1. Approach to overuse related shoulder injuries Dausen Harker MD Family Medicine

2. Objectives  Epidemiology Review  Shoulder anatomy review  Common causes of shoulder pain  General approach to exam  Special tests

3. Epidemiology  2 nd most common orthopedic problem in primary care sports medicine (second to knee injury)  Young athletes with overuse injuries is increasing  Overuse injuries common in military population  Most common overuse injuries Rotator Cuff Pathology Rotator Cuff Pathology Impingement Impingement Glenohumeral Instability/Labrum Tears Glenohumeral Instability/Labrum Tears Biceps Tendonitis Biceps Tendonitis AC Joint Pathology AC Joint Pathology

4. Anatomical structures  Please review images of shoulder anatomy prior to or while viewing slides  Major anatomical components involved in shoulder pain Rotator cuff muscles and tendons Rotator cuff muscles and tendons AC joint AC joint Glenoid and labrum Glenoid and labrum Biceps tendon Biceps tendon Skeletal components of shoulder Skeletal components of shoulder Shoulder related bursa Shoulder related bursa

5. Evaluation  Every shoulder exam should include: Appearance Appearance Range of Motion Range of Motion Active vs PassiveActive vs Passive Palpation Palpation Neurological testing Neurological testing Special tests Special tests

6. Rotator Cuff Injury  One of the most common causes of shoulder pain  Involves “SITS minor” muscles  Includes tendonitis and tears

7. Rotator Cuff Injury Tendonitis: Tendonitis: Most common condition among pt’s with shoulder complaints—especially >30 y/oMost common condition among pt’s with shoulder complaints—especially >30 y/o Supraspinatous or infraspinatousSupraspinatous or infraspinatous Repetitive over head activity most common causeRepetitive over head activity most common cause PainPain Worse with reaching and over head activity Worse with reaching and over head activity May awaken pt at night May awaken pt at night Associated with increased risk of tearAssociated with increased risk of tear

8. Rotator Cuff Injury Tears: Tears: <30 y/o: <1% of shoulder injury are complete tears<30 y/o: <1% of shoulder injury are complete tears >45 y/o: ~35% of shoulder injury are tears>45 y/o: ~35% of shoulder injury are tears Supraspinatous and InfraspinatousSupraspinatous and Infraspinatous Common mechanisms of injuryCommon mechanisms of injury Fall on an outstretched arm Fall on an outstretched arm direct blow to shoulder direct blow to shoulder rapid acceleration rapid acceleration Associated with chronic impingement, tendon degeneration or traumaAssociated with chronic impingement, tendon degeneration or trauma Clinical signs: Weakness, loss of shoulder function, and symptoms of tendonitisClinical signs: Weakness, loss of shoulder function, and symptoms of tendonitis

9. Special Tests  Drop Arm Test  Supraspinatous Strength Test  Lift Off Test  90 0 elbow flexion with external arm rotation and resistance

10. Drop Arm Test  Slowly lower fully ABducted arm  Active pressure may be applied at 90 0 ABduction  Positive test indicated by inability to keep arm ABducted at 90 0  Indicates rotator cuff tear

11. Supraspinatous Strength Test  Shoulder ABducted to 90 0 with 30 0 of forward flexion and arm pronation (thumb down)  Isolates supraspinatous  Positive test if asymmetric weakness or inability to maintain arm position

12. Lift Off Test  Dorsum of hand on back and push outward against resistance (isolates internal rotation)  Isolates subscapularis  Positive test indicated by asymmetric inability to lift hand from back

13. External Rotation  Elbow flexed to 90 0 with active resistance to external rotation  Isolates infraspinatous and teres minor  Positive test indicated by asymmetric weakness

14. Impingement  Describes compression of rotator cuff tendons and subacromial bursa between bony structures  Mechanisms of injury: Rounded shoulders, poor muscle development, repetitive over head motion  Presentation nearly identical to rotator cuff injury

