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The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

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Presentation on theme: "The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets."— Presentation transcript:

1 The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets

2 Case 1

3 History 25 yo right-handed female presents with pain and weakness in her left shoulder25 yo right-handed female presents with pain and weakness in her left shoulder She works in an office but is involved in several recreational sports including volleyball, water-skiing and snow skiingShe works in an office but is involved in several recreational sports including volleyball, water-skiing and snow skiing She has had problems with her shoulder since high school but symptoms have worsened in the last few monthsShe has had problems with her shoulder since high school but symptoms have worsened in the last few months

4 Her pain is anterior, posterior, and lateralHer pain is anterior, posterior, and lateral She denies any specific injury but notes that her arm would feel momentarily weak at various times with her athletic activitiesShe denies any specific injury but notes that her arm would feel momentarily weak at various times with her athletic activities She has had similar but milder symptoms in her opposite shoulderShe has had similar but milder symptoms in her opposite shoulder She was treated in high school with an exercise program but no supervised therapy. This seemed to relieve her symptomsShe was treated in high school with an exercise program but no supervised therapy. This seemed to relieve her symptoms

5 She has never had an x-ray or MRIShe has never had an x-ray or MRI Occasionally she describes tingling in her whole armOccasionally she describes tingling in her whole arm She takes oral contraceptives but is otherwise healthy. She had knee arthroscopy for a “patella problem” 4 years agoShe takes oral contraceptives but is otherwise healthy. She had knee arthroscopy for a “patella problem” 4 years ago

6 What Are the Key Points Learned From the History?

7 What Is Your Differential Diagnosis?

8 Exam No significant tendernessNo significant tenderness ROM –fullROM –full Impingement tests – negativeImpingement tests – negative Instability testsInstability tests –Positive load-shift and drawer tests –Equivocal sulcus sign & relocation test

9 Apprehension tests produce discomfort onlyApprehension tests produce discomfort only Strength full in all muscle groupsStrength full in all muscle groups No crepitus, no atrophy or swellingNo crepitus, no atrophy or swelling Neurocirculatory exam – normalNeurocirculatory exam – normal Cervical spine exam - normalCervical spine exam - normal

10 Demonstration Apprehension testsApprehension tests Relocation testRelocation test Load-shiftLoad-shift Drawer testDrawer test Sulcus signSulcus sign

11 On Physical Exam, How Do You Tell Apart Uni- Versus Multi- directional Instability and Why Is That Important?

12 When Do You Order X-rays and What Views?

13 Imaging - X-rays Possible positive findingsPossible positive findings –Bony Bankart lesion –Hill-Sachs lesion

14 Hill-Sachs Lesion

15 When Do You Order an MRI?

16 MRI Possible positive findingsPossible positive findings –Labrum tears –Capsular abnormalities – increased volume, avulsions

17 Normal Labrum

18 Bankart Lesion

19 Enlarged Capsule

20 Describe Your Initial Treatment

21 How Long Should You Continue Non-operative Treatment?

22 Initial Treatment No labrum tearNo labrum tear –Physical therapy – supervised TIW – 6 weeks minimum StrengtheningStrengthening Neuromuscular controlNeuromuscular control Scapular stabilizationScapular stabilization Core stabilizationCore stabilization

23 Labrum Tear Present Referral for surgical consultationReferral for surgical consultation

24 Results Multidirectional instability without labrum tearMultidirectional instability without labrum tear –Very high success rate with non-operative management May require prolonged and specialized therapy programMay require prolonged and specialized therapy program

25 Instability With Labrum Tear Very high rate of unsatisfactory results without surgeryVery high rate of unsatisfactory results without surgery –Early referral

26 What Is the Surgical Decision- making Process in This Case?

27 Case 2

28 Patient History 47 yo female complains of pain in her dominant right shoulder. Onset was about 3 months ago.47 yo female complains of pain in her dominant right shoulder. Onset was about 3 months ago. She thought her pain may have started after she caught herself from falling in the shower, but the incident was so mild she quickly had forgotten about it. Since that time, she has steadily worsened.She thought her pain may have started after she caught herself from falling in the shower, but the incident was so mild she quickly had forgotten about it. Since that time, she has steadily worsened.

29 She feels weak and has a lot of pain when she lifts her arm overhead. She describes the pain as being deep within the shoulder.She feels weak and has a lot of pain when she lifts her arm overhead. She describes the pain as being deep within the shoulder. Some ADLS have become difficult, including fastening her bra.Some ADLS have become difficult, including fastening her bra. She has no paresthesias or neck pain.She has no paresthesias or neck pain.

30 She went to an urgent care facility and had x-rays. She was told these were normal. An NSAID was given at that time and it helped “a little”.She went to an urgent care facility and had x-rays. She was told these were normal. An NSAID was given at that time and it helped “a little”. She takes Lipitor, Wellbutrin, and Glucophage.She takes Lipitor, Wellbutrin, and Glucophage.

