6 Subacromial SpaceBursaSubacromial spaceSource of pain down arm
7 Rotator cuff musclesSupraspinatus, infraspinatus, teres minor, subscapularisForm cuff around humeral headKeeps humeral head within joint (head depresser)Abduction, external rotation, internal rotationSupraspinatus – abduction (also with deltoid). Infraspinatus and teres – external rotation. Subscapularis – internal rotation.
8 Physical Exam Visualize from front and back Asymmetry Atrophy Pts with rotator cuff tears hold shoulder higherAtrophySign of chronic glenohumeral joint pathologyEffusionsShoulder joint can hide a lot of fluidCan see atrophy with chronic RA. Shoulder joint can hide a lot of fluid because of capsule redundancy.
9 Active range of motion Forward flexion Abduction/adduction Painful arc of abduction – sensitive, not specificExternal rotationInternal rotationFlexion – arms outstretched, up in front. Abduction – to the side. External rotation – either the penguin, or putting hands behind back (like relaxing).Internal rotation – have pt use thumb to touch the highest point on the spine. Apley scratch test does both abduction and external rotation – reach behind head and touch the superior angle of the opposite scapula. Can touch the inferior angle of the opposite scapula for testing of internal rotation and adduction.
10 Passive range of motion Immobilize the scapula to prevent rotationUse one arm to push down on shoulderUse other arm to do the PROM exercisesAbductionInternal and external rotationHave arm at patient’s side and abducted to 90 degreesPreventing scapula from moving isolates the GH joint. When abducted – internal rotation is pointing down, external rotation is pointing up.
11 Physical ExamExternal RotationInfraspinatusTeres Minor
12 Physical ExamSupraspinatus45 Degrees from front
13 Physical ExamImpingementGreater Tuberosity under acromion
14 Physical ExamCross Arm TestSpecific for AC Joint
15 Biceps Strength Testing Arms outstretched with palms up at level of shoulderForced supination of hand with elbow flexed at 90 degreesCan be positive for SLAP TestBicipital tendonitis – pain at long head of the biceps.s
16 Etiology of Shoulder Pain TraumaOveruseChronicPrevious SurgeryInstabilityNeck PainInfectionDislocationFrozen Shoulder
30 Impingement syndromeCompression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromion (type 3)Repetitive overhead motionsMain cause of rotator cuff tendonitisCan lead to bursitis, partial or full rotator cuff tears
32 RC Tear Rotator Cuff Tear (Most Common) – Night Pain Pain Radiating up / downNumbnessWeaknessDecrease Motion50+ age group
33 Radiology for rotator cuff tears Interpret carefully34% asymptomatic pts (all ages) and 54% pts >60 yo have partial rotator cuff tearsAbnormal rotator cuff signal after trauma may represent strain rather than tearX-raysLook for high riding humeral headUltrasoundHighly operator dependentMRIU/S limitations include with fat patients or small tears.
35 Tx of rotator cuff tears Ice, NSAIDs, restrict aggravating motionsWeighted pendulumNo arm slingsSteroid injectionSurgery – refer if young pts, full/large tears, dominant armBest if done within 6 weeksAcromioplasty and debridementNo overhead positioning, reaching, lifting. Steroid injection could possibly weaken tendon, but Up to Date says there is no influence on tendon healing. Rotator cuff is NOT necessary for most normal activities of a sedentary life.
36 Injection Subacromial Space GH Joint 22 Gauge needle 1.5” 10 cc total vol.40 mg kenelogPost placementAim for CoracoidGH JointSpinal needle 3”10 cc total vol.40 mg KenelogStraight AimPosterior placementBeware of Diabetics
37 Treatment Rotator Cuff / Biceps – Good clinical Exam to Start Conservative Options – PT / Injections / MedsXray and MRI helpfulSurgery (Arthroscopic only way to these days in my opinion)Rehab Course Better
38 Frozen Shoulder Frozen Shoulder – Diabetics Decrease range of motion in all planesPain with any motion40-50 age group
39 Radiology for adhesive capsulitis X-rays have limited useMight see calcifications or degenerative changes that would lead to frozen shoulderMRIEnhancement of joint capsule and synovial membrane4 mm thickening is 70% sensitive and 95% specificX-rays: could see evidence of calcific tendonitis or degenerative changes that would suggest problems that could eventually lead to frozen shoulder.