15. Special Tests  Hawkins Test  Neers Test

16. Special Tests  Hawkins Test 90 0 forward flexion, 45-90 0 elbow flexion and passive internal rotation 90 0 forward flexion, 45-90 0 elbow flexion and passive internal rotation Drives greater tuberosity into coracoacromial arch Drives greater tuberosity into coracoacromial arch Positive test indicated by pain Positive test indicated by pain More sensitive than Neers test for impingement More sensitive than Neers test for impingement

17. Special Tests  Neer Test Arm internally rotated while fully extended and forward flexion to 180 0 Arm internally rotated while fully extended and forward flexion to 180 0 Positive test indicated by pain with motion Positive test indicated by pain with motion

18. Glenohumeral Instability/Labral tears  GHI Characteristic group: Women, poor muscular development, large Rotator cuff tears, athletes < 40 (especially swimmers, throwers) Characteristic group: Women, poor muscular development, large Rotator cuff tears, athletes < 40 (especially swimmers, throwers) Clinical presentation: Vague symptoms, may see excessive ROM Clinical presentation: Vague symptoms, may see excessive ROM TUBS: Traumatic, Unidirectional instability, Bankart lesion (glenoid labrum tear), frequently require Surgery TUBS: Traumatic, Unidirectional instability, Bankart lesion (glenoid labrum tear), frequently require Surgery AMBRI: Atraumatic, Multidirectional shoulder laxity Bilaterally, usually responds to Rehabilitation, when sugery is necessary it involves tightening of Inferior capsule AMBRI: Atraumatic, Multidirectional shoulder laxity Bilaterally, usually responds to Rehabilitation, when sugery is necessary it involves tightening of Inferior capsule

19. Glenohumeral Instability/Labral Tears  LT Caused by similar mechanism as rotator cuff injuries Caused by similar mechanism as rotator cuff injuries Greatest risk with repetitive overhead activities Greatest risk with repetitive overhead activities Clinical presentation: Deep shoulder pain, catching sensation, instability Clinical presentation: Deep shoulder pain, catching sensation, instability

20. Special Tests  GHI Sulcus Sign Sulcus Sign Apprehension Test Apprehension Test Anterior/Posterior Drawer Test Anterior/Posterior Drawer Test  LT Crank Test Crank Test

21. Special Tests  Sulcus Sign Arm relaxed, neutral position with downward traction at wrist Arm relaxed, neutral position with downward traction at wrist Positive indicated by development of sulcus Positive indicated by development of sulcus Important to assess symmetry of test Important to assess symmetry of test Sulcus sign recorded as cm of sulcus Sulcus sign recorded as cm of sulcus

22. Special Tests  Apprehension Test Supine position, 90 0 ABduction, neutral rotation Supine position, 90 0 ABduction, neutral rotation Apply slight leverage at proximal humerus while externally rotating Apply slight leverage at proximal humerus while externally rotating Positive test indicated by pt apprehension that shoulder will give way Positive test indicated by pt apprehension that shoulder will give way

23. Special Tests  Anterior/Posterior Drawer Test Best to have patient in supine position Best to have patient in supine position Humeral head slid anteriorly and posteriorly in glenoid while scapula is stabilized Humeral head slid anteriorly and posteriorly in glenoid while scapula is stabilized Positive test with painful click/clunk, apprehension or increased movement compared to other shoulder Positive test with painful click/clunk, apprehension or increased movement compared to other shoulder

24. Special Tests  Crank Test Pt supine or seated with arm elevated to 160 0 Pt supine or seated with arm elevated to 160 0 Force applied along axis with internal and external rotation Force applied along axis with internal and external rotation Drives humeral head against labrum Drives humeral head against labrum Positive test if pain is reproduced or catching +/- click is noted Positive test if pain is reproduced or catching +/- click is noted

25. Biceps Tendonitis  Inflammation of long head of biceps as it passes through bicipital groove  Assoc with repetitive lifting or overhead activity that leads to inflammation  Can lead to spontaneous rupture (10%)  Pain aggravated by lifting, carrying bags or overhead reaching;  pt often localizes pain directly to bicipital groove

