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Shoulder Syndromes VOMA September 2011

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1 Shoulder Syndromes VOMA September 2011
P. Gunnar Brolinson, DO, FAOASM, FACOFP, FAAFP Head Team Physician, Virginia Tech Chief of Sports Medicine Edward Via Virginia College of Osteopathic Medicine Director Primary Care Sports Medicine Fellowship

2 Objectives Review anatomy of the shoulder complex
Review motions of the shoulder complex Describe the functional biomechanical evaluation of the shoulder Understand and be able to perform an evaluation of shoulder using various functional and special tests Review some common shoulder problems

3 Introduction Shoulder injury is very common in the active patient population. It is a complex joint and presents unique challenges to diagnosis and subsequent treatment.

4 Introduction Shoulder Pain is the third most common MS complaint in primary care offices Second to knee pain for referrals to ortho/sports medicine physicians Incidence 25/1000 patients Peak incidence in year olds 8-13% of athletic injuries involve the shoulder Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7)

5 Introduction The shoulder complex is a loosely constructed highly mobile complex of bones, muscles and ligaments. It is designed for increased mobility to the upper extremity with only sufficient stability to provide a proper foundation for muscular function which is vital for the performance of sports or activities of daily living (ADL)

6 Introduction Effective diagnosis and treatment of the shoulder requires a mastering of the relationship of structure and function of this complicated joint.

7 Anatomy It is composed of 3 joints (sternoclavicular, acromioclavicular and glenohumeral) and one articulation (scapulothoracic). All four work together in a synchronous rhythm for full range dynamic motion.

8 Anatomy…SC Joint The sternoclavicular joint (SCJ) enables the humerus to achieve 180 degrees of Abduction. It is a saddle shaped joint made up of the medial end of the clavicle, the manubrium sternum and the cartilage of the 1st rib. There is an articular disc separating the surfaces which adds strength to the joint.

9 SC Joint

10 Anatomy…AC Joint A plane synovial joint that augments the range of motion (ROM) in the humerus. It is made up of the acromiom process of the scapula and the lateral edge of the clavicle.

11 Anatomy…AC Joint It is surrounded by a fibrous capsule and an articular disc separates the surfaces. Primary strength is supplied by the acromioclavicular and coracoclavicular ligaments trapezoid ligament conoid ligaments

12 AC Joint

13 AC Joint Type I 17% Type II 43% Type III 40%
Type III found in up to 80% of RC tears Compared with 3% in Type I LYONS: Med Sci Sports Exerc, Volume 30(4) Supplement 1.April Bigliani, L. Subacromial impingement syndrome. Journal of Bone and Joint Surgery ; 79:

14 AC Joint/Subacromial Articulation
Impingement Greater tubercle Acromion Coracoacromial ligaments Supraspinatus tendon Between 48-72% of shoulder pain in PCP office is subacromial impingement Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7)

15 Anatomy…GH Joint A multi-axial ball and socket joint surrounded by a capsule. Most of the support is provided by the rotator cuff muscles.

16 Anatomy of GH Joint The glenoid labrum is a ring of fibrocartilage that surrounds and deepens the glenoid fossa which increases the available contact area by approximately 70%.

17 Functional Anatomy…GH Joint
The relaxed position of the humerus has it placed in the upper portion of the glenoid cavity. Contraction of the rotator cuff muscles pulls the humerus down into the lower/wider portion of the glenoid cavity. Without the “dropping down”, full Abduction is impossible.

18 GH Joint Static stabilizers Dynamic stabilizers Labrum Capsule
Adhesion-cohesion Intra-articular pressure Dynamic stabilizers RC muscles Deltoid Long head of biceps Scapulothoracic muscles Proprioceptive feedback

19 GH Joint…Static Restraints
Labrum Ring of fibrocartilage Deepens the glenoid fossa Increases contact area ~70% Ligaments Superior Glenohumeral Middle Glenohumeral Inferior Glenohumeral (important when shoulder is abducted and externally rotated)

20 The Scapulothoracic Articulation
The scapula serves as a mobile platform from which the upper limb operates. It is made up of the body of the scapula and the muscles covering the posterior chest wall.

