SHOULDER PAINA Real Pain in the Neck

Michael Wolk, MDNortheastern Rehabilitation Associates

October 31, 2017

THE SHOULDER JOINT (S)

1. glenohumeral

2. suprahumeral

3. acromioclavicular

4. scapulocostal

5. sternoclavicular

6. costosternal

7. costovertebral

ROTATOR CUFF MUSCLES

Supraspinatusattach to greater tubercle from above

(Abduct)

Infraspinatusattach to greater tubercle posteriorly (Ext. Rot.)

Teres Minorattach to greater tubercle posteriorly (Ext. Rot.)

Subscapularisattach to lesser tubercle anterior (Int. Rot.)

RANGE OF MOTION

MOVEMENT NORMAL RANGE

Forward Flexion 180o

Extension (behind back) 40o

Abduction 180o (with palms up)

Adduction 0o

External rotation* 45o (arm at side, elbow flexed)

Internal rotation* 55o (arm at side, elbow flexed)

FORWARD FLEXION

Arm straight and brought upward through frontal plane, and move as far as patient can go above his head

0° is defined as straight down at patient's side, & 180° is straight up

ABDUCTION

Arm straight

Hand – palm up (arm

supinated)

ROM measured in degrees

as for forward flexion

EXTERNAL AND INTERNAL ROTATION

Arm at side, elbow flexed to 90° and held at waist

Examiner externally or internally rotates arm

APLEY SCRATCH TEST FOR ER/IR*

• Internal rotation and adduction

• Reach for lower scapula• Compare bilaterally –

note level reached

• External rotation and abduction

• Reach for upper scapula• Compare bilaterally –

note level reached

STRENGTH TESTS

Flexion Extension

STRENGTH TESTS*

External rotation

• Infraspinatus

• Teres minor

Internal rotation

• Subscapularis

STRENGTH TESTS

Empty can test*

• Supraspinatus

Lift off test*

• Subscapularis

SPECIAL TESTS

•Drop arm testRotator cuff

•Neer’s sign

•Hawkin’s test

Impingement tests

•Biceps tendonSpeed’s test

•O’Brien’s test

•Crank testLabral tear

•Anterior release

•Relocation testInstability tests

ROTATOR CUFF

Empty Can Test

•Supraspinatus

Lift off test

•Subscapularis integrity

Drop Arm Test

•Rotator cuff tear or supraspinatus dysfunction

DROP ARM TEST Purpose: tears in the rotator cuff,

primarily supraspinatus muscle

Method: patient abducts (or examiner passively abducts) arm and then slowly lowers it May be able to lower arm slowly to 90° (deltoid

function)

Arm will then drop to side if rotator cuff tear

Positive test: patient unable to lower arm further with control If able to hold at 90º, pressure on wrist will

cause arm to fall

IMPINGEMENT – NEER’S SIGN*

Patient seated with arm at side, palm down (pronated)

Examiner standing

Examiner stabilizes scapula and raises the arm (between flexion and abduction)

Positive test = pain

IMPINGEMENT – HAWKIN’S TEST*

Patient standing

Examiner forward flexes shoulder to 90°, then forcibly

internally rotates the arm

Positive test = pain in area of

superior GH joint or AC joint

SPEED’S TEST - BICEPS TENDON

Forward flex shoulder against

resistance while maintaining

elbow in extension and

forearm in supination

Positive test = tender in

bicipital groove (bicipital tendinitis)

LABRAL TEAR (SLAP) O'Brien's Active Compression Test

Patient standing

Arm forward flexed 90°, adducted 15° to 20°with elbow straight

Full internal rotation so thumb pointing down

Examiner applies downward force on arm -patient resists

Patient externally rotates arm so thumb pointing up

Examiner applies downward force on arm -patient resists

Positive test = Pain or painful clicking elicited with thumb down and decreased or eliminated with thumb up

LABRAL TEAR Crank Test

Shoulder elevated to 160° in the

scapular plane

A gentle axial load is applied through

glenohumeral joint with one hand,

while other hand does IR and ER

Positive test = pain, catching, or

clicking in the shoulder

ROTATOR CUFF TEAR MRI ULTRASOUND

SHOULDER PATHOLOGY

1. 90 asymptomatic adults between the ages of 30 and 99

years using ultrasound

2. No statistically significant difference in the dominant arms

or between genders

3. Increased prevalence as age

Continued…

J Bone & Joint Surgery. 1995 March;77B(2):296-298.

