Evaluation & Treatment of Disclaimer Shoulder and Elbow Pain in ! I, William T Crowe, have relevant financial relationships to be the Adult Patient© discussed, directly or indirectly, William T. Crowe, RN-C, FNP, referred to or illustrated with or MSN, MBA without recognition within the presentation as follows: –"None Objectives Anatomy ! Review anatomy of the shoulder and elbow ! Bony structures –" Clavicle ! Define elements of subjective history –" Scapula –" Humerus ! Discuss basic exam of the shoulder and elbow ! Discuss current treatment regimens for common problems Anatomy - clavicle Anatomy - Scapula 1 Anatomy Anatomy ! Connective tissue ! Joint capsule –" Ligaments ! Acromioclavicular –" Hyaline cartilage –" Fibrocartilage (labrum) Anatomy Anatomy ! Passive stabilizers ! Active stabilizers (muscles) –" Ligaments –" Glenohumeral (aka Rotator Cuff) –" Joint capsule (supraspinatus, subscapularis, infraspinatus, teres minor) –" Thoracohumeral (pectoralis major, latissimus dorsi) –" Biceps brachii (crosses both shoulder & elbow) Anatomy Anatomy * ! 4 separate joints –" Glenohumeral –" Acromioclavicular –" Sternoclavicular –" Scapulothoracic 2 Anatomy Anatomy ! Planes of motion ! Normal ROM –" Flexion & extension –" 180 degrees flexion –" Internal & external rotation –" 45 - 60 degrees extension –" Abduction/adduction –" 150 degrees abduction –" Circumduction (combination of above) –" 90 degrees external rotation –" 70-90 degrees internal rotation Anatomy Anatomy ! Bony structures ! Connective tissue –" Humerus –" Ligaments (4 –" Radius primary) –" Ulna ! UCL*, RCL, Annular, Quadrate Anatomy Anatomy ! Passive stabilizers ! Active stabilizers –" Ligaments (UCL, RCL, Annular, Quadrate) –" Flexors (biceps brachii, brachioradialis, –" Joint capsule brachialis) –" Extensors (triceps, anconeus) –" Supinators (supinator, biceps brachii) –" Pronators (pronator quadratus, pronator teres, flexor carpi radialis) 3 Anatomy* Anatomy ! 3 separate joints ! Planes of motion –" Humeroulnar –" Flexion & extension –" Humeroradial –" Internal & external rotation (radiocapitellar) –" Proximal radioulnar Anatomy Subjective/History ! Normal ROM ! Where does it –" 140 - 150 degrees flexion hurt? –" 0 - 10 degrees extension –" 90 degrees supination (forearm) –" 80 – 90 degrees pronation (forearm) Location of pain* Location of Pain ! Anterior – superior shoulder ! Lateral/medial elbow –" Pathology of AC joint –" Tendonitis –" Ligamental injury ! Lateral deltoid ! Olecranon –" RC, adhesive capsulitis, OA of glenohumeral –" Bursitis 4 Subjective/History Subjective/History ! Where does it hurt? ! Severity – rest & activity ! When did it start? ! Instability ! What happened? ! Alleviating/Aggravating factors ! If injury, ROM? ! Treatment to date ! Previous injury ! Review of PMH/PSH/MEDS/DA ! RECONSTRUCT THE STORY Objective/Exam Objective/Exam ! Always begin by assessing: ! Observation –"cervical spine –" “can’t see, can’t treat” – BOTH shoulders –"shoulder " –"general neurovascular examination Objective/Exam* Objective/Exam ! Observation ! Inspection –" Deformity –" Swelling –" Swelling –" Ecchymosis –" Atrophy –" Deformity –" Atrophy 5 Objective/Exam Objective/Exam ! Palpation ! Palpation –" AC & SC joints –" Bones –" Cervical spine ! Epicondyles –" Biceps tendon ! Supracondylar lines ! Olecranon and fossa –" Anterior glenohumeral joint ! Radial head – Coracoid process " –" Acromion –" Scapula Objective/Exam Objective/Exam ! Maneuvers ! Maneuver –" ROM (active & passive) –"Spurling’s Test Objective/Exam Objective/Exam* ! Maneuvers ! Maneuvers –"Wall pushup –" Empty can – supraspinatus 2012, “Fingers to Toes”, UTSW, Chris Espinoza, MD 6 Objective/Exam Objective/Exam ! Maneuvers ! Maneuvers –" Resisted external –" Neer’s test – rotation – impingement of the infraspinatus/teres RC under minor coracoacromial arch Objective/Exam Objective/Exam ! Maneuvers ! Maneuvers –" Hawkins’ test – –"Subscapularis subacromial Liftoff impingement or RC ! tendonitis ! Belly press Objective/Exam Objective/Exam ! Maneuvers ! Maneuvers –" Cross arm test – AC –"Long head of Biceps joint disorder ! Speed test – outstretched arm, palm up 7 Objective/Exam Objective/Imaging ! Maneuvers ! Radiographs –" Lateral epicondylitis ! CT scan –" Medial epicondylitis ! MRI –" UCL stability –" MCL stability Objective/Imaging Objective/Imaging 2012, “Fingers to Toes”, UTSW, Chris Espinoza, MD Objective/Imaging ! Missed diagnosis – Dislocation for several months ! MUST get 2 views 2012, “Fingers to Toes”, UTSW, Chris Espinoza, MD 8 Objective/Imaging Objective/Imaging AP thorax True AP ! Axillary Lateral 2012, “Fingers to Toes”, UTSW, Chris Espinoza, MD 2012, “Fingers to Toes”, UTSW, Chris Espinoza, MD Objective/Imaging Objective/Imaging 96 asymptomatic patients -"34% (33/96) with RC tear -" 54% (25/46) > 60 y/o with RC tear Sher et al, JBJS 1995 Objective - Studies Shoulder pain* ! 