Shoulder Conditions Lecture (Week 2--Aragaki) Flashcards by Jill Klausner

2 things shoulder pain can be due to

1) Intrinsic disorders: 85%, inflammation of the joints, bursae, tendons, surrounding ligaments or periarticular structures
2) Referred pain: 15%, cervical, cardiac, biliary

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Layers of shoulder

Joints (GH, AC)

Capsule/ligaments

Rotator cuff and biceps tendons

Subacromial/subdeltoid bursa

Deltoid muscle

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Nerves that supply muscles

Axillary nerve –> deltoid, teres minor

Radial nerve –> triceps

Long thorac nerve –> serratus anterior

Spinal accessory nerve (CN XI) –> trapezius (and SCM)

Suprascapular nerve –> supraspinatus/infraspinatus

Dorsal scapular nerve –> rhomboids, levator scapulae

Musculocutaneous –> biceps, brachialis, coracobrachialis

Lower subscapular nerve –> teres major, subscapularis

Upper subscapular nerve –> subscapularis

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Physical exam for shoulder injury

Inspect

Palpate

ROM

Neurovascular screen (include C-spine)

Special testing

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Inspection

Symmetry (position, atrophy)

Scapular winging (prominent medial border w/resisted adduction/flexion, indicates serratus anterior, trapezius, rhomboid weakness; have pt push against wall)

Dislocation/subluxation (“Sulcus sign”)

Edema, erythema, lesions/scars

Functional impairment? (dressing = clue)

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Palpation

Sternoclavicular, acromioclavicular, glenohumeral joints (crepitus, tender)

Coracoid process

Bicipital groove

Greater tuberosity

Supraspinatus, infraspinatus

Scapular spine and borders

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Range of motion (ROM)

Flexion: 160 - 180 degrees

Abduction: 170 - 180 degrees

External rotation: 80 - 90 degrees (or Apley’s Scratch)

Internal rotation: 60 - 100 degrees (or Apley’s Scratch)

Extension: 50 - 60 degrees

Horizontal adduction/cross-flexion: 130 degrees

Scapular protraction/retraction

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How do you test active flexion and abduction?

Touchdown sign

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Apley’s Scratch Test

1) Abduction and external rotation (hand over shoulder)
2) Adduction and internal rotation (hand under armpit)

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Spurling’s maneuver

Part of neurologic screen

Cervical root compression reproduces radicular symptoms

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Special tests

Provocative maneuvers

Clues for pathology

Focus diagnostic work-up

Guide treatment options

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Sulcus test

Test for glenohumeral instability

Downward traction applied to humerus and watch for depression lateral or inferior to acromion

Positive test is space/depression: if lax capsular ligaments or weak rotator cuff and deltoid muscles; multidirectional instability; often asymptomatic; common in young

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Hawkin’s sign

Sign of rotator cuff impingement

This test pulls greater tubercle to acromion and squeezes/impinges on subacromial bursa/rotator cuff tendons

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Bigliani–Acromion shapes

Type I: straight

Type II: slightly curved

Type III: very curved, smaller space for humeral head

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Empty Can Test

Tests supraspinatus

Positive if pain/weakness when you push down

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Drop Arm Test

Have patient slowly lower arm

Positive if can’t control drop down and do it too quickly

Indicates complete rotator cuff tear

Lift-Off Test

Tests subscapularis

Arm behind back and push outward against my hand

Biceps tendon rupture

Proximal long head biceps tendon rupture is common

Causes humerus head to come all the way to top of glenoid?? Bicep itself sticking out??

When to order x-rays

Suspect arthritis, dislocation, fracture

Anticipating injection or specialist referral

Fails PRICE treatment

When to order MRI

Suspect rotator cuff tear, tumor, infection

Anticipate surgery

Arthrogram if suspect labral tear

Who to refer to

PM&R: subacute/chronic pain, bursitis, arthritis, cervical radiculopathy, injections, therapy requests, impaired function

Orthopedic surgery: acute fractures or traumatic dislocations, neurovascular compromise, failed conservative treatment

Rheumatology: if systemic disease

Glenohumeral osteoarthritis case

Gradual onset shoulder pain over many years

Prior trauma during army service

Limited ROM with feeling of grinding in joint with overhead reaching

Body tries to compensate for damage by laying down more bone and increasing surface area of joint but doesn’t work!

Multidirectional instability of shoulder case

Shoulder “achy” pain for a few months while on vacation (lifting heavy objects); no acute trauma, swelling, fever/chills, neck pain, distal weakness/numbness

X-rays normal

Positive Sulcus Sign

TUBS vs. AMBRI for instability

TUBS: traumatic, unilateral, Bankart (Hill-Sachs lesions), surgery

AMBRI: atraumatic, multidirectional instability, bilateral, rehabilitation, inferior capsular surgery

Bankart and Hill-Sachs lesions

**Bankart**: chip of **inferior anterior glenoid** (sounds like "bang hard" and that's how it happens--dislocation and damage then reduced back) **Hill-Sachs**: **posterior lateral humeral head** chipped

What nerve can dislocation cause injury to?

**Axillary** nerve damaged by dislocation

Shoulder impingement case

**Sharp anterolateral** shoulder pain develop over a few weeks **Worse pain by abduction or overhead activity**, relieved by ibuprofen and icepack (think inflammation!) No weakness, numbness, dysfunction, neck pain, distal arm pain, no muscle atrophy Mild AC joint tenderness, positive **Crepitus** with shoulder ROM, **positive Hawkins test, positive Empty Can test, negative Drop Arm test** Due to **osteophytes**, **joint** **laxity**, **muscle** **imbalance**, **acromion** **shape** (Type III hooked so not enough space for bursa to live!), **space narrowing** **Abduction irritates subacromial bursa and supraspinatus (rotator cuff) tendon** Can lead to rotator cuff TEAR Spectrum: AC osteoarthritis, bursitis, tendonitis, etc

Muscles involved in abduction of shoulder

**Supraspinatus** pulls in during early abduction to stabilize humeral head into glenoid **Deltoid** muscle pulls up to abduct

Bicipital tendonitis case

**Pain in anterior shoulder** for 2 weeks, worse lifting cargo, steering, raising arm, mild giveaway weakness with forward flexion, reproduceable **pain with palpation of bicipital groove** No neck or distal arm pain Long head bicipital tendon runs through bicipital groove Repetitive lifting and reaching leads to **inflamation, tearing, degeneration**

Rotator cuff tear case

**Difficulty abducting** arm and sharp shoulder pain since fall 1 month ago, muscle weakness, **supraspinatus atrophy**, **reduced active ROM (full passive)**, tender superolaterally, **positive drop arm test, positive empty can sign** **Diabetics** **tear tendons** more often because of **lack of blood supply** **Supraspinatus** is most common rotator cuff tear

Adhesive capsulitis (frozen shoulder) case

Shoulder feels locked, **gradual onset** after wearing a sling for several weeks Severely **reduced flexion, abduction, external rotation (passive and active)** X-ray shows mild **glenohumeral OA** Stiff glenohumeral joint capsule Often associated with rotator cuff tendonitis

Cervical radiculopathy case

Chronic **neck pain referred to right shoulder and thumb** Worse by painting ceilings, lifting heavy equipment **Atrophy** of deltoid, supraspinatus, infraspinatus, biceps, **positive Spurling's test**, reduced biceps reflex, paresthesias in lateral arm/hand **EMG** showed active **degeneration in C5-6 myotome**