SHOULDER PATHOLOGY

4. Partial of Full thickness tears present in:➢ 15% 40-49 year old

➢ 35% 50-59 year old

➢ 55% 60-69 year old

➢ 75% 70-79 year old

➢ 85% 80-99 year old

5. Regard RTC tears as normal part of aging

6. Recommend treatment based on clinical findings,

not on imaging results

J Bone & Joint Surgery. 1995 March;77B(2):296-298.

SHOULDER PATHOLOGY

J Shoulder Elbow Surgery. 1999 Jul-Aug;8(4):296-9.– 411 asymptomatic volunteers – u/s

– Tears RTC 23% overall

Number Age - yrs % RTC tears

Group 1 167 50 - 59 13

Group 2 108 60 - 69 20

Group 3 87 70 - 79 31

Group 4 49 >= 80 51

SHOULDER PATHOLOGY

• Regard RTC tears as normal part of degeneration

• Not a cause of pain or functional impairment

J Shoulder Elbow Surgery. 1999 Jul-Aug;8(4):296-9.

J Bone Joint Surg Br. 2009 Feb;91(2):196-200.

Moosmayer S, Smith HJ, Tariq R, Larmo A.

• Clinical and ultrasonographic examination of shoulders of

420 asymptomatic volunteers aged between 50 and 79

years. MRI was performed in selected cases

• Full-thickness tears of the rotator cuff were detected in 32

subjects (7.6%)

SHOULDER PATHOLOGY

"Prevalence and characteristics of asymptomatic tears of

the rotator cuff: an ultrasonographic and clinical study“

• Prevalence increased with age:

– 50 to 59 years, 2.1%

– 60 to 69 years, 5.7%

– 70 to 79 years, 15%

• Tear localization was limited to the supraspinatus tendon in most

cases (78%)

• Asymptomatic tears of the rotator cuff should be regarded as

part of the normal aging process

SHOULDER PATHOLOGY

DIAGNOSIS

Recommend treatment based on clinical findings and not on imaging results

Consider other diagnosis of shoulder weakness

PHYSICAL EXAM The Power Of “P”

d

NERVES

• All shoulder joint muscles are innervated from the brachial plexus

• Lateral pectoral nerve arising from C5, C6, & C7– Pectoralis major (clavicular head)

• Medial pectoral nerve arising from C8 & T1– Pectoralis major (sternal head)

• Thoracodorsal nerve arising from C6, C7, & C8– Latissimus dorsi

NERVES

• Axillary nerve branching from C5 & C6– Deltoid

– Teres minor

– Sensation to lateral patch of skin over deltoid region of arm

• Upper subscapular nerves arising from C5 & C6– Subscapularis

NERVES• Lower subscapular nerve arising from C5 & C6

– Subscapularis

– Teres major

• Suprascapula nerve originating from C5 & C6

– Supraspinatus

– Infraspinatus

NERVES

• Musculotaneous nerve

branching from C5, C6, & C7

– Coracobrachialis

– Sensation to radial aspect of

forearm

NERVE ROOTBrachial Plexus Injuries

The common mechanism for traction injuries of the brachial plexus is violent distraction of the entire arm from the rest of the body.

These injuries usually result from a motorcycle accident or a high-speed motor vehicle accident.

A fall from a significant height may also result in brachial plexus injury, either traction type or from a direct blow.

SYMPTOMS

Pain, especially of the neck and shoulder.

Pain in a nerve distribution is common with rupture, as opposed to lack of percussion

tenderness with avulsion

Paresthesias and dysesthesias

Weakness or heaviness in the extremity

NERVE ROOTBrachial Plexus Injuries

Cervical

RootClinically Relevant Gross Motor Function

C5 Shoulder abduction, extension, and external rotation; some

elbow flexion

C6 Elbow flexion, forearm pronation and supination, some wrist

extension

C7 Diffuse loss of function in the extremity without complete paralysis of a specific muscle group, elbow extension,

consistently supplies the latissimus dorsi

C8 Finger extensors, finger flexors, wrist flexors, hand intrinsics

T1 Hand intrinsics

NERVE ROOTBrachial Plexus Injuries

Numbness and weakness in the upper extremity may persist.

Symptoms are reproduced by extending, and side bending

the neck.

Function gradually returns from the proximal muscle groups to

the distal muscle groups.

OUTLINE OF THE CAUSES OF PAIN FELT

IN THE UPPER EXTREMITY

OUTLINE OF THE CAUSES

OF PAIN FELT IN THE UPPER

EXTREMITY

OUTLINE OF THE CAUSES

OF PAIN FELT IN THE UPPER

EXTREMITY

OUTLINE OF THE CAUSES

OF PAIN FELT IN THE

UPPER EXTREMITY