3rd most common musculoskeletal complaint ! 2nd most common referral to ortho ! ~ 20% of all Americans will experience in their lifetime ! 8-13% of athletic injuries 9 Rotator Cuff pathology Impingement Syndrome* ! Impingement Syndrome ! Prevalence –" As of 1/2010, no –" Subacromial bursitis documented studies for prevalence of – 5-40% –" Rotator cuff tendonitis of general pop may –" Rotator cuff tendon tear have but no pain Debaradino & Chang ! Causes –" Acromial morphology (hooked) –" Osteophytes –" Trauma (macro & micro) –" Repetitive overhead activity –" Subacromial bursa Impingement Syndrome Impingement Syndrome* ! Subjective ! Objective –" Gradual increase in pain –" Pain with abduction/flexion of the shoulder –" Pain increases with overhead motions –" Neer’s test + –" Difficult to sleep, especially on affected –" Hawkins’ test + shoulder Subacromial bursitis / RC Impingement Syndrome tendonitis ! Treatment –" Conservative ! Rest ! NSAIDs ! Physical Therapy ! Cortisone injection –" Surgical ! Arthroscopic 10 RC tear* AC pathology ! Treatment ! Chronic –" Conservative –" Arthritis ! Rest ! NSAIDs ! Physical Therapy ! Acute ! Cortisone injection –" AC separation –" Surgical ! Arthroscopic ! Mini-open ! Open AC pathology AC pathology ! Subjective ! Objective –" Pain usually well localized, front of shoulder –" Visible deformity –" Pain with motion, esp cross body –" Pain on palpation –" Cross-body adduction AC pathology AC pathology* ! Treatment –" Conservative ! NSAIDs ! Cortisone injections –" Surgical ! Distal clavicle excision ! ORIF 11 Osteoarthritis Osteoarthritis ! Subjective ! Objective –" Gradual pain, usually centered in back of –" Weakness in muscles, atrophy shoulder –" Decreased ROM –" Loss of motion –" Age > 50 Osteoarthritis Osteoarthritis* ! Treatment –" Conservative ! NSAIDs ! Physical therapy (with caution) ! Cortisone injection – controversial –" Surgical ! Joint replacement Instability Instability ! Causes ! Subjective –" Repetitive trauma –" “loose” –" Recurrent dislocation –" Hx of recurrent dislocations 12 Instability Instability ! Objective ! Treatment –" Apprehension test + –" REFER to Orthopedic specialist Elbow pain Tendonitis (epicondylitis) ! No hard numbers ! Age –" 30 – 50 years of age (most common) Tendonitis (epicondylitis) Tendonitis (epicondylitis) ! Subjective ! Objective –" Pain over epicondyle –" POP over the lateral or medial epicondyle –" Pain increases with grasping –" Lateral epicondylitis test + –" May have burning sensation –" Medial epicondylitis test + –" No radiographic studies indicated 13 Lateral epicondylitis Medial epicondylitis Tendonitis (epicondylitis)* Sprain ! Treatment ! Subjective –" Conservative (85-90%) –" Hx of trauma – direct blow or twisting ! Rest –" Throwing injury (UCL) ! NSAIDs –" Pain ! Physical therapy –" Joint instability ! Bracing ! Cortisone injection to site –" Surgical (80%) ! Epicondylar release Sprain Sprain* ! Objective ! Treatment –" Swelling –" Conservative –" Decreased ROM ! REST –" Ligamental laxity ! RICE –" Surgical –" Valgus stress (milking) ! REFER if conservative Tx fails 14 Olecranon Bursitis Olecranon Bursitis ! Causes ! Subjective –" Trauma –"Pain/edema to posterior of elbow –" Extended pressure –" Infection –" Underlying medical conditions (RA, gout) Olecranon Bursitis Olecranon Bursitis ! Objective ! Treatment –" “Goose egg” to –"Conservative posterior elbow ! RICE –" Decreased ROM ! NSAIDs –" Redness to ! Antibiotics (infectious) posterior elbow ! Aspirate (symptomatic relief) –" XR ?? (injury, ! Cortisone injection to site infection) –" Surgical Cubital Tunnel Syndrome Cubital Tunnel Syndrome Ulnar Nerve Entrapment Ulnar Nerve Entrapment ! Prevalence ! Subjective –" 2nd most common compressive neuropathy –" Hand (4th & 5th fingers) falls asleep when elbow –" Males 3-8x > females flexed (sleeping, phone usage) ! Cause –" Aching to the medial elbow –" Weakened grip –" ??? ! Risk factors –" Previous elbow injury/fx –" Bone spurs 15 Cubital Tunnel Syndrome Cubital Tunnel Syndrome Ulnar Nerve Entrapment Ulnar Nerve Entrapment ! Objective ! Treatment –" Tinel’s sign + –" Conservative –" Elbow flexion test + ! Soft splinting –" EMG/NCV studies ! NSAIDs –" Surgical ! Anterior transposition Fractures Fractures Fractures Fractures 16 .