Sports Medicine Workshop

Shoulder Problem Evaluation

Second most common musculoskeletal complaint Difficult joint to examine Multidirectional range of motion- UNIQUE! Shoulder injury can affect nearly every sport and many daily activities

Objectives Review pertinent anatomy Discuss common pathology Discuss historical clues to diagnosis Select cases Physical exam in small group discussions

Bony Anatomy Anterior

Bony Anatomy Anterior and Posterior 6

Radiographic Anatomy 7

Where do things go wrong?? Fractures

Where do things go wrong?? Dislocations and Separations Dislocations and separations are protected by both “static” and “dynamic” stabilizers…

Where do things go wrong?? Dislocations and Separations Oh, yeah…Arthritis can happen at these joints, too…

Glenohumeral Joint Shallow (“golf ball sitting on a tee”) Inherently unstable (maximizes ROM) Static stabilizers glenohumeral ligaments, glenoid labrum and capsule Dynamic stabilizers Predominantly rotator cuff muscles Also scapular stabilizers Trapezius, leavator scapulae, serratus anterior, rhomboids

Bony Anatomy “Static Stabilizers”

What goes wrong… Besides separations and dislocations?? Instability!!! 13

LABRUM

What goes wrong? Tears and tendonopathies

The Rotator Cuff Muscles “dynamic stabilizers”

The Rotator Cuff Muscles Supraspinatus Infraspinatus Teres minor Supscapularis

The Rotator Cuff Muscles: SITS Teres minor ER Supscapularis IR Supraspinatus ABD Infraspinatus ER Depress humeral head against glenoid to allow full abduction

Finally…the subacromial space

What can go wrong??? Impingement!!!!!!!

Impingement 21

Other Anatomy Deltoid Rotator cuff Latissimus dorsi Biceps Teres major Pectoralis muscles 17 muscles create the movement of the shoulder

Shoulder Anatomy 23

Don’t forget the scapular stabilizer muscles

So…what causes shoulder pain? Impingement Labrum and biceps pathology A-C joint pathology Rotator Cuff Injury Instability Among other things…

Clinical Exam History Pain Acute Chronic Weakness Deformity

Clinical Exam History Single event Repetitive overload Instability Does it feel like it’s going to come out? Catching/Locking

Clinical Exam History Sport / Occupation Previous injury Previous treatment Other joints involved Disability

Physical Exam: Big 6 Inspection Palpation Range of Motion Strength Neurovascular Special Tests

Special Tests Impingement Rotator Cuff Integrity Labrum and Biceps AC (SC) Joints Instability 30

Physical Exam The physical exam will be demonstrated during small group discussions…

Which rotator cuff muscle(s) are responsible for external rotation Supraspinatus Infraspinatus Subscapularis Teres Minor Both 2 and 4

The apex (bottom) of the scapula is at what level of the spine? :00

Case #1 22-year-old male rugby player falls onto his right shoulder while being tackled Severe pain on top of his right shoulder

Case #1 Notable deformity over superior shoulder Painful range of motion Unable to lift right arm above waist Special Tests?? Diagnosis???

Acromioclavicular (A-C) Sprain Special Tests Shear Test Cross Arm Test A-C Palpation Resisted Extension Active compression test

Acromioclavicular (A-C) Sprain Damage to A-C joint ligaments Pain and/or deformity over A-C joint Graded I-VI I-III usually treated non-operatively IV-VI referred to orthopedic surgery

AC Joint Sprain Treatment Analgesics, ice prn Sling for as long as needed Physical Therapy ROM restoration Gradual strength exercise Return to sport activity as tolerated

Case #2 24-year-old male handball player Fell onto his shoulder after being pushed Intense pain Hand is tingling and arm feels like it’s hanging X-rays

X RAYS

Shoulder Dislocation/Anterior Instability Humeral head dislocates from glenoid fossa Almost always anterior (95%) Usually traumatic with injury to capsule-labrum complex

