Approach to overuse related shoulder injuries Dausen Harker

Approach to overuse related shoulder injuries Dausen Harker MD Family Medicine

Objectives Ø Epidemiology Review Ø Shoulder anatomy review Ø Common causes of shoulder pain Ø General approach to exam Ø Special tests

Epidemiology Ø Ø 2 nd most common orthopedic problem in primary care sports medicine (second to knee injury) Young athletes with overuse injuries is increasing Overuse injuries common in military population Most common overuse injuries l l l Rotator Cuff Pathology Impingement Glenohumeral Instability/Labrum Tears Biceps Tendonitis AC Joint Pathology

Anatomical structures Please review images of shoulder anatomy prior to or while viewing slides Ø Major anatomical components involved in shoulder pain Ø l l l Rotator cuff muscles and tendons AC joint Glenoid and labrum Biceps tendon Skeletal components of shoulder Shoulder related bursa

Evaluation Ø Every shoulder exam should include: l l Appearance Range of Motion • Active vs Passive l l l Palpation Neurological testing Special tests

Rotator Cuff Injury Ø One of the most common causes of shoulder pain Ø Involves “SITS minor” muscles Ø Includes tendonitis and tears

Rotator Cuff Injury l Tendonitis: • Most common condition among pt’s with shoulder complaints—especially >30 y/o • Supraspinatous or infraspinatous • Repetitive over head activity most common cause • Pain l l Worse with reaching and over head activity May awaken pt at night • Associated with increased risk of tear

Rotator Cuff Injury l Tears: • • <30 y/o: <1% of shoulder injury are complete tears >45 y/o: ~35% of shoulder injury are tears Supraspinatous and Infraspinatous Common mechanisms of injury l l l Fall on an outstretched arm direct blow to shoulder rapid acceleration • Associated with chronic impingement, tendon degeneration or trauma • Clinical signs: Weakness, loss of shoulder function, and symptoms of tendonitis

Special Tests Ø Drop Arm Test Ø Supraspinatous Strength Test Ø Lift Off Test Ø 900 elbow flexion with external arm rotation and resistance

Drop Arm Test Ø Slowly lower fully ABducted arm Ø Active pressure may be applied at 900 ABduction Ø Positive test indicated by inability to keep arm ABducted at 900 Ø Indicates rotator cuff tear

Supraspinatous Strength Test Shoulder ABducted to 900 with 300 of forward flexion and arm pronation (thumb down) Ø Isolates supraspinatous Ø Positive test if asymmetric weakness or inability to maintain arm position Ø

Lift Off Test Dorsum of hand on back and push outward against resistance (isolates internal rotation) Ø Isolates subscapularis Ø Positive test indicated by asymmetric inability to lift hand from back Ø

External Rotation Ø Elbow flexed to 900 with active resistance to external rotation Ø Isolates infraspinatous and teres minor Ø Positive test indicated by asymmetric weakness

Impingement Ø Describes compression of rotator cuff tendons and subacromial bursa between bony structures Ø Mechanisms of injury: Rounded shoulders, poor muscle development, repetitive over head motion Ø Presentation nearly identical to rotator cuff injury

Special Tests Ø Hawkins Test Ø Neers Test

Special Tests Ø Hawkins Test l l 900 forward flexion, 45 -900 elbow flexion and passive internal rotation Drives greater tuberosity into coracoacromial arch Positive test indicated by pain More sensitive than Neers test for impingement

Special Tests Ø Neer Test l l Arm internally rotated while fully extended and forward flexion to 1800 Positive test indicated by pain with motion

Glenohumeral Instability/Labral tears Ø GHI l l Characteristic group: Women, poor muscular development, large Rotator cuff tears, athletes < 40 (especially swimmers, throwers) Clinical presentation: Vague symptoms, may see excessive ROM TUBS: Traumatic, Unidirectional instability, Bankart lesion (glenoid labrum tear), frequently require Surgery AMBRI: Atraumatic, Multidirectional shoulder laxity Bilaterally, usually responds to Rehabilitation, when sugery is necessary it involves tightening of Inferior capsule

Glenohumeral Instability/Labral Tears Ø LT l l l Caused by similar mechanism as rotator cuff injuries Greatest risk with repetitive overhead activities Clinical presentation: Deep shoulder pain, catching sensation, instability

Special Tests Ø GHI l l l Sulcus Sign Apprehension Test Anterior/Posterior Drawer Test Ø LT l Crank Test