26. Special Tests  Speed Test  Yergason Test

27. Special Tests  Speed Test Shoulder forward flexed to 60 0, arm flexed to 30 0 and supinated Shoulder forward flexed to 60 0, arm flexed to 30 0 and supinated Downward force applied to distal forearm Downward force applied to distal forearm Positive test indicated by pain or weakness Positive test indicated by pain or weakness

28. Special Tests  Yergason Test Arm neutral, elbow flexed to 90 0 Arm neutral, elbow flexed to 90 0 Pt attempts to supinate and flex elbow against resistance Pt attempts to supinate and flex elbow against resistance Positive test indicated pain or a “painful pop” Positive test indicated pain or a “painful pop”

29. AC Joint Pathology  Injury type: Sprain, partial or complete tear  Associated with overuse (reaching across chest or overhead) or trauma (especially falls on tip of shoulder)  Associated with anterior shoulder pain  Pt usually localize pain directly to AC joint (i.e. pt will point to AC joint)

30. Special Tests  Cross Chest ADduction Test (Cross Arm Test) Forward flexed to 90 0 and hand to opposite shoulder Forward flexed to 90 0 and hand to opposite shoulder Examiner hyperADducts shoulder Examiner hyperADducts shoulder Positive test indicated by pain at AC joint Positive test indicated by pain at AC joint May be false + with impingement May be false + with impingement

31. Summary  Shoulder injury common in primary care sports medicine  Difficult exam due to complexity of shoulder Made easier by following step wise approach Made easier by following step wise approach  The Big 5’s Overuse Injuries: Rotator cuff pathology, Impingement, GHI/LT, Biceps tendonitis, AC joint pathology Overuse Injuries: Rotator cuff pathology, Impingement, GHI/LT, Biceps tendonitis, AC joint pathology Physical Exam: Appearance, ROM, Palpation, Neurologic, Special Tests Physical Exam: Appearance, ROM, Palpation, Neurologic, Special Tests

32. Summary Special Tests  Rotator Cuff Drop Arm Test Drop Arm Test Supraspinatous Strength Test Supraspinatous Strength Test Lift Off Test Lift Off Test External Rotation External Rotation  Impingement Hawkins Test Hawkins Test Neer’s Test Neer’s Test  GHI Sulcus Sign Apprehension Test Anterior/Posterior Drawer Test  LT Crank Test  Biceps Tendonitis Speed Test Yergason Test  AC Joint Cross Arm Test

33. Resources Anderson, Bruce. “Acromioclavicular Injury.” UpToDate®. www.uptodate.com. ©2006. Howard, www.uptodate.com Anderson, Bruce. “Biceps Tendonitis and Rupture.” UpToDate®. www.uptodate.com. © 2006. www.uptodate.com Anderson, Bruce. “Multidirectional Instability of the Shoulder.” UpToDate®. www.uptodate.com. ©2006. www.uptodate.com Anderson, Bruce. “Rotator Cuff Tendonitis.” UpToDate®. www.uptodate.com. © 2006 www.uptodate.com Anderson, Bruce and Michael Roberts. “Shoulder Impingement Syndrome.” UpToDate®. www.uptodate.com. ©2006. www.uptodate.com Anderson, Bruce and Ronald Anderson. “Evaluation of the Patient with Shoulder Complaints.” UpToDate®. www.uptodate.com. © 2006. www.uptodate.com Anderson, Bruce, et. al. “Rotator Cuff Tear.” UpToDate®. www.uptodate.com. © 2006. www.uptodate.com Cassas, Kyle J. and Amelia Cassettari-Wayhs. “Childhood and Adolescent Sports-Related Overuse Injuries.” American Family Physician. March 2006. Vol 73, No. 6. pp 1014-1022. Thomas M., Francis G. O’Conner. “The Injured Shoulder. Primary Care Assessment.” Archives of Family Medicine July/August 1997, Vol. 6. pp 376-384