Case 25 - 38 yo with shoulder pain

Question 1

Rotator muscle names and function

Answer 1

supraspinatus - abduction
infraspinatus - external rotation
teres minor - external rotation
subscapularis - internal rotation

Question 2

Non- MSK causes of referred shoulder pain

Answer 2

MI, cholecystitis, lung cancer, ruptured ectopic

Question 3

MSK causes of shoulder pain requiring urgent management

Answer 3

Septic arthritis - local redness, swelling, fever
often caused by staph
urgent eval with U/S MRI and aspiration needed
followed by drainage and antibiotics

Question 4

MSK causes that restrict passive ROM

Answer 4

• adhesive capsulitis - contracture of joint capsule

- glenohumeral arthritis - less common site of OA

Question 5

Tinea pedis

Answer 5

due to dermatophyte infection, caused by local friction and warmth, dry red skin with cracks seen on exam, dx is clinical, rx is tinactin (tolnaftate) twice a day

Question 6

Shoulder exam

Answer 6

1. Inspection
   - arm is adducted and internally rotated - posterior dislocation
   - poor posture or rounded shoulders - impingement
2. Palpation - look for areas of tenderness or abnlities
3. ROM - active then passive
   - flex, extend, abduction, adduction, internal and external rotation, scratch test
4. Strength testing
   - flex, abduct
   - rotator cuff: infraspinatous - ext rot, supraspinatous - empty can, subscap - int rot

Question 7

Apley scratch test

Answer 7

Tests abduction and external rotation of shoulder, unable to raise arm = rotator cuff tear, pain indicates impingement or bursitis

Question 8

Empty can test

Answer 8

Have patient abduct arms to 90 degrees, thumbs down and resist downward pressure, tests supraspinatous

Question 9

Neer test

Answer 9

Passive forward flexion, pain at full overhead position indicates subacromial impingement

Question 10

Hawkins-Kennedy test

Answer 10

Shoulder at 90 degrees abduction, and elbows 90 degrees flexion, internally rotate, pain indicates supraspinatous tendon impingement

Question 11

Anterior/Posterior translate

Answer 11

Head sublux indicates major instability

Question 12

Sulcus sign

Answer 12

With arm hanging by patients side, apply downward traction and look for dimple to appear just below acromion process (sulcus), indicates inferior glenohumeral instability

Question 13

Apprehension test

Answer 13

with elbow flexed, abduct shoulder to 90 degrees, then externally rotate passively, positive with apprehensoin for anterior glenohumeral instability

Question 14

Relocation test

Answer 14

Provide posterior pressure to humerus while in anterior apprehension position, positive test is a sense of relief. Anterior glenohumeral instability

Question 15

Speed’s test

Answer 15

Resist elbow flexion with forearm supinated, pain indicates biceps tendonitis

Question 16

Yergason’s test

Answer 16

flex patients elbow to 90 degrees with thumb up, grasp wrist and resist external rotation and supination, anterior shoulder pain is a positive test for biceps tendonitis

Question 17

Clunk test

Answer 17

Palpate the shoulder joint, move shoulder through passive ROM, feel for popping or clicking, positive test shows labral pathology

Question 18

O’Brien test

Answer 18

Patient with shoulder at 90 degrees forward flexion and 30-45 degrees of horizontal adduction and maximal internal rotation, have patient resist downward pressure
Anterior shoulder popping or pain indicates slap lesion, specific superior labral tear
False positive with acromioclavicular pathology or tendinits

Question 19

Differential diagnosis for shoulder pain

Answer 19

1. Rotator cuff tendonitis - positive apley’s scratch test with preserved ROM
2. rotator cuff tear - limited ROM with significant pain, with atrophy
3. Subacromial impingement or bursitis - great pain with overhead ranges of motion, r/o with negative Neer and Hawkins Kennedy
4. Shoulder instability - indicated by positive sulcus sign and anterior/posterior translation tests
5. Labral pathology - secondary to repetitive damage, frank dislocations or sudden trauma
   Less likely: biceps tendonitis (speed and yergesons test), degenerative glenohumeral arthritis, septic arthritis, shoulder dislocation, RA, AC joint separation, adhesive capsulitis (caused by restriction of ROM or risk factors like diabetes)

Question 20

Studies for shoulder pain

Answer 20

• no imaging on initial evaluation
• xray in setting of acute injury if fracture is suspected
• MRI - soft tissue injury

Question 21

Management of rotator cuff tendonitis and shoulder instability

Answer 21

• relative rest
• physical therapy
• NSAIDS as needed
• subacromial injection if needed