21 The Scapulothoracic Articulation
The GHJ moves 120 degrees as the scapula swings about 60 degrees around the chest wall in a smooth 2:1 ratio.

22 The Scapulothoracic Articulation
The articulation allows the scapula to glide medially, laterally, superiorly and inferiorly and rotate over the posterolateral chest cage. Asymmetry of position usually indicates asymmetry of motion.

23 The Scapulothoracic Articulation
In any given arm position, the scapula aligns itself to allow the glenoid cavity to be in the best position to receive the head of the humerus. The apparent simple motion of the scapula is neurologically complex due to relatively little “direct” muscle action.

24 Scapulothoracic Articulation

25 Extrinsic Muscles of the Shoulder Region
Deltoid Anterior (Flex/IR) Mid-portion (ABd) Posterior (Ext/ER) Pectoralis Major (ADd/flex/IR) Biceps (Flex) Triceps (Ext) Teres Major (ADd/IR) Latissimus dorsi (Ext/ADd/IR)

26 Intrinsic Muscles of the Shoulder Region
Rotator Cuff Supraspinatus (ABd) Infraspinatus (ER) Teres Minor (ER) Subscapularis (IR)

27 Muscles of the Scapulothoracic Articulation “Scapular Stabilizers”
Trapezius Superior (Elev) Middle (Retract) Inferior (Depress) Levator Scapulae (Elev) Pectoralis Minor (Depress) Rhomboids (Retract) Serratus anterior (Protract)

28 Shoulder Stability The shoulder consists of passive and dynamic stabilizers.

29 Static Shoulder Stability
The static stabilizers are: Glenoid glenoid labrum capsule ligaments (superior glenohumeral, middle glenohumeral and inferior glenohumeral), joint cohesion Intra-articular negative pressure.

30 Dynamic Shoulder Stability
The dynamic stabilizers are the rotator cuff muscles along with the long head of the biceps. The scapulothoracic stabilizers are the rhomboids, trapezius, serratus anterior, and the pectoralis minor.

31 Ultimately Our Goal is Joint Congruence
Maintenance of the articular surfaces’ apposition is the keystone to avoiding injury Altered engrams (motor activation patterns) increases loads on tissues, resulting in a singular macrotrauma or repetitive microtraumas More than a tight capsule and strong rotator cuff…

32 Shoulder Examination HISTORY
“Listen to the patient long enough and they will tell you what is wrong with them” Where/when/what/how/why Specific mechanism of injury (MOI) (if any?) Chronic vs. acute What makes symptoms better or worse Instability/weakness Pain (0/10) Crepitation Radicular symptoms (pain radiation)

33 Shoulder Examination HISTORY
Pain in shoulder coming from rotator cuff or bursa radiates to lateral deltoid – NOT past elbow! Pain that wakes on rolling over in bed suggests bursitis Pain that wakes from sleep suggests rotator cuff tear 88% sensitive, 20% specific Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7)

34 Shoulder Exam Physical exam should be done in the same manner each time so that nothing is forgotten: Inspection Palpation ROM Active and Passive Strength and Neurologic Testing Regional Osteopathic Structural Examination Special Testing

35 Shoulder Pain Diagram

36 Shoulder Exam Inspect Expose the area Step offs Deformities Ecchymosis

37 ROM Forward flexion 1800 Extension 450 ABduction 1800 ADduction 450
IR 550 ER

38 A/PROM tests Apley “scratch” test: ER and aBduction (C7)
IR and aDduction (T7) Asymmetry can be indicative of: limited GH adduction internal/external rotation scapular movement Painful arc of motion 33% sensitive 81% specific Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7)

39 Scapular Dyskinesis Functional base for shoulder
Alterations in the resting position affects timing and magnitude of: Acromial upward rotation Excessive movement of the glenoid Decrease maximal RC activation Often associated with other upper extremity disorders Kibler, WB. Clin Sports Med 2004; 23: Malposition of scapula alters working length of shoulder girdle muscles. Treatment of shoulder problems necessitates and often starts with evaluation and treatment of scapulothoracic position and motion.

