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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Shoulder Pain: How to Make the
Diagnosis
Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
5-14-09
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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Shoulder Pain: How to Make the
Diagnosis
Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
5-14-09
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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Shoulder Pain: How to Make the
Diagnosis
Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
5-14-09
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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Shoulder Pain: How to Make the
Diagnosis
Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
5-14-09
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.
from - Burkhead WZ, Arcand MA, Zeman C, Habermeyer P, Walch G,The Biceps Tendon,
In: The Shoulder, Rockwood CA, Matsen FA (Saunders, Philadelphia, 1998), 1035.
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.
from - Burkhead WZ, Arcand MA, Zeman C, Habermeyer P, Walch G,The Biceps Tendon,
In: The Shoulder, Rockwood CA, Matsen FA (Saunders, Philadelphia, 1998), 1037.
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Shoulder Pain: How to Make the
Diagnosis
Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
5-14-09
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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Shoulder Pain: How to Make the
Diagnosis
Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
5-14-09
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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Shoulder Pain: How to Make the
Diagnosis
Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
5-14-09
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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Shoulder Pain: How to Make the
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Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
5-14-09
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
Shoulder Pain Algorithm: AAOS Clinical Guideline on ShoulderPain, in Orthopaedic Knowledge Update: Shoulder and Elbow 2(AAOS, 2002), p. 448-455.
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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Shoulder Pain: How to Make the
Diagnosis
Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
5-14-09
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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Shoulder Pain: How to Make the
Diagnosis
Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
5-14-09
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!
Shoulder Pain Algorithm: AAOS Clinical Guideline on ShoulderPain, in Orthopaedic Knowledge Update: Shoulder and Elbow 2(AAOS, 2002), p. 448-455.
[more]
[more]
Imaging
Special Studies MRI scan
With or without gadolinium
CT scan
Ultrasound
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Shoulder Pain: How to Make the
Diagnosis
Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
5-14-09
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.
Shoulder Pain Algorithm: AAOS Clinical Guideline on ShoulderPain, in Orthopaedic Knowledge Update: Shoulder and Elbow 2(AAOS, 2002), p. 448-455.
Differential Diagnosis Categories
Rotator Cuff DisordersFrozen shoulderGH Instability
Arthrosis
AC Joint Disorder
Fibromyalgia
Shoulder Pain Algorithm: AAOS Clinical Guideline on ShoulderPain, in Orthopaedic Knowledge Update: Shoulder and Elbow 2(AAOS, 2002), p. 448-455.
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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Shoulder Pain: How to Make the
Diagnosis
Mary Lloyd Ireland, M
40th Lexington Family Medicine Review,
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
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