and not be able to lower their arm smoothly, thus the arm will drop quickly to their side. This suggests a complete In the belly-press test, the palm of the hand is put on the mid- rotator cuff tear especially of the supraspinatus tendon.11 abdomen (belly) and the palm is pushed onto the abdomen. If there is a tear in the subscapularis tendon the patient will main- Validity of the Supraspinatus Test tain pressure on the abdomen by allowing the elbow to move posterior thus extending rather than internally rotating the A blinded comparison of clinical evaluation of the previously de- shoulder.34 scribed supraspinatus test with surgical findings at a tertiary shoulder center in Toronto, Ontario, was reported.10 The Validity of the Lift-Off and Belly-Press Tests authors found that sensitivity to partial thickness tears was 62%, a full thickness tear was 41%, and sensitivity to large massive Two studies have evaluated the needle EMG activity of the sub- tears was 88%. The specificity values were between 54-70%. scapularis muscle during the lift-off and belly-press tests and AAEM Course Painful Shoulder 5 have found the best position for activation of the lower sub- positive bone scan.42 Another retrospective study of 35 patients scapularis is in the mid-lumbar region, and that other internal used distal clavicle resection as the reference standard. They re- rotators are not as active.7 The lift-off test more selectively acti- ported a sensitivity and accuracy of 77% and 79% for the vates the lower subscapularis and the belly press activates the crossed arm test, 41% and 92% for O’Brien’s test, and 72% and upper subscapularis.34 This author could find no studies to assess 84% for the AC resisted extension test.4 the reproducibility or validity of these tests.

SUPERIOR LABRUM ANTERIOR TO POSTERIOR TEARS ACROMIOCLAVICULAR JOINT History Crossed Arm Adduction Test Tears of the labrum near the area of insertion of the long head of For assessing AC joint pain, the crossed arm adduction test is the biceps were first described in 1985 and the term “superior often performed. The humerus is forward flexed to 90° and then labrum anterior to posterior” tears or “SLAP” lesion was coined hyper-adducted across the midline of the body, compressing the in 1990.31 Patients usually have vague nonspecific shoulder pain AC joint. A positive test causes pain in the AC joint area. If the that is exacerbated by overhead arm activity often associated with humerus is internally rotated during this maneuver the patient popping, locking, and snapping. There may also be associated may have pain from a positive impingement sign and confuse in- instability or rotator cuff symptoms. The onset of symptoms is terpretation.3 frequently associated with some kind of trauma—usually traction or compression of the shoulder—although in many cases no Paxinos Sign traumatic history can be elicited and the onset is insidious.23,31

To test for the Paxinos sign, the examiner’s thumb is placed Physical Examination under the posterolateral aspect of the acromion of a seated patient. Then the index and long fingers of the same or con- There are several tests described in the literature that are thought tralateral hand are placed on the superior aspect of the middle to help diagnose SLAP lesions. Unfortunately, the physical ex- part of the ipsilateral clavicle. The examiner then applies pres- amination of patients with SLAP lesions is associated positive sure, in an anterosuperior direction, to the acromion with the tests such as Speeds, Neer, Hawkins, and Apprehension (39% in thumb and simultaneously pushes inferiorly to the midpart of one study population)23 which are used to help diagnose other the clavicle with the index and long fingers. The test is positive disorders Four of these tests will be discussed; (1) compression if there is an increase in pain in the region of the AC joint.42 rotation test, (2) anterior slide test, (3) O’Brien’s active compression test, and (4) anterior slide test. Resisted Extension Test Compression Rotation Test The resisted extension test was first described in 1997 by Jacob and Sallay.13 In this test, the patient’s arm (shoulder) is flexed 90° When performing the compression rotation test, the patient is with the elbow flexed to 90°, and then the patient is asked to supine with the arm abducted to 90°, the elbow flexed 90°, and extend the arm (shoulder) against resistance. This test is consid- the humerus compressed into the glenoid. An axial load is placed ered positive if pain is created at the AC joint.4 on the shoulder, by compression over the elbow as it is circum- ducted and internally and externally rotated. This is an attempt Palpation of the Acromioclavicular Joint to catch a labral fragment. The test is considered positive if there is a click or pain with compression.21,33 Palpation directly over the AC joint causing pain is also helpful to assist in a diagnosis of AC joint pain, which coexists with Anterior Slide Test other shoulder problems. This author found two somewhat conflicting descriptions of the Accuracy of Diagnosing Acromioclavicular Arthritis anterior slide test.21,33 When performing the anterior slide test, the patient has their affected arm positioned with the hand on One rigorous (level 1) blinded, prospective study, using 50% the hip and the thumb anterior21 or posterior.32 The examiner pain relief to AC joint injection as the reference standard, re- stands behind the patient and stabilizes the shoulder by putting ported a sensitivity of 96% for AC tenderness, 79% for the their hand on the shoulder and the index finger over the anterior Paxinos sign, and 16% for O’Brien’s active compression test.42 acromion with one arm, while using the other arm to apply an However, with stepwise regression analysis, they found a 99% anterior/superior directed axial load on the humerus at the post-test probability of accuracy with a positive Paxinos test and elbow. The patient is then asked to push back against this force.32 6 The Use of History and Physical AAEM Course

The test is positive if there is a click or deep pain in the shoul- reports of abnormal findings on magnetic resonance imaging der. Pain in another location of the shoulder is not considered a that are not symptomatic. The prevalence of asymptomatic positive test result.14,21,33 SLAP lesions has not been well-evaluated for arthroscopy.5,22

O’Brien Active Compression Test Accuracy of Clinical Testing for Superior Labrum Anterior and Posterior Lesions When performing the O’Brien active compression test, the patient is in a standing position and the affected arm (shoulder) The initial study of the O’Brien active compression test reported is flexed forward to 90° and adducted across the body 10° with an amazing sensitivity of 100% and specificity of 98.5%.26 the thumb pointing towards the ground. The patient then is Subsequent studies are much less optimistic. One retrospective asked to keep their arm in that position as the examiner pushes review of 426 patients undergoing shoulder arthroscopy com- down on the arm. The O’Brien test is repeated with the shoul- pared the sensitivity and specificity of the compression rotation der in the same position and the palm of the hand pointing test, the anterior slide test, and the O’Brien active compression upward. The test is positive if there is initial pain deep in the test. Results of arthroscopy showed that 39 patients had SLAP shoulder and that pain is eliminated with the palm up. Pain lesions (Type II, III, or IV) and the remaining 387 patients had located in the AC joint or elsewhere in the posterior or anterior a Type I lesion (not clinically significant) or no lesion and were shoulder or the deltoid is not considered a positive test. Pain in considered the control group. The O’Brien active compression the AC joint is indicative of AC arthritis.21,24,33 test was the most sensitive test at 47%, the anterior slide test was most specific at 84%, the active compression test had the highest Crank Test positive predictive value at only 10%, and the anterior slide test had the highest overall accuracy of 77%. The compression rota- The crank test has been described with at least two minor variation test had an accuracy of 71% and the active compression test tions. The patient is supine or seated. The shoulder is abducted was 54%.21 to 160° (or full abduction). In either position the humerus is internally and externally rotated while axially loading the gleno- Two separate studies have reported the crank test as not helpful humeral joint. If there is pain, this test is positive. Some report in the diagnoses of SLAP lesions. Disappointing numbers of pain or clicking as a positive test.8,31,33 The name “crank test” has 46% sensitivity and 56% specificity in one study,31 and not also been used interchangeably with the apprehension test de- proving statistically predictive in another study8 make the clini- scribed in the shoulder instability section.16 cal utility of the crank test doubtful. The O’Brien test was somewhat better with 63% sensitivity and 73% specificity8 in one Problems With Determining Accuracy of Clinical Testing for study, and 31% sensitivity and 54% specificity in a second Superior Labrum Anterior to Posterior Tear Lesions report.31

In part, the SLAP lesion is a new disease which complicates the accuracy of diagnosing shoulder injuries and also makes it com- EVALUATION FOR BICIPITAL TENDONITIS plicated for physicians to agree on a diagnosis. In addition to the other typical problems seen with physical examination testing, History there are at least two more problems. First, most SLAP lesions do not occur in isolation. Studies show that most patients with With bicipital tendonitis, patients usually have pain in the ante- SLAP lesions also have other intra-articular lesions. One study rior shoulder at the bicipital groove. There is considerable demonstrated 77% of patients had one or more of the following: overlap between other shoulder problems especially impinge- supraspinatus tendon tears, infraspinatus tendon tears, Bankart ment syndrome, rotator cuff tears, and SLAP lesions. Chronic lesions, Hill-Sachs lesions, or arthritic changes.21 Another bicipital tendonitis or tendonosis may present with a rupture of prospective study of 65 patients reported that 70% had partial the long head of the biceps tendon after an audible pop followed or complete rotator cuff tears and 89% had inflammation of the by bruising in the anterior arm and the presence of a lump in the subacromial space.31 This is consistent with other studies.8 It distal biceps muscle. This rupture may relieve the long-standing appears that patients with isolated SLAP lesions are unusual. anterior shoulder pain.27

It Is Not Clear That Pathology Seen Is Actually Causing Yergason Test Symptoms The Yergason test was first described in 1931 in a case report and The use of arthroscopic findings as the reference standard or is performed with the elbow flexed to 90°, forearm pronated, gold standard may not be totally accurate. There are many and the arm (shoulder) adducted at the side of the body. The ex- AAEM Course Painful Shoulder 7 aminer holds the wrist and the patient then attempts to force- Bilateral shoulder findings, and responds to fully supinate their forearm against resistance. There are several Rehabilitation, and may benefit from ways this is interpreted. If pain is referred to the bicipital groove Inferior capsular shift.18 with this maneuver, it constitutes a positive test and is suggestive for biceps tendonitis.8,27,32 There is a second way this test has Multidirectional instability has been defined as instability in two been performed. With the patient in the same position as previ- or three directions. There are several classifications of multidi- ously described, he/she attempts to flex the elbow while the ex- rectional instability. Depending on the definition and criteria aminer externally rotates the arm and pulls downward on the used, the same patients may be classified as having different types elbow. If the biceps tendon is unstable in the bicipital groove, the of instability.21 This makes defining a “gold standard” for the di- long head of the biceps will pop out of the groove and the agnosis impossible. patient will experience pain.11 The second method is probably an unusual problem and not the most common use of the Yergason test. ASSESSMENT FOR SHOULDER INSTABILITY

Speeds Test Laxity examinations should not cause symptoms in normal people. The presence of symptoms during most of these tests With the Speeds test (palm up test) the patient forward flexes the suggests abnormality. shoulder against resistance with the forearm supinated and the elbow extended. Pain in the anterior shoulder and bicipital Apprehension Test groove reflects a positive test suggestive of biceps tendonitis or, less commonly, SLAP lesions.24,32 The apprehension test has also been referred to as the crank test, fulcrum test, or Feagin maneuver.16 The patient is supine with Accuracy of Yergason’s Test and Speeds Test the shoulder in 90° of abduction and external rotation. The arm is further externally rotated until there is an end range of motion Sensitivity and specificity for the Yergason and Speeds tests and or the patient requests the examiner to stop. If they have pain or labral pathology has been reported as statistically insignificant.8 apprehension the test is positive.37 Another study correlating Speeds test to arthroscopic findings of biceps/labral pathology reported a specificity of 14% and a sen- Relocation Test sitivity of 90%.2 The relocation test is performed immediately after the apprehension test. The examiner places posterior force on the INSTABILITY OF THE SHOULDER humerus, relocating the humerus. If symptoms are reduced, the test is positive.37 The definition for instability of the shoulder is not widely and definitively agreed upon. There are several definitions and classi- Release Test fications. Classifications include: (1) dislocation and subluxation; (2) traumatic, atraumatic, or repetitive microtrauma; (3) The release test (or surprise test) is performed immediately after direction of instability, such as anterior, posterior, inferior, or the relocation test. If the examiner suddenly releases the poste- multidirectional; (4) voluntary or involuntary; or (5) abnormal rior pressure and the patient has increased symptoms, the test is examination under anesthesia.20,36 Another classification popu- positive.37 larized by Matsen uses acronyms to classify shoulder instability into two separate classes. The TUBS acronym represents pa- Load and Shift Test tients who have: There have been several variations of the load and shift test de- Traumatic instability, scribed,33,35 with the patient either seated or supine. The anterior Unidirectional in nature, with an associated and posterior drawer tests on the shoulder are also variations of Bankart lesion, and usually responds to this test with some change in positioning. In the supine position, Surgery. the center of the scapula is at the edge of the examining table and the arm can be abducted to 20-90°. An axial load is applied by On the other end of the spectrum is the AMBRI variant of in- putting pressure on the humerus (pushing the humerus in to the stability. Patients present with: glenoid cavity) with the elbow flexed to 90°. Once the humerus is loaded, the examiner then attempts to shift the humeral head Atraumatic etiology that is anterior, posterior, or inferior. The results have been graded Multidirectional in nature, frequently with between 0 to 3. Grade 0 demonstrates little to no movement of 8 the Use of History and Physical AAEM Course the humeral head; in grade 1 the humeral head was shifted so who had alternative diagnoses nor were any normal subjects that it could start to ride up on the glenoid labrum; in grade 2 evaluated. When apprehension was used as a positive sign (as the humeral head could be shifted off the glenoid and dislocated opposed to pain), the apprehension was much more reliable. but spontaneously relocated once the pressure is eased; and in The ICCs were as follows; 0.47 for the apprehension, 0.71 for grade 3 the humeral head could be shifted off the glenoid and the relocation test, and 0.63 for the release test. When pain was remain dislocated. This test can be performed in different posi- used as the criteria, the ICC dropped about 50% for each.37 tions of shoulder abduction while seated or supine.33,35 Another study reported the mean interobserver reliability for all three tests to be 0.83.16 Sulcus Sign Accuracy of the Apprehension Test, Relocation Test, and The sulcus sign is tested with the patient sitting and their arm Release Test hanging at their side. The examiner grasps the elbow and pulls down. An observation of a sulcus in the subacromial region is One retrospective study looking at 46 patients with a variety of measured in centimeters.37 This is thought to be most suggestive diagnoses and blinded observers has been reported. The criteria of inferior instability.20 for determining diagnoses were not clearly stated. In subjects who had a feeling of apprehension on all three tests, the mean Interexaminer Reliability of Tests for Shoulder Instability positive predictive value was 93.6% and the negative predictive value was 71.9%. The release test was the single most accurate There is disagreement among studies on this issue. One study test (sensitivity = 63.89%; specificity = 98.91%). The relocation using 4 examiners and 13 symptomatic patients (no control sub- test added little to the value of the tests.16 jects) assessed these tests and found good intraclass correlation coefficients (ICC) for most of the examinations suggesting good reliability.35 At least two other studies show a much lower inter- TRYING TO PULL THE DIAGNOSES AND PHYSICAL rater reliability.15,25 EXAMINATION TOGETHER – CAN ANYBODY DO IT RELIABLY?

Interexaminer reliability of the load and shift test showed fairly It is not clear how many of these studies resemble real life. good ICC in general, ranging between 0.53 and 0.79 with the Patients do not come to the clinician having sorted themselves most reliable testing in 90° of abduction.37 into groups and diagnoses. Many studies look at patients who are highly selected which can improve reliability studies. In ad- Interexaminer reliability of the sulcus sign showed fair to good dition, there may be a positive publication bias which may over- ICC of 0.6 with an average sulcus sign measurement of 0.5 cm.37 estimate the true reliability of these tests. There are few studies Other authors have used a different grading scale for the sulcus that attempt to assess multiple potential diagnoses using multi- sign, with Grade I defined as <1.0 cm; Grade II, as 1.0-2.0 cm; ple clinicians. Two of the best studies on this topic will be and Grade III, as >2.0 cm.20 This variability in grading scales in- reviewed. dicates disagreement between different authors as to what is considered normal. Another study that aligned a group of four blinded physicians examined 43 asymptomatic college athletes. METHODS: STUDY 1 This study showed much worse intra- and interobserver reliability.15 Eighty-six consecutive Danish patients with longstanding shoulder joint pain were blindly examined by two trained doctors; a Interexaminer Reliability of the Apprehension Test, rheumatologist and an orthopedic surgeon. The patients had Relocation Test, and Release Test shoulder pain of at least 2 months and had failed previous treatment of steroid injection. Patients with adhesive capsulitis were Thirteen symptomatic patients were systematically evaluated excluded. The examiners took a standardized history and physi- with the apprehension test, relocation test, and the release test. cal. The physical examination consisted of ROM, strength Positive tests were considered to be patient pain, apprehension, testing, and the following previously described tests: Neer, or both. Subjects of the study were highly selected patients who Hawkins, supraspinatus, apprehension, relocation, release, load (1) had sufficiently symptomatic shoulder pain to warrant refer- and shift, crank, anterior slide, sulcus sign, and AC palpation. ral to an orthopaedic shoulder specialist, and (2) had a history The examiners received results of the ultrasound of the shoulder, suggestive of glenohumeral instability. There were no patients and each examiner came up with a diagnosis. Examiners then AAEM Course Painful Shoulder 9 discussed their findings and decided on a diagnosis and treat- treatment. Despite the different diagnoses, there was agreement ment plan, which lead to 42 patients (49%) having arthroscopy. in the treatment; all three rheumatologists recommended steroid They reported interrater reliability and diagnostic accuracy. injections followed by physiotherapy for most of the patients.1

