41 th shoulder pain ireland

8/10/2019 41 TH Shoulder Pain Ireland

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Shoulder Pain: How to Make the

Diagnosis

Mary Lloyd Ireland, M

40th Lexington Family Medicine Review,

5-14-09

Shoulder Pain:How to Make the Diagnosis

By

Mary Lloyd Ireland, M.D.

40th Annual Family Medicine Review

May 14th, 2009

Lexington, Kentucky

Objectives

Develop concepts of cor relation anatomy,injury mechanism, PE and imaging to make

correct diagnosis

Show case-based examples of shoulderdisorders

Understand making the corr ect primarydiagnosis will improve patient outcomesand management of shoulder pain patients

Differential Diagnosis

Think Joint Mechanism

Joints (3) Glenohumeral One Event

SC

AC

Spaces (2) Subacromial Repetitive

Scapulothoracic

Referred Neck Repetitive - No event

Scapula

Lung

Ribs

FUNCTIONAL ANATOMY: Joints

Primary Diagnosis

Involved Structure

Age Group

Younger Instability (40 yrs)

Diagnosis

Inflammation

Tear

Sprain

Instability

Elevation/Depression of the Scapula


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Diagnosis



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Upward/Downward Rotation of theScapula

Musculature: Protractors and Retractorsof the Scapula

Abduct ion/Adduction of the Shoulder Flexion/Extension of the Shoulder

Scapular Winging

Scapular winging indicates weakness of the serratus anteriormuscle and is evident when the patient does a push-up o rpushes agains the wall.

Remember to examine scapular posi tion

Have patient reproduce symptoms

If scapula is unstable, shoulder problems

will result An unstable scapula is similar to f ir ing a

cannon out of a canoe


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Diagnosis



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Scapular Dysfunction

If exists, shoulder function is likefir ing a cannon out of a canoe!

Remember the scapula! Tightness anterior Forward head Overdeveloped pectoralis

Scapular movements

Touch medial borders Elbows to back pocket Shrugs Clockwise/counterclockwise

Is the pain referred?

Neck

Scapula Lung

Ribs

Tumor

Muscle Testing Abnormal Shoulder Differential Diagnosis

ROTATOR CUFF

SupraspinatusInfraspinatusTeres minor

The SIT

Muscles

Palpate and ManualMuscle Test

Arm in varyingdegrees ofabduction androtation

Internal and External Rotators


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Diagnosis



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Rotator Cuff Testing

Empty can position

Weakness in external rotation

Be Specific:

The diagnosis should define the structure that isinjured and the condition

Diagnosis Rotator Cuff

Inflammation

Tear Partial vs. Complete

Art icu lar s ide v s. Bursal sid e

Complete Tear

Suspension bridge Free side of tear (cable)

At tachments of tearor (supports at each end)

MRI

Full Thicknesssupraspinatus tear

Window shade to sill(cuff) (great er t uberosi ty )Use this comparison for patient education

SIZEof

TEAR

There are many clini cal tests named aftersomeone. Instead of description by name:

Think of the motion of jo int and forces you apply:

Is it labral?

(Axial loading like McMurrays)

Is it the rotator cuff? (compressing or impinging)

Is it instability?

(distraction of joint capsule subluxing the humeral head)


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Diagnosis



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Named Tests vs. Movement Description

Many tests for biceps tendon dis orders

Think about patient hist ory, anatomy andmove the arm, load the joint to reproducepatients symptoms

Do the most painful part of the exam LAST

Tests for proximal biceps tendondysfunction long head

Ludingtons Yergasons Abbott and Saunders DeAnquins Matsens Speeds

Include these for complete exam

Rarely isolated biceps problem

Think associated tear subscap/labrum/RC

Abbott and Saunders test

from - Burkhead WZ, Arcand MA, Zeman C, Habermeyer P, Walch G,The Biceps Tendon,

In: The Shoulder, Rockwood CA, Matsen FA (Saunders, Philadelphia, 1998), 1036.

DeAnquins test

Matsens test

Speeds test

The biceps resistance test is performed with the

patient flexing the shoulder against resistance, with

the elbow extended and the for earm supinated.

Pain referred to the biceps tendon area constitutes a

positive result.



Yergasons testWith the arm fl exed, the

patient is asked to

forcefully supinate

against resistance from

the examiners hand.

Pain referred to theanterior aspect of the

shoulder in the region of

the bicipital groove

constitutes a positive

result.

from - Burkhead WZ, Arcand MA, Zeman C, Habermeyer P, Walch G,The Biceps Tendon, In: The

Shoulder, Rockwood CA, Matsen FA (Saunders, Philadelphia, 1998), 1036.

Ludingtons testThe patient is asked to

put his or her hands

behind the head and

flex the biceps. The

examiners finger can

be in the bicipital

groove at the time of

the test.

Subtle differences in

the contour of the

biceps are best noted

with this maneuver. In

this illustration the

patient has a ruptured

biceps at the left

shoulder.




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Diagnosis



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Labrum & Capsule

Labral Function

Stability

Bumper

Biceps attachment

Shock absorber

Glenoid : Labrum

Tee : Golf BallSeal : Ball

Contact Lens : Eyebal l

Guanche CA and Jones DC, Clinical Testing for Tears of the GlenoidLabrum, in Arthroscopy: The Journal of Arthroscopic and Related

Surger y, vol 19, no 5 (May-June 2003), 517-523.

