Shoulder assessment_HANDOUTS.pptx

3/3/14 Shoulder Assessment Tony Kochhar Introduc9on -­‐ TK Overview   Anatomy of the Shoulder   General Examina9on of the shoulder   Tips and tricks – The Key is in the History   Shoulder condi9ons – Impingement and RC tears -­‐ Frozen Shoulder -­‐Throwing arm injuries -­‐ AC Joint Osteolysis – weightliNer’s shoulder -­‐ Calcific Tendoni9s -­‐ ?The Unstable Shoulder   When to Operate?   Shoulder Doctor   Ques9ons 1 3/3/14 Shoulder injuries second only to back pain Top 4 musculoskeletal complaints presented to GPs (%) Shoulder pain 21 Lower back pain 27 Neck pain 20 Knee pain 16 0 5 10 15 20 25 30 Source: Picavet, H, Schouten J. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC study. Pain 2003;102(1): 167-­‐178. Anatomy: bones Anatomy: ligaments 2 3/3/14 Shoulder examina9on Anatomy: muscles (not all of them) Shoulder examina9on 3 3/3/14 General shoulder examina9on  
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was9ng swelling asymmetry prominent ACJ scars bony landmarks SCJ  Clavicle  ACJ SA Bursa/cuff inser9on scapula temperature abduc9on forward flexion external rota9on internal rota9on Rotator cuff tears   Group of tendons that connect the muscles that rotate the shoulder to the humerus   Wear and tear injury   Poor blood supply   Insidious onset   Trauma9c cause: acute onset   Overuse aNer inac9vity   Type I and Type II acromion   Associated with impingement Impingement   Usually enough room for tendons to slide under acromion   Arm raised  small amount of rubbing and pinching of tendons & bursa   This is called impingement. It is normal   Impingement becomes problema9c when it causes irrita9on/damage to tendons   Con9nuous work with arms overhead/
throwing/repe99ve shoulder movements leads to problem   Bone spurs caused by wear and tear of AC joint rub on tendons   Type I and II acromion 4 3/3/14 History   Affects sleep, dressing, pumng on a jacket   Complains of jerky movement   Pain on abduc9on and forward flexion   Pain worse when reaching behind, outward, overhead   Sharp pain when reaching into back pocket   Unable to sleep on affected arm   Weakness & inability to raise the arm  total cuff tear Complete rotator cuff tear   Trauma9c cause: listen in history for fast strong force applied on shoulder e.g.: –  trying to catch heavy falling object –  LiNing very heavy object with arm extended   Inability to ac9vely abduct the arm   Full passive range of mo9on Special tests: RCT/Impingement   Painful arc in abduc9on: 80-­‐120˚   Arm drop test   Pain and weakness in External rota9on   External rota9on lag test   Recent systema9c review found Neer’s test and Hawkin’s-­‐Kennedy test not of diagnos9c u9lity* * Hegedus E et al. "Physical examina9on tests of the shoulder: a systema9c review with meta-­‐analysis of individual tests." Brit J Sport Med 42.2 (2008):80-­‐92. 5 3/3/14 Painful arc in abduc9on: 80-­‐120o   +ve test: When pa9ent abducts arm there is pain from 80-­‐120˚   Indicates rotator cuff disorder   80.5% sensi9vity* * Çalış M, et al. "Diagnos9c values of clinical diagnos9c tests in subacromial impingement syndrome." Annals of the rheuma9c diseases 59.1 (2000): 44-­‐47. Arm drop test   Arm abducted passively by examiner   Pa9ent instructed to keep arm up   Examiner releases arm   +ve test  pa9ent unable to keep arm up   Confirms rotator cuff tear   Considered highly specific* * Hegedus, E et al. "Physical examina9on tests of the shoulder: a systema9c review with meta-­‐analysis of individual tests." Brit J Sport Med42.2 (2008): 80-­‐92. Resisted external rota9on   Instruct pa9ent on external rota9on   Examiner resists pa9ents movement   Compare both