Shoulder Conditions Lecture (Week 2--Aragaki)

Question 1

2 things shoulder pain can be due to

Answer 1

1) Intrinsic disorders: 85%, inflammation of the joints, bursae, tendons, surrounding ligaments or periarticular structures
2) Referred pain: 15%, cervical, cardiac, biliary

Question 2

Layers of shoulder

Answer 2

Joints (GH, AC)

Capsule/ligaments

Rotator cuff and biceps tendons

Subacromial/subdeltoid bursa

Deltoid muscle

Question 3

Nerves that supply muscles

Answer 3

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

Question 4

Physical exam for shoulder injury

Answer 4

Inspect

Palpate

ROM

Neurovascular screen (include C-spine)

Special testing

Question 5

Inspection

Answer 5

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)

Question 6

Palpation

Answer 6

Sternoclavicular, acromioclavicular, glenohumeral joints (crepitus, tender)

Coracoid process

Bicipital groove

Greater tuberosity

Supraspinatus, infraspinatus

Scapular spine and borders

Question 7

Range of motion (ROM)

Answer 7

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

Question 8

How do you test active flexion and abduction?

Answer 8

Touchdown sign

Question 9

Apley’s Scratch Test

Answer 9

1) Abduction and external rotation (hand over shoulder)
2) Adduction and internal rotation (hand under armpit)

Question 10

Spurling’s maneuver

Answer 10

Part of neurologic screen

Cervical root compression reproduces radicular symptoms

Question 11

Special tests

Answer 11

Provocative maneuvers

Clues for pathology

Focus diagnostic work-up

Guide treatment options

Question 12

Sulcus test

Answer 12

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

Question 13

Hawkin’s sign

Answer 13

Sign of rotator cuff impingement

This test pulls greater tubercle to acromion and squeezes/impinges on subacromial bursa/rotator cuff tendons

Question 14

Bigliani–Acromion shapes

Answer 14

Type I: straight

Type II: slightly curved

Type III: very curved, smaller space for humeral head

Question 15

Empty Can Test

Answer 15

Tests supraspinatus

Positive if pain/weakness when you push down

Question 16

Drop Arm Test

Answer 16

Have patient slowly lower arm

Positive if can’t control drop down and do it too quickly

Indicates complete rotator cuff tear

Question 17

Lift-Off Test

Answer 17

Tests subscapularis

Arm behind back and push outward against my hand

Question 18

Biceps tendon rupture

Answer 18

Proximal long head biceps tendon rupture is common

Causes humerus head to come all the way to top of glenoid?? Bicep itself sticking out??

Question 19

When to order x-rays

Answer 19

Suspect arthritis, dislocation, fracture

Anticipating injection or specialist referral

Fails PRICE treatment

Question 20

When to order MRI

Answer 20

Suspect rotator cuff tear, tumor, infection

Anticipate surgery

Arthrogram if suspect labral tear

Question 21

Who to refer to

Answer 21

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

Question 22

Glenohumeral osteoarthritis case

Answer 22

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!

Question 23

Multidirectional instability of shoulder case

Answer 23

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

Question 24

TUBS vs. AMBRI for instability

Answer 24

TUBS: traumatic, unilateral, Bankart (Hill-Sachs lesions), surgery

AMBRI: atraumatic, multidirectional instability, bilateral, rehabilitation, inferior capsular surgery

Question 25

Bankart and Hill-Sachs lesions

Answer 25

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

Question 26

What nerve can dislocation cause injury to?

Answer 26

Axillary nerve damaged by dislocation

Question 27

Shoulder impingement case

Answer 27

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

Question 28

Muscles involved in abduction of shoulder

Answer 28

Supraspinatus pulls in during early abduction to stabilize humeral head into glenoid

Deltoid muscle pulls up to abduct

Question 29

Bicipital tendonitis case

Answer 29

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

Question 30

Rotator cuff tear case

Answer 30

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

Question 31

Adhesive capsulitis (frozen shoulder) case

Answer 31

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

Question 32

Cervical radiculopathy case

Answer 32

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