Presentation on theme: "Shoulder Syndromes VOMA September 2011"— Presentation transcript:
1 Shoulder Syndromes VOMA September 2011 P. Gunnar Brolinson, DO, FAOASM, FACOFP, FAAFPHead Team Physician, Virginia TechChief of Sports MedicineEdward Via Virginia College of Osteopathic MedicineDirector Primary Care Sports Medicine Fellowship
2 Objectives Review anatomy of the shoulder complex Review motions of the shoulder complexDescribe the functional biomechanical evaluation of the shoulderUnderstand and be able to perform an evaluation of shoulder using various functional and special testsReview some common shoulder problems
3 IntroductionShoulder injury is very common in the active patient population.It is a complex joint and presents unique challenges to diagnosis and subsequent treatment.
4 IntroductionShoulder Pain is the third most common MS complaint in primary care officesSecond to knee pain for referrals to ortho/sports medicine physiciansIncidence 25/1000 patientsPeak incidence in year olds8-13% of athletic injuries involve the shoulderStevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7)
5 IntroductionThe 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 IntroductionEffective diagnosis and treatment of the shoulder requires a mastering of the relationship of structure and function of this complicated joint.
7 AnatomyIt 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 JointThe 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.
10 Anatomy…AC JointA 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 JointIt is surrounded by a fibrous capsule and an articular disc separates the surfaces.Primary strength is supplied by the acromioclavicular and coracoclavicular ligamentstrapezoid ligamentconoid ligaments
13 AC Joint Type I 17% Type II 43% Type III 40% Type III found in up to 80% of RC tearsCompared with 3% in Type ILYONS: Med Sci Sports Exerc, Volume 30(4) Supplement 1.AprilBigliani, L. Subacromial impingement syndrome. Journal of Bone and Joint Surgery ; 79:
14 AC Joint/Subacromial Articulation ImpingementGreater tubercleAcromionCoracoacromial ligamentsSupraspinatus tendonBetween 48-72% of shoulder pain in PCP office is subacromial impingementStevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7)
15 Anatomy…GH JointA 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 JointThe 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-cohesionIntra-articular pressureDynamic stabilizersRC musclesDeltoidLong head of bicepsScapulothoracic musclesProprioceptive feedback
19 GH Joint…Static Restraints LabrumRing of fibrocartilageDeepens the glenoid fossaIncreases contact area ~70%LigamentsSuperior GlenohumeralMiddle GlenohumeralInferior 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.
25 Extrinsic Muscles of the Shoulder Region DeltoidAnterior (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 CuffSupraspinatus (ABd)Infraspinatus (ER)Teres Minor (ER)Subscapularis (IR)
27 Muscles of the Scapulothoracic Articulation “Scapular Stabilizers” TrapeziusSuperior (Elev)Middle (Retract)Inferior (Depress)Levator Scapulae (Elev)Pectoralis Minor (Depress)Rhomboids (Retract)Serratus anterior (Protract)