40 Range of Motion Asymmetry is the Key!
Master the feel of normal/abnormal endpoints and restrictions of motion. Extra-articular blockage: rubbery feel and gives slightly under pressure Intra-articular blockage: inflexible and ROM ends abruptly

41 Physical Exam Neurologic exam Muscle & tendon pain worse with:
Passive stretch Active contraction in a neutral position Palpation Ligaments/capsule pain worse with: Passive & active loading, usually only at the end ROM

42 Reflex and Sensory Testing

43 Spurling’s Test Puts pressure on posterolateral complex (articular pillars, facets, & neural foramina Could be a ligament, muscle/tendon, disc, osteoarthritis, nerve root inflammation (virus, etc.), or tumor

44 Lhermitte’s Sign/Test
the “Barber Chair” phenomenon Trauma to cervical spinal cord Space occupying lesion (tumor, disc) Multiple sclerosis Cervical spondylosis Vitamin B12 deficiency

45 Muscle Testing Range of “normal” muscle strength.
When testing for strength, keep in mind that you are also testing for neurological function.

46 Special Testing Special testing can be done to add information for the diagnosis of the problem. Structured to uncover a specific type of pathology or dysfunction. Shoulder special testing includes but not limited to the following….

47 Specific Special Tests
Biceps tendonitis Yergason’s Speed’s Rotator Cuff Empty Can Full Can Lift Off/Napolean Scapular Retraction Instability Apprehension Jobe relocation Anterior Release Glide/Load and Shift Sulcus Test Impingement Hawkins Neer’s Cross Arm Adduction SLAP lesion O’Brien’s Clunk or Crank Resisted Supination/ER Biceps load I and II Zaslav TOS Adson’s Roos

48 Biceps Tendonitis Yergason’s Test
Patient flexes elbow to 900 Physician grasps the elbow with one hand and the wrist with the other The examiner resists as patient attempts to supinate and flex the elbow The test is positive if pain is elicited as the biceps tendon or bicipital groove

49 Biceps Tendonitis Speed’s Test
Patient fully extends the elbow, flexes the shoulder and supinates the forearm Physician resists further flexion The test is positive when there is tenderness in the bicipital groove

50 Supraspinatus Testing
Position the arms in a position of 900 ABduction and 300 forward flexion with the thumbs pointing down Apply a downward force as the patient resists The test is positive with weakness or pain 89% sensitive; 68% specific “Full Can Test” Less impingement Minimized infraspinatus 86% sensitive; 74% specific Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7) Itoi, E, et al. Which is more useful, the “full can test” or the “empty can test” in detecting the torn supraspinatus tendon? AJSM (1),

51 Supraspinatus Test Scapular Retraction Test
Scapular dyskinesis may decrease maximum RC activation With arm in empty can test position, scapula is lightly held in retraction by forearm pressure on the medial scapular border while the patient exerts maximum resistance Strength values increased by 24% in injured group, and 13% in control Kibler, WB et al. Evaluation of Apparent and Absolute Supraspinatus Strength in Patients With Shoulder Injury Using the Scapular Retraction Test. AJSM 2006; 34 (10):

52 Subscapularis Test Gerber Lift Off Test/Napoleon Test
Internal rotation Minimal activation of pectoralis and latisimus Ability to “lift off” 62% sensitive 100% specific Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7)

53 Infraspinatus Test 00 abduction and 450 IR of humerus
Minimal activation of supraspinatus and deltoid Contribute more from 00 to 450 ER