Prospective study 61 shoulders, 62 patients Tests Used

Jobe relocation test OBrien test Ant erio r apprehen sion tes t Bicipital groove tenderness Crank test Speed test Yergason test

Only OBrien and Jobe relocation test werestatistically cor related with presence of labrum tear,including SLAP Other five not found useful for labral tears None of the tests or combinations statistically valid for

SLAP lesion only

OBriens Test

Shoulder Palpation Crank Tests Shoulder Stability


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Diagnosis



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18 YO Freshman Football Athlete

18 YO Freshman RB for EKU w/ dominantright shoulder injury

Opening game, 8/31/2000 No previous H/O injury

Dead Arm Complaints

Mechanism of Injury thought to be a lateralblow to the shoulder while being tackled

Clinic Radiographs

Confirm humeral head radiolucency consistentwith Hill -Sachs lesion

MRI

Hill-Sachs lesion approx. 20% Anteroinferio r Labral Detachment Anterosuper ior Labral Detachment

24967JG_MRI_02.jpg; 24967JG_MRI_08.jpg

Posterior Instability Test Prone Posterior Instability Test


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Diagnosis



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Vicious Cycle: Laxity to Instability Multi-Directional Instability

Voluntary posterior direction - symptomatic

S/P Open anterior shoulder reconstru ctionMulti-Directional Instability, bilateral shoulders.

More symptomatic on operated right si de.

18 YO Right-Hand-Dominant DiscusThrower

Threw the di scus

Felt pop, pain,inability to move her arm Went to the emergency room

Posterior Dislocation X-rays showed humeral head posteriorly

dislocated on axillary view

This direction of dislocation still is missed inemergency roo ms

ER viewAxil lary

PosteriorlyDislocated

Posteriorly dislocated

Stryker view


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Diagnosis



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Shoulder Pain Algorithm: AAOS Clinical Guideline on ShoulderPain, in Orthopaedic Knowledge Update: Shoulder and Elbow 2(AAOS, 2002), p. 448-455.

[more]

[more]

Imaging

Plain films

Make the diagnosis by histo ry and physicaland plain films

Institute treatment

Re-examine

Then special Imaging Studies


Initial Imaging True AP in 0 external rotation

Lateral i n scapular p lane

Axial ly view When imaging studies are indicated during the i nitial

evaluation and treatment of a patient with sho ulder pain,appropriate plain x-rays should be obtained. Moresophisticated imaging studies (such as shoulder MRI,ultrasound, or arthrography) are not indicated.

IMAGING

AP Internal View Stryker Notch View


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Diagnosis



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Outlet View Outlet Upright View

Axil lary Lateral View Modified Axillary View inHumeral External Rotation

Subscapularis Muscle Subscapularis Tears

Lift Off (75% tear 5-30) Hand or back Lspine

Maximum LR

Napoleon (50% tear) Press belly, flexes wrist Bear Hug (Upper tear, most sensitive)

Hand on opposite shoulder

Elbow forward

Examiner pulls h and off shoulder


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Diagnosis



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12 YO Male Soccer Ath lete

Pain in left shoulder, 1 to 2 years

No injury

PE: normal stability

Mildly tender firm axillary mass

22YO LHD Male

Multiple osteochondroma

Girlfriend noted scapular asymmetry

True space occupying mass

Causing winging and snapping

Ax ial skeleton os teochondroma

Underwent resection mass

Diagnosis: osteochondroma, no malignantchange

Make

the

Primary

Diagnosis!


[more]

[more]

Imaging

Special Studies MRI scan

With or without gadolinium

CT scan

Ultrasound


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Diagnosis



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Ultrasonography

In office

Accurate

Low cost

Churchi ll RS, Fehringer EV, Dubinsky TJ,Matsen FA, Rotator cuff ultrasonography:diagnostic capabilities, J Am Acad Orthop Surg2004 Jan-Feb;12(1):6-11.

Ultrasound showing symptomatic progressionof previously asymptomatic rot ator cuff tear.

1991 1997

Yamaguchi K et. al., Natural history of asymp tomatic rotatorcuff tears: A longitudinal analysis of asymptomatic tearsdetected sonographically,J Shoulder Elbow Surg 2001;10:199-203.


Differential Diagnosis Categories

Rotator Cuff DisordersFrozen shoulderGH Instability

Arthrosis

AC Joint Disorder

Fibromyalgia


Needs specialized care

Refer to specialist

Definition of muscu loskeletal specialist:licensed physician who focuses onmanagement of muscu loskeletal con ditions

CONCLUSIONS

Dont order a test if you cant read it.

Communicate with the radiologist at your imagingcenter.

A bad scan is worse than no scan.

In KY, we have many MRI scanners. Shoulderscans are notoriously bad ifordered by someone who is unable to examine ashoulder.

CONCLUSIONS Sometimes an MRI report just doesnt help. . .


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Diagnosis



Conclusions

By: Knowing Anatomy

Understanding Biomechanics Sport of injury

Mechanism

Physical Exam makes senseand Specific Diagnosis is made Nolan Ryan didnt

start pitching untilhe was in highschool

Little League pitchers doNOT becomeBig League pitchers

Try to put the whole picture together

Treat the entire patient!

The End . . . Thank You!

QUIT

41 th shoulder pain ireland

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