FOR PRACTITIONERS IN STUDENT HEALTH SETTINGS Matthew Lunser, DO Team Physician University of Vermont 11.2.17 Objectives Learning Objective #1: Identify etiologies of shoulder problems in college health. Learning Objective #2: List the elements of and perform a systematic examination of the shoulder. Learning Objective #3: Explain management plans for common shoulder conditions in college students. Disclosures I have no financial disclosures Thank you Michele Bliss, MS, ATC Eugene Santos, MS, ATC Lisa Hardy, MS, ATC Add a Slide Title - 1 Anatomy Review Bones Ligaments Muscles Neurovascular Anatomy Anatomy Anatomy Ligaments Muscles Infraspinatus Shoulder Examination - History Dominant arm Sports participation Prior injuries along kinetic chain Discoloration or swelling of arm Night pain Neck problems Shoulder Examination - Referred pain patterns Supraspinatus Infraspinatus Shoulder Examination - Referred pain patterns Subscapularis Physical Examination Inspection Posture Deformity (dislocation, fractures) Fractures swell, dislocations don’t Scapulothoracic motion A special test? Physical Examination Palpation Sternoclavicular joint Clavicle Acromioclavicular joint (springy) Long head biceps tendon Physical Examination Range of Motion Flexion (180˚) Abduction (180˚) External rotation (90˚) Cervical spine motion Physical Examination Strength Testing Flexion Abduction External rotation Internal rotation Elbow flexion Practice! History Inspection Palpation Range of Motion Strength Testing Sternoclavicular Dominant arm Shoulder height Flexion Flexion joint Sports Posture Clavicle Abduction Abduction Acromioclavicular Arm swelling Musculature External rotation External rotation joint Scapulothoracic Long head biceps Prior injuries Internal rotation Internal rotation motion tendon Physical Examination Special Tests Provocative maneuvers Lack sensitivity and specificity Multiple named tests for each structure 140 named shoulder tests Neer’s Test Supraspinatus Impingement Arm internally rotated and passively moved into maximal flexion “neer - pinky to ear” Abnormal is reproducible pain Sensitivity: 64-80% Specificty: 30-53% Hawkin’s Test Supraspinatus Impingement Patient standing, shoulder flexed to 90 degrees and then passively internally rotated “hawk wing” Abnormal is reproducible pain Sensitivity: 55-80% Specificity: 38-59% AKA Hawkins-Kennedy Test Empty Can Test Supraspinatus strain/tear Arm flexed to 90 degrees, horizontal adducted to 30 degrees, elbows extended and thumbs down ---> Resisted flexion Abnormal is pain or weakness Sensitivity: 64-74% Specificity: 29-65% “Full Can test” is also valid (1996) AKA: Jobe’s Test, Scaption Test External Rotation Test Infraspinatus strain/tear Elbow at side and flexed 90˚, resist examiner’s internal rotation force Abnormal is pain or weakness Lift Off Test Subscapularis strain/tear Dorsum of hand on back, lift off back against examiner’s resistance Abnormal is pain/weakness Sensitivity: 17.6% Specificity: 100% Lower portion of subscapularis Bear Hug Test Subscapularis strain/tear Arm across body with fingers flat and pushing down onto top of the contralateral shoulder, resist examiner’s external rotation pressure Abnormal is weakness/pain Sensitivity: 60% Specificity: 91.7% Upper portion of subscapularis O’Brien’s Test Labrum tear – SLAP lesion Shoulder flexed to 90˚ and horizontal adduction to 15-20˚, point thumb down and resist examiner’s downward force. Compare with palm up. Abnormal is pain with thumb down, pain relieved with palm up. Sensitivity: 63-94% Specificity: 28-53% Biceps Load II Test Labral Tear Arm abducted 120˚, full external rotation, resist the patient’s elbow flexion Abnormal is pain at the labrum Sensitivity: 89.7% Specificity: 96.9% Cross Arm Test Acromioclavicular joint sprain Shoulder at 90 degrees, passive full adduction across chest Abnormal is pain at the acromioclavicular joint Sensitivity: 77% Speed’s Test Biceps tendon pathology Shoulder flexed to 90˚, elbow fully extended, arm supinated ---> resisted shoulder flexion Abnormal with pain in bicipital groove Sensitivity: 32-60% Specificity: 38-67% Apprehension Test Anterior instability/dislocation Shoulder at 90˚ abduction, and 90˚ external rotation, apply a gentle external rotation force Abnormal is sensation of instability, apprehension” Sensitivity: 40-100% Specificity: 42-96% Relocation Test Anterior instability/dislocation Apply a posterior force on the humeral head while performing the apprehension test Reduced sense of apprehension confirms instability Sulcus Sign Multidirectional instability Arm at side, examiner pulls inferiorly on humerus Abnormal is formation of a “sulcus” superior to the humeral head Thoracic Outlet Syndrome Tests Allen Test – Wright Test Adson Maneuver Halstead Maneuver