25: 38-year-old man with shoulder pain Flashcards
Urgent Diagnosis and Management of Acute Bacterial/Pyogenic Infection of a Joint or Bursa
Why do these merit urgent diagnosis and management?
Delay in recognition and treatment of a septic glenohumeral (“shoulder joint”) arthritis or septic subacromial bursitis may lead to local tissue destruction and loss of function, extension of infection locally to deeper spaces such as bone (osteomyelitis) or more distant sites by way of bacteremia and that may progress to sepsis.
When should you suspect these?
»“Red flags:” Patient reports of local complaints such as redness or swelling and/or systemic complaints such fever, chills, and myalgias.
»Predisposing factors: Diabetes, alcoholism or other immune-compromising conditions.
If you suspect these, what should you do?
»Urgent evaluation (with ultrasound or MRI) and immediate, same day consultation with an orthopedic surgeon.
»Definitive evaluation will include aspiration and culture of related fluid. Common bacterial pathogens include gram positive organisms, primarily staph (including methicillin-resistant staph aureus-MRSA) and to a lesser extent strep species.
»Definitive treatment of confirmed septic arthritis or bursitis entails surgical drainage and tailored antibiotic therapy. Hospitalization is warranted if this diagnosis is confirmed.
Loss of Shoulder Range of Motion
A patient with loss of active and passive ROM is more likely to have joint disease; whereas a patient with loss of only active ROM is more likely to have an issue with muscle tissue.
The following joint diseases will produce restricted active and passive ROM of the shoulder:
»Adhesive capsulitis, a condition common in patients with metabolic diseases such as diabetes and hypothyroidism in which there is contracture of the joint capsule
»Glenohumeral arthritis, a much less common site of osteoarthritis than the primary weight-bearing joints of the lower extremity
The following muscle tissue issues will compromise only active ROM
(although may still elicit passive ROM pain in the case of rotator cuff impingement): Rotator cuff tear and impingement (conditions that may well occur together)
Anatomy of Rotator Cuff Muscles
Supraspinatous
Superior and posterior aspect of the scapula (shoulder blade)
Greater tuberosity of the humerus
Assists with raising of the arm (abduction)
Infraspinatous
Lower and posterior aspect of the scapula (beneath the scapular spine)
Greater tuberosity
Assists with external rotation of the shoulder
Teres minor
Below the infraspinatous
Greater tuberosity
Assists the infraspinatous in external rotation of the shoulder
Subscapularis
Anterior of the scapula
Lesser tuberosity of the humerus
Assists with internal rotation of the shoulder
Anatomic Stabilizers of the Shoulder Joint
Labrum
Adds stability by increasing the articulating surface area and depth of the glenoid fossa.
Rotator muscle group
Essential dynamic stabilizer of shoulder joint.
Glenohumeral or “capsular” ligaments
Provide added support and static stability to the shoulder joint.
Tendinitis vs. Tendinopathy
Tendinitis implies an inflammatory etiology that occurs only in the first days after an acute tendon injury; not appropriate unless injury is very acute.
Tendinopathy is a more general term that may imply a degenerative pathology. It is a chronic condition that is characterized by a fibroblastic response, lack of acute phase reactants, and collagenous degeneration.
Pathophysiology of Shoulder Impingement
Impingement describes the mechanical forces being placed on structures by things external to those structures.
In the case of rotatory cuff tendinopathy / impingement, the supraspinatus tendon, and possibly other rotator cuff tendons are being impinged upon by the roof of the subacromial space, which is formed by the acromion and the coracoacromial ligament.
Processes that decrease the subacromial space, such as weakened rotator cuff muscles or weakened scapular stabilizers will promote this process, while strong rotator cuff and scapular stabilizing musculature will improve or prevent it.