RESULTS: STUDY 1 SUMMARY

The history questions had variable agreement with 8 out of 23 The previously discussed two studies document what seems to questions having poor agreement (Kappa < 0.4). The physical be true in most clinical situations. The interrater reliability and examination tests in general had poor interrater reliability the diagnostic accuracy in patients with shoulder problems is (Kappa < 0.4). Only the Hawkins test, supraspinatus test (for problematic and needs improvement. As physicians learn more pain), pain with internal/external rotation, tenderness in the in- about shoulder pathophysiology, it is hoped the diagnostic accu- fraspinatus muscle and the anterior drawer (load and shift) racy will improve. At this stage, the use of a history and physical showed moderate or good reliability. The interrater reliability examination to diagnose shoulder pathology is problematic. was poor (Kappa <0.4) on examination alone, even with history While the literature reveals differing and suboptimal levels of added. The diagnostic accuracy (using arthroscopy as the refer- sensitivity and specificity in trials, clinical acumen and intra-rater ence standard) was also partially reported. The surgeon had rea- reliability have not been carefully evaluated. Trying to attain con- sonable results for complete supraspinatus tears (sensitivity 67%, sistency between clinicians during physical examination after specificity 90%, and accuracy of 79%.). However, the diagnos- thorough history should help improve a semi-accurate diagnosis. tic accuracy was less than 65% for partial supraspinatus lesions, This holds implications for prescription for treatment, further labral lesions, and all of the rheumatologist’s diagnoses. Accuracy diagnosis, and referral for additional evaluation. was not improved with adding history, and was marginally improved for supraspinatus tears when ultrasound data was added.25 REFERENCES

1. Bamji AN, Erhardt CC, Price TR, Williams PL. The painful shoul- METHODS: STUDY 2 der: can consultants agree? Br J Rheumatol 1996;35:1172-1174. 2. Bennett WF. Specificity of the Speed's test: arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove. Another study reported poor interrater reliability for the final di- Arthroscopy 1998;14:789-796. agnoses of shoulder pain. Three British rheumatologists exam- 3. Chen AL, Rokito AS, Zuckerman JD. The role of the acromioclavic- ined the same 44 patients with shoulder pain and independently ular joint in impingement syndrome. Clin Sports Med 2003;22:343- recorded their diagnosis and recommended treatment. These 357. physicians diagnosed five different problems: adhesive capsulitis, 4. Chronopoulos E, Kim TK, Park HB, Ashenbrenner D, McFarland EG. Diagnostic value of physical tests for isolated chronic acromio- rotator cuff/subacromial joint lesions, biceps tendonitis, AC clavicular lesions. Am J Sports Med 2004;32:655-661. joint disease, or destructive arthritis (Milwaukee shoulder). 5. Connor PM, Banks DM, Tyson AB, Coumas JS, D’Alessandro DF. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. Am J Sports Med RESULTS: STUDY 2 2003;31:724-727. 6. Gorski JM, Schwartz LH. Shoulder impingement presenting as neck pain. J Bone Joint Surg Am 2003;85:635-638. There was complete diagnostic agreement in only 46% of the 7. Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R. cases. In the second phase of this study, the three rheumatolo- Validation of the lift-off test and analysis of subscapularis activity gists examined 18 patients together, discussed the symptoms and during maximal internal rotation. Am J Sports Med 1996;24:589- signs, and recorded their diagnoses separately. Their level of 593. agreement improved to 78%. There were difficulties with agree- 8. Guanche CA, Jones DC. Clinical testing for tears of the glenoid labrum. Arthroscopy 2003;19:517-523. ment on the presence of more than one lesion, and differences 9. Holtby R, Razmjou H. Accuracy of the Speed's and Yergason's tests in interpretation of physical signs. Had the diagnoses of SLAP in detecting biceps pathology and SLAP lesions: comparison with lesions and glenohumeral instability been included to further arthroscopic findings. Arthroscopy 2004;20:231-236. separate the examiners, it seems likely this diagnostic agreement 10. Holtby R, Razmjou H. Validity of the supraspinatus test as a single would have decreased even further. Interestingly, it is not clear clinical test in diagnosing patients with rotator cuff pathology. J Orthop Sports Phys Ther 2004;34:194-200. that making the diagnosis mattered much with regard to their 10 The Use of History and Physical AAEM Course

11. Hoppenfeld S. Physical examination of the spine and extremities. 27. Patton WC, McCluskey GM 3rd. Biceps tendinitis and subluxation. Norwalk: Appleton-Century-Crofts; 1976. Clin Sports Med 2001;20:505-529. 12. Itoi E, Kido T, Sano A, Urayama M, Sato K. Which is more useful, 28. Rowlands LK, Wertsch JJ, Primack SJ, Spreitzer AM, Roberts MM. the “full can test” or the “empty can test,” in detecting the torn Kinesiology of the empty can test. Am J Phys Med Rehabil supraspinatus tendon? Am J Sports Med 1999;27:65-68. 1995;74:302-304. 13. Jacob AK, Sallay PI. Therapeutic efficacy of corticosteroid injections 29. Silliman JF, Hawkins R. Classification and physical diagnosis of in- in the acromioclavicular joint. Biomed Sci Instrum 1997;34:380- stability of the shoulder. Clin Orthop 1993;291:7-19. 385. 30. Spurling RG, Scoville WB. Lateral rupture of the cervical interverte- 14. Kibler WB. Specificity and sensitivity of the anterior slide test in bral discs: a common cause of shoulder and arm pain. Surg Gynecol throwing athletes with superior glenoid labral tears. Arthroscopy Obstet 1944;78:350-358. 1995;11:296-300. 31. Stetson WB, Templin K. The crank test, the O'Brien test, and 15. Levy AS, Lintner S, Kenter K, Speer KP. Intra- and interobserver re- routine magnetic resonance imaging scans in the diagnosis of labral producibility of the shoulder laxity examination. Am J Sports Med tears. Am J Sports Med 2002;30:806-809. 1999;27:460-463. 32. Tennent TD, Beach WR, Meyers JF. A review of the special tests as- 16. Lo IK, Nonweiler B, Woolfrey M, Litchfield R, Kirkley A. An evalu- sociated with shoulder examination. Part I: the rotator cuff tests. Am ation of the apprehension, relocation, and surprise tests for anterior J Sports Med 2003;31:154-160. shoulder instability. Am J Sports Med 2004;32:301-307. 33. Tennent TD, Beach WR, Meyers JF. 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Peripheral Nerve Disorders in the Shoulder Region: Mechanisms and Differential Diagnosis

Kerry H. Levin MD Head, Section of Neuromuscular Disease/EMG Cleveland Clinic Cleveland, Ohio

INTRODUCTION Root Lesions

The shoulder is a complicated anatomic structure. In addition to Damage at the root level results from traction on the arm with its role as a joint with amazing range of motion, it is a conduit the trunk fixed, based on cadaver studies.6 Examples include de- for the vessels and nerve trunks supplying the arm. Considering liveries in the transverse presentation and reduction of a dislo- the proximity of the brachial plexus and main nerve trunks to cated shoulder by pulling on an outstretched arm. Roots are the shoulder joint itself, it is surprising that the incidence of protected in a cone-shaped dural envelope, which continues as nerve pathology in the area is as low as it is. the epineurium of the spinal nerve. Nerve roots are also relatively protected by root ligaments, fibrous attachments from the spinal The topics to be covered in this manuscript include the major nerve epineurium to the transverse process of the spine. Root lig- mechanisms of nerve trauma in the shoulder region, shoulder aments are missing from the C8 and T1 spinal nerves, which dislocation, clavicular fracture, neurological disorders in the may account for their increased tendency to be avulsed. shoulder region, and electrodiagnostic (EDX) considerations. However, at the other levels spinal nerve rupture may occur from the traction.21 When the plexus is forcibly depressed or the cervical spine pushed to the other side, the course of the C5 and C6 MAJOR MECHANISMS OF NERVE TRAUMA IN THE SHOULDER roots in particular is altered when entering the intervertebral REGION foramen. These spinal nerves are stretched over the transverse processes as they course downward to their foramina, adding fix- Nerve trauma in the shoulder region occurs as the result of the ation and vulnerability.2 Forcible downward traction on the arm combination of forceful stretch associated with extreme move- produces greatest stretch on the C5 spinal nerve, followed by C6 ment.6 Much of the scientific work that has led to an under- and occasionally C7. C8 is less affected, but the T1 spinal nerve standing of these concepts was performed on cadavers in the mid is flattened over the first rib. 1820s to the early 1900s. These grotesque pathological studies involved experiments such as letting a corpse fall on the head and Supraclavicular Plexus Lesions shoulder after being lifted to the ceiling.13 These studies forcibly produced pathological situations such as widening the shoulder- In general, these lesions occur as a result of traction on the arm neck angle and dislocation of the shoulder. Other studies have or widening of the shoulder-neck angle. Plexus elements get been performed on animals, or have analyzed autopsies of pa- stretched between points of fixation. Examples include the at- tients after clinical reduction of shoulder dislocation.8 tachment sites of the C5 - C6 spinal nerves to the transverse 12 Peripheral Nerve Disorders in the Shoulder Region AAEM Course processes proximally and the trunk-cord junction distally, and Infraclavicular Plexus Lesions origin of the medial cord proximally and the point where it winds around the coracoid distally.6 Factors operating at this level include the proximity of the neurovascular bundle to the glenohumeral joint, and the close at- In cadaver experiments, widening the shoulder-neck angle and tachment sites of the infraclavicular plexus. The axillary nerve downward traction on the arm resulted in comparable lesions. and posterior cord are the most vulnerable structures in the infr- These actions are much more likely to involve the upper and aclavicular plexus. With the arm in abduction, all elements of middle trunks, since traction applied to the lower trunk is more the infraclavicular plexus are under tension. However, traction likely to result in root avulsion.6 With further traction, C8 and with the arm adducted does not affect this area.17 T1 fibers bend over the first rib and the posterior cord becomes crushed between the clavicle and the first or second rib. This sit- Internal rotation of the abducted arm adds tension to the axil- uation occurs to motorcyclists thrown from their bikes on to the lary nerve, radial nerve, and posterior cord across the humeral road, especially when the arm is behind the trunk (Figure 1).1 head (Figure 2). This can occur when falling on the laterally

Figure 1 Traumatic mechanisms resulting in supraclavicular brachial plexus injuries. From Coene, with permission.6 AAEM Course Painful Shoulder 13

Figure 2 Relationships between the axillary nerve, the infraclavicular neurovascular bundle, and the humeral head in internal (A and C) and external (B and D) rotation. A and B are frontal, C and D are caudal views. In internal rotation, the inferior glenohumeral ligament prevents further abduction. Both the axillary nerve and neurovascular bundle are caudal to the humeral head and stretched over it. In external rotation, the neurovascular bundle is ventral to the humeral head. Only extension will stretch it in this position. The axillary nerve runs from a ventral subcoracoid position to the dorsal side of the humeral neck and is the only nerve stretched during dislocation. The glenohumeral ligament does not prevent further abduction. Note that the humerus is in 30% retroflexion to the scapular plane (C and D), and the humeral head projects about 50% ventral to the anterior glenoid rim. From Coene, with permission.6

outstretched arm with movement of the scapula blocked by the damage may follow, and the median and ulnar nerves after. The ground (Figures 3 and 4).6 The tension is additive on the axillary axillary artery is also subject to disruption, which occurs in about nerve and posterior cord because their distal anchorage point is 50% of extensive infraclavicular plexus lesions. close to the glenohumeral joint. Progressive stretch of the plexus over the humeral head also occurs when the arm at 90° of ab- The Scapula And Suprascapular Nerve Lesions duction is extended behind the frontal plane of the body. External rotation adds tension to the musculocutaneous nerve Fixed in the suprascapular notch, the suprascapular nerve is put trunk. under tension during normal abduction of the arm. With this maneuver, the scapula moves laterally, rotates, and turns around As more tension is applied in the traumatic event, other struc- the thorax. With pathological traction or abduction of the tures may be involved. Musculocutaneous and radial nerve scapula, the suprascapular nerve is tethered at the notch and 14 Peripheral Nerve Disorders in the Shoulder Region AAEM Course

Figure 3 Skeletal injuries. When a person falls sideways on the extended and internally rotated arm, the impact is initially on the hand, forearm, or elbow. The mass of the torso causes hyperabduction of the glenohumeral joint and forcible separation of the humerus and scapula. The impact is all on one side and the thorax hits the solid ground. Forced inclination of the scapula is blocked by the ground, and the humerus and scapula are subsequently separated with more force. This mechanism may produce injury to the hand, forearm, elbow, shoulder, scapula and ribs, successively. A dislocation or humeral neck fracture may occur. From Coene, with permission.6

undergoes progressive stretch, which can accompany both supr- scapularis muscle with its insertion on the shoulder joint. aclavicular and infraclavicular plexus lesions.15,25 When supras- Anterior dislocation is often associated with other trauma, in- capular nerve damage results from trauma, it is often due to a cluding fracture of the greater tuberosity, humeral neck fracture, stretching force, such as exaggerated outstretching of the arm, or and associated hematoma. The presence of an associated lesion repeated strong movements of the outstretched arm, such as increases the likelihood of nerve damage. hammering and sorting.5 De Laat and colleagues reported on 101 consecutive patients Shoulder Dislocation with dislocation or humeral neck fracture resulting from low- energy impacts.7 Forty-four patients had a primary shoulder dis- In regard to nerve disorders associated with shoulder dislocation, location, 57 had humeral neck fracture, and 70% of the patients discussion can be limited to anterior dislocation. Posterior dislo- were women. Patients with fracture were older (mean age 69 cation occurs in less than 2% of cases, and the direction of dis- years, versus 53 for primary dislocation). Seven of the 44 placement is away from the plexus and nerve trunks, minimizing primary dislocations were associated with fracture of the greater their risk. With anterior dislocation the head of the humerus is tuberosity; 26 patients had associated hematoma, all but 3 of displaced downward and forward, against the brachial plexus whom had humeral head fractures. Table 1 summarizes these and the neurovascular bundle. This can result from low-energy findings. impacts, such as a fall from a normal height or minor sports injuries, as well as from high-energy impacts, such as motor vehicle Sixty-four patients had a question of neuropathy and underwent accidents. Dislocations may also occur after minor activities or needle electromyography (EMG) studies; 45 patients (45% of may be recurrent. The tendency to dislocate increases with weak- the total group with dislocation or humeral neck fracture) were ness of muscles around the shoulder girdle, especially the sub- ultimately determined to have sustained axon loss nerve damage; AAEM Course Painful Shoulder 15

Figure 4 Top: a fall on the backward extended elbow (A) or arm (B) produces stretch of the neurovascular bundle over the humeral head. The humeral neck is blocked by the acromion/spina scapulae and dislocation or humeral fracture may occur. Bottom: extension in 90° abduction. The neurovascular bundle is stretched over the humeral head, and excessive widening of the scapulohumeral angle occurs (A and B). (C) Caudal view into the axilla. From Coene, with permission.6

31 of the 45 had humeral head fractures (54% of all humeral volved by EDX examination in the 45 patients. Among the pa- head fractures); and 14 had dislocations (32% of all primary dis- tients with associated hematoma, 73% sustained nerve damage. locations). Axillary neuropathy occurred in 37 patients: 8 in iso- In the group without hematoma, only 35% sustained nerve lation, 9 associated with suprascapular neuropathy, and 9 damage. associated with suprascapular and radial neuropathies. The remaining 19 cases involved axillary neuropathy in combination In this study, all but eight of the patients with nerve damage had with other mononeuropathies. Table 2 lists the nerve trunks insignificant recovery within 4 months. The eight had a Medical

Table 1 Findings in 101 patients, from de Laat7 Table 2 Involvement of nerves in the 45 patients with needle electromyography evidence of axon loss after anterior shoulder 7 41 without hematoma➔ 12 with nerve damage dislocation or humeral head fracture 44 Dislocations 3 with hematoma➔ 2* with nerve damage NERVE NUMBER OF PATIENTS 101 Patients Axillary 37 34 without hematoma➔ 6 with nerve damage Suprascapular 29 57 Fractures Musculocutaneous 19 23 with hematoma➔ 17* with nerve damage Radial 22 Ulnar 8 * denotes assumed value based on text 16 Peripheral Nerve Disorders in the Shoulder Region AAEM Course

Research Council scale power of 3 or less in at least one of the affected muscles. Repeat EMG studies demonstrated no recov- Table 3 Distribution of axon loss nerve lesions in dislocation of the shoulder23 ery in two patients and partial recovery in three. Nerves SS AX RA MC ME UL Patients A study of 77 patients with primary anterior dislocation identi- Affected fied 48% of cases with axon loss nerve injury by needle EMG criteria.23 Twelve of the patients had an associated fracture of the 1 + 2 greater tuberosity and two had fracture of the rim of the glenoid. In the group with fractures, 71% had evidence of axon loss nerve damage, and the severity of nerve damage and the number of + 15 nerves affected were increased compared to patients without associated fracture. The clinical finding of bruising around the + 1 shoulder was associated with a 4.4 times greater probability of nerve injury, and the severity of nerve damage and the number of nerves affected increased significantly in this group. Table 3 + 1 lists the distribution of axon loss nerve damage in the 37 affected patients. In general, the prognosis was good, with recovery of nerve function within 12-45 weeks in all but four patients. They 2 + + 6 found that the presence or absence of clinical sensory deficits did not correlate with the degree of motor deficits, although abnor- + + 1 malities of sensation in the lower arm correlated with severe nerve injury. The authors concluded that the axillary nerve is most vulnerable due to its close proximity to the glenohumeral + + 3 joint, and that the musculocutaneous and radial nerves are vulnerable to traction because the distance between anchorage points in the axilla is short. + + 1

A different study reported on 55 patients with primary anterior 3 + + + 1 dislocation of the shoulder who underwent needle EMG studies, 36 of whom showed nerve lesions (14 with associated rotator 22 cuff tears). Thirty-five patients had evidence of axillary neu- + + + 1 ropathy, five of whom had additional nerves affected.