28 Shoulder StabilityThe shoulder consists of passive and dynamic stabilizers.
29 Static Shoulder Stability The static stabilizers are:Glenoidglenoid labrumcapsuleligaments(superior glenohumeral, middle glenohumeral and inferior glenohumeral),joint cohesionIntra-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 injuryAltered engrams (motor activation patterns) increases loads on tissues, resulting in a singular macrotrauma or repetitive microtraumasMore 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/whySpecific mechanism of injury (MOI) (if any?)Chronic vs. acuteWhat makes symptoms better or worseInstability/weaknessPain (0/10)CrepitationRadicular 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 bursitisPain that wakes from sleep suggests rotator cuff tear88% sensitive, 20% specificStevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7)
34 Shoulder ExamPhysical exam should be done in the same manner each time so that nothing is forgotten:InspectionPalpationROMActive and PassiveStrength and Neurologic TestingRegional Osteopathic Structural ExaminationSpecial Testing
36 Shoulder Exam Inspect Expose the area Step offs Deformities Ecchymosis Asymmetry
37 ROM Forward flexion 1800 Extension 450 ABduction 1800 ADduction 450 IR 550ER
38 A/PROM tests Apley “scratch” test: ER and aBduction (C7) IR and aDduction (T7)Asymmetry can be indicative of:limited GH adductioninternal/external rotationscapular movementPainful arc of motion33% sensitive81% specificStevenson, 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 rotationExcessive movement of the glenoidDecrease maximal RC activationOften associated with other upper extremity disordersKibler, 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 pressureIntra-articular blockage: inflexible and ROM ends abruptly
41 Physical Exam Neurologic exam Muscle & tendon pain worse with: Passive stretchActive contraction in a neutral positionPalpationLigaments/capsule pain worse with:Passive & active loading, usually only at the end ROM
43 Spurling’s TestPuts pressure on posterolateral complex (articular pillars, facets, & neural foraminaCould be a ligament, muscle/tendon, disc, osteoarthritis, nerve root inflammation (virus, etc.), or tumor
44 Lhermitte’s Sign/Test the “Barber Chair” phenomenonTrauma to cervical spinal cordSpace occupying lesion (tumor, disc)Multiple sclerosisCervical spondylosisVitamin 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 TestingSpecial 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 tendonitisYergason’sSpeed’sRotator CuffEmpty CanFull CanLift Off/NapoleanScapular RetractionInstabilityApprehensionJobe relocationAnterior ReleaseGlide/Load and ShiftSulcus TestImpingementHawkinsNeer’sCross Arm AdductionSLAP lesionO’Brien’sClunk or CrankResisted Supination/ERBiceps load I and IIZaslavTOSAdson’sRoos
48 Biceps Tendonitis Yergason’s Test Patient flexes elbow to 900Physician grasps the elbow with one hand and the wrist with the otherThe examiner resists as patient attempts to supinate and flex the elbowThe 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 forearmPhysician resists further flexionThe 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 downApply a downward force as the patient resistsThe test is positive with weakness or pain89% sensitive; 68% specific“Full Can Test”Less impingementMinimized infraspinatus86% sensitive; 74% specificStevenson, 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 activationWith 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 resistanceStrength values increased by 24% in injured group, and 13% in controlKibler, 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 rotationMinimal activation of pectoralis and latisimusAbility to “lift off”62% sensitive100% specificStevenson, 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 deltoidContribute more from 00 to 450 ER
54 GH Instability Apprehension Test Jobe Relocation Test Causes anterior translation (subluxation)Sens 40%, Spec 87%Jobe Relocation TestPosterior pressure on the head alleviates the discomfort (relocation)Sens 56%, Spec 93%Anterior Release TestAllows for quick anterior translation/apprehension returnsSens 92%, Spec 89%
55 GH Instability Glide Test This test is performed to assess of A/P instabilityCompare bilaterallyThe 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 tableThe physician holds the arm out 900 abductionAssess movement in the shoulder joint in the anterior and posterior directionsGrade 0-3“Lachman” of the shoulder1Grade 0:Little/no movementGrade 1:Shift to edge of glenoidGrade 2:Shift over edge of glenoid, spontaneously relocatesGrade 3:Shift over edge of glenoid doesn't spontaneously relocate23
57 Inferior GH Instability Sulcus Test Apply traction in an inferior direction with the arm relaxedThe test is positive if it causes inferior subluxation of the humeral head and widening of the sulcus between the humerus and the acromionAbout 25% of patients with MDI will have sulcus of 2cm or more
58 Multidirectional Instability (MDI) Usually not difficult to diagnoseLaxity in at least the anterior and posterior planes, inferior is usually lax as wellCan be overlaid by another pathologyOften a laxity in a joint is the compensatory result of restriction elsewhereImaging not usually necessary or helpful