Military Brace Position Roos Test ALL HAVE POOR RELIABILITY Spurling’s Test Cervical radiculopathy With the neck extended, sidebent ipsilateral, and rotated contralateral, examiner applies a downward pressure to the head Abnormal is pain radiating to the involved shoulder Sensitivity: 30% Specificity: 93% Practice Impingement Rotator cuff Labrum Stability Other Neer’s test Empty can O’Brien’s test Apprehension test Cross arm test External rotation Hawkin’s test Biceps load II test Relocation test Speed’s test test Lift off test Sulcus sign Spurling’s test Bear hug test Common Shoulder Problems in College Students Dislocation, subluxation, and instability Acromioclavicular joint sprain Labral tear Rotator cuff tear Biceps tendonitis Impingement syndrome Clavicle fracture Thoracic outlet syndrome Shoulder Dislocation, Subluxation, Instability First time dislocation/reduction Chronic subluxers Shoulder pain with underlying instability Shoulder Dislocation Anterior most common Reduction with traction gentle external rotation Dislocation doesn’t swell Post reduction xrays Fractures swell Sling for comfort Physical therapy Shoulder Dislocation Most first time dislocation/reduction can be treated conservatively Orthopedic referral First-time traumatic shoulder dislocation with Bankart lesion confirmed by MRI in athlete younger than 25 years of age “High demand athletes” Orthobullets.com Chronic subluxation Recurrent subluxation or dislocations Refer to orthopedics Physical therapy Multidirectional Instability More common in athletic individuals Often treated adequately with physical therapy Acromioclavicular joint sprain “Separated shoulder” Fall onto shoulder Palpation can make diagnosis Type I – II nonoperative Sling for comfort, better in 3 – 6 weeks Type III controversial 25 – 100% increased Type III coracoclavicular distance Type IV – VI orthopedic referral Labral tear Can be acute or chronic Types I – VIII Deep shoulder pain, clicking Physical exam special tests are helpful MRI arthrogram increases visualization of the labrum Consider early referral Refer if no improvement Rotator cuff tear Supraspinatus is most common Acute vs. chronic Partial vs. full thickness Acute tear with significant weakness consider MRI/referral repair within 6 weeks Consider short interval reevaluation Physical therapy, scapular stabilization Biceps tendonitis Long head of the biceps Overuse injury Diagnose with palpation Differentiate from tendon subluxation Transverse view Usually conservative treatment Subluxation has lower threshold for referral Impingement Syndrome Less common in college students Repetitive overhead activities lifting, tennis, climbing Almost always nonoperative Physical therapy and activity modification Clavicle fracture 75% occur at mid-clavicle Nonoperative if less than 100% displacement (> 1 bone width) Pain control, sling Elbow ROM several times daily within 3 days Shoulder use as tolerated Union ~6 weeks, xray Distal and proximal third fracture requires referral Thoracic outlet syndrome Beware of upper extremity DVT Weight lifters Shoulder pain case “A” Shoulder pain “A” HPI: 20 y/o male two months intermittent lateral right shoulder pain likes lifting weights, overhead press, squats had self limited discoloration of the right arm question tingling elbow to hand Shoulder pain “A” Exam: 138/75 101 F 105 bpm Normal inspection no palpable pain full shoulder and neck ROM 5/5 shoulder and elbow strength (-) neck axial compression (-) Spurling’s test (-) Holmstead maneuver (-) Allen test Shoulder pain “A” Assessment: vascular thoracic outlet syndrome Plan: Stretching for pec minor, anterior scalene f/u 1 week lifting as tolerated Shoulder pain case “B” Shoulder pain “B” HPI: 20 y/o male several falls snowboarding last week having right shoulder pain and neck pain enjoys lifting weights self limited arm discoloration after pushups yesterday question numbness right arm question right hand swelling Shoulder pain “B” Exam: 130/74 97.4F 66 bpm Normal inspection 5/5 right upper extremity strength sensation normal (+) Allen test (+) Roos test Shoulder pain “B” Assessment: thoracic outlet syndrome Plan: reviewed online exercises avoid weight lifting f/u PRN Shoulder pain “A” 1 week f/u HPI: shoulder pain improved still having positional discoloration in hand/forearm no tingling trying home stretching exercises, not lifting Exam: 126/72 72 bpm slight darker color to right hand/forearm capillary refill <2 seconds (-) Allen’s test Shoulder pain “A” 1 week f/u Assessment: thoracic outlet syndrome, r/o DVT Plan: upper extremity venous ultrasound complete today Shoulder pain “B” 3 day f/u HPI: Right arm feels “full” Having discoloration No weakness Exam: increased redness of the right upper extremity also mild arm swelling (-) Allen