Shoulder dislocation is rarely associated with vascular trauma. + + + 1 This is usually in the form of an intimal tear of the axillary artery, but frank rupture can occur as well. Vascular damage can lead to axillary artery thrombosis, hematoma, or pseudoaneurysm for- + + + 1 mation.4,9,20 The likelihood of severe nerve trunk damage is higher in this setting because the brachial plexus and major ar- + + + + 1 teries and veins travel together in a common fascial conduit. Compartment syndrome has been reported in the neurovascular sheath. This patient developed a total plexus lesion 4 days fol- 4 + + + + 1 lowing uneventful reduction of an anterior shoulder dislocation.4 The clinical symptoms of nerve damage may be delayed by days to up to a month after the initial dislocation or shoulder re- 5 0 duction.4,9 6 + + + + + + 1 Rotator cuff tears are seen in the setting of shoulder dislocation. Whether rotator cuff tears by themselves can lead to nerve damage is uncertain. One report suggests that at least four pa- AX = axillary; MC = musculocutaneous; ME = median; RA = radial; SS = supras- tients suffered isolated rotator cuff tears and nerve damage, two capular; UL = ulnar of whom had no acute trauma or evidence of dislocation.3 AAEM Course Painful Shoulder 17

Clavicular Fracture pathophysiology is axon loss, but those individuals who return to normal function within weeks are likely to have a component Fracture of the clavicle rarely leads to pathological sequelae. of demyelinating conduction block.24 Marked permanent motor Nonunion of the clavicle fracture (estimated at 1% of all clavic- deficits are seen in individuals who have suffered severe axon ular fractures),18 exuberant callus formation, and subclavian loss. artery pseudoaneurysm can occur, and may rarely be associated with brachial plexus damage. One report described a patient There is a marked predilection for pure or predominantly motor with nonunion, callus formation, and development of needle nerve trunks. Those affected most commonly are the long tho- EMG-documented total plexus damage.14 The medial cord is racic, suprascapular, axillary, anterior interosseous, and posterior most likely to receive the brunt of involvement, owing to its po- interosseous nerves. In some individuals, there may also be se- sition between the clavicle and the first thoracic rib (costoclavic- lective denervation of individual muscles in a mixed nerve trunk ular space). Fractures of the mid third of the clavicle are more distribution, such as the pronator teres muscle in the median likely to be associated with brachial plexus damage, because of nerve distribution.10 The musculocutaneous nerve trunk is less their increased tendency to become displaced with the proximal often involved, and the median, ulnar, and radial nerve trunks fracture tip depressed and angled posteriorly from the weight of are rarely affected. Occasionally other nerve trunks are affected, the shoulder.19 Another report described a patient with lesions of including the spinal accessory, laryngeal, and phrenic. Sensory the medial cord, upper trunk, and suprascapular nerve from ex- nerve involvement is rare, and essentially limited to the lateral uberant callus after nonunion.11 Another case report without antebrachial cutaneous nerve distribution.24 Any combination of needle EMG localization described the development of a the above mentioned nerves can be seen in individual cases. Horner’s syndrome and forearm and hand weakness associated with delayed development of a subclavian artery pseudoa- This disorder is almost exclusively axon loss in character. Nerve neurysm after clavicular fracture.12 conduction studies (NCSs) may be normal, or may show low amplitude compound muscle action potentials (CMAPs) recorded from weak muscles in the distribution of nerve trunk NEUROLOGICAL DISORDERS IN THE SHOULDER REGION damage (such as the deltoid, biceps, and supraspinatus muscles). Sensory NCSs are usually normal, but occasionally the lateral The neurological differential diagnosis of shoulder pain and antebrachial cutaneous sensory nerve action potential (SNAP) weakness includes neuralgic amyotrophy, C5 - C6 radiculopa- may be reduced, even when the musculocutaneous CMAP and thy, upper trunk/lateral cord brachial plexopathy, and individual the biceps needle electrode examination are normal.24 shoulder girdle mononeuropathies, such as spinal accessory, suprascapular, axillary, long thoracic, and musculocutaneous The needle electrode examination (NEE) is the most important neuropathies. part of the EDX study in patients with neuralgic amyotrophy. Even as early as 3-4 weeks after onset of weakness, marked Neuralgic Amyotrophy numbers of fibrillation potentials and severe loss of motor unit action potentials can be seen. The more extensive the NEE, the The clinical presentation of this disorder (also known as more nerve trunk involvement is likely to be uncovered, since Parsonage Turner syndrome and acute brachial neuritis) can partially involved nerve distributions are easily overlooked clini- mimic acute shoulder disease. The disorder is often described as cally. a supraclavicular brachial plexopathy because it commonly man- ifests with shoulder region pain, weakness, and atrophy of shoul- Cervical Radiculopathy der girdle muscles. It is more accurate to consider this disorder a form of acute mononeuropathy multiplex, primarily but not ex- Cervical radiculopathy, in specific acute C5 or C6 spinal nerve clusively involving nerve trunks around the shoulder girdle. The root lesions, can also mimic acute shoulder joint disease. Patients disorder is heralded by acute posterior scapular or shoulder pain may have more pain in the shoulder or upper arm than in the that may extend into the arm. This is followed within hours or neck, and the associated guarding will make examination diffi- days by rapidly progressive weakness, sometimes as the pain is re- cult. ceding. Infrequently there are sensory complaints. The shoulder region pain can be extremely severe, preventing sleep in bed, and The clinical distinction between C5 - C6 radiculopathy and usually resolves within several weeks to several months. Patients neuralgic amyotrophy may be difficult. Patients with radicu- rarely describe chronic pain. In general, the condition rapidly lopathy may have patchy involvement, such that not all muscles reaches a maximum, although some patients develop a stuttering in the myotome are equally affected. In some patients, therefore, course of progressive mononeuropathies over weeks or 1-2 the distinction between a musculocutaneous or axillary neu- months, sometimes affecting the contralateral arm. Significant ropathy and partial C5 - C6 radiculopathy will not be clear clin- recovery usually occurs over 6-12 months. The underlying ically. Many patients with radiculopathy will not have 18 Peripheral Nerve Disorders in the Shoulder Region AAEM Course radiculopathy-specific symptoms such as radicular pain or val- salva symptoms. Atrophy is an earlier and more prominent Table 4 Screening nerve conduction studies for shoulder girdle feature of moderate-severe neuralgic amyotrophy, compared neuropathy with radiculopathy. Symptoms of sensory disturbance are more common in patients with radiculopathy. Sensory Nerve Conduction Studies Median (digit 2) A number of features on the EDX examination can help distin- Ulnar (digit 5) guish these two disorders. With cervical radiculopathy the amount of fibrillation potentials is typically less profound than Radial (digit 1 base) in neuralgic amyotrophy. While reduced recruitment of motor Motor Nerve Conduction Studies unit activation is seen in moderate to severe radiculopathy, pro- Median (thenar eminence) found motor unit drop out is unusual. Ulnar (hypothenar eminence) The distribution of NEE findings can also help distinguish these two disorders. The presence of paraspinal fibrillation is a strong support for radiculopathy, but may be absent in a third or more of patients with C5 - C6 radiculopathy.16 Of 16 patients with Table 5 Additional nerve conduction studies for shoulder surgically proven C5 or C6 radiculopathy, needle EMG findings girdle neuropathy were confined to a single peripheral nerve trunk distribution in only 1, although several patients had distributions of involvement that conformed to partial involvement of multiple shoul- Sensory Nerve Conduction Studies der girdle or upper arm nerve trunks.16 Among patients with C6 Median (digits 1 and 3) radiculopathy, approximately half demonstrated a distribution Lateral antebrachial cutaneous of muscle involvement that corresponds to the C5 radiculopathy pattern, and about half corresponded to the pattern seen with Motor Nerve Conduction Studies C7 radiculopathy. Musculocutaneous (biceps) Axillary (deltoid) Suprascapular (infraspinatus) SHOULDER PAIN AND WEAKNESS: ELECTRODIAGNOSTIC Spinal Accessory (upper trapezius) EVALUATION

Although any EDX evaluation must be tailored to the patient’s clinical symptoms, because of the uncertainty regarding the specific nerve(s) involved, a careful work up for shoulder pain and approach to assessing abnormality of CMAP and SNAP ampli- weakness requires an extensive evaluation of the nerve trunks in tudes. the region. A work up for brachial plexopathy can be designed to focus on the upper or lower root segments, depending on the Because most of the nerve trunks in the shoulder girdle region distribution of the clinical symptoms. A screening set of NCSs is provide branches to a number of muscles, it is possible in some required before focusing further. Table 4 lists a reasonable set of cases to localize the site of the lesion by identifying the level screening NCSs. In the presence of clear neurogenic weakness or above which nerve branches along a specific nerve trunk are sensory loss, a more extensive NCS workup should be consid- spared. ered. It is also reasonable to proceed with the NEE before com- mitting to a time consuming and costly extension to the basic Upper Trunk Brachial Plexopathy NCS workup. Table 5 lists additional motor NCSs that can be useful in defining individual nerve trunk involvement around Distinguishing upper trunk plexopathy from C5 - C6 radicu- the shoulder girdle, and additional sensory NCSs that may help lopathy (proximally) and lateral and posterior cord lesions (dis- identify sensory axon loss in the upper trunk/lateral cord distri- tally) can be difficult clinically and electrodiagnostically. Lateral bution. Because many of these NCSs are not routinely per- and posterior cord lesions will spare branches arising from the formed in EDX laboratories, precise normative data may not be upper trunk. These branches include the dorsal scapular nerve to available. Performing bilateral studies provides the most sensitive the rhomboid muscles (the most proximal of upper trunk AAEM Course Painful Shoulder 19 branches), suprascapular nerve to the spinati, and the lateral pec- Musculocutaneous Nerve toral nerve to the upper portion of the pectoralis major. Involvement of some of these nerve trunks will suggest damage The musculotaneous nerve trunk gives off no branches at or at the upper trunk level, while involvement of all these nerve above the shoulder joint and humeral head, but is closely posi- trunks suggests a high upper trunk plexus lesion, or root or an- tioned to the shoulder joint as it enters the arm, giving off terior primary ramus lesions. Involvement of the rhomboid branches to the coracobrachialis muscle followed by the major muscle is most likely to reflect damage at the C5 spinal brachialis and biceps muscles. All branches would be expected to root level. Although the long thoracic nerve to the serratus ante- be involved after damage from shoulder dislocation, including rior branches from the upper trunk more proximally than any the lateral cutaneous nerve of the forearm. other nerve trunk, its dual innervation from the upper and middle trunks (C5 - C7 root segments) does not allow for specific upper trunk localization. A lateral cord lesion will likely be SUMMARY associated with lateral antebrachial cutaneous and median SNAP (digits 1, 2, and 3) amplitude loss. An upper trunk lesion Predictable distributions of nerve damage result from shoulder may additionally involve the radial SNAP amplitude, but the and upper extremity trauma. The patterns of damage occur due median SNAP loss is more likely to be to digits 1 and 2, sparing to forceful stretch and extreme movements of the shoulder. digit 3. C5 - C6 radiculopathy will spare the SNAP responses. Other associated mechanisms include nerve compression due to hematoma and nerve disruption due to fracture. Nontraumatic Axillary Nerve neurological disorders involving shoulder girdle nerve trunks or roots can be mistaken for traumatic lesions. A comprehensive The radial nerve trunk gives off a branch to innervate the teres EDX evaluation can define the nature and extent of nerve minor, just before coursing around the posterior aspect of the damage in many cases, and can aid in the differentiation of trau- humerus to innervate the deltoid muscles. A lesion of the axil- matic and nontraumatic neuropathies. lary nerve due to humeral neck fracture could spare the branch to teres minor. REFERENCES Radial Nerve 1. Barnes R. Traction injuries of the brachial plexus in adults. J Bone The radial nerve is what remains of the posterior cord after Joint Surg 1949;31:10-16. branches are given off to the thoracodorsal nerve (latissimus 2. Bonnel F, Rabischong P. Anatomy and systematisation of the brachial plexus in the adult. Anat Clin 1981;2:289-298. dorsi), the axillary nerve, and the posterior cutaneous nerve of 3. Brown TD, Newton PM, Steinmann SP, Levine WN, Bigliani LU. the forearm. Radial nerve damage from shoulder dislocation is Rotator cuff tears and associated nerve injuries. Orthopedics always associated with axillary neuropathy, and would be ex- 2000;23:329-332. pected to include all branches of the radial nerve.23 Damage at 4. Byström S, Vinnars B. Late posttraumatic compartment syndrome in the posterior cord level in such cases would be difficult to dis- the axillary neurovascular sheath- a case report. Acta Orthop Scand 1999;70:517-522. tinguish from individual axillary and radial nerve lesions. The as- 5. Clein LJ. Suprascapular entrapment neuropathy. J Neurosurg sociated presence of damage to the latissimus dorsi (first branch 1975;43:337-342. from the posterior cord) would confirm localization to the pos- 6. Coene LN. Mechanisms of brachial plexus lesions. Clin Neurol terior cord. Neurosurg 1993;95:S24-S29. 7. de Laat EA, Visser CP, Coene LN, Pahlplatz PV, Tavy DL. Nerve Suprascapular Nerve lesions in primary shoulder dislocations and humeral neck fractures: a prospective clinical and EMG study. J Bone Joint Surg Br 1994;76:381-383. The main nerve trunk of the suprascapular nerve gives off a 8. Delbet P, Cauchoix A. Les paralysies dans les luxations de l’épaule. branch to the supraspinatus muscle after crossing under the Rev Chir 1910;41:327-352, 667-687. transverse scapular ligament at the suprascapular notch. After 9. Emadian S, Lee WW. Axillary artery pseudoaneurysm and axillary coursing around the spinoglenoid notch the nerve trunk ends in nerve palsy: delayed sequelae at anterior shoulder dislocation. Am J Emerg Med 1996;14:108-109. the infraspinatus muscle. A lesion sparing the supraspinatus 10. England JD, Sumner AJ. Neuralgic amyotrophy: an increasingly muscle is likely situated at or distal to the spinoglenoid notch. diverse entity. Muscle Nerve 1987;10:60-68. 20 Peripheral Nerve Disorders in the Shoulder Region AAEM Course

11. England JD, Tiel RL. AAEM Case Report #33: Costoclavicular mass 20. Sarma A, Saranchak H, Levinson ED, Sigman R. Thrombosis of the syndrome. Muscle Nerve 1999;22:412-418. axillary artery and brachial plexus injury secondary to shoulder dislo- 12. Hansky B, Murray E, Minami K, Korfer R. Delayed brachial plexus cation. Conn Med 1981;45:513-514. paralysis due to subclavian pseudoaneurysm after clavicular fracture. 21. Sunderland S. Mechanisms of cervical root avulsion in injuries of the Eur J Cardiothorac Surg 1993;7:497-498. neck and shoulder. J Neurosurg 1974;41:704-714. 13. Horsley V. On injuries to peripheral nerves. Pract 1899;63:131-144. 22. Toolanen G, Hildingsson C, Hedlund T, Knibestöl M, Öberg L. 14. Kay SP, Eckardt JJ. Brachial plexus palsy secondary to clavicular Early complications after anterior dislocation of the shoulder in pa- nonunion: case report and literature survey. Clin Orthop tients over 40 years: an ultrasonographic and electromyographic 1986;206:219-222. study. Acta Orthop Scand 1993;64:549-552. 15. Kopell HP, Thompson WA. Peripheral entrapment neuropathies. 23. Visser CP, Coene LN, Brand R, Tavy DL. The incidence of nerve Baltimore: Williams and Wilkins; 1963. injury in anterior dislocation of the shoulder and its influence on 16. Levin KH, Maggiano HJ, Wilbourn AJ. Cervical radiculopathies: functional recovery: a prospective clinical and EMG study. J Bone comparison of surgical and EMG localization of single-root lesions. Joint Surg Br 1999;81:679-685. Neurology 1996;46:1022-1025. 24. Wilbourn AJ. Brachial plexopathies. In: Katirji B, Kaminski HJ, 17. Milton GW. The mechanism of circumflex and other nerve injuries Preston DC, Ruff RL, Shapiro BE, editors. Neuromuscular disorders in dislocation of the shoulder, and the possible mechanisms of nerve in clinical practice. Boston: Butterworth-Heinemann; 2002. p 901- injuries during reduction of dislocation. Aust N Z J Surg 1953;23:25- 902. 30. 25. Zoltan JD. Injury to the suprascapular nerve associated with anterior 18. Pyper JB. Non-union of fractures of the clavicle. Injury 1978;9:268. dislocation of the shoulder: case report and review of the literature. J 19. Rowe C. An atlas of anatomy and treatment of mid-clavicular frac- Trauma 1979;19:203-206. tures. Clin Orthop 1968;58:30. 21

Shoulder Pathokinesiology and Rehabilitation

Marko V. Bodor, MD Physical Medicine and Rehabilitation Queen of the Valley Hospital Napa, California