54 GH Instability Apprehension Test Jobe Relocation Test
Causes anterior translation (subluxation) Sens 40%, Spec 87% Jobe Relocation Test Posterior pressure on the head alleviates the discomfort (relocation) Sens 56%, Spec 93% Anterior Release Test Allows for quick anterior translation/apprehension returns Sens 92%, Spec 89%

55 GH Instability Glide Test
This test is performed to assess of A/P instability Compare bilaterally The test is positive if there is excessive mobility

56 GH Instability Load and Shift Test
Patient lie flat on the back so that the center of the scapula is on the edge of the table The physician holds the arm out 900 abduction Assess movement in the shoulder joint in the anterior and posterior directions Grade 0-3 “Lachman” of the shoulder 1 Grade 0:Little/no movement Grade 1:Shift to edge of glenoid Grade 2:Shift over edge of glenoid, spontaneously relocates Grade 3:Shift over edge of glenoid doesn't spontaneously relocate 2 3

57 Inferior GH Instability Sulcus Test
Apply traction in an inferior direction with the arm relaxed The test is positive if it causes inferior subluxation of the humeral head and widening of the sulcus between the humerus and the acromion About 25% of patients with MDI will have sulcus of 2cm or more

58 Multidirectional Instability (MDI)
Usually not difficult to diagnose Laxity in at least the anterior and posterior planes, inferior is usually lax as well Can be overlaid by another pathology Often a laxity in a joint is the compensatory result of restriction elsewhere Imaging not usually necessary or helpful

59 Multidirectional Instability (MDI) Treatment considerations
Neuromuscular retraining Maintenance of joint congruence Kinetic chain TX Somatic Dysfunction Reduction of capsule laxity Prolotherapy Bankhart or capsular plication

60 Impingement Syndrome Primary Secondary
Repetitive overhead motion Supraspinatus impinges on acromion Prominent coracoacromial ligament Secondary GH laxity and instability of shoulder Cephalad migration of humeral head Labral lesion possible Internal (posterior-superior glenoid) Inferior supraspinatus trapped between greater tuberosity and posterior superior labrum Posterior superior synovitis and partial under-surface tears Tensile failure Often as a result of fatigue and tears with eccentric loading Based on some studies anywhere between 48-72% of shoulder pain in PCP office is subacromial impingement (Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7))

61 Impingement Tests Neer’s Test
Patient seated, passively IR arm so that thumb is downward Flex the arm while stabilizing scapula The test is positive if discomfort or pain is elicited Impingement of the humerus against the coracoacromial arch 81% sensitive 50% specific ***False + = arthrosis, Calcific tendonitis, bony lesion

62 Impingement Tests Hawkins Test
Tests supraspinatus impingement against the coracoacromial ligament Elevate the patients shoulder to 900, flex the elbow to 900 and place the forearm in neutral position IR the humerus The test is positive when there is pain or discomfort 90% sensitive, 60% specific ***False + = AC pathology, labral tears Stevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7)

63 Impingement Syndrome Treatment
Injection Diagnostic Therapeutic Larger volume PT Up to 6 mos 60-90% resolve OMT

64 AC Joint/Posterior Capsule Cross Arm Test
With the patient seated, bring the arm across the chest as far as possible The test is positive if there is pain elicited at the AC joint By comparison with the opposite side one can ascertain the tightness or laxity of the posterior capsule

65 Superior Labral Anterior Posterior Lesions (SLAP)
Anterior pain Posterior tightness Clicking or popping Dominant arm Mechanisms Eccentric loading of biceps during throwing Fall with compressive load Forced Abd/ER Excessive traction from weight lifting MVA from seatbelt

66 SLAP - O’Brien’s Test Shoulder 900 flexion, adduction, thumb pointed down Patient resists downward pressure Rotate to supination and resist flexion Test is positive if pain alleviated in palm-up position Sensitivity 67% Specificity 49%

67 SLAP - Crank Test Patient shoulder aBducted to 900
Axial load placed by examiner Humerus then IR The test is positive if pain is noted with or without an “clunk”, or reproduction of activity related symptoms Sensitivity 59% Specificity 82%