40 Tx of adhesive capsulitis Watchful waitingUp to 2 years for resolutionIncomplete recovery more likely in pts with DM, or pts with >50% loss of external rotation/abductionSteroid injection (2 locations)Manipulation under anesthesiaAggressive therapyPain medicationExercise – (1) weighted pendulum exercises, (2) passive stretching. Up to 50% will respond to exercise therapy.
41 Biceps tendonitis Inflammation of long head of biceps Passes through bicepital groove of anterior humerusUsually due to repetitive lifting or reachingInflammation, microtearing, degenerative changesUp to 10% pts will have spontaneous rupturePopeye deformityBiceps – elbow flexion and supination.
42 Sx of biceps tendonitis Anterior shoulder painWorse with lifting or overhead reachingOften pts point to bicepital grooveUsually no weakness in elbow flexionBicipital groove is about 1” below the anterolateral tip of the acromion. Pts can seem weak because of pain.
43 Exam for biceps tendonitis Bicipital groove tendernessLook for subacromial impingementTendon ruptureTest biceps strengthYergason testElbows flexed with forearms in frontPt actively resisting external rotationTendon may pop out of bicipital groove when downward pressure applied to forearm
44 Ruptured biceps tendon Usually rotator cuff tear also presentGet the “popeye” signRarely get significant weaknessBrachioradialis and short head of biceps provide 80-85% elbow flexor strengthTx is supportiveUsually proximal end of the long head ruptures.
45 Tx of biceps tendonitis Reduce inflammationStrengthen biceps muscle and tendonPrevent ruptureIce, NSAIDs, avoid aggravating motions5-10% risk of rupture with noncomplianceWeighted pendulumElbow flexion toning exercisesSteroid injectionSurgical referral if sx persist >3 monthsSurgery rarely necessary since flexion strength only minimally decreased and it usually ends up being a cosmetic issue. Can get slight improvement in elbow flexion and supination.
46 Glenohumeral Osteoarthritis Same risk factors as with OA in other areasTrauma, obesity, ageLess common than OA in weight bearing joints or spinePain, stiffness over months to yearsAnterior shoulder is most painful areaWorse with activityDistinguish from RA, adhesive capsulitisRA – morning stiffness, better with activity. Shoulder sx in RA is common, especially in late stages of dse.
47 Exam for Glenohumeral OA GH joint line tenderness and swellingJust below coracoid processUse outward and upward pressureEffusion may be very hard to seeDecreased ROMExternal rotation, abductionEndpoint stiffnessCrepitus
48 Imaging for glenohumeral OA Joint space narrowing (loss of articular cartilage)OsteophytesHumeral head sclerosis and flatteningClub-like deformityGoat’s Beard on X-ray
49 Treatment Arthritis – From trauma or genetic Conservative – PT (sometimes) / Injections / Meds / Lifestyle modificationSurgery – Partial vs Total (Reverse Shoulder)Rehab
50 Glenohumeral Joint Infection Very rareIncreased incidence in diabetics, immuno-compromised patients.Shoulder looks normal, just bigger.SEVERE pain. Any motion hurts.Often a fever. Get labs (CBC, blood cultures, ESR, CRP), XR, then:Get a consult.
51 Ref for Shoulder: Burkhart, Stephen MD et al, Arthroscopic Rotator Cuff Repair, Journal of American Academy of Orthopedic Surgery, Vol 14, No 6, June 2006, Iannotti, JP et al, Partial-thickness tears of the rotator cuff: evaluation and management, Journal of American Academy of Orthopedic Surgery 1999; 7: Bedi, Asheesh et al, Massive Tears of the Rotator Cuff, The Journal of Bone and Joint Surgery (American). 2010;92:
52 Thank You Manish A. Patel, MD, FAAOS Office: (757) 562-7301 Pager: (757)Cell: (215)
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