sides to gauge differences   +ve result  pain and weakness   Indicates rotator cuff disorder 6 3/3/14 External rota9on lag test   Pa9ents arm passively held in near maximal external rota9on by examiner   Pa9ent instructed to hold arm in ER posi9on   Examiner releases arm   +ve test  pa9ent unable to hold arm in same posi9on (as livle as 5˚ change in ER)   Indicates rotator cuff disorder   100% posi9ve predic9on*   56% nega9ve predic9on* * Tennent T et al. "Clinical sports medicine update. A review of the special tests associated with shoulder examina9on Part I: the rotator cuff tests." Am J Sport Med 31.1 (2003): 154-­‐160. RC Tears -­‐ Non-­‐surgical treatment   In trauma9c injury, generally pa9ents with <50% tear will not need surgery   Painkillers and an9-­‐inflammatory meds   Physiotherapy   Strengthening exercises   Recovery 6-­‐8 weeks Surgical treatment   Pa9ents with >50% tear   Complete cuff repairs never heal without surgery   A tear does not usually happen without a coexis9ng problem   Likely problems e.g. impingement or AC joint osteoarthri9s may also need to be addressed   Arthroscopic repair with suture anchors   Ac9ve physiotherapy 6 weeks post-­‐op Strengthening exercises 12 weeks post-­‐op   Full recovery around 6 months 7 3/3/14 Arthroscopic RC repair Adhesive capsuli9s/Frozen shoulder   Affects 3% of the popula9on   More common in diabe9cs and women*   Ae9ology unknown but it is an inflammatory condi9on   Can occur aNer injury, disloca9on, fracture, surgery, immobilisa9on   Capsule surrounding joint contracts   Contrac9on and scar forma9on restricts movement   Spending 9me in a sling can cause frozen shoulder   Maintain movement of joint aNer injury/surgery to prevent frozen shoulder * Mitchell C, Adebajo A, Hay E, et al; Shoulder pain: diagnosis and management in primary care. BMJ. 2005 Nov 12;331(7525):1124-­‐8. History   Insidious onset: shoulder became gradually s9ffer   Trauma induced: injury lead to pain so did not move joint  now s9ff   Surgery: Shoulder immobilised in sling   Unable to move shoulder around   Can’t comb hair   Dressing difficult, especially upper garments 8 3/3/14 3 stages 1.  Painful or Freezing Stage: 6-­‐12 weeks (can take months) +
+Pain with onset of restricted movement 2.  Frozen or restricted stage: 4-­‐6 months. During this stage pain usually sevles, but s9ffness worsens 3.  Thawing stage: >1 year. Gradual, mo9on steadily improves over a lengthy period of 9me   80% pa9ents have complete pain resolu9on   Some have permanent slight loss of ROM Source: Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975; 4:193–196. Examina9on   Range of mo9on limited with ac9ve and passive movement   Loss of passive external rota9on & abduc9on   X-­‐ray and arthrogram can eliminate other differen9als DDX: In rotator cuff disease ac2ve range of mo2on is limited but passive ROM is good. Frozen Shoulder -­‐Non-­‐surgical treatment Frustra9ng and slow – takes many months Rest and an9-­‐inflammatory medica9on Steroid injec9on Physiotherapy 90% success rate over 4 months for physio & injec9on combina9on1   Hydrodilata9on and post-­‐injec9on stretching –  Surgeon distends shoulder joint with fluid, and break down contractures –  Accelerates staging process  breaks down capsule for physio –  Effec9ve if done in early stages of frozen shoulder2  
