Shoulder Conditions Lecture (Week 2--Aragaki) Flashcards
2 things shoulder pain can be due to
1) Intrinsic disorders: 85%, inflammation of the joints, bursae, tendons, surrounding ligaments or periarticular structures
2) Referred pain: 15%, cervical, cardiac, biliary
Layers of shoulder
Joints (GH, AC)
Capsule/ligaments
Rotator cuff and biceps tendons
Subacromial/subdeltoid bursa
Deltoid muscle
Nerves that supply muscles
Axillary nerve –> deltoid, teres minor
Radial nerve –> triceps
Long thorac nerve –> serratus anterior
Spinal accessory nerve (CN XI) –> trapezius (and SCM)
Suprascapular nerve –> supraspinatus/infraspinatus
Dorsal scapular nerve –> rhomboids, levator scapulae
Musculocutaneous –> biceps, brachialis, coracobrachialis
Lower subscapular nerve –> teres major, subscapularis
Upper subscapular nerve –> subscapularis
Physical exam for shoulder injury
Inspect
Palpate
ROM
Neurovascular screen (include C-spine)
Special testing
Inspection
Symmetry (position, atrophy)
Scapular winging (prominent medial border w/resisted adduction/flexion, indicates serratus anterior, trapezius, rhomboid weakness; have pt push against wall)
Dislocation/subluxation (“Sulcus sign”)
Edema, erythema, lesions/scars
Functional impairment? (dressing = clue)
Palpation
Sternoclavicular, acromioclavicular, glenohumeral joints (crepitus, tender)
Coracoid process
Bicipital groove
Greater tuberosity
Supraspinatus, infraspinatus
Scapular spine and borders
Range of motion (ROM)
Flexion: 160 - 180 degrees
Abduction: 170 - 180 degrees
External rotation: 80 - 90 degrees (or Apley’s Scratch)
Internal rotation: 60 - 100 degrees (or Apley’s Scratch)
Extension: 50 - 60 degrees
Horizontal adduction/cross-flexion: 130 degrees
Scapular protraction/retraction
How do you test active flexion and abduction?
Touchdown sign
Apley’s Scratch Test
1) Abduction and external rotation (hand over shoulder)
2) Adduction and internal rotation (hand under armpit)
Spurling’s maneuver
Part of neurologic screen
Cervical root compression reproduces radicular symptoms
Special tests
Provocative maneuvers
Clues for pathology
Focus diagnostic work-up
Guide treatment options
Sulcus test
Test for glenohumeral instability
Downward traction applied to humerus and watch for depression lateral or inferior to acromion
Positive test is space/depression: if lax capsular ligaments or weak rotator cuff and deltoid muscles; multidirectional instability; often asymptomatic; common in young
Hawkin’s sign
Sign of rotator cuff impingement
This test pulls greater tubercle to acromion and squeezes/impinges on subacromial bursa/rotator cuff tendons
Bigliani–Acromion shapes
Type I: straight
Type II: slightly curved
Type III: very curved, smaller space for humeral head
Empty Can Test
Tests supraspinatus
Positive if pain/weakness when you push down
Drop Arm Test
Have patient slowly lower arm
Positive if can’t control drop down and do it too quickly
Indicates complete rotator cuff tear
Lift-Off Test
Tests subscapularis
Arm behind back and push outward against my hand
Biceps tendon rupture
Proximal long head biceps tendon rupture is common
Causes humerus head to come all the way to top of glenoid?? Bicep itself sticking out??
When to order x-rays
Suspect arthritis, dislocation, fracture
Anticipating injection or specialist referral
Fails PRICE treatment
When to order MRI
Suspect rotator cuff tear, tumor, infection
Anticipate surgery
Arthrogram if suspect labral tear
Who to refer to
PM&R: subacute/chronic pain, bursitis, arthritis, cervical radiculopathy, injections, therapy requests, impaired function
Orthopedic surgery: acute fractures or traumatic dislocations, neurovascular compromise, failed conservative treatment
Rheumatology: if systemic disease
Glenohumeral osteoarthritis case
Gradual onset shoulder pain over many years
Prior trauma during army service
Limited ROM with feeling of grinding in joint with overhead reaching
Body tries to compensate for damage by laying down more bone and increasing surface area of joint but doesn’t work!
Multidirectional instability of shoulder case
Shoulder “achy” pain for a few months while on vacation (lifting heavy objects); no acute trauma, swelling, fever/chills, neck pain, distal weakness/numbness
X-rays normal
Positive Sulcus Sign
TUBS vs. AMBRI for instability
TUBS: traumatic, unilateral, Bankart (Hill-Sachs lesions), surgery
AMBRI: atraumatic, multidirectional instability, bilateral, rehabilitation, inferior capsular surgery
Bankart and Hill-Sachs lesions
Bankart: chip of inferior anterior glenoid (sounds like “bang hard” and that’s how it happens–dislocation and damage then reduced back)
Hill-Sachs: posterior lateral humeral head chipped
What nerve can dislocation cause injury to?
Axillary nerve damaged by dislocation
Shoulder impingement case
Sharp anterolateral shoulder pain develop over a few weeks
Worse pain by abduction or overhead activity, relieved by ibuprofen and icepack (think inflammation!)
No weakness, numbness, dysfunction, neck pain, distal arm pain, no muscle atrophy
Mild AC joint tenderness, positive Crepitus with shoulder ROM, positive Hawkins test, positive Empty Can test, negative Drop Arm test
Due to osteophytes, joint laxity, muscle imbalance, acromion shape (Type III hooked so not enough space for bursa to live!), space narrowing
Abduction irritates subacromial bursa and supraspinatus (rotator cuff) tendon
Can lead to rotator cuff TEAR
Spectrum: AC osteoarthritis, bursitis, tendonitis, etc
Muscles involved in abduction of shoulder
Supraspinatus pulls in during early abduction to stabilize humeral head into glenoid
Deltoid muscle pulls up to abduct
Bicipital tendonitis case
Pain in anterior shoulder for 2 weeks, worse lifting cargo, steering, raising arm, mild giveaway weakness with forward flexion, reproduceable pain with palpation of bicipital groove
No neck or distal arm pain
Long head bicipital tendon runs through bicipital groove
Repetitive lifting and reaching leads to inflamation, tearing, degeneration
Rotator cuff tear case
Difficulty abducting arm and sharp shoulder pain since fall 1 month ago, muscle weakness, supraspinatus atrophy, reduced active ROM (full passive), tender superolaterally, positive drop arm test, positive empty can sign
Diabetics tear tendons more often because of lack of blood supply
Supraspinatus is most common rotator cuff tear
Adhesive capsulitis (frozen shoulder) case
Shoulder feels locked, gradual onset after wearing a sling for several weeks
Severely reduced flexion, abduction, external rotation (passive and active)
X-ray shows mild glenohumeral OA
Stiff glenohumeral joint capsule
Often associated with rotator cuff tendonitis
Cervical radiculopathy case
Chronic neck pain referred to right shoulder and thumb
Worse by painting ceilings, lifting heavy equipment
Atrophy of deltoid, supraspinatus, infraspinatus, biceps, positive Spurling’s test, reduced biceps reflex, paresthesias in lateral arm/hand
EMG showed active degeneration in C5-6 myotome
