1. Shoulder Pain: Evidence Based Evaluation & Management Frank J. Domino, M.D. Professor Department Family Medicine & Community Health University of Massachusetts Medical School

2. Disclosure Editor in Chief: 5 Minute Clinical Consult Author and Editor for Up To Date Pri Med Curriculum Committee Author/Editor: www.Epocrates.com, Rxpalm, Inc., www.Familydoctor.org

3. By the end of this session, you will: 1 Understand the normal and abnormal anatomy of the shoulder 2. Learn to use the history and physical examination to narrow the differential diagnosis 3. Develop an evidence based diagnostic and treatment algorithm for use

4. Causes of Shoulder Pain in the Primary Care Setting: Impingement Syndrome>70% Adhesive Capsulitis12% Bicipital Tendonitis4% A/C Joint OA7% Other (Instability, Infection)7% Smith, J Gen Intern Med 1992

5. Stats 101 Sensitivity: % of People with Disease who Test + (TP / (TP + FN)) = a/(a+c) Specificity: % of People without Disease who test Negative (TN/(TN+FN) = b/(b+d) PPV: Percent of + Test Results that are truly positive TP/(TP+FP) = a/(a+b) Disease + - T E + a b S T - c d

6. 1. Impingement Syndrome aka Rotator Cuff Tendonitis 1. Impingement Syndrome aka Rotator Cuff Tendonitis 1. Impingement Syndrome Typically Age > 25 Years Supraspinatous Tendon Insidious Onset 2. Adhesive Capsulitis aka: “Frozen Shoulder” RCT Pain -> ↓ ROM ---> Contracture of joint capsule

7. 3. Biceps Tendonitis 3. Biceps Tendonitis Inflammation of long head of biceps tendon Repetitive lifting, overhead reaching or supination Anterior humeral pain; tenderness bicipital groove Tear of Biceps Tendon: Chronically inflamed tendon Loss of flexion/supination “Popeye Sign”—proximal to antecubital fossa Holtby, Arthroscopy 2004 Long Short

8. Instability (Laxity) Instability (Laxity) 4. INSTABILITY Age < 25 & Trauma Derangement of G/H Joint Capsule  Dysfunction of Shoulder Stabilizers  Pain, subluxation or dislocation. Labral Tear: SLAP: Superior Labrum from Anterior to Posterior; --damage to superior labrum --deep pain; clunking with overhead

9. 7% Other Cervical Radiculopathy (neck pain, pain that radiates to the elbow) Infection (G/N, Lyme) Left Sided: CVD/Anginal Equivalent

10. Introduction to Examination The shoulder is a multiaxial ball-and- socket synovial joint Depends on muscles and ligaments rather than bones for support and stability Easily forgettable terms/anatomy

11. Supination & Pronation

12. Shoulder Flexion & Extension Flexion is moving the arm FORWARD Extension (like reaching for you wallet) extending behind you

13. The Rotator Cuff Muscles UpToDate, 2006 Rotator Cuff Supraspinatus: Abduction Infraspinatus: External rotation Teres Minor: External rotation Subscapularis: Internal rotation

14. Approach to Exam 1. Observe 2. Palpate

15. 3. Range of Motion Active and Passive –Abduction –Internal Rotation –External Rotation Impingement: Pain w/ active Abduction Pain w/ active Abduction (Supraspinatus Tendon) Adhesive Capsulitis: Pain w: both active & passive ROM Pain w: both active & passive ROM

16. 4. Provocative Testing Thanks: J. Herb Stevenson, M.D. Lee Mancini, M.D. Impingement:+ Empty Can, Neer, Hawkin’s –Adhesive Capsulitis Loss of ROM Instability ”Laxity”: Apprehension Testing Biceps Tendonitis: Speed’s

17. Testing/Provocation Impingement: Empty Can Resist Forward Flexion & Internal Rotation Test of Supraspinatus Impingement

18. Impingement: Neer Neer Impingement Test –Passive forward flexion of the forearm resulting in pain

19. Impingement: Hawkins’ Test Hawkins, Am J Sports Med 1980 Woodward, Am Fam Phys 2000

20. Instability Testing Apprehension Apprehension Test –laxity most common source shoulder pain <25 –Passive external rotation that results in discomfort and the feeling “that the shoulder will pop out” –Indicative of glenohumeral laxity