INTRODUCTION trapezius, levator scapulae, rhomboids, and pectoralis minor. The rotator cuff muscles include the subscapularis, infraspinatus, The shoulder is an integral component of the upper extremity supraspinatus, and teres minor. The prime movers incude the kinetic chain. When dysfunctional, the shoulder may contribute deltoid, pectoralis major, latissimus dorsi, biceps short and long to other problems, including neck pain, radiculopathy, forearm heads, long head of triceps, and teres major. pain, and carpal tunnel syndrome (CTS). In patients presenting with pain, numbness, or weakness, symptoms prompting referral to an electrodiagnostic (EDX) specialist, several disorders BIOMECHANICS may be present. A determination of which disorder is causing which symptoms and findings of how they are related is essen- The shoulder is the most complex and mobile joint in the body, tial to an outstanding EDX consultation and an effective treat- possessing an unequaled range of motion (ROM) of up to 230° ment plan. in the sagittal and coronal planes, 180° in the transverse plane, and 140° along the long axis of the humerus.9 This high degree of mobility is attributable to the presence of two joints next to ANATOMY each other: a shallow or minimally constrained ball and socket joint (the glenohumeral joint), and a tilting, rotating, or sliding The shoulder consists of three bones—the clavicle, scapula, and joint (the scapulothoracic) joint. humerus—with its only attachment to the thorax at the stern- oclavicular joint. In most quadrupeds, the clavicle is missing and The high degree of mobility and function present in the shoul- there are no bony attachments to the thorax. Animals such as der requires a complex system of restraints to provide stability. It horses, cats, and dogs rely on the muscular sling of the serratus was thought that ligaments provided primary stability to the anterior for support of the thorax. Animals such as birds, shoulder, but now it is known that while ligaments provide some monkeys, or beavers that use their forelimbs with high forces and stability and limit maximum rotation, it is the coordinated in multiple planes have well-developed clavicles, which serve as action of the innermost layer of the shoulder muscles, the rotator struts to stabilize their limbs and improve efficiency.10 cuff, that maintains the humeral head within the glenoid fossa and prevents its displacement.13 There are 17 muscles directly associated with the shoulder. These can be divided into three functional groups: (1) the scapular ro- For years the mechanism preventing downward dislocation or tators and stabilizers; (2) the rotator cuff; and (3) the prime subluxation of the shoulder (static stability) had not been movers. The scapular muscles include the serratus anterior, explained. Some investigators believed that the vertical 22 Shoulder Pathokinesiology and Rehabilitation AAEM Course scapulohumeral muscles, such as the deltoid and biceps, main- It appears that the overall strategy of arm abduction is to avoid tained low levels of tonic activity to maintain the humeral head utilizing the scapular rotators initially so as to minimize energy in the glenoid fossa with the arm at one’s side.14,17 Using con- expenditure, but as torque on the shoulder increases, these centric needle electromyography (EMG), Basmajian demon- muscles are recruited to rotate the glenoid under the humeral strated that the deltoid was inactive even with heavy loads, head for maximum support (Figure 1).13 whereas the supraspinatus was active in direct proportion to the weight of the load in the hand.3 He wrote, “With moderate or Although the importance of scapular rotation to shoulder func- heavy loads, the supraspinatus is called upon to reinforce the tion was identified by Duchenne,4 it was not until the needle horizontal tension of the capsule; in some persons it is required EMG studies of Inman24 that the role of the scapular rotator even without load.” He concluded that the arm was kept in its muscles was studied in detail. The scapular rotator muscles work socket because of a combination of horizontal tension in the by exerting forces tangential to the axis of rotation in order to coracohumeral ligament, supraspinatus muscle activity, and rotate or hold the scapula in place. During abduction, the levator slightly upward (approximately 5°) inclination of the glenoid.4 scapulae, upper trapezius, lower trapezius, and serratus anterior work together to rotate the scapula.24 During passive adduction, It is currently believed that factors in addition to these are re- if the line of pull is in line with gravity, muscle force is not nec- sponsible for static glenohumeral stability. These include articu- essary, but during forceful adduction, the levator scapulae, lar conformity, the glenoid labrum, negative intraarticular rhomboids, and latissimus dorsi are activated.4 pressure, adhesion-cohesion, and capsuloligamentous structures. The role of negative intraarticular pressure—on the order of -40 Scapular movement not only positions the glenoid optimally cm of water at rest and -80 cm with a 25 N inferior force under the humerus, but also follows the humerus so as to maxi- applied13—is emphasized by some investigators (JP Warner, per- mize range of motion and prevent impingement. One can expe- sonal communication, 2004). rience bony impingement by attempting to abduct one’s arm while the hand is internally rotated. At approximately 135°, ab- With regard to dynamic shoulder stability, multiple factors have duction stops unless the arm is externally rotated. External rota- been identified including joint compression, ligament dy- tion allows the humerus and scapula to move so the greater namization, scapular rotator activation, proprioception, and tubercle can clear the acromion (Figure 2). These scapulo- biceps long head activation. The role of ligament dynamization humeral adjustments are made subconsciously to achieve fluid has received attention recently, but in their chapter on gleno- movement. humeral stability,13 Cole and Warner conclude that “the dynamic effects of rotator cuff contraction upon the ligaments From an orthopedic standpoint, the primary function of the remains unclear,” without reference to what appears to have rotator cuff muscles is to provide stability to the shoulder and been an elegant description of this concept by Basmajian in maintain the humeral head within an approximately 2 mm locus 1959.4 in the glenoid. In providing stability to the glenohumeral joint in scapular plane abduction, the rotator cuff muscles use only a fraction of their available amplitude of contraction for primary KINESIOLOGY joint stabilization (0.4/7.0 cm for subscapularis, 3.8/6.7 cm for supraspinatus, and 3.5/8.6 cm for infraspinatus).20 At the ex- Codman observed that during normal shoulder abduction the tremes of range of motion, the humeral head normally translates scapula rotates on the thorax approximately 1° for every 2° of up to 8 mm away from the center of the glenoid.31 The rotator glenohumeral rotation, a relationship he termed “scapulo- cuff is perfectly positioned to control these excursions and humeral rhythm.”10 Quantification of scapulohumeral rhythm prevent dislocation. has been complicated by the fact that the instant axis of rotation of the shoulder shifts from medial to lateral during abduction.2 From a kinesiologic standpoint, the rotator cuff muscles con- In general, during the first 30° of arm abduction, most of the tribute significantly to abduction power, especially at low angles movement occurs at the glenohumeral joint, although this varies when the lever arm of the deltoid is short. When either the axil- between individuals.2 Between approximately 60° and 140°, the lary or suprascapular nerve is blocked, abduction strength is ratio of scapulothoracic to glenohumeral motion is approxi- reduced by about 50%.11,12 Most texts make a point of stating mately equal. Beyond 140°, greater glenohumeral motion that the rotator cuff muscles have smaller lever arms and are occurs.2 Note that the greatest degree of scapular rotation occurs therefore unable to generate the same degree of torque as the in the range where the shoulder experiences the highest torque, deltoid, pectoralis major, or latissimus dorsi.1,5,22,29 While this is or when the cosine of the abduction angle is greater than 0.5 as true, the advantages of smaller lever arms are rarely mentioned. per this author’s calculations. These are as follows: (1) higher velocity of movement given the AAEM Course Painful Shoulder 23 same muscle force, and (2) lower muscle energy expenditure and teres major, can be deduced from their anatomy. The deltoid given the same velocity of movement.16 is active in all movements of the arm except adduction. Its anterior portion is active in flexion and horizontal flexion-adduction, The basic functions of the rotator cuff muscles are: The the middle portion in abduction, and the posterior portion in supraspinatus initiates and remains active throughout abduc- extension and horizontal extension-abduction. The biceps tion. The subscapularis internally rotates the humerus. The in- brachii flexes the elbow, but can also flex the shoulder if the fraspinatus and teres minor externally rotate the humerus. When elbow is kept extended.4 the subscapularis and infraspinatus are activated together, their internal and external rotation torques cancel each other while The triceps extends the elbow and, although its long head takes their combined downward components depress and abduct the origin from the inferior aspect of the glenoid, its role in shoulder humerus.24 As will be discussed later, humeral head depression is function is rarely discussed. The teres major is characterized by desirable because it relieves pressure on the rotator cuff tendons its inactivity during low force shoulder movements and activity in the subacromial space. for high force internal rotation, adduction, and extension.4,24 The latissimus dorsi is a primary adductor and powerful exten- The roles of the prime movers, the deltoid, pectoralis major, sor of the upper limb. The pectoralis major has two heads, the latissimus dorsi, biceps short and long heads, triceps long head, clavicular and sternocostal, the tendons of which are crossed

Figure 1 (Top row) Normal scapulothoracic rotation positions the glenoid underneath the humeral head so that it acts as a stable platform. (Bottom row) Failure of proper scapulothoracic motion results in loss of the stable glenoid platform underneath the humeral head. This is analogous to a seal balancing a ball on its nose. (From Warner JJP, Caborn DNM. Overview of shoulder instability. Crit Rev Phys Rehabil Med 1992;4:145-198, with permission.) 24 Shoulder Pathokinesiology and Rehabilitation AAEM Course

PATHOKINESIOLOGY

Everyone is familiar with the patient referred for EDX consultation who arrives wearing a splint, complaining that their arm, neck, and shoulder hurt, and that they have numbness in the hand. Upon performing EDX studies, the only abnormality found is a median neuropathy at the wrist (CTS). The patient’s symptoms started with numbness in the hand at night. They were then seen by their physician and advised to wear a splint at all times. Since then, the patient has developed new symptoms and overall feels worse. Could all of these symptoms be related? Perhaps.

In a recent article using three-dimensional (3-D) motion analysis, King and colleagues27 demonstrated that wearing a wrist orthosis resulted in increased shoulder flexion for stacking and pouring tasks. If ROM is suddenly increased at a particular joint, it is equivalent to increasing overall workload at that joint (increased distance x force = increased work). One can understand how this could trigger an overuse syndrome such as tendonitis or bursitis.

Once shoulder dysfunction starts, is there any evidence to show that it can lead to neck pain? Shoulder texts mention that trapezius pain is a common feature among patients with shoulder problems and that this may be secondary to compensatory Figure 2 The scapula rotates with arm elevation, clearing the overuse of the trapezius and other scapulothoracic acromion away from the impingement zone. (From Kuhn JE, muscles.1,5,10,23 Deutsch and colleagues15 found increased scapu- Hawkins RJ. Evaluation and treatment of scapular disorders. In: lothoracic movement in patients with Type I and II impinge- Warner JP, Lannotti JP, Gerber C, editors. Complex and revision 19 problems in shoulder surgery. Philadelphia: Lippincott-Raven, ment. Graichen and colleagues, using 3-D magnetic resonance 1997;357-375, with permission). imaging (MRI) reconstruction techniques, found that a significant subset of subjects with shoulder impingement had markedly increased scapulothoracic motion (43° versus 29°). They were unsure whether these findings were the cause or the when the arm is in the anatomical position. The two tendons lie effect of impingment, but this author’s interpretation would be parallel to each other when the arm is flexed. Its sternocostal and that these findings are an adaptation to painful glenohumeral clavicular heads are active in vertical and horizontal adduc- motion. Increased trapezius activation was documented in sub- tion.4,24 jects with impingement syndrome in a surface EMG study by Ludewig.28 Some interesting observations can be made with regard to the evolution of the shoulder girdle. The levator scapulae and serra- Could increased activity of the trapezius and levator scapulae tus anterior muscle are related structures among quadrupeds, cause axial spine pain? Choi and Vanderby8 studied maximal iso- both arising from the axial skeleton and attaching to the medial metric contractions of cervical spine muscles in response to borders of the scapula. The deltoid is small or nonexistent in lateral bending loads, including activation of the trapezius up to quadrupeds, but attains prominence in primates, consistent 80% of maximum voluntary contraction. Their calculations in- with the evolution of upright posture and a free limb. The dicated an approximately 1000 N compressive load at the C4-5 deltoid insertion migrates distally in the hominid line, with disc, several-fold lower than required to cause fracture or liga- humans having the largest deltoid and most distal insertion. The ment disruption, but possibly enough to cause disc deformation length of the scapula and size of the infraspinatous fossa increase if repeated frequently. One could imagine that in certain pa- within the hominid line, consistent with the notion that a well- tients even low-grade trapezius activation could result in axial developed infraspinatous muscle is necessary for orthograde neck pain. posture and a free limb.24 AAEM Course Painful Shoulder 25

IMPINGEMENT SYNDROME Among athletes, including baseball players, tennis players, and swimmers, the primary cause of shoulder pain and dysfunction, Impingement syndrome is one of the most common causes of including impingement, is attributable to shoulder laxity. The shoulder pain among patients referred for EDX consultation. concept of laxity and to which degree it is normal versus patho- Impingement is characterized by a painful arc of motion, typi- logical is an area of controversy, but nevertheless it is thought to cally in the mid-range of abduction. Impingement occurs exist secondary to the high demands of the athletic shoulder because of the narrow supraspinatus outlet present between the with extremes of velocity (up to 7000°/second), acromion and the humerus through which passes the ROM and repetition.1,18 These patients need to be evaluated for supraspinatus tendon. Any inflammation of the tendon or sub- the usual anatomical and muscular factors contributing to im- acromial bursa or narrowing of the outlet can result in impinge- pingement, but also for the presence of scapular malposition and ment. dyskinesis.

Anatomical factors associated with impingement include a Type Kibler has written extensively on scapular dysfunction in athletes II or Type III acromion (Figure 3), acromioclavicular joint os- and described the SICK scapula syndrome (Scapular malposi- teoarthritis, and a laterally downsloping acromion.23 Muscular tion, Inferior border prominence, Coracoid pain and malposi- factors associated with impingement include any deficiencies in tion, and dysKinesis of scapular movement). When viewed from the rotator cuff or scapulothoracic musculature that could con- the back, athletes with SICK scapula have the appearance of a tribute to narrowing of the subacromial space. These include lower shoulder or “dropped scapula” affecting the dominant or weakness of the infraspinatus or subscapularis muscles which throwing arm, which is secondary to anterior (acromion ante- normally depress the humeral head, or weakness of the serratus rior) and medial (following the curve of the ribs) tilt of the anterior and lower trapezius muscles which tilt the scapula pos- scapula. There are three types of SICK scapula: type I, inferior teriorly (acromion posterior). Anteriorly and medially (along the medial scapular border prominence; type II, medial scapular lateral curve of the ribs) tilted scapulae occur among individuals border prominence; and type III, superomedial scapular border with rounded shoulders, large breasts, obesity, and thoracic prominence. Types I and II are associated with labral pathology, kyphosis and are associated with impingement. and type III with impingement and rotator cuff lesions.6,9,25,26

A second type of impingement referred to as “internal impingement” was described by Walch and colleagues in 1991.30 This occurs in all shoulders to some degree, but only causes symptoms in some. Internal impingement occurs during the cocking position of throwing and can be seen arthroscopically or via diagnostic ultrasound as a pinching of the undersurface of the rotator cuff between the posterior superior glenoid rim and the humerus when the shoulder is abducted to 90° and maximally externally rotated. Tightness of the posterior inferior capsule, manifested as glenohumeral internal rotation deficit (referred to as GIRD) is thought to exacerbate both types of impingement by shifting the glenohumeral rotation point posteriorly and su- periorly during external rotation.6,7

A third type of rare impingement was described in 1985 by the now well-known Swiss shoulder surgeon, Dr. Christian Gerber.21 It is referred to as “coracoid impingement” or impingement of the subscapularis tendon under the acromion, and is manifested by pain in the coracoid region with flexion and internal rotation.

REHABILITATION

Figure 3 Acromion morphology: type I, flat; type II, curved; type The rehabilitation of shoulder dysfunction starts with an accurate III, hooked. (Adapted with permission from Cotton.14)* diagnosis of the shoulder problem or problems and identification 26 Shoulder Pathokinesiology and Rehabilitation AAEM Course of any other neuromuscular or musculoskeletal problems such as A comprehensive shoulder rehabilitation program would ideally radiculopathy, CTS, or spine or hip problems. Sometimes, strengthen every one of the 17 shoulder muscles as well as the despite thorough work-up, the source of shoulder pain remains spine, trunk, and lower extremities. Many shoulder specialists unclear. In this case, lidocaine injections to the subacromial are proponents of so-called closed kinetic chain exercises in the space, the glenohumeral joint, the biceps tendon sheath (ideally early phases of rehabilitation, particularly after surgery, disrup- using ultrasound guidance), or the acromioclavicular joint can tion of the shoulder capsule, ligaments, or rotator cuff.6,7,25,26 be helpful in establishing the source of pain. For closed kinetic chain exercise (CKCE), the weight of the body Upon determination of a diagnosis, precipitating factors at work, or limb is used for resistance and the line of force typically crosses at home, during sports and recreational activities, and while several joints, requiring multiple muscles to be activated. For sleeping at night need to be identified and eliminated or ame- open kinetic chain exercise (OKCE), an external weight is used liorated. In the presence of CTS, ask that the patient wear the and the line of pull typically crosses only one joint and activates wrist splint only at night. If work requires a great deal of reach- fewer muscles. The advantage of CKCE is improved joint stabi- ing, recommend placing frequently used items on a lower shelf lization, making it particularly useful in ligament deficient or having the worker stand on a platform. For the athlete, analy- joints. The advantage of OKCE is its ability to isolate a particu- sis of movement by a coach and correction of errors in technique lar muscle for specific strengthening. The ability of OKCE to might be helpful. For fitness enthusiasts, exercises with a propen- produce joint shear forces is both a disadvantage and an advan- sity for shoulder pain such as straight arm dumbbell raises may tage, as will be discussed later. need to be discontinued. For patients with shoulder pain at night, consideration for a medium-firm as opposed to extra-firm Closed kinetic chain exercises might include standing at the side mattress may need to be given. of a table and pushing on a ball or against the wall with one’s hand, concentrating on protracting or retracting the scapula and Because of the limited space between the humeral head and the internally and externally rotating the humerus. Open kinetic coracoacromial arch, any inflammation of the subacromial bursa chain exercises traditionally used for rotator cuff rehabilitation or rotator cuff is likely to exacerbate impingement. This in turn include internal and external rotation exercises using elastic can lead to a vicious cycle of more impingement and inflamma- bands or weights to strengthen the subscapularis-infraspinatus tion. A corticosteroid injection to the subacromial space can be force couple, starting at 0° abduction and progressing to 90° ab- a quick and efficient way of resolving this problem. duction as tolerated. A concern with elastic bands is their non- linear force response, but their ease of use and portability make If injection is indicated, this author’s approach is to provide 6 ccs them an attractive choice for many patients. of solution containing triamcinolone acetonide 40 mg and lidocaine 1% via a posterior lateral approach. Immediately after- For individuals with higher strength goals, free weights or wards, the patient lies prone with the arm relaxed and hanging weights attached to pulleys should be used. As strength improves toward the floor, making small circles and pendulum move- and pain resolves, exercises can be performed at higher velocities ments with the hand. These exercises—known as Codman’s ex- and with free weights and other objects to simulate required job ercises10—are helpful in restoring ROM in the early stages of tasks. Baseball players may throw a weighted ball back and forth rehabilitation when ROM in the upright position causes pain. (plyometrics) to simulate the acceleration and deceleration re- More often than not, the patient experiences excellent pain relief quirements of throwing. Weight training in the eccentric mode as the injection spreads in the subacromial space and the scapu- for the infraspinatus and teres minor, muscles which decelerate lothoracic muscles relax. the throwing arm, may be beneficial, particularly to those with shoulder instability. Also, because movement of the whole body Codman’s exercises may continue to be performed up to several is utilized in the throwing motion, correction of any flexibility or times per day or as necessary for pain relief, muscle relaxation, strength deficits in the hip, spine, and trunk can ensure fluidity and improvement of ROM. Passive elevation can also be per- of movement and reduce peak acceleration and deceleration formed by having the patient lie in a supine position and allow forces at the shoulder.1,25,26 gravity to flex his arm overhead. When tolerated, the patient can progress to upright ROM exercises, including wall climbs, reach- Finally, it is interesting to note that certain exercises can produce ing across the chest and behind the back. Specific areas of tight- favorable translations of the humerus. Hinterwimmer and col- ness, such as the posterior capsule, may require special exercises. leagues, in a recent article23 demonstrated through the use of Posterior capsule stretching is properly performed lying on the 3-D MRI reconstruction techniques, that adducting forces at affected side with the shoulder and elbow flexed at 90°, at which the shoulder (OKCE) of only 15 N at the distal humerus re- point one uses the opposite hand to attempt to push the forearm sulted in significant increases in subacromial space width (Figure down towards the table.6,7 4). Hopefully, as 3-D MRI reconstruction techniques become AAEM Course Painful Shoulder 27

dorsi muscle force couple depresses the humeral head and widens the subacromial space. Rehabilitation involves strengthening these and ideally all 17 muscles acting at the shoulder, as well as the trunk and lower extremities.

