Shoulder Pain Evidence Based Evaluation Management BY ABDULLAH

Shoulder Pain: Evidence Based Evaluation & Management BY ABDULLAH RADWAN

Causes of Shoulder Pain in the Primary Care Setting: Impingement Syndrome >70% Adhesive Capsulitis 12% Bicipital Tendonitis 4% A/C Joint OA 7% Other (Instability, Infection) 7% Smith, J Gen Intern Med 1992

Stats 101 Sensitivity: % of People with Disease + - 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) T E S T + a b - d c

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

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 Long Short Holtby, Arthroscopy 2004

4. INSTABILITY Instability (Laxity) 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

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

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

Supination & Pronation

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

The Rotator Cuff Muscles Rotator Cuff Supraspinatus: Infraspinatus: Teres Minor: Subscapularis: Abduction External rotation Internal rotation Up. To. Date, 2006

Approach to Exam 1. Observe 2. Palpate

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

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

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

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

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

Instability Testing 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

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

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

Demonstration Observe, Palpate, ROM, Provocation

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

Basic Approach to Treatment 1. Eliminate Cause 2. Pain Control NSAIDs/Acetaminophen Corticosteroid Injection 3. Stretching 4. Rehabilitation

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

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

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 m. L Triamcinolone (Kenalog) 40 mg/m. L or – betamethasone sodium phosphate and acetate (Celestone Soluspan)

http: //familydoctor. org/268. xml; http: //www. orthoassociates. com/shoulder 1. htm

Demonstration Physical Therapy/Rehab

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

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.

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.

Biceps Tendonitis Exercise 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

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

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

Cervical Radiculopathy Treatment Change Work Environment X-Rays NSAID’s Physical Therapy ? Meditation

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

Instability/Laxity NSAIDs Aggressive strengthening and neuromuscular rehab Surgery if fails conservative care

Shoulder Summary History Physical Diagnosis <25, new Activity, Trauma, + Apprehension Overhead Sports, Acute or Chronic 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)

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