Shoulder Dislocation/Anterior Instability Treatment Reduction of dislocation Protection & rehab, rehab, rehab Most will have future dislocations and/or instability At least 70%!!! (young) May require surgical tightening/repair of the capsule/labrum complex

Special Tests Glenoid Labrum and Instability Biceps Load I and II Kim Test Jerk Test Active-Compression Test (O’Brien) Crank Test Apprehension Test Relocation Test Load and Shift Sulcas Sign

Which of the following structures can be “impinged”? Biceps tendon Subacromial Bursa Rotator Cuff Tendons All of the above 30 10

Case #3 35-year-old male tennis player Shoulder pain exacerbated by practicing serves Develops dull, aching pain in right shoulder

SHOULDER PAIN Physical Exam Tenderness to palpation anterior shoulder Pain with abduction starting around 90 degrees Unable to lift arm past 120 degrees Pain with forward flexion at 90-120 degrees Special Tests??? Diagnosis???

Shoulder Pain Physical Exam Hawkin’s positive Neer’s positive IMPINGEMENT??? 47

Impingement as a Clinical Sign Repetitive overhead activities Subacromial bursa and/or rotator cuff impinged between acromion & humerus Physical therapy, activity modification +/- medications

Diagnoses associated with clinical sign of Rotator Cuff Impingement: Subacromial bone spurs and / or bursal hypertrophy AC joint arthrosis and /or bone spurs Rotator cuff disease Superior labral injury Glenohumeral instability Scapular dyskinesis Biceps tendinopathy A diagnostic injection sometimes helps to clarify the diagnosis

Case #4 45-year-old weight lifter Caught bar as it was falling off his shoulder Sudden pain Severe weakness left shoulder Worse with overhead activities; while sleeping at night Pain in anterior lateral shoulder Special tests?

Case #4 Drop Arm Test Positive External Rotation Lag Sign positive Weakness with Empty Can Sign Normal bear hug and belly press tests… Diagnosis????? 51

Rotator Cuff Tear Supraspinatus tendon most common Acute trauma or chronic tendinopathy Treatment dependent upon age/activity Young, active usually require operative treatment Older, low-activity usually respond to non-operative treatment

Case #5 42-year-old female with dull pain right shoulder Pain is diffuse in nature Sometimes spreads to between shoulder blades Seems worse at night

Physical Exam Obese, pleasant female Diffuse pain Normal shoulder exam Not able to reproduce pain during exam What else do you want to do???

Shoulder pain isn’t always the shoulder!! Get more history… Gall bladder disease Peptic Ulcer Disease Cervical radiculopathy Cardiac ischemia Pulmonary conditions ie Pancoast’s tumor, Pneumonia

In the human body, which is the most incredible joint? PIP Knee Ankle Shoulder None of the above

Case #6 40-year-old male Recently shoveled 16” of snow Can hardly lift left arm due to pain Special Tests? Diagnosis?

Biceps Tendonopathy Speed Test Yergason Test Direct palpation

Biceps Tendonopathies Repetitive overhead activity Repetitive forearm flexion/supination Difficult to discern from rotator cuff tendinopathy or impingement 59

Conclusion Shoulder injuries are common. Knowledge of the anatomy is crucial to correct patho-anatomic diagnosis. Impingement is a clinical sign, not a diagnosis. Don’t forget about medical causes.