Special Tests Ø Sulcus Sign l l Arm relaxed, neutral position with downward traction at wrist Positive indicated by development of sulcus Important to assess symmetry of test Sulcus sign recorded as cm of sulcus

Special Tests Ø Apprehension Test l l l Supine position, 900 ABduction, neutral rotation Apply slight leverage at proximal humerus while externally rotating Positive test indicated by pt apprehension that shoulder will give way

Special Tests Ø Anterior/Posterior Drawer Test l l l Best to have patient in supine position Humeral head slid anteriorly and posteriorly in glenoid while scapula is stabilized Positive test with painful click/clunk, apprehension or increased movement compared to other shoulder

Special Tests Ø Crank Test l l Pt supine or seated with arm elevated to 1600 Force applied along axis with internal and external rotation Drives humeral head against labrum Positive test if pain is reproduced or catching +/- click is noted

Biceps Tendonitis Ø Inflammation of long head of biceps as it passes through bicipital groove Ø Assoc with repetitive lifting or overhead activity that leads to inflammation Ø Can lead to spontaneous rupture (10%) Ø Pain aggravated by lifting, carrying bags or overhead reaching; Ø pt often localizes pain directly to bicipital groove

Special Tests Ø Speed Test Ø Yergason Test

Special Tests Ø Speed Test l l l Shoulder forward flexed to 600, arm flexed to 300 and supinated Downward force applied to distal forearm Positive test indicated by pain or weakness

Special Tests Ø Yergason Test l l l Arm neutral, elbow flexed to 900 Pt attempts to supinate and flex elbow against resistance Positive test indicated pain or a “painful pop”

AC Joint Pathology Ø Injury type: Sprain, partial or complete tear Ø Associated with overuse (reaching across chest or overhead) or trauma (especially falls on tip of shoulder) Ø Associated with anterior shoulder pain Ø Pt usually localize pain directly to AC joint (i. e. pt will point to AC joint)

Special Tests Ø Cross Chest ADduction Test (Cross Arm Test) l l Forward flexed to 900 and hand to opposite shoulder Examiner hyper. ADducts shoulder Positive test indicated by pain at AC joint May be false + with impingement

Summary Shoulder injury common in primary care sports medicine Ø Difficult exam due to complexity of shoulder Ø l Ø Made easier by following step wise approach The Big 5’s l l Overuse Injuries: Rotator cuff pathology, Impingement, GHI/LT, Biceps tendonitis, AC joint pathology Physical Exam: Appearance, ROM, Palpation, Neurologic, Special Tests

Summary Special Tests Ø Rotator Cuff l l Ø Drop Arm Test Supraspinatous Strength Test Lift Off Test External Rotation Impingement l l Hawkins Test Neer’s Test Ø GHI l l l Ø LT l Ø Crank Test Biceps Tendonitis l l Ø Sulcus Sign Apprehension Test Anterior/Posterior Drawer Test Speed Test Yergason Test AC Joint l Cross Arm Test

Resources Anderson, Bruce. “Acromioclavicular Injury. ” Up. To. Date®. www. uptodate. com. © 2006. Howard, Anderson, Bruce. “Biceps Tendonitis and Rupture. ” Up. To. Date®. www. uptodate. com. © 2006. Anderson, Bruce. “Multidirectional Instability of the Shoulder. ” Up. To. Date®. www. uptodate. com. © 2006. Anderson, Bruce. “Rotator Cuff Tendonitis. ” Up. To. Date®. www. uptodate. com. © 2006 Anderson, Bruce and Michael Roberts. “Shoulder Impingement Syndrome. ” Up. To. Date®. www. uptodate. com. © 2006. Anderson, Bruce and Ronald Anderson. “Evaluation of the Patient with Shoulder Complaints. ” Up. To. Date®. www. uptodate. com. © 2006. Anderson, Bruce, et. al. “Rotator Cuff Tear. ” Up. To. Date®. www. uptodate. com. © 2006. Cassas, Kyle J. and Amelia Cassettari-Wayhs. “Childhood and Adolescent Sports-Related Overuse Injuries. ” American Family Physician. March 2006. Vol 73, No. 6. pp 1014 -1022. Thomas M. , Francis G. O’Conner. “The Injured Shoulder. Primary Care Assessment. ” Archives of Family Medicine July/August 1997, Vol. 6. pp 376 -384