REFERENCES

1. Andrews JR, Wilk KE. The athlete’s shoulder. New York: Churchill Livingstone Inc; 1994. 2. Bagg SD, Forrest WJ. A biomechanical analysis of scapular rotation during arm abduction in the scapular plane. Am J Phys Med Rehab 1988;67:238-245. 3. Basmajian JV, Bazant FJ. Factors preventing downward dislocation of the adducted shoulder joint. An electromyographic and morphologic study. Am J Orthop 1959;41:1182-1186. 4. Basmajian JV, DeLuca CJ, editors. Muscles alive: their functions revealed by electromyography, 5th edition. Baltimore: Williams & Wilkins; 1985. 5. Bunker TD, Schranz PJ. Clinical challenges in orthopedics: the Figure 4 A-C. Three-dimensional reconstruction images of a shoulder. Oxford: ISIS Medical Media; 1998. healthy subject shows shoulder at 30° (A), 90° (B), and 150° (C) 6. Burkhart SS, Morgan CD, Kibler WB. Current concepts: the dis- of elevation with abducting muscle activity. D-F. Three-dimensional abled throwing shoulder: spectrum of pathology. Part I: reconstruction images of a healthy subject shows shoulder at 30° pathoanatomy and biomechanics. Arthroscopy 2003;19:404-420. 7. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoul- (D), 90 (E), and 150° (F) of elevation with abducting muscle ac- ° der: spectrum of pathology. Part III: the SICK scapula, scapular dysk- tivity. Comparing the two muscle activities, adduction leads to an inesis, the kinetic chain, and rehabilitation. Arthroscopy expansion of the subacromial space width in all positions of eleva- 2003;19:641-661. tion. 8. Choi H, Vanderby R Jr. Muscle forces and spinal loads at C4/5 level during isometric voluntary efforts. Med Sci Sports Exerc 2000;32:830-838. 9. Cocchiarella L, Andersson GB. Guides to the evaluation of perma- more available, there will be more opportunities to learn about nent impairment, 5th edition. Chicago: AMA Press; 2000. 10. Codman EA. The shoulder. Rupture of the supraspinatus tendon and the effects of various exercises on the shoulder. other lesions in or about the subacromial bursa. Boston: Thomas Todd Company; 1934. 11. Colachis SC Jr, Strohm BR. Effects of suprascapular and axillary SUMMARY nerve blocks on muscle force in upper extremity. Arch Phys Med Rehabil 1971;52:22-29. The shoulder, the most mobile joint in the body, is an integral 12. Colachis SC Jr, Strohm BR, Brechner VL. Effects of axillary nerve block on muscle force in the upper extremity. Arch Phys Med Rehabil component of the upper extremity kinetic chain. 1969;50:647-654. Neuromuscular disorders affecting the wrist or cervical spine 13. Cole BJ, Warner JP. Anatomy, biomechanics, and pathophysiology of may contribute to shoulder dysfunction. The simultaneous pres- glenohumeral joint instability. In: Iannotti JP, Williams GR, editors. ence of several disorders may cause numbness, tingling, or Disorders of the shoulder: diagnosis and management. Philadelphia: weakness affecting the entire limb. Shoulder movement occurs Lippincott William & Wilkins; 1999. p 207-232. 14. Cotton FJ. Subluxation of the shoulder downward. Boston Med Surg at the glenohumeral and scapulothoracic joints. In case of re- J 1921;185:405-407. striction at one joint, compensatory movement may occur at the 15. Deutsch A, Altchek DW, Schwartz E, Otis JC, Warren RF. other. Thus, rotator cuff impingement may lead to overuse of Radiologic measurement of superior displacement of the humeral the upper and lower trapezius and serratus anterior muscles. head in the impingement syndrome. J Shoulder Elbow Surg Subacromial impingement, the most common of three types of 1996;5:186-193. impingement, may be caused by narrowing of the subacromial 16. Dickinson MH, Farley CT, Full RJ, Koehl MA, Kram R, Lehman S. How animals move: an integrative view. Science 2000;288:100-106. outlet or alteration of scapular movement. Simultaneous activa- 17. Fairbank TJ. Fracture-subluxations of the shoulder. J Bone Joint Surg tion of the subscapularis-infraspinatus or pectoralis-latissimus Br 1948;30:454-470. 28 Shoulder Pathokinesiology and Rehabilitation AAEM Course

18. Fleisig G, Dillman CJ, Andrews JR. Biomechanics of the shoulder 25. Kibler WB. Rehabilitation of rotator cuff tendinopathy. Clin Sports during throwing. In: Andrews JR, Wilk KE, editors. The athlete’s Med 2003;22:837-847. shoulder. New York: Churchill Livingstone; 1994. p 355-368. 26. Kibler WB, McMullen J, Uhl T. Shoulder rehabilitation strategies, 19. Graichen H, Stammberger T, Bonel H, Wiedemann E, Englmeier guidelines, and practice. Orthop Clin North Am 2001;23:527-538. JH, Reiser M, Eckstein F. Three-dimensional analysis of shoulder 27. King S, Thomas JJ, Rice MS. The immediate and short-term effects girdle and supraspinatus motion patterns in patients with impinge- of a wrist extension orthosis on upper-extremity kinematics and range ment syndrome. J Orthop Res 2001;19:1192-1198. of shoulder motion. Am J Occup Ther 2003; 57:517-524. 20. Gerber C. Massive rotator cuff tears. In: Iannotti JP, Williams GR, 28. Ludewig PM, Cook TM. Alterations in shoulder kinematics and as- editors. Disorders of the shoulder: diagnosis and management. sociated muscle activity in people with symptoms of shoulder im- Philadelphia: Lippincott Williams & Wilkins; 1999. p 57-92. pingement. Phys Ther 2000;80:276-291. 21. Gerber C, Terrier F, Ganz R. The role of the coracoid process in the 29. Perry J. Anatomy and biomechanics of the shoulder in throwing, impingement syndrome. J Bone Joint Surg Br 1985;67:693-708. swimming, gymnastics, and tennis. Clin Sports Med 1983;2:247- 22. Iannotti JP, Williams GR, editors. Disorders of the shoulder: diagno- 270. sis and management. Philadelphia: Lippincott Williams & Wilkins; 30 Walch G, Liotard JP, Boileau P, Noel E. Postero-superior glenoid im- 1999. pingement: another shoulder impingement. Rev Chir Orthop 23. Hinterwimmer S, Von Eisenhart-Rothe R, Siebert M, Putz R, Reparatrice Appar Mot 1991;77:571-574. Eckstein F, Vogt T, Graichen H. Influence of adducting and abduct- 31. Werner CM, Nyffeler RW, Jacob HA, Gerber C. The effect of capsu- ing muscle forces on the subacromial space width. Med Sci Sports lar tightening on humeral head translations. J Orthop Res Exerc 2003;35:2055-2059. 2004;22:194-201. 24. Inman VT, Saunders, JB, Abbott LC. Observations on the function of the shoulder joint. J Bone Joint Surg 1944;26:1-30. 29

Looking at the Surgical Options for Shoulder Pain

John L. Andary, MD, MBA Shoulder & Knee Center Idaho Falls, Idaho

INTRODUCTION high on preoperative mental, social, and physical health scores have better outcomes than those patients who score below age For surgeons treating shoulder pain, it is helpful to group pa- and gender matched control subjects.60 The informed consent tients into three groups. The first group includes patients with discussion is also critical to patient selection. Patients who un- shoulder problems attributed to a known mechanical cause to derstand their condition, accept the risks of surgery, and under- which there is a mechanical solution. A patient with anterior stand their role in preoperative preparation and recovery have a shoulder instability with a repairable Bankart lesion would fit greater chance of a successful surgical outcome. into this group. The second group includes patients with a known cause for a shoulder problem, but no known mechanical After an appropriate evaluation and diagnosis, the best question solution. An example of this would be shoulder pain and weak- is whether or not the surgeon is the right surgeon to perform the ness secondary to brachial neuritis. The third group includes pa- surgery. The “fit” of the patient, surgeon, procedure, and tients with shoulder problems without a definite medical cause. problem is extremely important. One surgeon may feel uncom- For instance, a patient with nonspecific shoulder pain after an fortable treating a particular shoulder problem with surgery, automobile accident, or a worker’s compensation patient with while another may operate on the same problem several times in generalized shoulder and arm pain who is unhappy with their any given week.60 job. Only those patients in the first group are surgical candidates and therefore they are the topic of this manuscript. Patients in This manuscript will not include a discussion of fractures, the second or third group should not have surgery. tumors, and infections since these conditions should routinely be referred to orthopedists. Instead, this manuscript will con- When considering a patient for surgery, the general health of the centrate on shoulder problems that present and are treated by patient is of great importance. Specific medical conditions or practitioners, and include: medications can alter the approach or even preclude patients from surgical options. If the patient had surgery previously and 1) Rotator cuff pathology the results were poor, it is best to temper the patient’s expecta- a. Subacromial impingement tions for the revision surgery. Whether a patient smokes is also a b. Partial thickness rotator cuff tears factor to consider. Smoking compromises soft tissue and bone c. Full thickness rotator cuff tears healing as well as postoperative respiratory health. Patients d. Cuff tear arthropathy should be encouraged to quit smoking. Some surgeons will 2) Glenohumeral arthritis perform routine preoperative questionnaires such as the Medical 3) Glenohumeral instability Outcomes Study Short Form survey (SF-36). Patients who score a. Traumatic 30 Looking at the Surgical Options for Shoulder Pain AAEM Course

b. Atraumatic healing. The harmful effects of repeated steroid injections have 4) Biceps/Labral complex injuries been well documented and should be used with caution. a. Superior labral, anterior to posterior lesions Performing Neer’s test (Neer’s impingement sign before and after (SLAP) subacromial injection of local anesthetic) to diagnose impinge- b. “Internal impingement” ment has been shown to be a positive predictor for surgical 5) The stiff shoulder acromioplasty if the injection offered relief.87 Others have dis- puted this finding.55 Since this is the surgeon’s approach to shoulder pain, the focus will be on treatment, especially the operative treatment options Indications for surgery for subacromial impingement syndrome and outcomes, but not techniques. include patients who are appropriate surgical risks and fail conservative treatment. The main indication for surgery is pain and this is a quality-of-life issue. Counseling patients on performing ROTATOR CUFF PATHOLOGY an acromioplasty to prevent a future rotator cuff tear is un- founded in the literature.47 In 1972, Neer reported that impingement occurs against the anterior acromion, the coracoacromial ligament and the acromio- The subacromial space varies from 1-1.5 cm. Acromioplasty is a clavicular (AC) joint.68 He described four stages of impingement procedure designed to smooth and open this space. This can be as a continuum: performed with classic open techniques described by Neer or with arthroscopic techniques. Most authors report the indica- Stage I: Edema, inflammation, and hemorrhage tions of arthroscopic decompressions are the same as open Stage II: Fibrosis, tendonitis surgery described by Neer in 1972: Stage III: Bony spurs and excrescences, tears of the rotator cuff tendons Anterior acromioplasty . . . is used for all impingement Stage IV: Cuff tear arthropathy problems in patients over 40 years of age and in the few under that age with demonstrable skeletal prominences The natural history of rotator cuff disease is unclear. Nobody has at the undersurface of the acromion . . . is considered established the definite continuum or cause and effect of this only after symptoms have persisted despite adequate widely accepted theory, but Neer’s stages will be used as a general conservative treatment for at least 1 year and the pain is outline to discuss impingement, partial and full thickness tears, temporarily relieved by the impingement injection and cuff tear arthropathy. test.68

External or Subacromial Impingement These are clearly conservative indications. However, when compared to the rate at which Neer used open acromioplasty in his The etiology of rotator cuff pathology has been attributed to practice it is apparent that arthroscopic acromioplasty is used both intrinsic and extrinsic factors. The intrinsic factors which much more commonly with broader indications. It is important include overuse, insufficient blood supply of the cuff, and more to use caution and judicious conservative treatment before per- recently, theories on apoptosis, currently cannot be altered with forming acromioplasty as the rate of failures has been as high as surgery. The extrinsic factors thought to cause abrasion to the 25%.9 rotator cuff and contribute to “impingement syndrome” include acromial shape, AC joint pathology, the coracoacromial (CA) As a nonoperative musculoskeletal physician, it is reasonable to ligament, and the subacromial bursa. These anatomic structures treat impingement with 6 months of conservative treatment, can be altered with surgery. Neer recommended 9-12 months before performing surgery. Today athroscopists are more aggressive. Once the diagnosis of subacromial impingement has been made, a trial of nonoperative treatment should be attempted including Additionally, acromioplasty for impingement in athletes has avoidance of repeated activity, restoration of flexibility and been disappointing. Neer warned about acromioplasty in strength with aerobic exercise, and modifications of work and younger patients. A study by Tibone and colleagues reported sport as needed. Emphasis is on a low-tech, easily reproducible only 43% of the competitive athletes they studied returned to program that can be performed unassisted. Subacromial injec- pre-injury level of competition. In addition, only 4 of 18 in- tions have been reported to produce symptomatic short-term volved in competitive throwing returned to their pre-injury relief by some10,43 while others question their worth. level.97 These results question the diagnosis of “external” or Withrington and McInerney found no evidence of efficacy.62,106 outlet impingement as the cause of these symptoms in athletes. Steroid injections may produce tendon atrophy and impair It is likely there is another cause. It is important to look for AAEM Course Painful Shoulder 31 shoulder instability or periscapular dyskinesia as the main The relatively high incidence of partial and full thickness cuff pathology causing secondary impingement. Additionally, “inter- tears in cadavers (30% older than 40 years of age)32 and MRI nal impingement” may be the source of pain. studies question the cause of cuff tears as a source of pain. Sher and Uribe reported 15% full thickness tears and 20% partial Arthroscopic acromioplasty offers some advantages over open thickness tears in asymptomatic shoulders tested. This increased surgery. With arthroscopic acromioplasty there is less insult to with age to 54% in patients over 60 years of age.88 However, the deltoid, less scarring, and less postoperative pain. In addition, Fukuda states: “We conclude that a partial-thickness cuff tear is the hospital stay is shorter, which decreases costs, and the patient an important cause of shoulder disability, which deserves much can return to activity faster. Arthroscopy also allows better in- more clinical attention; misdiagnosis is common and leads to spection of the subacromial space and the glenohumeral joint, mismanagement. When conservative treatment fails, accurate which can often reveal concomitant pathology such as labral diagnosis and proper surgical repair are essential.”31 pathology, biceps or cartilage lesions, and loose bodies. The surgical treatment of partial thickness cuff tears includes de- Most series of arthroscopic acromioplasty in patients without bridement of the tear alone, acromioplasty alone, a combination cuff tears report 83-94% good results with recovery ranging of debridement and acromioplasty, and converting a partial tear from 2-4 months. To keep things in perspective, Brox and col- into a full tear followed by repair. Andrews and colleagues re- leagues compared the effectiveness of acromioplasty, an exercise ported 85% excellent and good results using arthroscopic de- program, and a placebo in a randomized trial. The authors con- bridement only. The study suggested debridement may initiate a cluded that surgery or a supervised exercise program significantly healing response.2 They noted a high percentage of concomitant and equally improved rotator cuff disease and impingement pathology (i.e., labral pathology) with difficulty determining the symptoms when compared to a placebo. Surgery, of course, was cause of pain. Ogilvie-Harris and Wiley reported 50% failure more costly.15 This was confirmed by a subsequent study.14 with debridement alone.74 Gartsman reported 83% satisfactory results in partial tears treated with acromioplasty.37 Olsewki and Gartsman offers the following six keys to successful arthroscopic Depew reported 81% satisfactory results with debridement and surgical decompression: (1) resection of the entire anterior pro- acromioplasty.75 Cordasco and colleagues reported increased tuberance of the acromion; (2) flatten the undersurface of the failure (38%) of bursal surface partial cuff tears after acromio- acromion; (3) ensure the deltoid fibers are visible from the AC plasty and stated that the patients “may have been better served joint to the lateral acromion after appropriate resection; (4) with primary repair.”24 Weber could not reproduce the out- smooth the undersurface of the acromion; (5) completely resect standing results of prior studies of cuff debridement and re- the CA ligament; and (6) perform a complete bursectomy.34-37 ported better results with primary repair. Partial tears went on to full thickness tears despite acromioplasty which may not prevent Results are best in well-motivated patients over the age of 40 rotator cuff tear progression.105 Additionally, Weber reported the whose injuries are not work-related, who have an absence of pos- healing of the partial tear was never observed at second-look terior capsule tightness, an absence of glenohumeral instability, a arthroscopy. positive subacromial crepitance, and when positive impingement maneuvers reproduce the patient’s pain. Some authors have advocated debridement and acromioplasty for partial tears less than 50% thickness, while those tears greater Partial Thickness Rotator Cuff Tears than 50% thickness should be taken down to a full thickness tear and repaired. There are no good studies to support this. Miller Rotator cuff tears range from small partial tears to massive ir- and colleagues reported more failures (26%) in debridement of reparable “cuff tear arthropathy.” Three types of partial tears are partial cuff tears less than 50% thickness when compared to fail- recognized: bursal surface, articular surface, and intrasubstance ures of repairs of partial tears greater than 50% (12.5%).64 tears. Bursal surface partial rotator cuff tears coincide and are Furthermore, determining thickness of a tear can be difficult, perhaps a result or continuum of external impingement.32 but clearly high-grade tears should be treated as full thickness tears. While the physician can guess at the presence of a partial thickness tear based on history and physical examination (especially When discussing the surgical treatment of partial cuff tears it is weakness), only imaging studies such as magnetic resonance difficult to: (1) define the indications for surgery; (2) determine imaging (MRI) can determine the presence of a partial tear which aspects of the patient’s pathology are responsible for (short of surgery). Once established, treatment for partial thick- symptoms; (3) determine why 15-50% of patients failed to ness rotator cuff tears is similar to treatment of impingement achieve satisfactory results; and (4) decide what procedure to with emphasis on nonoperative treatment. A primary indicator perform. Lengthy conservative treatment should not be criti- for surgery is pain that has been resistant to conservative treat- cized, but suspicion for high-grade partial tears should be treated ment, although weakness is a secondary indicator. as full thickness tears. 32 Looking at the Surgical Options for Shoulder Pain AAEM Course