Physical Exam Inspection Front & back Height of shoulder and scapulae Muscle atrophy, asymmetry 61

Physical Exam Range of Motion Abduction 0-180o 62

Physical Exam Range of Motion Forward flexion: 0o – 180o 63

Physical Exam Range of Motion Extension 0o – 40 to 60o 64

Physical Exam Range of Motion Internal rotation T5 segment External rotation 80-90o 65

Physical Exam Strength Empty can test 30o angle Steady downward pressure Tests supraspinatus strength and pain 66

Physical Exam Strength Resisted external rotation Tests infraspinatus, teres minor strength 67

Physical Exam Strength of Subscapularis Liftoff test Belly press test 68

Cross-Arm Adduction Test AC joint pathology Arm flexed to 90° Hyperadduct arm across body as far as possible Pain in AC = (+) test 69

A-C Shear Test Interlock fingers with hand on distal clavicle and spine of scapula Pain in A-C joint when hands squeezed together = (+) test 70

Sulcus Sign Inferior instability Arm relaxed in neutral position, pull downward at elbow (+) test = sulcus at infra-acromial area compare to unaffected side 71

Apprehension Test Anterior instability Shoulder at 90° abducted, slight anterior pressure & External rotation (+) test = dislocation apprehension some false (+) 72

Relocation Test Perform after positive apprehension test Apply post force over humeral head during external rotation (ER) (+) test = increased ER tolerance 73

Load & Shift Test Test for multidirectional instability Grasp humeral head, slide anteriorly and posteriorly while securing rest of shoulder (+) if greater than 50% displacement (graded 1-3) 74

Impingement Signs Hawkins Neer 75

Drop Arm Test Suggestive of Rotator Cuff Tear Passive abduction to 90° Instruct patient to slowly lower arm At 90° abducted arm will suddenly drop, may need to add slight pressure (+) drop = (+) test 76

Speed’s Test Biceps Tendinopathy Long head of biceps tendonitis Fwd flex to 90°, abd 10°, full supination Apply downward force to distal arm Pain = (+) test weakness w/o pain = muscle weakness or rupture 77

O’Brien’s Active Compression SLAP lesion (Superior Labrum Antero-Posterior) Labral/AC pathology Arm flexed to 90°, elbow extended, adduct 10-15°, resist downward force + if AC pain or internal pain/click 78

O’Brien’s Active Compression SLAP lesion Supination should be pain free (decreased pain) 79

Crank Test Labral injury Glenoid labrum tear Abduct arm to 160°, pt is supine or upright, elbow secured with one hand axial load at shoulder with other (+) if audible/painful catch/grind is noted 80

Knee Problems

Anatomy Review

Tibia Fibula Femur Patella Medial & lateral Gerdy’s tubercle Condyles Gerdy’s tubercle Pes anserine area Tibial tuberosity Tibial plateau Tibial spines Fibula Head Neck Femur Medial & lateral Condyles Epicondyles Trochlear groove Intercondylar notch Patella Superior pole (base) Inferior pole (apex) Medial & lateral facets

Anatomy – Major Ligaments & Tendons Quadriceps tendon Patellar tendon Medial & lateral patellar retinaculua

MCL LCL

ACL and PCL

Iliotibial band (ITB)

Anatomy – Menisci of the Knee Medial meniscus Lateral meniscus Meniscal ligaments Functions of the menisci Meniscal zones White-white Red-white Red-red

Knee Exam Overview Inspection Palpation Range of Motion Strength Neurovascular Special Tests

Case 1 – Medial Right Knee Pain 16yo HS soccer player, previously healthy Tackled from right side while running Immediate onset of medial jt line pain Delayed onset local medial edema, stiffness Able to bear weight

Key Questions in the History Mechanism of Injury? Acute or Chronic? Location and level of pain? Able to walk? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries?

Case 1 - Exam Inspection: Mild medial knee edema Palpation: + ttp medial knee ROM: can’t bend >80d Strength: mildly decreased Neurovascular: normal Special tests: Neg Lachman, Anterior Drawer, McMurray, varus stress + mild increased gap on valgus stress (compared to left) with good endpoint

Special Tests - ACL Injury Lachman Test 93

Special Tests - PCL Injury Posterior Drawer Test Sag Sign Quad-Active Test 94

Varus/Valgus stress for LCL and MCL Injury 95

Features that should prompt an xray after acute knee injury include: Unable to bear weight Can’t flex >90d Patella TTP Fibular head TTP Age <18 or >55 All of the above

5 Ottawa Knee Rules i.e. When to order a knee xray after acute injury Age > 55 or < 18 Unable to walk TTP on PATELLA TTP on FIBULAR HEAD Unable to flex 90 deg

Case 1 - Imaging Normal!

