Case 25 - 38 yo with shoulder pain Flashcards
Rotator muscle names and function
supraspinatus - abduction
infraspinatus - external rotation
teres minor - external rotation
subscapularis - internal rotation
Non- MSK causes of referred shoulder pain
MI, cholecystitis, lung cancer, ruptured ectopic
MSK causes of shoulder pain requiring urgent management
Septic arthritis - local redness, swelling, fever
often caused by staph
urgent eval with U/S MRI and aspiration needed
followed by drainage and antibiotics
MSK causes that restrict passive ROM
- adhesive capsulitis - contracture of joint capsule
- glenohumeral arthritis - less common site of OA
Tinea pedis
due to dermatophyte infection, caused by local friction and warmth, dry red skin with cracks seen on exam, dx is clinical, rx is tinactin (tolnaftate) twice a day
Shoulder exam
- Inspection
- arm is adducted and internally rotated - posterior dislocation
- poor posture or rounded shoulders - impingement - Palpation - look for areas of tenderness or abnlities
- ROM - active then passive
- flex, extend, abduction, adduction, internal and external rotation, scratch test - Strength testing
- flex, abduct
- rotator cuff: infraspinatous - ext rot, supraspinatous - empty can, subscap - int rot
Apley scratch test
Tests abduction and external rotation of shoulder, unable to raise arm = rotator cuff tear, pain indicates impingement or bursitis
Empty can test
Have patient abduct arms to 90 degrees, thumbs down and resist downward pressure, tests supraspinatous
Neer test
Passive forward flexion, pain at full overhead position indicates subacromial impingement
Hawkins-Kennedy test
Shoulder at 90 degrees abduction, and elbows 90 degrees flexion, internally rotate, pain indicates supraspinatous tendon impingement
Anterior/Posterior translate
Head sublux indicates major instability
Sulcus sign
With arm hanging by patients side, apply downward traction and look for dimple to appear just below acromion process (sulcus), indicates inferior glenohumeral instability
Apprehension test
with elbow flexed, abduct shoulder to 90 degrees, then externally rotate passively, positive with apprehensoin for anterior glenohumeral instability
Relocation test
Provide posterior pressure to humerus while in anterior apprehension position, positive test is a sense of relief. Anterior glenohumeral instability
Speed’s test
Resist elbow flexion with forearm supinated, pain indicates biceps tendonitis
Yergason’s test
flex patients elbow to 90 degrees with thumb up, grasp wrist and resist external rotation and supination, anterior shoulder pain is a positive test for biceps tendonitis
Clunk test
Palpate the shoulder joint, move shoulder through passive ROM, feel for popping or clicking, positive test shows labral pathology
O’Brien test
Patient with shoulder at 90 degrees forward flexion and 30-45 degrees of horizontal adduction and maximal internal rotation, have patient resist downward pressure
Anterior shoulder popping or pain indicates slap lesion, specific superior labral tear
False positive with acromioclavicular pathology or tendinits
Differential diagnosis for shoulder pain
- Rotator cuff tendonitis - positive apley’s scratch test with preserved ROM
- rotator cuff tear - limited ROM with significant pain, with atrophy
- Subacromial impingement or bursitis - great pain with overhead ranges of motion, r/o with negative Neer and Hawkins Kennedy
- Shoulder instability - indicated by positive sulcus sign and anterior/posterior translation tests
- Labral pathology - secondary to repetitive damage, frank dislocations or sudden trauma
Less likely: biceps tendonitis (speed and yergesons test), degenerative glenohumeral arthritis, septic arthritis, shoulder dislocation, RA, AC joint separation, adhesive capsulitis (caused by restriction of ROM or risk factors like diabetes)
Studies for shoulder pain
- no imaging on initial evaluation
- xray in setting of acute injury if fracture is suspected
- MRI - soft tissue injury
Management of rotator cuff tendonitis and shoulder instability
- relative rest
- physical therapy
- NSAIDS as needed
- subacromial injection if needed
