1. Sports Medicine Workshop

2. Shoulder Problem Evaluation

3. 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

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

5. Bony Anatomy Anterior

6. Bony Anatomy Anterior and Posterior6

7. Radiographic Anatomy 7

8. Where do things go wrong?? Fractures

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

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

11. 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

12. Bony Anatomy “Static Stabilizers”

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

14. LABRUM

15. What goes wrong? Tears and tendonopathies

16. The Rotator Cuff Muscles “dynamic stabilizers”

17. The Rotator Cuff Muscles
Supraspinatus Infraspinatus Teres minor Supscapularis

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

19. Finally…the subacromial space

20. What can go wrong???
Impingement!!!!!!!

21. Impingement 21

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

23. Shoulder Anatomy 23

24. Don’t forget the
scapular stabilizer muscles

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

26. Clinical Exam History
Pain
Acute
Chronic
Weakness
Deformity

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

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

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

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

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

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

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

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

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

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

37. 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

38. 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

39. 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

40. X RAYS

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

42. 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

43. 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

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

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

46. 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 degrees
Special Tests??? Diagnosis???

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

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

49. 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

50. 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?

51. 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

52. 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

53. 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

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

55. 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

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

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

58. Biceps Tendonopathy
Speed Test
Yergason Test
Direct palpation

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

60. 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.

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

62. Physical Exam Range of Motion
Abduction 0-180o 62

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

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

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

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

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

68. Physical Exam Strength of Subscapularis
Liftoff test Belly press test 68

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

70. 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

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

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

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

74. 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

75. Impingement Signs
Hawkins
Neer 75

76. 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

77. 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

78. 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

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

80. 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

81. Knee Problems

82. Anatomy Review

83. 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

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

85. MCL LCL

86. ACL and PCL

87. Iliotibial band (ITB)

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

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

90. 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

91. 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?

92. 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

93. Special Tests - ACL Injury
Lachman Test 93

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

95. Varus/Valgus stress for LCL and MCL Injury95

96. 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

97. 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

98. Case 1 - Imaging
Normal!

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

100. MCL Sprain
Diagnosis?

101. 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 *^%*

102. 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)

103. 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

104. 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?

105. 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

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

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

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

109. 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

110. 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”

111. 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?

112. 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)

113. Patellofemoral Joint Exam

114. Patellofemoral Joint Exam
Patellar Grind Test

115. Case 3 – Plain Films
Lateral AP

116. Case 3 – Plain Films
Sunrise
Tunnel

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

118. 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)

119. 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

120. 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?

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

122. Ober test Noble test

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

124. 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

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

126. Plica Syndrome?

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

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

129. 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

130. 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

131. 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

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

133. 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

134. 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.

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

136. 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

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

138. 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

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