Case 1 – Differential Diagnosis More Likely Less Likely Meniscal Tear Ligamentous Injury Which ligament? ACL PCL MCL LCL Muscle Strain Fracture Patellofemoral Pain Plica

MCL Sprain Diagnosis?

What grade of sprain is likely present of the MCL? Grade 1: no laxity, but hurts Grade 2: mild laxity, still intact Grade 3: complete tear Grade 4: hurts like *^%*

MCL Sprain Treatment? RICE Relative Rest Hinge Brace only if unstable on exam Achieve full ROM Progressive Strengthening Neuromuscular Control (Balance exercises) Functional Exercises (Sport-specific)

Case 2 56 yo retired Army LTC 15 years worsening L>R knee pain Former parachutist, no specific trauma No previous knee surgeries Stiffness worse in morning Pain is worse with activity, better with rest

Case 2 – Key Questions Insidious Onset Mechanism of Injury? Chronic Difficult to localize; mild No None Occasional Lots of “Bad Landings” No surgery Activity Rest Mechanism of Injury? Acute or Chronic? Where/how bad is pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better?

Case 2 – Physical Exam Inspection: Genu varus Bony enlargement at Med/Lat joint lines Palp: Posterior medial joint line ttp ROM: Decreased flexion, 110 deg, mild crepitus Strength: normal Neurovascular: normal Special Tests: no ligamentous laxity, neg meniscal tests

Special Tests - Meniscal Injuries Joint line tenderness McMurray Tests Thessaly test Bounce-home test Full Squat 106

Case 2 – Plain Films Joint space narrowing Subchondral Sclerosis Osteophytes Subchondral Cysts

What is your diagnosis? Meniscal tear Plica syndrome Osteoarthritis Bone tumor 10

Osteoarthritis Pharmacologic Treatment: Nonpharmacologic Treatment: Nonpainful aerobic activity Weight loss Physical Therapy Improve ROM, increase strength Bracing Pharmacologic Treatment: APAP Supplements Glucosamine and Chondroitin NSAIDs, COX-2’s Tramadol Viscosupplementation Intrarticular Steroids

Case 3 31 year old female, L knee pain Recreational runner Localizes pain to front of knee No trauma, insidious onset Localizes pain “around kneecap” Worse with stairs Worse after prolonged sitting Knee occasionally “gives out”

Case 3 – Key Questions Insidious Onset Mechanism of Injury? Chronic Anterior knee No, but sometimes gives out None Running, Stairs Multiple days of rest Mechanism of Injury? Acute or Chronic? Where is the pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better?

Physical Exam Inspection: mild genu valgus Palpation: TTP lateral > medial patellar facets ROM: full w/o pain Strength: normal Neurovascular: normal Special Tests: + patellar grind Decreased patellar glide Inflexible hamstrings (Popliteal angle)

Patellofemoral Joint Exam

Patellofemoral Joint Exam Patellar Grind Test

Case 3 – Plain Films Lateral AP

Case 3 – Plain Films Sunrise Tunnel

What’s your diagnosis? Patellar tendinopathy Patellar instability Patellofemoral syndrome Plica syndrome

Patellofemoral Syndrome Treatment: Relative rest; non-painful aerobics Physical Therapy Improve Quad/Hamstring flexibility Quad, Hip abductor strengthening Core strengthening Patellar stabilization brace/taping Foot orthotics Surgery (last-ditch effort)

Case 4 34 yo Army MAJ training for 1st marathon Atraumatic onset of R lateral knee pain 1 week ago after 10 mile run Sharp burning pain Better with rest, returns with running

Case 4 – Key Questions Insidious Onset Mechanism of Injury? Acute Lateral knee No, but sometimes gives out None Running Multiple days of rest Mechanism of Injury? Acute or Chronic? Where is the pain? Mechanical Symptoms? (Locking, popping, catching?) Associated instability? Swelling? Previous injuries or surgeries? What makes it worse? What makes it better?