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1 Levine W et al. Nonopera9ve management of idiopathic adhesive capsuli9s. J Shoulder Elbow Surg. 2007; 16:569–573 2 Dacre J et al Injec9ons and physiotherapy for the painful s9ff shoulder. Ann Rheum Dis. 1989; 48:322–325. 9 3/3/14 Surgical treatment   Surgery for more severe cases   Arthroscopic surgery to remove scar and fibrous 9ssue   Coracohumeral ligament cut   Small part of joint capsule removed   Gentle joint manipula9on   This helps free the capsule   Physiotherapy required Source: Warner J, Allen A, Marks P, Wong P. Arthoscopic release for chronic, refractory adhesive capsuli9s of the shoulder. J Bone Joint Surg Br. 1996; 78(12):1808-­‐1816. SLAP lesions – internal impingement   Injury to where the biceps tendon avaches to labrum   Labrum is a cuff of car9lage that surrounds the socket of the shoulder joint   Without the labrum, the ball and socket joint is extremely shallow and inherently unstable   A sharp pulling on the bicep tugs on the labrum (e.g. chest fly or biceps exercise)   This can cause it to tear and pull away from the glenoid   Flap of labral tear can catch in the joint  internal impingement History   Plays racquet sports, swimming, climbing, throwing sports   Catch of pain when throwing/serving/swimming   Symptoms of impingement but less signs   A recent systema9c review suggests current tests for diagnosing SLAP lesions are of limited u9lity*   Thus arthroscopic inves9ga9on considered gold standard * Calvert E et al. "Special physical examina9on tests for superior labrum anterior posterior shoulder tears are clinically limited and invalid: a diagnos9c systema9c review." J Clin Epidemiol 62.5 (2009): 558-­‐563. 10 3/3/14 SLAPprehension test   Arm held in horizontal flexion across the body   Elbow extended   Forearm is pronated   +ve test pain in the bicipital groove   With or without audible click   Indicates SLAP lesion   87.5% sensi9vity for unstable SLAP lesion Source: Berg E and Ciullo J. "The SLAPprehension test." Journal of the Southern Orthopaedic Associa8on 4.3 (1995): 237. Speed test   Pa9ent standing   Arm held at side of body   Elbow full extension, forearm supinated   Pa9ent instructed to ac9vely flex arm forward   Examiner resists arm movement by pressing down on forearm   +ve test: pain felt in bicipital groove   Indicates biceps tendon pathology or possible SLAP lesion   32% specificity, 79% sensi9vity of biceps tendon inflamma9on or SLAP lesion* * Karlsson J. "Physical examina9on tests are not valid for diagnosing SLAP tears: a review." Clin J Sport Med 2010;20(2): 134. Yergason’s test   Pa9ent’s arm adducted to side of body   Elbow flexed to 90o and forearm pronated   Examiner holds wrist   Pa9ent instructed to supinate wrist   Examiner resists movement   +ve test: pain felt in bicipital groove   Indicates pathology of the biceps tendon   43% sensi9vity, 75% specificity for biceps tendon pathology or SLAP lesion* * Holtby R et al"Accuracy of the Speed’s and Yergason’s tests in detec9ng biceps pathology and SLAP lesions: comparison with arthroscopic findings." Arthroscopy 2004;20.3:231-­‐236. 11 3/3/14 Non-­‐surgical treatment   Most pa9ents with SLAP tears respond well to non-­‐
surgical treatments   These treatments may include an9-­‐inflammatory medica9on, rest, and physical therapy   Some9mes cor9sone injec9ons are performed Surgical treatment   Several procedures may have to be performed   Labral debridement   SLAP repair   Biceps tenodesis (repair)   2-­‐4 weeks in sling   Physiotherapy   Full recovery 12-­‐16 weeks   Success rate 87%* * Brockmeier, Stephen F., et al. "Outcomes aNer arthroscopic repair of type-­‐II SLAP lesions." The Journal of Bone and Joint Surgery (American) 91.7 (2009): 1595-­‐1603. Surgical treatment – SLAP repair 12 3/3/14 Distal clavicular osteolysis – WeightliNer’s Shoulder   Repe99ve training/stress causes fractures at distal end of clavicle   Bench-­‐press and chest fly exercises to blame   Places shoulders in excessive