21. Biceps Tendonitis Speed’s Test With elbow extended and hand supinated, palpate bicipital groove while patient attempts to forward flex shoulder 30 degrees against resistance Siegel, Am Fam Phys 1999

22. Spurling’s Maneuver Cervical Radiculopathy Extend Neck Rotate toward Side with Pain Axial Load

23. Demonstration Observe, Palpate, ROM, Provocation

24. Plain X-Rays Impingement: AP, Int/Ext Rotation Laxity: “Y” view Clavicle Acromion Humerus Glenoid Fossa

25. Basic Approach to Treatment 1. Eliminate Cause 2. Pain Control NSAIDs/Acetaminophen Corticosteroid Injection 3. Stretching 4. Rehabilitation Don’t Do it

26. Case 1. Doc, why does my shoulder hurt? 55 year old carpenter presents with 3 month history of right shoulder pain. Gradual onset without h/o trauma. Pain at night when he lies on affected side Pain with overhead activity Pain w/AROM, + Empty Can, Hawkins

27. Rotator Cuff Tendonitis: Treatment Reduce offending activities Physical Therapy NSAIDs or subacromial steroid injection –Each is better than placebo –Little long term difference –No benefit in combination treatment Obtain X-rays: AP w/Internal & External Rotation

28. Materials for Glenohumeral Joint injection 5-10 cc Syringe 22 or 25 g 1 ½ needle 3-5 ml of 1% or 2% Lidocaine w/o Epi. 1-2 ml of –1 to 2 mL Triamcinolone (Kenalog) 40 mg/mL or –betamethasone sodium phosphate and acetate (Celestone Soluspan)

29. Subacromial Bursa Injection

30. http://familydoctor.org/268.xmlhttp://familydoctor.org/268.xml; http://www.orthoassociates.com/shoulder1.htmhttp://www.orthoassociates.com/shoulder1.htm

31. Demonstration Physical Therapy/Rehab

32. Adhesive Capsulitis: Treatment Pain w/ AROM & PROM: Reduce offending activities Reduce offending activities Physical Therapy NSAIDs or subacromial steroid injection –Most resolve with conservative treatment: Stretching/Exercises x 18 months; –Orthopedic Referral

33. Case 2: “What happened to my arm?” Just started working out again Lifting weights; curls with free weights Went to driving range, felt a sharp pain and pop in arm. Now “lump” in middle of forearm.

34. Biceps Tendonitis Eliminate Offending Activity NSAIDs/Steroid Injection (Subacromial after age 50 – tendon rupture) Ice/Physical Therapy/Exercises Biceps Tendon Rupture; ? surgical repair. Orthopedic referral.

35. 5 to 10 pounds; Arm kept vertical and close to the body Swing arm back and forth or in a small diameter circle (no greater than one foot in any direction). 20 biceps curls 1-2 x/day Increase weight every 5 days as tolerated Biceps Tendonitis Exercise

36. Case 3: Doc, my shoulder and arm hurts 45 year old transcriptionist Now needs reading glasses to see computer screen No pain with ROM of shoulder + Spurling’s

37. Spurling’s Maneuver Cervical Radiculopathy Extend Neck Rotate toward Side with Pain Axial Load

38. Cervical Radiculopathy Treatment Change Work Environment X-RaysNSAID’s Physical Therapy ? Meditation

39. 48 Year Old Painter falls off ladder “My Shoulder is killing me” “Feels like it is going to pop out” No pain at rest DX: Instability: + Apprehension

40. Instability/Laxity NSAIDs Aggressive strengthening and neuro- muscular rehab Surgery if fails conservative care

41. Shoulder Summary HistoryPhysicalDiagnosis <25, new Activity, Trauma, Overhead Sports, Acute or Chronic + Apprehension Shoulder Instability 25-40, gradual onset, pain overhead activity + Empty Can + Neer Stage I Impingement (Supraspinatous Tendonopathy) >40, gradual onset, pain overhead activity, night pain + Empty Can + Neer + Hawkins Stage II/III Impingement (partial/complete rotator cuff tear) Gradual onset painful stiff shoulder. Often no h/o trauma + Decrease active and passive ROM +Neer Adhesive Capsulitis Repetitive motion, new lifting regimen, OA + Speed + Yergason Biceps Tendonitis (if Popeye, Biceps Tendon Rupture)

42. Thank you Frank.domino@umassmemorial.org