Physical Exam Inspection: normal Palpation: TTP over lateral femoral condyle ROM: full Strength: normal Neurovascular: normal Special tests: + Noble test Tight on Ober test

Ober test Noble test

What’s your diagnosis? Osteoarthritis Meniscal tear Iliotibial band syndrome LCL sprain

Iliotibial Band Syndrome Treatment: Ice massage, pain meds Relative Rest; nonpainful activity Physical Therapy Specific ITB stretches Hip abductor strengthening Core strengthening (Gluteus Medius) Slow return to activity Extrinsic factors: shoes, running surface, training errors

What the heck is a Plica? Congenital thickening of joint capsule Redundant meniscus Loose piece of intra-articular cartilage Figment of my imagination

Plica Syndrome?

Before we break for hands-on Questions? Before we break for hands-on

Special Tests - ACL Injury Lachman Test Knee flexed to 15-30 degrees Stabilize distal femur Anteriorly translate tibia on femur Watch & feel for amount of translation & end point Pivot Shift 128

Special Tests - PCL Injury Posterior Drawer Test Knee flexed to 90 degrees Posteriorly translate tibia on femur Watch & feel for amount of translation & end point Sag Sign Knees flexed, quads relaxed  compare both sides Look for tibial posterior “sag” relative to femur Quad-Active Test Knee flexed; hamstrings fully relaxed Slide foot along table (quad active) Observe for anterior relocation 129

Special Tests - MCL Injury Valgus Stress Testing Knee flexed to 30 degrees Relax ACL/PCL & joint capsule Valgus stress applied to knee Look and feel for translation and endpoint Compare to uninjured side May repeat with knee in full extension 130

Special Tests - LCL Injury Varus Stress Testing Same test as valgus stress testing Except applying a varus stress instead LCL, IT band, & PLC are tested 131

Special Tests - Meniscal Injuries Joint line tenderness Full Squat McMurray Tests Thessaly test Bounce-home test 132

McMurray test for Meniscal injury Test Med and Lat meniscus separately 3 concurrent maneuvers: Grind it (Rotate tibia AWAY from it) Crunch it (varus or valgus) Pinch it (flex/extend knee) Positive: Painful “pop” Patient supine Heel of patient’s injured leg held while knee fully flexed Fingers of other hand palpate medical joint line while thumb palpates lateral aspect of joint Valgus stress applied Patient’s knee extended with tibia held externally rotated Pain or palpable click over medial joint line indicates medical meniscal tear 133

Special Tests - Meniscal Injuries Thessaly Test Pt stands on affected leg Knee bent at 20 degrees Examiner holds pt’s hands and rotates pt to both sides Meniscal grind Positive test: pain, painful click.

Anterior Knee Exam Palpation of patellar facets Glide and lift patella medially & laterally Palpate undersurface of patella for tenderness

Patellar Exam Patellar Glide Patellar Apprehension Knee in extension, relaxed Medial & lateral patellar displacement Measured in quadrants Normal: 1-2 quadrants Patellar Apprehension Lateral patellar displacement  patient apprehension or guarding

Anterior Knee Exam Patellar Grind Test Knee 10 deg flexion Glide patella distally, and firmly compress patella against trochlear groove Active quadriceps contraction  pain

Special Tests – Ober’s Test Lateral decubitus with testing side up, testing knee flexed Adduct and fully flex hip  Abduct, externally rotate, & extend hip Slowly release support against gravity from leg, allowing gravity to take leg towards table Positive test: leg remains abducted despite examiner releasing leg

Special Tests Noble’s test Palpate lateral femoral condyle Flex and Extend Knee + Test is pain at site of palpation