extension causing excessive trac9on on AC joint   Bone doesn’t heal before next session   Bone starts to dissolve   Chronic inflamma9on   Cyst forma9on, ↑ osteoclast ac9vity, car9lage disrup9on History of AC joint osteolysis   Uses weights (bench-­‐press, chest fly)   Goes to gym   Involved in lots of manual ac9vity   Catching pain over AC joint   Especially when reaching across or behind body Scarf test   Hand from affected side is placed on contralateral shoulder   Examiner then pushes elbow towards pa9ents body   Hand should slide backwards over scapula   +ve test: Pain in AC joint   Indicates AC joint problem (DDX arthri9s)   No evalua9on of accuracy available 13 3/3/14 Cross body adduc9on   Pa9ents arm is passively moved across their body   +ve test: elicits ACJ pain complained of in history   Indicates AC joint problem (DDX arthri9s)   77% sensi9vity* * Chronopoulos E et al . Diagnos9c value of physical tests for isolated chronic acromioclavicular lesions. Am J Sports Med 2004;32:655–61. Non-­‐surgical treatment ACJ osteolysis   Rest to allow joint to heal   Permanent changes in training and technique –  Narrow hand spacing on bench-­‐press –  End bench press 2 inches above chest –  Prevents over extension and takes load off distal clavicle   Strongly advise against ‘working through the pain’ ac9vity modifica9on essen9al   Stress avoidance of overtraining, allow for recovery 9me   Stop smoking! Smoking impairs bone healing   Non steroid an9-­‐inflammatory medica9on   May require steroid injec9on to reduce pain   Resolu9on within 1-­‐2 years with ac9vity modifica9on Surgical treatment ACJ osteolysis   For those who refuse to change regime or limit ac9vi9es   For when conserva9ve treatment has failed   ‘Arthroscopic resec9on of distal clavicle’   Damaged por9on of clavicle removed (4-­‐7mm)   91% success rate* * Schwarzkopf R et al. Distal clavicular osteolysis: a review of the literature. Bull NYU Hosp Jt Dis. 2008;66(2):94-­‐101. 14 3/3/14 Calcific tendoni9s   Calcium deposits form on rotator cuff (supraspinatus tendon)   Degenera9ve calcifica9on, wear and tear   Reac9ve calcifica9on, calcium crystals deposit (pain) then reabsorbed (pain subsides)   Reac9ve  Unknown ae9ology History   Classic signs of impingement   But X-­‐ray finds calcium deposits OR   Acute severe pain   Pa9ent ~30-­‐40yrs   Can’t sleep – almost systemically unwell   No movement   DDX sep9c arthri9s  check for fever, hot joint Special tests  false posi9ves   Same as impingement/RCT   Painful arc in abduc9on: 80-­‐120o   Arm drop test   Pain and weakness in External rota9on   External rota9on lag test   Revealed on X-­‐ray to be calcifica2on 15 3/3/14 Non-­‐surgical treatment   First aim: to control pain   Rest and An9-­‐inflammatory medica9on   Cor9sone injec9on may be used   Physio – ultrasound therapy   Lavage may be useful –  2 large needles into the shoulder –  Flush area with sterile saline –  Calcium deposits may be washed out Surgical treatment   Arthroscope used to locate calcifica9ons on RC   Calcium deposits resected   Area rinsed   Loose calcium deposits removed   92% success rate*   Physio starts immediately   Aim to strengthen RC as this causes less pain from deposits * Seil, Romain, et al. "Arthroscopic treatment of chronically painful calcifying tendini9s of the supraspinatus tendon." Arthroscopy: The Journal of Arthroscopic & Related Surgery 22.5 (2006): 521-­‐527. When to Operate   Failure of Conserva9ve Treament   Defini9ve Repair required   Pa9ent requirements/logis9cs – 50/50 – eg. ACJ separa9on GIII 16 3/3/14 Shoulder Doctor Prac9ce   Best prac9ce   MOST PATIENTS DON’T NEED SURGERY   Efficient -­‐ eg. One