31 What Are the Key Points Learned From the History?

32 What Is Your Differential Diagnosis?

33 Exam Tenderness anteriorly and posteriorly around the acromionTenderness anteriorly and posteriorly around the acromion ROM – FF 90 degrees, ER – 20 degrees with arm at the side, IR – to about the SI jointROM – FF 90 degrees, ER – 20 degrees with arm at the side, IR – to about the SI joint Impingement tests – all cause pain at end range of motionImpingement tests – all cause pain at end range of motion Strength near normal in all groupsStrength near normal in all groups

34 Mild crepitusMild crepitus No atrophy or swellingNo atrophy or swelling Neurocirculatory exam – normalNeurocirculatory exam – normal Instability tests – negativeInstability tests – negative Cervical spine exam – normalCervical spine exam – normal

35 Demonstration ROM testingROM testing C-spine and other ancillary testingC-spine and other ancillary testing

36 How Does Your Exam Eliminate Rotator Cuff Problems From the Differential?

37 When Do You Order X-rays and What Views?

38 Imaging - X-rays Possible positive findingsPossible positive findings –Generally normal x-rays –Osteopenia?

39 When Do You Order an MRI?

40 MRI Possible positive findingsPossible positive findings –Need to know cuff and labrum status –Many false positives in older age group

41 Describe Your Initial Treatment

42 What Is the Role of Corticosteroid Injections?

43 How Long Should You Continue Non-operative Treatment?

44 Initial Treatment Always non-operativeAlways non-operative –Unless history of contralateral frozen shoulder unresponsive to therapy Get control of painGet control of pain –NSAIDs –Supplemental non-narcotic analgesics –TENS

45 Physical therapy – supervised TIWPhysical therapy – supervised TIW –Specify aggressive ROM/stretching Myofascial/trigger point approachMyofascial/trigger point approach Aquatic programAquatic program Combine with home programCombine with home program Reassess in 4 weeksReassess in 4 weeks Insurance often limits visits – “save” visits for post-op PTInsurance often limits visits – “save” visits for post-op PT Referral if no progressReferral if no progress

46 What Is the Surgical Decision- making Process in This Case?

47 Results Majority respond to PTMajority respond to PT First operative intervention is manipulation under anesthesiaFirst operative intervention is manipulation under anesthesia

48 Case 3

49 Patient History 54 yo male maintenance supervisor and recreational softball player complains of a 6 month history of dominant shoulder pain54 yo male maintenance supervisor and recreational softball player complains of a 6 month history of dominant shoulder pain Pain is localized to the anterior aspect of the shoulder with radiation to the deltoid insertionPain is localized to the anterior aspect of the shoulder with radiation to the deltoid insertion He recalls no specific injury but has had several similar bouts of pain over the last 5 or 6 years. Each of these episodes resolved with activity modification aloneHe recalls no specific injury but has had several similar bouts of pain over the last 5 or 6 years. Each of these episodes resolved with activity modification alone

50 His current pain is worse with overhead activities and with reaching. He is occasionally wakened from sleep by his shoulder painHis current pain is worse with overhead activities and with reaching. He is occasionally wakened from sleep by his shoulder pain He notes no numbness, tingling, or neck painHe notes no numbness, tingling, or neck pain He has mild treated hypertension but has no other significant medical historyHe has mild treated hypertension but has no other significant medical history

51 What Are the Key Points Learned From the History?

52 What Is Your Differential Diagnosis?

53 Exam Tenderness anteriorly – acromion, AC joint, and anterior deltoidTenderness anteriorly – acromion, AC joint, and anterior deltoid ROM – near full,mild restriction of IRROM – near full,mild restriction of IR Impingement tests – positive in full forward flexion, internal rotation at 90 degrees flexion, and in adductionImpingement tests – positive in full forward flexion, internal rotation at 90 degrees flexion, and in adduction

54 Strength decreased to external rotation and forward flexionStrength decreased to external rotation and forward flexion Painful arc of motion 60 to 100 degrees forward flexionPainful arc of motion 60 to 100 degrees forward flexion Mild crepitusMild crepitus No atrophy or swelling, neurocirculatory exam – normal, instability tests – negative, cervical spine exam – normalNo atrophy or swelling, neurocirculatory exam – normal, instability tests – negative, cervical spine exam – normal

55 Demonstration Emphasize proper exposureEmphasize proper exposure InspectionInspection PalpationPalpation Strength testsStrength tests Impingement signsImpingement signs

56 What Is the Most Reliable Physical Exam Finding to Differentiate Cuff Tendinitis From Cuff Tear?

57 How Do You Tell If the AC Joint Is Involved?

58 When Do You Order X-rays and What Views?

59 Imaging - X-rays Possible positive findingsPossible positive findings –Acromial hook –Sclerosis – acromial & greater tuberosity –AC joint narrowing & spurring –Calcific deposits

60 Acromial Hook

61 AC Arthritis

62 Rotator Cuff Tear

63 When Do You Order an MRI?

64 MRI Possible positive findingsPossible positive findings –Increased signal in cuff –Fluid in bursa –Discontinuity –Muscle atrophy

65 RC Tendinitis

66 RC Tear

67 Describe Your Initial Treatment

68 Initial Treatment Tendinitis/partial rotator cuff tearTendinitis/partial rotator cuff tear –NSAIDs –Activity modification –Physical therapy – supervised TIW StrengtheningStrengthening StretchingStretching ModalitiesModalities

69 How Long Should You Continue Non-operative Treatment?

70 What Is the Role of Corticosteroid Injections?

71 Results Tendinitis/partial rotator cuff tearTendinitis/partial rotator cuff tear –Non-operative treatment successful – 60 to 70% of cases Maintenance exercise programMaintenance exercise program Gradual progression to full activityGradual progression to full activity Assessment of workplaceAssessment of workplace –Transitional work program Non-operative treatment not successful after 6 weeksNon-operative treatment not successful after 6 weeks –Referral

72 Full Thickness Rotator Cuff Tear Referral to orthopaedic surgeonReferral to orthopaedic surgeon

73 What Is the Surgical Decision- making Process in This Case?

74 Full Thickness Rotator Cuff Tear Arthroscopic cuff repairArthroscopic cuff repair Some tears are irreparable!Some tears are irreparable!

75 Thanks… and enjoy the game!


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