Shoulder Pain Review of Physical Exam and An Approach To The Differential Diagnosis David G. Liddle, MD Assistant Professor of Orthopedics Assistant Professor of Internal Medicine Vanderbilt University Medical Center Nashville, TN Vanderbilt Sports Medicine Disclosures • No financial disclosures or conflicts of interest Vanderbilt Sports Medicine Objectives • Review pertinent anatomy and pathology associated with common causes of shoulder pain • Review historical and physical exam findings that help differentiate common causes of shoulder pain • Review imaging findings relevant to these causes of pain and discuss a rationale for appropriate use of diagnostic tests • Review the best evidence available to the guide treatment of these conditions Vanderbilt Sports Medicine Vanderbilt Sports Medicine Syst. Reviews of RCT Level I – Randomized Controlled Trials Observational studies Level II – Prospective Cohort Level III – Case-Control or Retrospective Cohort Level IV – Case studies Level V – Anecdote and personal opinions Vanderbilt Sports Medicine Anatomy Review http://www.aafp.org/afp/2004/1115/p1947.html http://www.bandhayoga.com/images/Blog/blog2 Vanderbilt Sports Medicine 3_serratus_anatomy.jpg XR Review AP Int. & Ext. Rotation & Axillary views +/- Scapular-Y view Vanderbilt Sports Medicine Non-Arthritis Shoulder Pain Non-Operative Operative &/or Non-Op • Subacromial Impingement • Rotator Cuff Tear • Subacromial Bursitis – Acute, Known Injury • Adhesive Capsulitis – Chronic, Unknown Injury – “Frozen Shoulder” • Proximal Biceps Tendon Tear • Biceps Tendonitis • Labral Tear • Glenohumeral or AC Joint Arthritis • AC Joint Sprain – “Separated Shoulder” • Shoulder Instability Vanderbilt Sports Medicine Non-Arthritis Shoulder Pain Non-Operative Operative &/or Non-Op • Subacromial Impingement • Rotator Cuff Tear • Subacromial Bursitis – Acute, Known Injury • Adhesive Capsulitis – Chronic, Unknown Injury – “Frozen Shoulder” • Proximal Biceps Tendon Tear • Biceps Tendonitis • Labral Tear • Glenohumeral or AC Joint Arthritis • AC Joint Sprain – “Separated Shoulder” • Shoulder Instability Vanderbilt Sports Medicine Shoulder Pain Radiating Patterns • Sternoclavicular Joint Up SCM/Front of Neck • Acromioclavicular Joint Upper Trap/Lat. Neck • Subacromial Space Lateral Brachium • Biceps Tendons Anterior Brachium Vanderbilt Sports Medicine Subacromial Impingement History Exam • Pain radiates from superolateral • Scapular dyskinesis on forward shoulder to lateral brachium elevation (FE) • Pain with reaching • Limited passive internal rotation (IR) • No rest pain • PROM ≥ AROM – Different than sleep/night pain… • Tender To Palpation at Coracoid this will hurt • Pain AND weakness on Empty-Can – Rest = Sitting with hands in lap testing at 90 ABduction in scapular • Usually insidious onset plane but NL at 30 and other Rot. • May be capped by an event or start Cuff/Shoulder/Arm muscle strength NL some time after an event • Pain AND Weakness resolve/improve • Primary or Secondary disorder with scapular retraction test • No change in shoulder pain with • Pain with Neer’s and Hawkins’ tests Neck ROM Vanderbilt Sports Medicine Scapular Dyskinesis http://www.youtube.com/watch?v=ROsiiDsjm2o Vanderbilt Sports Medicine Empty-Can Test Vanderbilt Sports Medicine http://www.mhhe.com/hper/physed/athletictraining/illustrations/ch22/22-16a.jpg Scapular Retraction Test Vanderbilt Sports Medicine Kibler WB. Br J Sports Med 2010 Neer’s and Hawkins’ Tests for Impingement Vanderbilt Sports Medicine http://thepainsource.com Subacromial Impingement Imaging Treatment • 3-4 views of the Shoulder • Rehab – AP Int. & Ext. Rotation & – Strengthen Scapular Stabilizers Axillary +/- Scapular-Y view • Rhomboids, Middle Trapezius, – Usually normal Serratus Anterior • Obtain these in setting of – Stretch Tight Posterior Capsule and Pectoralis Minor injury and/or to screen for calcific rotator cuff • Subacromial CS Injection tendonopathy or – To improve tolerance for Rehab osteoarthritis • Subacromial Decompression • Neck XR only if reproducible only if conservative Tx fails radicular signs/symptoms Vanderbilt Sports Medicine Calcific Rotator Cuff Tendonopathy Vanderbilt Sports Medicine http://www.orthopaedicsone.com/display/MSKMed/Calcific+tendonitis+of+the+shoulder Calcific Rotator Cuff Tendonopathy Treatment • U/S Guided Lavage & CS Injection; Debridement if too large or failed CSI Vanderbilt Sports Medicine http://www.ultrasoundcases.info/files/Jpg/lbox_22380.jpg http://www.nguyenthienhung.com/2012_09_01_archive.html Subacromial Bursitis physioworks.com.au Vanderbilt Sports Medicine Subacromial Bursitis History Exam • Pain radiates from superolateral • Scapular dyskinesis on fwd. elev. (FE) shoulder to lateral brachium • Limited passive internal rotation (IR) • Pain with reaching • PROM ≥ AROM but pain in all planes • (+) Rest pain of motion – Different than sleep/night pain… • Tender To Palpation deep to this will hurt acromion – Rest = Sitting with hands in lap • Pain AND weakness in all planes but • Usually rapid/sudden onset esp. on Empty-Can testing; Biceps – 10/10 Pain out of “Clear Blue Sky” and Triceps usually NL • May start soon after an event or • Symptoms may improve with recent incr. in activity scapular retraction test • No change in shoulder pain with • Pain with Neer’s and Hawkins’ tests Neck ROM Vanderbilt Sports Medicine Subacromial Bursitis Imaging Treatment • 3-4 views of the Shoulder • Subacromial CS Injection – AP Int. & Ext. Rotation & • PO NSAIDs +/- Narcotics Axillary +/- Scapular-Y view – Ketorolac (Toradol) – Usually normal • Rehab after pain improvement • Obtain these in setting of to address Impingement injury and/or to screen for • Subacromial Decompression calcific rotator cuff +/- Bursectomy only if tendonopathy or conservative Tx fails osteoarthritis • Neck XR only if reproducible radicular signs/symptoms Vanderbilt Sports Medicine Adhesive Capsulitis http://physioworks.com.au/images/Injuries-Conditions/Frozen_Shoulder_Adhesive_Capsulitis.jpg Vanderbilt Sports Medicine Adhesive Capsulitis History Exam • (+) Rest Pain • Limited passive IR > ER > Abd > FE – Rest = Sitting with hands in lap • PROM = AROM • Pain worse with reaching • Diffusely Tender To Palpation • Progressive Loss of Motion • Pain in all planes of motion may limit – IR ER & Abd FE strength – Motion returns in opposite sequence • Limited motion can prohibit Neer’s • Most common in Females, 40-60 y/o and Hawkins’ tests • May have autoimmune or chronic inflammatory etiology – Diabetes (25%), Hypothyroidism, IBD • Usually insidious onset • May be capped by event or the start some time after an event/trauma • No change in pain w/ Neck ROM Vanderbilt Sports Medicine Adhesive Capsulitis • Education & Expectations • Average of 9-18 months to run its course – Stage 1 – Freezing • Pain at rest AND progressive loss of motion – Internal Rotation External Rotation and Abduction Forward Elevation – Motion returns in opposite sequence – Stage 2 – Frozen • Rest pain resolves but severely limited motion and pain with reaching – Stage 3 – Thawing • ROM returns (IR last) and Impingement symptoms predominate – Stage 4 – Shoulder function is back to normal Vanderbilt Sports Medicine Adhesive Capsulitis Imaging Treatment • 3-4 views of the Shoulder • Education and Expectations – AP Int. & Ext. Rotation & Axillary • Glenohumeral CS Injection +/- Scapular-Y view – Level I – Superior to PO with fewer • Axillary view most difficult due to systemic effects; Repeat every 4-6 loss of motion weeks in Stage 1 and early Stage 2 – Usually normal Lorbach O et al. J Shldr Elb Sg. 2010 • Narcotics, Sleep Aids, NSAIDs • Rehab only AFTER Rest Pain resolves • Viscosupplementation – Level I – Not Clinically Significant Callis M. Rheumatol Int. 2006 • Manipulation Under Anesthesia if conservative Tx fails Vanderbilt Sports Medicine Rotator Cuff Tear orthop.washington.edu Vanderbilt Sports Medicine http://stemcelldoc.files.wordpress.com/2009/01/mri-of-torn-rotater-cuff1.jpg Rotator Cuff Tear History Exam • Fall on outstretched arm • Limited AROM 2/2 weakness > – Abduction in scapular plane = pain but NL PROM Supraspinatus +/- Infraspinatus • Supraspinatus (70% of RCT) – External Rotation = Subscapularis – Weak Empty Can at 30 & Drop • c/o weakness > pain Arm test • Acute • Infraspinatus (20% of RCT) – Event after which c/o pain and – Weak ER & ER Lag Sign weakness and disability • Subscapularis (<1% of RCT) – ≤ 2-3 months – Weak IR & Belly Press or Lift Off • Chronic tests – Process/Gradual onset of weakness and pain – Event >3 months ago Vanderbilt Sports Medicine Drop Arm Test http://www.youtube.com/watch?v=qvwYEoeHPaA Vanderbilt Sports Medicine Lag Sign and Belly Press Tests • Infraspinatus/Teres Min. Tear • Subscapularis Tear Vanderbilt Sports Medicine http://www.psychiatrictimes.com/sites/default/files/rm/1628757.png http://www.psychiatrictimes.com/sites/default/files/rm/1628765.png Rotator Cuff Tear Imaging Treatment • 3-4 views of the Shoulder • Acute Tear = RCT Repair – AP Int. & Ext. Rotation & • Chronic Tear = Rehab Axillary +/- Scapular-Y view – Level II – 75% Return to NL Function – Usually normal & No Pain without Surgery at 2 yrs. – May show high riding humeral Kuhn JE. J Shoulder Elbow Surg. 2013 head above center of glenoid – Subacromial CS Injection for Pain • Loss of supraspinatus cap • Viscosupplementation • MRI if Acute RCT – Level I – Not Clinically Significant Chou WY. J Shoulder Elbow Surg. 2010 Meloni F. Eur J Radiol. 2008 Vanderbilt Sports Medicine Biceps Tendonopathy Vanderbilt