Full Thickness Rotator Cuff Tears Watson reported that finding quality tissue in 89 cuff repairs was good in patients who did not have cortisone injections.104 He The mere presence of a rotator cuff tear is not itself an indication found that 13 of 62 patients with one to four injections had for surgery. The presence of clinically asymptomatic full thick- poor tissue, and 17 of 20 with more than four injections had ness tears has been recognized.63 It is difficult to improve patients poor tissue.104 A list of prognostic factors found on preoperative ex- without symptoms, (although they will likely have weakness on amination for durability of rotator cuff repairs is listed in Table 1. testing) and a case for surgery to prevent future problems has not been convincing. Healthy, active patients who believe the potential benefit of increased strength merits surgery should be Table 1 Prognostic factors for durability of rotator cuff repairs considered as candidates.

The primary indication for repair of a full thickness cuff tear is Age younger than 55 pain resistant to conservative treatment. Weakness and func- Acute traumatic versus chronic atraumatic tional deficits are also indications, but are less predictably re- No relation to work stored with repair when compared to pain relief. This is a No smoking history quality-of-life issue weighing the potential benefits of surgery No history of steroid injections versus repeated steroid injections with the risks. Good general health There is substantial data available reporting the results of non- No previous shoulder surgery operative and operative treatment of rotator cuff tears. There is Mild to moderate weakness versus positive Lag signs little data comparing the two, and even less evidence-based med- No spinatus atrophy icine. Clinical improvement with nonoperative treatment of full Normal radiographs versus superior head migration thickness tears was noted in 33%, 44%, and 59% of patients.84,107 More recent reports of conservative treatment showed 66-75% good results with less favorable results in tears larger than 1 cm2. Hawkins and Dunlop found more than half of patients reported satisfaction in nonoperative treatment and “the authors were unable to show that individual parameters There are abundant reports of operative repair of rotator cuff tear such as rotator strength, symptom duration, or functional im- in the literature. In general these are surgeons reporting their pairment were useful to predict outcome.”43 However, it was good results. Cofield and colleagues averaged the reports in the found that those who had an insurance claim or who experi- literature and found 87% of post-surgery patients had pain enced significant sleep loss due to shoulder pain were unlikely to relief.23 Recovery of strength was less predictable, but more be satisfied with nonoperative treatment.43 Itoi and Tabata re- common in smaller tears.65 Most reports indicate prognostic ported deterioration of function in full thickness tears with factors, but the most critical factor is tear size. In a prospective time.50 Bassett and Cofield have shown that patients who have a study with long-term follow up of an average of 13.4 years, significant history of trauma and a full thickness tear have better Cofield and colleagues reported 91% satisfactory pain relief.23 outcomes when repaired within the first 3 weeks after injury.7 According to the authors, “Tear size was the most important de- Clearly conservative treatment can be defended and may be the terminant of outcome with regard to active motion, strength, treatment of choice in unhealthy patients as well as those with rating of the result, patient satisfaction, and need for a re-opera- poor tissue and atrophy of the cuff tissue precluding a quality tion.” Workers’ compensation patients likely will have worse repair. However, establishing a preset fixed time period of con- results after repair. Misamore and colleagues reported 42% of servative treatment before considering surgery for full thickness patients receiving workers’ compensation return to full activity tears ignores the diversity of individual patient presentations and compared to 94% of those not receiving it.65 expectations. Arthroscopic rotator cuff repair has gained popularity over the When assessing a patient for surgery and determining the repara- last 5 years. There is a steep learning curve with this repair tech- bility of a cuff tear, much can be obtained from the history, phys- nique and it should only be performed by surgeons with high ical examination, and plain radiographs. For instance, an arthroscopic skill. The advantages of arthroscopic repair when 80-year-old patient with a history of repeated cortisone injec- compared to open techniques are similar to those discussed pre- tions, a positive external rotation lag sign, and proximal migra- viously for arthroscopic acromioplasty. Open repair allows pos- tion of the humeral heads is a patient with a large to massive cuff sible use of bone tunnels for fixation of the cuff, while tear. Repeated cortisone injections should be used with caution. arthroscopic methods necessitate anchors. The short term results AAEM Course Painful Shoulder 33 of arthroscopic repair are similar to open techniques.34,92 among surgeons when approaching a massive tear. Reparability Arthroscopic acromioplasty for full thickness tears without of a cuff tear is variable and should be determined by the “fit” of repair yields inferior results.108 the surgeon. However, some rotator cuff tears are truly irreparable in the hands of any surgeon. These cuff tears are massive in The reported results of rotator cuff repairs are superior to non- size, retraction, and atrophy. Heroic repairs have been at- operative reports; however there are no good evidence-based tempted. Surgical options for these patients with irreparable studies at this time to confirm this dogma. One study has looked tears are guarded and are considered salvage type procedures. at cost effectiveness of operative repair compared to nonopera- Conservative treatment is emphasized for as long as it can be tol- tive treatment. While the greatest improvements were found in erated by the patient. the operative group, the nonoperative group was associated with the largest improvement per $1000 used for treatment.59 Savoie In patients with massive cuff tears, proximal migration of the looked at a cost analysis of successful rotator cuff repairs in a humeral head will likely be seen. There is no longer any cuff workers’ compensation population.85 Patients referred to a spe- tissue to depress and center the humeral head into the glenoid. cialist immediately following the diagnosis of a rotator cuff tear It is critical when operating on patients with humeral head ele- had total costs that averaged $25,870.64 and returned to work vation to maintain the superior restraints. This means the on average of 7 months post-operatively. Patients managed in a surgeon should not remove the CA ligament or perform a stan- “gatekeeper” system averaged $100,280.10 in total costs and the dard acromioplasty in patients with massive cuff tears. average return to work was 18 months.85 Of course this only Sacrificing the CA arch jeopardizes the secondary restraint to studied patients who had surgery—patients who improved further proximal migration. This will predispose the patient to without the need for surgery is unknown. Concomitant symp- superior “escape” of the humeral head leading to more pain and tomatic AC arthritis can be treated with open or arthroscopic disability with more difficult treatment options. distal clavicle resection. Recalcitrant calcific tendonitis deposits may require debridement and repair. Variable results have been reported for arthroscopic debridement and “smoothing” techniques. More recently, techniques of Postoperative therapy protocols are surgeon and patient specific. “tuberoplasty” (meaning debridement of the greater tuberosity With few exceptions, rehabilitation protocols should be dictated instead of the CA arch) to reduce abutment and mechanical pain by the operating physician. However, the importance of contin- has yielded acceptable results.29,86 New biologic implants ued postoperative exercise has been established demonstrating (porcine small intestine submucosa implant) are used as a re- strength gains over 1 year after surgery. Walker and colleagues sorbable scaffold for host tissue growth. This should be used as found significant improvements 6-12 months after surgery.102 an adjunct to a repairable cuff with poor tissue, and not a sub- Brems found improving external rotation strength over time stitute to absent or irreparable cuff tissue. Muscle transfers have with 20% at 3 months, 38% at 6 months, 57% at 9 months, been performed including latissimus dorsi for and 71% at 1 year. infraspinatus/supraspinatus insufficiency and pectoralis major transfer for subscapularis insufficiency. Surgery must not com- Do cuff repairs maintain integrity? Interestingly, few follow-up promise the deltoid function. studies have investigated the relationship of cuff repair integrity and quality of postoperative results. Magnetic resonance imaging Cuff Tear Arthropathy of asymptomatic patients 2 years after rotator cuff repairs found a 20% re-tear rate without significant deterioration of results.96 Cuff tear arthropathy is a condition of both massive cuff tear and Harryman and colleagues used ultrasound to review 105 repairs. arthritis of the shoulder. There is loss of articular cartilage and ra- Their study found no patients who had a repair of a small full diographic changes consistent with arthritis. Additionally, the thickness repair had a re-tear. They also found a 20% re-tear rate humeral head demonstrates significant superior migration in repairs involving just the supraspinatus, a 43% re-tear rate in causing direct articulation with the acromial arch and “acetabu- primary repairs of the supraspinatus and infraspinatus, and less larization” of the upper glenoid and the coracoacromial arch. than one third were still intact 4 years after repair of a 3-tendon This is a condition devoid of good surgical solutions. Browlee massive tear.41 and Cofield reported on 20 different treatment surgical options for cuff tear arthropathy suggesting no one good procedure. Long-standing chronic cuff tears undergo muscle atrophy, re- Hemiarthroplasty with humeral head replacement is probably traction, and fatty infiltration. Successful repairs may restore the most used procedure. Glenoid replacement is contraindi- muscle, tendon, and bone continuity, however the fatty infiltra- cated in cuff tear arthropathy secondary to predictable glenoid tion and muscle atrophy has not been proven to reverse. loosening.30 A novel constrained “reverse” prosthesis is experi- mental but has yielded some short-term good results.90 Failure of It was once said that an “irreparable cuff” reflects more on the this prosthesis creates very difficult solutions. Additionally, the surgeon than the tear. Indeed there are different skill levels 34 Looking at the Surgical Options for Shoulder Pain AAEM Course high price of the prosthesis makes it cost-prohibitive in some 73% at 15 years.95 The authors found (according to a rating medical environments. system) nearly half of all young patients who had TSA had un- satisfactory results and cautioned that care should be exercised when either a hemiarthroplasty or a TSA is offered to patients Glenohumeral Arthritis who are less than 50 years of age.94 The survivorship for TSA performed for arthritis that developed after previous instability Glenohumeral arthritis can be primary or secondary. Primary surgery was only 61% at 10 years.94 While this procedure pro- osteoarthritis (OA) of the glenohumeral joint is considered idio- vides pain relief and improved motion, it is complicated by in- pathic and comprises approximately 60% of those patients creased failure and the need for revision surgery in this relatively having total shoulder arthroplasty (TSA). Arthritis of the gleno- young population.94 The implants have a limited life span and humeral joint can also be secondary to many conditions including deferring shoulder replacement for as long as possible is prudent. inflammatory arthritis (i.e., rheumatoid), post-traumatic avascular necrosis, instability, post-surgical neurotrophic arthropathy (i.e., The most common reason for failure in hemiarthroplasty is pro- syringomyelia or diabetes), or tumor. gressive glenoid wear and subsequent pain from the unresurfaced glenoid. The solution is to resurface the glenoid. The most The indication for surgical intervention is pain resistant to con- common reason for failure in TSA is glenoid component loos- servative treatment. Functional deficits can be improved, but are ening, which can cause a challenging surgical solution. Clearly less predictable. After a patient has exhausted nonoperative treat- the glenoid presents a difficult aspect of shoulder replacement ment options, surgery can be considered for sufficiently healthy, surgery. well-informed, and motivated patients who have significant compromise to their quality of life. Should the surgeon choose hemiarthroplasty or TSA? There is some literature to help guide the surgeon in making this deci- Nonoperative measures include avoidance of aggravating activi- sion; however, if the surgeon is uncomfortable inserting a ties that cause pain and lifestyle modifications, nonsterioidal glenoid, then this procedure should not be chosen. An unac- anti-inflammatory drugs, a gentle home exercise program, and ceptably high percent of glenoid loosening occurs in TSA in cortisone injections. Intrarticular cortisone injections have shoulders with large rotator cuff tears. Total shoulder arthro- yielded some mild, short-term benefits. Hyaluronic acid visco- plasty provided superior pain relief when compared with hemi- supplementation is not yet Food and Drug Administration ap- arthroplasty in patients who had glenohumeral OA and an intact proved for shoulder arthritis although it is being prescribed by rotator cuff.36 The incidence of rotator cuff tears found in con- some physicians. Studies on arthritic knees have shown junction with primary glenohumeral arthritis is relatively low at hyaluronic acid to be slightly better than placebo57 and no dif- 5%. Rheumatoid patients had better pain relief with TSA com- ferent than cortisone injections over the short term.56 pared to hemiarthroplasty despite progressive glenoid loosening in 12% of total shoulder arthroplasties, which did not correlate The most widely used procedure for glenohumeral arthritis is with pain relief or range of motion.13 joint replacement surgery. Other procedures have been described. Synovectomy for rheumatoid patients with intact artic- Hemiarthroplasty may be a better fit for patients with (1) arthri- ular cartilage can yield moderate results,77 but is less commonly tis and a large cuff tear, (2) avascular necrosis of the humeral needed with improvements in modern rheumatologic manage- head with a normal glenoid, (3) proximal humerus fractures, ment. Glenohumeral arthrodesis (shoulder fusion) is becoming and (4) poor glenoid bone stock to hold a glenoid. In addition, less common and is reserved for: (1) concomitant paralysis/dys- hemiarthoroplasty is a better fit for young patients (more function of the deltoid and rotator cuff; (2) previous infection durable and avoid future glenoid loosening). Total shoulder with destruction of the joint; (3) refractory and disabling insta- arthroplasty can be used in primary OA with intact or small re- bility; and (4) failed reconstructive procedures such as joint repairable rotator cuff tears and in rheumatoid patients. Shoulder placement. Resection arthroplasty (removing the joint including replacement is contraindicated in patients with active infections the humeral head) is also a salvage procedure yielding less func- and neurotrophic joints. When a neurotrophic shoulder is en- tion than fusion. countered, a syrinx should be ruled out.