Stop Clinic   Latest techniques – eg. PRP   University of Greenwich – development of Strength and Condi9oning Thanks for listening Shoulder instability   Head of humerus held in place by muscles and ligaments of the shoulder   If strength of soN 9ssue anchors is lowered    joint more suscep9ble to disloca9ons   Instability caused by structural weakness or muscle paverning   Structural weakness can be caused by trauma i.e. disloca9on   Disloca9ons  tearing of the support structures   Minor trauma and wear and tear  instability   Muscle paverning: the voluntary dislocator 17 3/3/14 Bankart tear & Hill-­‐Sach’s lesion   Bankart’s tear is a tear to the labrum   ONen happens in disloca9ons   Can cause recurrent disloca9ons & instability   Hill-­‐Sachs lesion is a compression fracture of the humeral head   Can some9mes cause shoulder instability History and Examina9on   Trauma9c cause: history of disloca9ons   History of subluxa9on ( joint slips out and in again)   Shoulder feels loose   Shoulder feels like it might dislocate upon movement   Predisposed: Hypermobility in joints (Beighton score)   Muscle paverning cause: history of ‘party trick’ disloca9on Special tests for instability Load and shiN test   Gold standard for posterior and anterior instability   Provide axial load on humerus, compressing the glenohumeral joint   Move head of humerus anteriorly and posteriorly   +ve test: Humeral head displacement   Test can be repeated with pa9ent supine   Diagnos9c of instability   When posi9ve, test is extremely predic9ve for instability   Likelihood ra9o > 80* * Tzannes A, &Murrell G. "Clinical examina9on of the unstable shoulder." Sports Medicine 2002;32.7: 447-­‐457. 18 3/3/14 Jobe’s reloca9on test   Pa9ent lies supine with arm in abduc9on, elbow at 90o flexion   External rota9on un9l apprehension noted then stop   Posteriorly directed force over humerus, test repeated   +ve test if ER with posterior force > than when there is no posterior force applied – Indicates anterior instability   Differen9ates between anterior instability and impingement   64% sensi9vity, 99% specificity for instability* * Lo I et al. "An evalua9on of the apprehension, reloca9on, and surprise tests for anterior shoulder instability." Am J Sport Med 32.2 (2004): 301-­‐307. Biceps tendoni9s   Overuse injury   Con9nuous or repe99ve shoulder ac9ons   Cells have no 9me to recuperate before next use   Tendon fails to recover   Fibroblasts produced  collagen loses strength  breaks down and forms scar 9ssue   Tendon strands and fibres break   Tendon strength compromised, can lead to rupture   Can develop due to over shoulder condi9ons: RCT, impingement and instability History   Engages in repe99ve shoulder ac9vity/ strain   Especially overhead arm movements   Athletes who throw, swim, or swing a racquet or club are at greatest risk   Use Yergason and Speed test 19 3/3/14 Types of SLAP tear & internal impingement Type 1 (75% of Slap Lesions)   Par9al tear of the top of the labrum   Damage limited to a fraying of labrum-­‐glenoid connec9on   Surgery usually limited to debridement Type 2   Several types   Vary between the loca9on of the tear in respect to the midpoint of where the biceps tendon avaches Type 3   Tear leaves flap of labrum that hangs into the ball and socket joint  internal impingement   Causes catching or impingement within the joint   Surgical removal of flap then reavachment of remaining labrum Type 4   The tear of the labrum extends into the biceps tendon   Surgical reavachment of labrum and repair of biceps tendon required Shoulder Anatomy-­‐ Live General shoulder examina9on -­‐ Live 20 3/3/14 Surgical treatment ACJ osteolysis 21