Examples of conditions evident on visual inspection:
Posterior dislocation
Patient carries the arm in an adducted and internally rotated position
Impingement syndrome
Poor posture with scapulae protracted
Fracture of the clavicle or sprain of the acromioclavicular (AC) joint
Bony deformity in the area of the clavicle or AC joint
Anterior dislocation
Fullness of the anterior shoulder with a large dimple in the posterior shoulder
Immobilization or lack of use of the joint
Atrophy of the larger muscles of the shoulder girdle, like the deltoid or pectoralis major
Torn rotator cuff or nerve impingement
Atrophy of smaller muscles such as the supraspinatus or infraspinatus
Apporach to Examination of Acute Shoulder Injury
Inspection,
Palpation,
Range of motion: cervical spine; shoulder active range of motion and functional ROM, passive ROM
Strength testing: Testing the Strength of the Muscles Surrounding the Shoulder: empty can or jobes test; isolate each of the rotator cuff my; standing pushup against the wall
Special maneuvers: impingement testing; Neer test, Hawkins-kennedy test; stability testing, apprehension test, relocation test
To test for biceps tendinopathy:
Speed’s test
Flex the patient’s elbow 20-30 degrees with the forearm in supination and the arm in about 60 degrees of flexion.
Resist forward flexion of the arm while palpating the patient’s biceps tendon over the anterior aspect of the shoulder.
Yergason’s test
Flex the patient’s elbow to 90 degrees with the thumb up.
Grasp the wrist and resist attempts by the patient to actively supinate the arm and flex the elbow. A positive finding for biceps tendinopathy would be pain in the anterior area of the shoulder.
To test for labral injuries:
Labral injuries are not uncommon in the throwing athlete. The diagnosis, however is not easy and often must be made by ruling out other more common entities such as tendinopathy or impingement syndrome or through imaging modalities - especially magnetic resonance imaging with intra-articular contrast.
Clunk test
With the patient supine, the examiner rotates the patient’s arm and loads (force applied) from extension through to forward flexion. The examiner is checking for a “clunk” sound or clicking sensation arising from the glenoid labrum that can indicate a labral tear even without instability.
O’Brien Test
Have the patient stand with hands on his hips. Place one of your hands over the shoulder and the other hand behind the elbow. Apply anterior-superior force and ask the patient to push back against the force. Have the patient hold his shoulder in 90-degrees of forward flexion, 30 to 45-degrees of horizontal adduction, and maximal internal rotation. Grab his wrist and resist his attempt to horizontally adduct and forward flex the shoulder.
SLAP testing
Checks for a superior labral tear, also known as a ‘SLAP lesion’. It would elicit pain or possibly popping or clicking with labral pathology. As with many clinical tests however, other problems like acromioclavicular pathology or tendinopathy could cause false positives.
Approach to Management of Rotator Cuff Tendinopathy / Impingement: Physical Therapy
- Physical Therapy
Goals: - Re-establish a more normal range of motion.
- Followed by progressive strengthening of the rotator cuff and scapular stabilizers.
Rationale:
Only after the scapular stabilizers and rotator cuff are strengthened will the tendon be able to heal because this will stop the impingement process. Strong scapular stabilizers hold the scapula in retraction, which opens the subacromial space and decreases or prevents impingment.
Duration:
Physical therapy exercises for 6 weeks, then return to clinic for re-evaluation.
Many individuals are ready to go back to sports at this time, although some will need continued therapy.
Follow-up:
Functional progression, a progressive list of throwing exercises will ease the patient’s shoulder back to full sports participation.
Prevention:
To prevent recurrence of this injury, patients should continue doing some form of shoulder strengthening exercises while playing overhead throwing sports.
Management of Rotator Cuff Tear / Impingement
Recommended:
Relative rest
Can limit further damage while you focus on more active forms of treatment such as physical therapy and pain medications.
Pain medication as needed in topical and/or oral form
Before using nonsteroidal anti-inflammatory medications (NSAIDs), ask about:
1. Allergies or intolerance to NSAIDs.
2. Other medications the patient is taking to ensure you avoid drug-drug interactions. 3. The potential for pregnancy for female patients of childbearing age.
Topical NSAIDS have the advantage of decreased systemic side effects and toxicity such as gastric ulcers, hepatic inflammation, and renal failure (especially in patients with hypertension or diabetes), but typically have questionable efficacy.
Other therapies that are not recommended:
- sling immobilization
- orthopedic surgical consultation
- xrays
- MRI
- subacromial injection
Differential of Subacute Right Shoulder Pain Aggravated By Movement
- -rotator cuff tendinopathy
- torn rotator cuff
- impingement syndrome with bursitis
- labral tear