Hemiarthroplasty (replacement of the humeral head only) and total shoulder arthroplasty (replacement of the humeral head Shoulder Instability and glenoid) are the most used options for glenohumeral arthritis. Sperling and colleagues reported that survivorship of TSA is Instability for the shoulder ranges from a subtle increase in laxity 84% at 15 years and that survivorship of hemiarthroplasty is to acute frank dislocation. It is critical to make the proper diag- AAEM Course Painful Shoulder 35 nosis before embarking on surgical repair. Shoulder instability 3) Capsular stretching can be categorized by direction, frequency, degree of instability, 4) Humeral avulsion of the glenohumeral ligaments and etiology. The surgeons approach to post-traumatic anterior (HAGL) lesion instability and multidirectional instability will be discussed. 5) SLAP lesion 6) Axillary nerve injury Traumatic Instability 7) Rotator cuff tear in “middle-aged” patients 8) Greater tuberosity fractures Traumatic anterior (or anterior/inferior) shoulder dislocations are the most common type of shoulder instability. The natural The Bankart lesion is a disruption of the anterior casulolabral history of a primary anterior shoulder dislocation is recurrence structures (and more critically the inferior glenohumeral liga- of instability especially in younger patients. In 1961, Rowe and ment complex) from the anterior edge of the glenoid. This lesion colleagues reported recurrence of instability in 94% of patients occurs in 87-100% of the cases depending on the study or indi- below 20 years of age, in 74% of patients between 20 and 40 cations.6,71 While most lesions occur at the capsule-glenoid in- years of age, and in 14% of patients older than 40 years of age.82 terface, other lesions can occur less frequently at the humeral Simonet and Cofield demonstrated younger age and participa- insertion (HAGL lesion) or stretching of the midsubstance of tion in sports to be significant risk factors for recurrence.89 the capsule. Speer demonstrated in cadaver models that a Hovelius and colleagues found a 90% recurrence in hockey Bankart lesion alone does not produce enough instability for dis- players less than 20 years of age.46 Yoneda reported a 17% relocation and suggested there must be capsular tearing that also currence with an average 13-year follow up after 5 weeks of im- occurs at the time of dislocation.93 This is important because this mobilization and 6 weeks of graduated exercise. Aronen and capsular injury must be addressed during surgery. The classic Regan found 25% recurrence after immobilization and rehabil- Bankart lesion involves soft tissue, but there can be an associated itation in naval midshipmen.5 These studies suggest immobiliza- fracture of the anterior inferior glenoid known as a “bony tion and rehabilitation may decrease rates of redislocation. Bankart.” When looking directly at the glenoid, it has a pear However, Hovelius and colleagues concluded that the type and shape and is wider inferiorly. Large bony Bankart lesions can duration of the initial treatment had no effect on the rate of reproduce an “inverted pear” appearance such that the superior currence.45 glenoid becomes wider (secondary to the loss of bone inferiorly). This increases the risk of redislocation and should be treated After appropriate reduction of the shoulder is verified radi- with open repair rather than arthroscopic repair. ographically (axillary film must be included), the cornerstone for management is nonoperative treatment. Initially, a period of im- The Hill-Sachs lesion is the injury or defect created by the ante- mobilization with the arm at the side for 3-4 weeks is recom- rior glenoid in the posterior superior aspect of the humeral head mended to allow the capsulolabral complex to heal. A at the time of dislocation. The incidence of a Hill-Sachs lesion is rehabilitation program with range of motion and rotator cuff reported to be 87% and the size can vary tremendously.98 Large strengthening (especially the subscapularis) follows. Recently, Hill-Sachs lesions are a risk factor for recurrence. immobilization of the arm in external rotation (ER) has been shown to decrease the recurrence of dislocations. In a prospec- Axillary nerve injuries have been reported as high as 35%.59 If tive study, Itoi and colleagues compared different immobiliza- careful electrodiagnostic studies are carried out, the incidence of tion techniques after initial anterior dislocations; conventional nerve injury in dislocations may be as high as 45%,26 increasing immobilization in internal rotation (IR), and a new method of with patient age, energy, and amount of time the shoulder is dis- immobilization in ER. The recurrence rate was 30% in the IR located. This may manifest a delay in recovery of active shoulder group and 0% in the ER group at a mean of 15.5 months.48 The motion and the patient may have normal sensation in the axil- difference in recurrence rate was even greater among those who lary nerve distribution.11 It is critical to test all three heads of the were less than 30 years of age (45% in the IR group and 0% in deltoid and obtain a needle electromyography (EMG) when ap- the ER group).48 An MRI study revealed immobilization of the propriate if there is concern. Most injuries are traction neuro- arm in ER better approximates the Bankart lesion to the glenoid praxia and the nerve will recover. If no recovery occurs within 3 neck than does the conventional position of IR.49 months, the prognosis is not as good.

The pathology that can occur with an anterior shoulder disloca- Patients that are middle-aged (over 35) and suffer from shoulder tion is as follows: dislocations have a higher incidence of rotor cuff tears. The incidence exceeds 30% in patients over 40 years of age.80,98 Usually 1) “Perthes” or “Bankart” lesion (with or without repair of the cuff yields good results without need for a Bankart bone) repair. Greater tuberosity fractures have been reported as high as 2) Hill-Sachs lesion 22%, but are usually nondisplaced and do not require repair.98 36 Looking at the Surgical Options for Shoulder Pain AAEM Course

The indication for surgery for anterior instability is recurrent 5) Less risk of loss of motion episodes of instability (dislocations or subluxations) that are dis- 6) Cosmetically desirable abling. Debate exists whether to repair first time dislocators 7) Subscapularis left intact acutely. Primary risk factors for a high incidence of recurrence include: (1) young patients, (2) bone loss (from glenoid or pos- Disadvantages of arthroscopic Bankart repair include the follow- terior humeral head), (3) active in contact sports, and (4) associ- ing: ated ligamentous laxity. 1) Bony defects cannot be treated Some authors advocate acute repair in patients with one or all of 2) Steep learning curve for the surgeon these risk factors. Surgical intervention clearly changes the 3) Rate of recurrence is higher natural history of anterior instability with decreased rates of re- 4) Tissue cannot be reinforced currence. Recurrence rates after Bankart repairs are low and range from 0-10%, but 3.5% is the classic standard to compare Does untreated recurrent anterior shoulder instability cause other results.82 Kirkley and colleagues demonstrated that early arthritis, and will stabilization prevent arthritis? Unfortunately, arthroscopic stabilization not only altered natural history, but there are no studies to answer this question. Gleyze noted that confirmed improvements in disease-specific quality of life in pa- shoulders with more than five recurrent dislocations were found tients less than 30 years of age with their first traumatic anterior to have erosion of the anterior articular cartilage.59 Harryman dislocation of the shoulder.54 also reported significant articular erosion in redislocators.42 Matsoukis reported on required joint replacement for 28 pa- There are two types of repairs, anatomic repairs and tients with arthritis secondary to shoulder instability.61 Samilson nonanatomic repairs. The anatomic repair is known as a Bankart identified 74 patients with arthritis who had a history of shoul- repair and achieves a close anatomic repair of the injured struc- der instability.84 The rate of arthritis is much lower after Bankart tures. Nonanatomic procedures alter normal anatomy to achieve surgery when compared to nonanatomic repairs, but still is re- tightening of the joint and prevent dislocation. These include ported. In general, subsequent recurrences often take less energy the Magnuson-Stack, Putti-Platt, Brisow, and Laterjet proce- for dislocation, perhaps further injuring the stabilizing structures dures. These procedures have fallen out of favor when compared and cartilage. Is this analogous to the anterior cruciate ligament? to the Bankart procedure because of loss of motion and the high Why risk further damage in the high risk population when sta- percentage of subsequent secondary arthritis as described previ- bilization can be achieved preventing theoretical subsequent ously. The Laterjet procedure transfers the coracoid process to trauma? the anterior glenoid and can be used for continued failed Bankart repairs, or in shoulders with a large bony Bankart lesion. Posterior dislocations are much less common and can be traumatic, secondary to electrical shock or seizures. Hawkins re- The Bankart repair is preferred because of superior results in reviewed 41 cases of posterior dislocations and the average interval currence rates, restoration of “normal anatomy,” less loss of between injury and diagnosis was 1 year.44 This can be avoided motion, and less reported subsequent arthritis. Bankart repairs in every case if an axillary radiograph is obtained. Acute poste- can be performed through classic open techniques and newer rior dislocations should be reduced followed by a period of im- arthroscopic techniques. Early arthroscopic Bankart repairs were mobilization. Recurrent posterior instability is rare, but may inferior when comparing recurrence rates, but improved tech- require posterior stabilization, open subscapularis, or lesser niques demonstrated in more recent studies now show similar tuberosity transfer. Chronic dislocations may require humeral rates.35,53 head replacement secondary to destruction of cartilage.

Advantages of arthroscopic repair include the following: Multidirectional Instability or Recurrent Atraumatic Instability 1) Ability to assess and treat comorbitities (i.e., SLAP lesion) Multidirectional instability (MDI) or recurrent atraumatic insta- 2) Less pain bility arises without any specific trauma, or perhaps may be pro- 3) Less morbitity voked by minor trauma. Certain shoulders are more susceptible 4) Quicker and “easier” rehabilitation to developing atraumatic instability. A small or flat glenoid will AAEM Course Painful Shoulder 37 jeopardize the concavity compression suction cup theory of in- The preoperative examination under anesthesia is a critical com- stability. An excessively compliant or excessively capacious joint ponent to all shoulder surgery, especially in patients with atrau- capsule may allow abnormal translation and instability. Weak matic instability. With the patient under anesthesia and relaxed, rotator cuff muscles or poor scapula stabilizers may alter the a better determination of the degree of laxity and the direction normal mechanics resulting in atraumatic instability. It is appar- of instability can be assessed and help dictate the surgical inter- ent that atraumatic instability is not a simple diagnosis when vention. There are open and arthroscopic techniques available compared to traumatic anterior instability, but rather a syn- for the surgical treatment of atraumatic instability. The classic drome that may arise from multiple factors. open treatment is the anterior/inferior open capsular shift as described by Neer and Foster.69 This treatment achieves a reduction To help remember these various aspects one can recall the of the joint volume and inferior recess. The results of open treat- acronym AMBRII. This instability is Atraumatic, ment for atraumatic instability are difficult to ascertain and are Multidirectional (usually with an inferior component) and often likely elevated in most studies because they also include patients Bilateral. Treatment is predominately Rehabilitation directed at with a history of trauma (who do better with surgery). Bigliani restoring and improving neuromuscular control. If surgery is reported on capsular shifts performed on athletes with 75% re- needed, closing of the rotator Interval and tightening the turning to their same level of competition, and only 50% of Inferior capsule is addressed. throwing athletes returning to pre-injury condition.8 Pollack and colleagues reported more promising results with 96% maintain- Nonoperative treatment of atraumatic instability is the main ing stability rates and satisfaction, 92% returning to strenuous treatment. Patients with traumatic instability had increased work, but only 69% of athletes returning to premorbid levels.78 humeral head translation but were able to recenter their humeral Obremsky and colleagues looked at open capsular shift for pa- head with muscle contraction whereas atraumatic instability patients with just atraumatic instability (unpublished data). tients were not able to recenter their humeral heads.101 Patients failed on average of 17 months of vigorous rehabilita- Optimizing neuromuscular control with rotator cuff strengthen- tion, 57% had bilateral symptoms, 29% had generalized liga- ing and periscapular muscles has shown to be effective. mentous laxity, and the average age was 22 years. At an average Burkhead and Rockwood found that while only 16% of trau- of 27-month follow-up, 74% of patients were satisfied with their matic instability patients improved with a rehabilitation results, 46% were able to return to recreation, 69% retuned to program, 80-90% of atraumatic instability patients responded to their job, 39% had persistent pain, 57% had night pain, and a rehabilitation program.21 Nonoperative treatment is especially 68% had at least occasional instability. The most important cor- attractive in children, patients with voluntary instability, and for relate to dissatisfaction was not recurrence of instability but per- those requiring supranormal ranges of motion such as pitchers sistent pain and stiffness suggesting the surgery for MDI may and gymnasts. make matters worse.

It is often necessary to “cheerlead” patients through a rehabilita- Arthroscopic capsular placation for shoulder using suture placation program for atraumatic instability as the rehabilitation may tion is relatively new. It has yielded good early results with the 99 seem prolonged. Many patients would prefer a surgical cure. The obvious benefits of arthroscopic surgery over open surgery. patient must be willing to accept the exercise program and must There has been recent enthusiasm for treating shoulder instability with arthroscopically administered thermal energy. Heating also be informed that results will not occur overnight. It is useful collagen between 65° and 75°C will denature and shrink colla- to demonstrate that the often asymptomatic contralateral shoul- gen to achieve a “tightening” of the shoulder.1 This is technically der has substantial laxity yet is clinically stable. easier than suture plication. Animal studies suggest that heated collagen will restretch and perhaps become more lax with time.1 The ability to cure atraumatic instability with surgery may be Clinical studies are probably revealing this because the recent en- limited and the indications for surgery should be carefully con- thusiasm has been tempered. Several leading shoulder surgeons sidered. This is a quality-of-life decision and the patient’s major have reported unacceptably high failure rates in MDI patients functional problems must be clearly related to the shoulder in- treated with heat.25,28,70 Complications such as axillary nerve stability. The patient must have been compliant with and failed injury and complete capsular obliteration seen at the time of re- a rehabilitation program and should understand that a postop- vision surgery after previous application of thermal energy have erative rehabilitation program will be even more important. The been reported. Thermal capsulorraphy is still investigational and patient must be willing to accept some loss of rotation as surgery its role as an adjunct to other methods may be promising. will tighten the capsule. However, it should be used with caution. 38 Looking at the Surgical Options for Shoulder Pain AAEM Course

BICEPS/LABRAL PATHOLOGY Type I SLAP lesions may require debridement at the time of surgery, while type II-V require some combination of debride- Superior Labrium Anterior to Posterior Lesions ment and repair. These are performed arthroscopically. Debridement alone of SLAP lesions has proven ineffective with The importance of the biceps insertion as a possible source of 63% of patients reporting satisfactory pain relief and 45% re- pain was recognized by Andrews and colleagues in 1985.3 In an turning to previous levels of activity at 2 years.24 Treatment has EMG study, they showed that biceps contractions could lift the evolved to repairing the SLAP lesion back to the bony glenoid. biceps tendon off the glenoid origin and in throwers an overload Burkhart reported that of 102 patients with SLAP lesions, the might lead to injuries of the biceps origin.3 Snyder coined the results were 83% excellent, 14% good, 3% fair, and 0% poor acronym SLAP lesion for Superior Labrum, Anterior to after arthroscopic repair.17 Forty-four of the patients were base- Posterior lesion. Initially four types were described with a fifth ball pitchers and 84% returned to pre-injury levels of perfor- type later added, described as a SLAP lesion found with a mance. The three fair results had concomitant rotator cuff Bankart lesion.3 The incidence varies among the literature from repairs. 4-11%.52 Postoperatively, the biceps is protected with limited active elbow The function of the superior labrum/biceps complex has re- flexion. More recently with the advent of the peel back theory, ceived a lot of recent attention. Pagnani found increased gleno- active external rotation is limited in the early postoperative humeral translation in the presence of a SLAP lesion.76 Rodosky course. Postoperative protocols are surgeon specific and should found the superior labral complex adds support to the inferior always be deferred to the surgeon. glenohumeral ligaments (IGHL) and this support is absent with a SLAP lesion.79 Electromyography data from another clinic also Internal Impingement supports this theory of the biceps/labral complex offering support to the IGHL and resisting anterior translation.38 The Internal impingement is closely related to SLAP lesions and has mechanism of injury can be many including a fall on an out- received much attention at recent orthopedic meetings. Internal stretched arm, repetitive injury from throwing, traction injuries, impingement was first reported by Walsh in 1992 as sympto- and more recently torsional peel back in abduction and external matic contact between the undersurface of the posterior/superior rotation has been reported. rotator cuff and the posterior/superior labrum and glenoid margin while the shoulder is in abduction and external rotation. There has been recent interest in trying to diagnose SLAP This created undersurface pinching and tearing of the cuff and lesions. Since they present with a wide spectrum of clinical com- was thus termed “internal impingement.”60 Jobe later suggested plaints and examinations, MRI can help diagnostically with that this was a result of anterior “microinstability” secondary to varying degrees of sensitivity. The gadolinium-enhanced MRI repetitive capsular microtrauma from throwing (no science). does increase the sensitivity of diagnosing a SLAP lesion by MRI. Any orthopedists treating SLAP lesions should be com- Most recently Morgan and Burkhart21 have refuted this theory fortable reading the MRI themselves. There are normal and suggested the problem is not internal impingement or ante- anatomic variations (e.g., Buford Complex or a sublabral recess) rior microinstability, but actually a throwing-acquired poste- that can be interpreted as pathologic and only direct visualiza- rior/inferior capsular contracture.18 The tight posterior capsule tion is likely to reveal the truth. Any younger patient with per- draws the humeral head unnaturally posterior and superior sistent shoulder pain and possible mechanical symptoms should during late cocking of the throwing action causing a peel back be suspected of having a SLAP lesion. Arthroscopy is still the which forces the cause of the SLAP lesion and an undersurface gold standard for diagnosing SLAP lesions. cuff tear (seen in 70% of throwers with posterior SLAP lesions). This is diagnosed by measuring a glenohumeral internal rotation Conservative treatment for SLAP lesions has not been proven ef- deficit (GIRD) in the throwing shoulder when compared to the fective, especially in patients with mechanical symptoms. The opposite shoulder.18 This must be performed with the patient superior labral tears have not proven to heal spontaneously, and supine, the scapula stabilized by the examination table, and mea- arthroscopic surgical repair is needed. If the physician is skepti- suring internal rotation differences with the arm in 90° of ab- cal that the SLAP lesion is the source of pain, then conservative duction. The average GIRD for pitchers with proven SLAP II measures are appropriate. lesions was 53°.67 A GIRD greater than 25° predisposes the throwing shoulder to developing pain and SLAP lesions, while a AAEM Course Painful Shoulder 39