68 SLAP - Resisted Supination ER Test
Patient is supine with scapula near the edge Examiner supports the limb in 900 aBduction, elbow flexed , forearm in neutral Patient attempts to supinate, as examiner resists and then gently externally rotated to the maximal point The test is positive if anterior or deep pain, clicking, or reproduction of activity related symptoms 83% sensitive, 82% specific Myers, TH, et al. The Resisted Supination External Rotation Test: A New Test for the Diagnosis of Superior Labral Anterior Posterior Lesions. AJSM 2005; 33 (9):

69 SLAP - Biceps Load Test Loads the superior labrum via stress on the biceps tendon during resisted flexion force Positive test is pain or apprehension Test I is 900/900 Sens 91%, Spec 97% Test II is 1200/900 Sens 90%, Spec 97% Kim SH, Ha KI, Han KY: Biceps load test: a clinical test for superior labrum anterior and posterior lesions in shoulders with recurrent anterior dislocations. Am J Sports Med 1999, 27 (3): Kim SH, Ha KI, Ahn JH, et al: Biceps load test II: a clinical test for SLAP lesions of the shoulder. Arthroscopy 2001, 17 (2):

70 SLAP - Zaslav Test Helps to differentiate labral tears from impingement syndrome Positive test denoted by weakness, NOT pain Sensitivity 88%, Specificity 96% Zaslav, KR. Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. J Shoulder Elbow Surg Jan-Feb; 10(1): 23-7.

71 Thoracic Outlet Syndrome (TOS)
Compression of the neurovascular structures at the superior aperture of the thorax Etiology Neurologic Brachial plexus (95%) Vascular Subclavian vein (4%) Subclavian artery (1%) Neurologic - Female-to-male ratio approximately 3.5:1 Venous - More common in males than in females Arterial - No sexual predilection

72 TOS - Etiology Anatomic Trauma or repetitive activities
Scalene triangle (most common) Cervical ribs (more common in arterial) Congenital fibromuscular bands (up to 80% in neurologic) Transverse process of C7 is elongated Trauma or repetitive activities MVA, hyperextension injury, with subsequent fibrosis and scarring Effort vein thrombosis (ie, spontaneous thrombosis of the axillary veins following vigorous arm exertion) Playing a musical instrument: maintain the shoulder in abduction or extension for long periods Neurovascular entrapment Costoclavicular space between the 1st rib and the head of the clavicle C8-T1 (90%)-ulnar n. distribution

73 TOS - Adson’s Test Patency of subclavian artery “Classic” maneuver
Patient’s arm aBducted, extend and ER Patient then takes a deep breath and holds it while turning the head towards the side being tested Then turn head to the opposite direction Test is positive if diminished or absent pulse or reproduces symptoms

74 TOS - Roos Test Patient aBducts the shoulders to 900, ER, and flex the elbows to 900 Then patient then slowly opens and closes the hands for 3 minutes The test is positive if the arm becomes heavy or there are paresthesia of the hand Compression of subclavian artery and vein and the brachial plexus

75 Diagnostic Work-Up Depending on the injury, there are many diagnostic tests that can be done to evaluate an injury: X-rays CT Scan MRI CT/MR Arthrograms Selective injections Using anesthetic and/or steroids Serial exams in office Ultrasound Dynamic ultrasound In office US guided injections

76 Imaging X-rays AP GH dislocation best seen on axillary views, also on scapular Y view (Kibler)

77 Imaging X-rays Outlet views are obtained to evaluate impingement
For instability, West Point view or the Stryker notch view are used to better detect Bankart and Hill Sachs' lesions

78 Imaging Arthrogram Detailed anatomical information is obtained when combined with CT or MRI of the shoulder Excellent detail of capsular attachments and of the labrum (Kibler)

79 Thought for the Day… “Education is what you remember after you have forgotten what you studied for the test." Emerson

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