59 Multidirectional Instability (MDI) Treatment considerations Neuromuscular retrainingMaintenance of joint congruenceKinetic chainTX Somatic DysfunctionReduction of capsule laxityProlotherapyBankhart or capsular plication
60 Impingement Syndrome Primary Secondary Repetitive overhead motionSupraspinatus impinges on acromionProminent coracoacromial ligamentSecondaryGH laxity and instability of shoulderCephalad migration of humeral headLabral lesion possibleInternal (posterior-superior glenoid)Inferior supraspinatus trapped between greater tuberosity and posterior superior labrumPosterior superior synovitis and partial under-surface tearsTensile failureOften as a result of fatigue and tears with eccentric loadingBased 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 downwardFlex the arm while stabilizing scapulaThe test is positive if discomfort or pain is elicitedImpingement of the humerus against the coracoacromial arch81% sensitive50% specific***False + = arthrosis, Calcific tendonitis, bony lesion
62 Impingement Tests Hawkins Test Tests supraspinatus impingement against the coracoacromial ligamentElevate the patients shoulder to 900, flex the elbow to 900 and place the forearm in neutral positionIR the humerusThe test is positive when there is pain or discomfort90% sensitive, 60% specific***False + = AC pathology, labral tearsStevenson, JH and Trojian, T. Evaluation of shoulder pain. JFP July (7)
63 Impingement Syndrome Treatment InjectionDiagnosticTherapeuticLarger volumePTUp to 6 mos60-90% resolveOMT
64 AC Joint/Posterior Capsule Cross Arm Test With the patient seated, bring the arm across the chest as far as possibleThe test is positive if there is pain elicited at the AC jointBy comparison with the opposite side one can ascertain the tightness or laxity of the posterior capsule
65 Superior Labral Anterior Posterior Lesions (SLAP) Anterior painPosterior tightnessClicking or poppingDominant armMechanismsEccentric loading of biceps during throwingFall with compressive loadForced Abd/ERExcessive traction from weight liftingMVA from seatbelt
66 SLAP - O’Brien’s TestShoulder 900 flexion, adduction, thumb pointed downPatient resists downward pressureRotate to supination and resist flexionTest is positive if pain alleviated in palm-up positionSensitivity 67%Specificity 49%
67 SLAP - Crank Test Patient shoulder aBducted to 900 Axial load placed by examinerHumerus then IRThe test is positive if pain is noted with or without an “clunk”, or reproduction of activity related symptomsSensitivity 59%Specificity 82%
68 SLAP - Resisted Supination ER Test Patient is supine with scapula near the edgeExaminer supports the limb in 900 aBduction, elbow flexed , forearm in neutralPatient attempts to supinate, as examiner resists and then gently externally rotated to the maximal pointThe test is positive if anterior or deep pain, clicking, or reproduction of activity related symptoms83% sensitive, 82% specificMyers, 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 TestLoads the superior labrum via stress on the biceps tendon during resisted flexion forcePositive test is pain or apprehensionTest 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 TestHelps to differentiate labral tears from impingement syndromePositive test denoted by weakness, NOT painSensitivity 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 thoraxEtiologyNeurologicBrachial plexus (95%)VascularSubclavian vein (4%)Subclavian artery (1%)Neurologic - Female-to-male ratio approximately 3.5:1Venous - More common in males than in femalesArterial - 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 elongatedTrauma or repetitive activitiesMVA, hyperextension injury, with subsequent fibrosis and scarringEffort 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 periodsNeurovascular entrapmentCostoclavicular space between the 1st rib and the head of the clavicleC8-T1 (90%)-ulnar n. distribution
73 TOS - Adson’s Test Patency of subclavian artery “Classic” maneuver Patient’s arm aBducted, extend and ERPatient then takes a deep breath and holds it while turning the head towards the side being testedThen turn head to the opposite directionTest is positive if diminished or absent pulse or reproduces symptoms
74 TOS - Roos TestPatient aBducts the shoulders to 900, ER, and flex the elbows to 900Then patient then slowly opens and closes the hands for 3 minutesThe test is positive if the arm becomes heavy or there are paresthesia of the handCompression of subclavian artery and vein and the brachial plexus
75 Diagnostic Work-UpDepending on the injury, there are many diagnostic tests that can be done to evaluate an injury:X-raysCT ScanMRICT/MR ArthrogramsSelective injectionsUsing anesthetic and/or steroidsSerial exams in officeUltrasoundDynamic ultrasoundIn officeUS guided injections
76 ImagingX-raysAPGH 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 ImagingArthrogramDetailed anatomical information is obtained when combined with CT or MRI of the shoulderExcellent 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