GIRD of 10-12° is optimal for avoiding shoulder injury and Carette and colleagues performed a prospective trial and con- maximizing on field performance.66 cluded that a single intra-articular injection of corticosteroid combined with a simple home exercise program is effective in The treatment for GIRD is aggressive stretching to normalize improving shoulder pain and disability in patients with adhesive the GIRD. Ninety percent of patients will respond to stretching, capsulitis.22 Adding supervised physiotherapy provides faster im- and will typically gain 10° of internal rotation in the first week. provement in shoulder ROM. Some suggest addition of This should be performed in all pitchers without pain to prevent hyaluronate may be helpful.81 potential injury. The physician should assess the patient for scapular dyskinesia and improve any periscapular dysfunction. If Most studies on distention arthrography or Brisement profess an the patient has continued pain, mechanical symptoms, and an extremely low risk and high benefit ratio; however most in- examination consistent with a SLAP lesion, arthroscopy is indi- cluded therapy which is likely an important confounding vari- cated. These authors have reported superior results in elite over- able. In a small prospective randomized study, Gam and head athletes with 90% excellent and 10% good results. All 124 colleagues confirmed improved comfort and function with dis- pitchers treated returned to pitching.67 tension and steroid injection when compared to steroid alone.33 Vad and colleagues concluded that the distension procedure The Stiff Shoulder should be reserved for patients in stage II who do not progress despite participating in a physical therapy (PT) program.100 The stiff shoulder can be divided into primary and secondary causes. The frozen shoulder or “adhesive capsulitis” is primary Patients with recalcitrant frozen shoulders with continued pain and the cause is idiopathic. The pathology has been linked to and significant loss of ROM who have failed a minimum of 6 shoulder capsule contraction and fibrosis. Some authors have months of appropriate nonoperative treatment are candidates suggested a link between Dupuytren’s disease and adhesive cap- for surgical intervention. The surgical options include manipu- sulitis, but the etiology remains elusive.16 The shoulder stiffness lation under anesthesia (MUA), arthroscopic release with or may also be secondary to trauma or a post-surgical condition. without MUA, and open release with or without MUA. A long- Primary stiff shoulder, or adhesive capsulitis, has an incidence of acting interscalene block is a good modality used in conjunction 3% in the general population and an incidence of 11-30% with surgery as it allows longer pain relief to start motion im- among diabetics.66 mediately after surgery. Post operative non-steroidal anti-inflammatory drugs and analgesics, cold therapy, possible use of Adhesive capsulitis is generally a simple diagnosis to make. continuous passive motion machines, and certainly initial inten- Patients will have a global decrease in both active and passive sive PT (5 times a week for 2-3 weeks) followed by formal range of motion (ROM) with normal radiographs. The natural therapy or a sustained home program is recommended by most history is thought to be self-limiting with eventual resolution, surgeons. but how long does this take? Griggs and colleagues found that despite 90% satisfactory results at 22 months of follow up, 27% Manipulation under anesthesia has been the primary mode of had persistent mild-to-moderate shoulder pain with activity and treatment for over a century and its effectiveness is well docu- 50% still had abnormal ROM.39 At an average of 7 years follow mented. Kessel demonstrated that patients who suffered symp- up, Shaffer found 60% still had a restriction in ROM and 50% toms for at least 6 months had better improvements after MUA had complaints of pain.87 Simmonds observed that “complete than those with shorter duration of symptoms.52 recovery . . . is not my experience.”60 DePalma wrote, “it is erro- Contraindications of MUA include severe osteopenia of the neous to believe that in all instances restoration of function is at- humerus, recent surgical repair (i.e., rotator cuff) and long term tained.” For diabetics the outcome is likely worse. At 29 months diabetes. Complications after MUA do occur but the cumulative of follow up, one author reported that 35% had regained normal reported risk of an inadvertent event is less than 1%. Reported ROM, 48% had persistent restriction in ROM “without func- complications include rotator cuff tear, proximal humerus frac- tional limitation” and 17% had significant limitations that ture, dislocation, and brachial plexus injury. The reported rate of handicapped activities of daily living.65 recurrent stiffness is between 5-20%. The reported success of MUA is variable ranging from 25% to over 90% of patients sig- Nonoperative treatment is the mainstay for adhesive capsulitis. nificantly improving at 3 months with an improvement of 70% Many studies confirm the efficacy of physiotherapy, either su- at 6 months after MUA.42 Janada reported an unacceptably high pervised or a home program for frozen shoulder. Some have con- rate of recurrence in patients with long standing insulin-depen- cluded that treatment and no treatment may result in the same dant diabetes. More recently Dodenhoff found 12.8% having outcome. The literature seems clear that intraarticular injections severe disability 3 months after MUA.27 Arthroscopic evaluation can relieve pain. Corticosteroid injections have been recom- after MUA demonstrates capsular tearing of the axillary pouch mended for stage I and II adhesive capsulitis with “rapid and and extending anterior and posterior.27 striking recovery” of a pain-free shoulder within 6 weeks.40 40 Looking at the Surgical Options for Shoulder Pain AAEM Course

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CME SELF-ASSESSMENT TEST

Select the ONE best answer for each question.

1. Which of the following is most true regarding patients that 5. Regarding the diagnosis and treatment of shoulder lesions, present with diffuse arm and shoulder pain? which is the most true? A. They are more likely to have rotator cuff tear than a su- A. Studies demonstrate high interrater reliability for the perior labrum anterior and posterior (SLAP) lesion. final diagnosis of patients with shoulder problems. B. They have a high probability of reporting psychological B. Studies looking at the accuracy of diagnosis of shoulder ill health. disorders based on physical examination demonstrate a C. They are most likely to have cervical radiculopathy. high level of accuracy when compared to arthroscopy. D. They are easier to diagnose than patients with focal, lo- C. Sensitivity of the physical examination to diagnose com- calized pain. plete rotator cuff tears has been reported in multiple E. If they have a positive impingement sign with diffuse studies as greater than 80%. pain, this suggests a SLAP lesion. D. Most studies show that the surgeon’s physical examination is highly accurate for diagnosing SLAP lesions, if 2. Which of the following tests is primarily used to assess for the surgeon does the arthroscopy. impingement syndrome? E. Rheumatologists treatment of shoulder disorders is A. Hawkins sign. highly dependent on the specific diagnosis made. B. The O’Brien active compression test. C. Compression rotation test. 6. The nerve trunk most likely to be damaged as a result of an- D. Speeds test. terior dislocation of the shoulder is: E. Yergason sign. A. Musculocutaneous. B. Radial. 3. Which of the following tests is most likely to be normal in a C. Axillary. patient with a complete supraspinatus tear? D. Posterior cord. A. Drop arm test. E. Suprascapular. B. Supraspinatus test. C. Empty can test. 7. When shoulder dislocation results in damage to the radial D. Resisted extension test. nerve, which of the following other nerve distributions is E. Strength testing of the shoulder abductors. always involved? A. Suprascapular. 4. When diagnosing SLAP lesions which is the most true? B. Musculocutaneous. A. Most patients with SLAP lesions have other intraarticu- C. Thoracodorsal. lar shoulder lesions. D. Axillary. B. Repeat studies on the O’Brien Active Compression Test E. Dorsoscapular. were able to reproduce the initial high level of sensitivity and specificity. C. The sulcus sign is usually positive. D. The compression rotation test is negative. E. The load and shift test is positive. 46 CME Self-Assessment Test AAEM Course

8. Which of the following spinal nerve roots is most vulnerable 14. Which of the following statements is FALSE? to avulsion injury during injuries that widen the shoulder- A. Classic shoulder impingement involves the supraspina- neck angle? tus under the acromion. A. C4. B. Coracoid impingement involves the subscapularis under B. C5. the coracoid. C. C6. C. Internal impingement occurs at the posterior glenoid D. C7. rim. E. C8. D. Scapular malposition, Inferior border prominence, Coracoid pain and malposition, and dysKinesis of 9. Middle third clavicle fracture is associated most frequently scapular movement occurs in athletes. with damage to which of the following nerve trunks? E. Glenohumeral internal rotation deficit is caused by an- A. Medial cord. terior capsular tightness. B. Lateral cord. CMiddle cord. 15. Which of the following statements is true? D. Lower trunk. A. Closed kinetic chain exercises typically involve one joint. E. Upper trunk. B. Codman’s exercises involve high speed throwing movements. 10. Neuralgic amyotrophy is distinguishable from C5 - C6 C. Plyometrics involves slow isokinetic movements. radiculopathy on the basis of its tendency to demonstrate: D. Open kinetic chain exercises typically cause greater joint A. Severe axon loss. shear forces. B. Denervation in the rhomboid major muscle. E. Activation of the shoulder adductors narrows the sub- C. Frequent sensory nerve action potential amplitude loss. acromial space. D. Conduction block as a frequent pathophysiological finding. 16. Choose the most correct statement about shoulder arthritis: E. Involvement of most muscles in the affected myotome. A. Total shoulder arthroplasty gives more predictable pain relief than hemiarthroplasty in primary and rheumatoid 11. Which two muscles act as a force couple to depress the arthritis of the shoulder. humeral head during abduction? B. Patients with both glenohumeral arthritis and ipsilateral A. Supraspinatus and infraspinatus muscles. massive rotator cuff tears are good candidates for total B. Infraspinatus and teres minor muscles. shoulder arthroplasty. C. Subscapularis and infraspinatus muscles. C. Most patients with glenohumeral arthritis will also have D. Deltoid and biceps muscles. a concomitant ipsilateral rotator cuff tear. E. Latissimus dorsi and pectoralis major muscles. D. Shoulder replacement surgery can give predictable pain relief caused by neurotrophic destruction of the shoul- 12. Which muscles rotate the scapula during abduction? der. A. Levator scapulae and serratus anterior muscles. E. The primary indication for shoulder replacement B. Infraspinatus and teres minor muscles. surgery is restoration of function and range of motion. C. Subscapularis and infraspinatus muscles. D. Deltoid and biceps muscles. 17. When a patient presents with shoulder pain, what is the E. Latissimus dorsi and rhomboids muscles. most accurate and efficient means to rule out a shoulder dislocation? 13. Wearing a wrist splint for upper limb activities has been A. Computed tomography scan. shown to result in which of the following kinesiologic B. Standard anterior-posterior film of the shoulder. changes? C. Physical examination. A. Decreased elbow flexion. D. Axillary film. B. Increased shoulder flexion. E. Magnetic resonance imaging (MRI). C. Decreased shoulder extension. D. Increased wrist flexion. E. Decreased shoulder abduction. AAEM Course CME Self-Assessment Test 47

18. Choose the FALSE statement: 20. Choose the most correct statement about rotator cuff A. Magnetic resonance imaging is the gold standard for di- pathology: agnosing a SLAP lesion. A. Patients with massive cuff tears showing an elevated or B. Glenohumeral internal rotation deficit (GIRD) of 25 “high riding” humeral head that abuts the acromion on degrees or greater may predispose pitchers to shoulder radiographs may benefit from an acromioplasty and pain and SLAP lesions. coracoacromial ligament resection. C. GIRD can be successfully treated with an appropriate B. Rotator cuff repair does not reverse fatty infiltration and rehabilitation protocol. atrophy seen in chronic cuff tears. D. The incidence of adhesive capsulitis is greater among di- C. Acromioplasty can prevent future full thickness rotator abetics when compared to age-matched population. cuff tears. E. Relative contraindications for manipulation under anes- D. The primary indication for rotator cuff repair surgery is thesia for the treatment of adhesive capsulitis include pa- restoration of function and range of motion. tients with severe osteopenia, recent rotator cuff repair, E. The results of rotator cuff repair in workers’ compensa- and longstanding diabetes. tion patients are similar to the results in patients not receiving workers’ compensation. 19. In patients older than 40 years of age with a history of a standard anterior shoulder dislocation, the physician should be particularly concerned and suspicious of what? A. Deltoid tear. B. SLAP lesion. C. Rotator cuff tear. D. Pectoralis major tear. E. Long head of the biceps dislocation. 48 AAEM Course AAEM Course 49 Painful Shoulder

EVALUATION

Select ANY of the answers that indicate your opinions. Your input is needed to critique our courses and to ensure that we use the best faculty instructors and provide the best course options in future years. Please use the computer form to answer the following questions. For the purpose of tabulating evaluations, please enter the last 4 digits of your telephone number in the ID NUMBER box beginning with the left column and fill in the appropriate ovals below each number. Make additional comments or list suggested topics or faculty for future courses on the comment form provided at the end.

21. How would you rate the quality of instruction received 25. How would you rate the quality of instruction received during Dr. Michael Andary’s presentation? during Dr. Bodor’s presentation? A. Best possible. A. Best possible. B. Good. B. Good. C. Average. C. Average. D. Fair. D. Fair. E. Worst possible. E. Worst possible.

22. Select any item(s), that, if changed, would have appreciably 26. Select any item(s), that, if changed, would have appreciably improved Dr. Michael Andary’s presentation: improved Dr. Bodor’s presentation: A. Quality of slides. A. Quality of slides. B. Quality of handout. B. Quality of handout. C. Amount of clinically relevant information in the presen- C. Amount of clinically relevant information in the presentation. tation. D. Amount of scientific content in the presentation. D. Amount of scientific content in the presentation. E. Other: please explain on the comment form at the back E. Other: please explain on the comment form at the back of this handout. of this handout.

23. How would you rate the quality of instruction received 27. How would you rate the quality of instruction received during Dr. Levin’s presentation? during Dr. John Andary’s presentation? A. Best possible. A. Best possible. B. Good. B. Good. C. Average. C. Average. D. Fair. D. Fair. E. Worst possible. E. Worst possible.

24. Select any item(s), that, if changed, would have appreciably 28. Select any item(s), that, if changed, would have appreciably improved Dr. Levin’s presentation: improved Dr. John Andary’s presentation: A. Quality of slides. A. Quality of slides. B. Quality of handout. B. Quality of handout. C. Amount of clinically relevant information in the presen- C. Amount of clinically relevant information in the presentation. tation. D. Amount of scientific content in the presentation. D. Amount of scientific content in the presentation. E. Other: please explain on the comment form at the back E. Other: please explain on the comment form at the back of this handout. of this handout. 50 Evaluation AAEM Course

29. As a result of your attendance at this course, did you learn 31. Should this topic be presented in the future by a different anything that will improve the care of your patients? method of presentation. A. Yes, substantially. A. No, the topic of presentation should remain as a course. B. Yes, somewhat. B. Yes, the topic should be presented as a dinner seminar. C. Not sure. C. Yes, the topic should be incorporated into the plenary D. Probably not. session. E. This course was not applicable to my patients. D. Yes, the topic should be discussed during a breakfast session. 30. Select ALL items where improvement was needed. E. Yes, the topic should be organized as a special interest A. The accuracy of advance descriptions of this course. group. B. The specific topics selected for presentation. C. The number of speakers in this course. D. The amount of time allotted for discussion in this course. E. Other: please add other areas and outline specific recommendations for areas needing improvement on the comment form at the back of this handout. AAEM Course 51 FUTURE MEETING RECOMMENDATIONS

Select ANY of the answers that indicate your opinions. The following questions are included with all dinner seminar, course, and plenary session evaluations. It is only necessary to answer these questions once during the course of the entire meeting.

32. Please indicate below your specialty: 38. How would you rate this meeting? A. Neurologist. A. Poor. B. Physiatrist. B. Fair. C. PhD. C. Good. D. Other. D. Very good. E. Excellent. 33. How often do you attend AAEM meetings? A. Annually. 39. Did this meeting meet your expectations? B. Every 2-3 years. A. Not at all. C. Every 4 or more years. B. Somewhat. D. This is the first AAEM meeting I have attended. C. As expected. D. Exceeded expectations. 34. With regard to this years meeting, which of the smaller E. Best ever. group sessions did you attend? (mark all that apply) A. Experts’ roundtables. 40. Was the printed program clear and easy to follow? B. Workshops. A. Yes. C. Dinner seminars. B. No. D. None of the above. 41. With regard to the meeting hotels: 35. If you answered none of the above to the previous question, A. I stayed at one of the meeting hotels. please answer the following. The reason I did not attend the B. I did not stay at one of the meeting hotels. small group sessions was due to: A. The timing of the event. 42. If you answered B to the question above, please explain why B. The cost of the event. you did not stay at one of the meeting hotels (please make C. My lack of interest in the topics offered. your comments under Comments, page 51). D. The session was full. 43. How did you first learn about the meeting? (choose the 36. Did this meeting provide information that will enhance care method where you first learned about the meeting) of your patients? A. Preliminary brochure mailing. A. Extremely. B. Registration brochure mailing. B. Somewhat. C. The internet. C. Very little. D. Email message. D. Not at all. E. From a friend.

37. With regard to the social event: 44. Did you perceive any commercial bias in any of the educa- A. I am signed up to attend the social event. tional sessions offered by the AAEM at this meeting? B. I did not sign up because of the cost of the event. A. Yes. C. I did not sign up because of the day the event was B. No. offered. D. I did not sign up because I am not interested in attending this type of function. 52 Future Meeting Recommendations AAEM Course

45. Did you attend any of the industry forums provided this 48. How do you prefer to learn new information? year? A. Lecture only. A. Yes. B. Lecture in conjunction with questions and answers. B. No. C. Small group hands-on. D. Small group discussion. 46. If you answered yes to question 45 and you attended the Pfizer Industry Forum, how would you rate the quality of the 49. I plan to attend the 2005 AAEM meeting in Monterey, session? California, September 21-24. A. Best possible. A. Yes, definitely. B. Good. B. No, definitely. C. Average. C. Will wait to see the program content. D. Fair. D. Will wait to see if budget allows my attendance. E. Worst possible. On Page 53 under comments, please provide any other 50. I would be more likely to attend the 2005 AAEM meeting if comments you have about your attendance at the Pfizer (please make your comments under Comments, page 53): Industry Forum.

47. If you answered yes to question 45 and you attended the Allergan Industry Forum, how would you rate the quality of the session? A. Best possible. B. Good. C. Average. D. Fair. E. Worst possible. On Page 53 under comments, please provide any other comments you have about your attendance at the Allergan Industry Forum. COMMENTS

Given time and budget constraints, is there something we could do in terms of altering the format of the meeting that would significantly increase the likelihood of your attendance at future AAEM meetings? Explain:

Write out any additional comments about specific courses or the plenary session (please indicate which), and list suggestions for topics and speakers for future meetings. Leave at the AAEM Registration and Information Center or mail to the AAEM Executive Office at 421 First Avenue SW, Suite 300 East, Rochester, MN 55902. AAEM 421 First Avenue SW, Suite 300 East Rochester, MN 55902 (507) 288-0100 / Fax: (507) 288-1225 [email protected] www.aaem.net