Shoulder Symposium 4th Annual Federal Workers Compensation Conference

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Shoulder Symposium4th Annual Federal
WorkersCompensation Conference
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The Shoulder

• Ann Dew DO
• Grace Stringfellow MD

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Course Objectives

• Review of shoulder anatomy and physiology
• Review of evaluation, diagnosis, and treatment of
  common shoulder injuries
• Review of mechanism of injury and prevention of
  work related injuries

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Anatomy and Physiology

• Bones
• Muscles
• Joints
• Tendons
• Nerves

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A Brief Examination of the Shoulder and Upper
Extremity

• Dr. Philip Reisweg, MD
• Chief of Orthopedics
• Loma Linda VA Medical Center

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Common Conditions

• Impingement Syndrome
• Rotator cuff tendinitis
• Rotator cuff tear
• Frozen shoulder
• Acromioclavicular Strain/Osteoarthritis
• Biceps tendinitis
• Subscapular bursitis
• Glenohumeral osteoarthritis
• Instability

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Impingement Syndrome

• Description
• Compression of the rotator cuff tendons and the
  subacromial bursa between the greater tubercle of
  the humeral head and the undersurface of the
  acromial process
• I feel like my bones are rubbing together
• Its too painful to raise my arm up

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Exam Summary

• 1. Positive painful arc maneuver
• 2. Focal subacromial tenderness
• 3. Painless testing of resisted abduction
  (supraspinatus), external rotation
  (infraspinatus), adduction (subscapularis) and
  elbow flexion (biceps)
• 4. Normal ROM of Glenohumeral joint
• 5. Preserved strength all directions

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Diagnosis

• History of lateral shoulder pain
• Abnormal signs of local subacromial tenderness
  below middle of acromion
• Painful arc
• Absence of signs of active tendinitis
• Initial xrays optional

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Treatment

• Goal Increase subacromial space
• Rest and restriction of overhead positioning and
  reaching
• Weighted pendulum stretching exercises using 5-10
  lb, 5 min x 1-2 q d with passive stretching
• Ice to control pain
• Avoid simple slings and immobilizers
• Isometric toning of infraspinatus

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Rotator Cuff Tendinitis

• Inflammation of the supraspinatus and
  infraspinatus tendons lying between the humeral
  head and the acromial process.
• Aggrevated by repetitive overhead reaching,
  pushing, pulling and lifting with the arms
  outstretched repeated abduction, elevation and
  torque to the shoulder

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Exam Summary

• 1. Focal subacromial tenderness
• 2. Painful arc maneuver
• 3. Pain with resisted midarc abduction and
  external rotation, isometrically performed
• 4. Normal range of motion of the glenohumeral
  joint
• 5. Preserved strength of midarc abduction and
  external rotation (lidocaine test)

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Diagnosis

• History of shoulder pain aggravated by reaching,
  evidence of subacromial impingement, and pain
  with isometric testing of the supraspinatus,
  infraspinatus, or subscapularis.
• I cant sleep on my shoulder if I roll over it
  wakes me up
• I cant reach up or back anymore

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Treatment

• Goals reduce tendon swelling and inflammation,
  increase subacromial space, and prevent
  progressive damage to tendons
• NSAIDS
• Weighted pendulum stretching exercises
• Ice to control pain
• Toning infraspinatus and supraspinatus tendons
• Avoid slings and immobilizers

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Frozen Shoulder

• Stiff shoulder joint a glenohumeral joint that
  has lost significant range of motion
• Common causes rotator cuff tendinitis, acute
  subacromial bursitis, fractures of humeral head
  and neck, and paralytic stroke
• May be accompanied by reflex sympathetic
  dystrophy (RSD)

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Exam Summary

• Abnormal Apley scratch test (inability to scratch
  lower back)
• Restricted abduction and external rotation,
  measured passively
• No xray evidence of glenohumeral arthritis
• Its getting hard to put on my coat
• I cant comb my hair

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Diagnosis

• Demonstrated loss of range of motion of
  glenohumeral joint
• Xrays ruling out arthritis of the glenohumeral
  joint however, most plain films are
  nondiagnostic

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Treatment

• Goals treat any underlying periarticular or
  bony process, stretch GH joint lining, and
  restore normal range of motion
• Heat
• Weighted pendulum exercises BID, performed
  passively
• Daily stretching exercises, performed passively
• When improved, rotator cuff muscle toning,
  isometrically

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Rotator Cuff Tendon Tear

• Loss of the normal integrity of the infraspinatus
  or supraspinatus tendons or both, occur as the
  end result of chronic subacromial impingement and
  progressive tendon degeneration or from traumatic
  injury or both.
• Falls onto the outstretched arm, directly onto
  outer shoulder, vigorous pulling, unusual heaving
  pushing and pulling

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Exam Summary

• Loss of smooth overhead motion
• Weakness and pain with isometric testing of
  midarc abduction, external rotation, or both
• Painful arc usually positive
• Subacromial tenderness
• Atrophy of the infraspinatus and/or supraspinatus
  noted over the scapula

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Diagnosis

• Requires special testing
• Lidocaine injection test, persistent weakness
• MRI, good for large tears but cannot distinguish
  a small tear from active tendinitis
• Arthrography demonstrates subtendinous tears,
  small splits, and large tendon tears
• Plain xrays subacromial space measurement of lt
  1 cm is highly suggestive of degenerative
  thinning, tear, or both

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Treatment

• Goals recover and improve lost strength in
  external rotation and abduction, to improve the
  global function of the shoulder, and to treat any
  rotator cuff tendinitis
• Small and medium tears physical therapy toning
  exercises of external rotation and abduction
• 50-62 year olds with large tear surgery referral

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Initial Care

• Ice to control pain or swelling
• Plain xrays
• Restrict overhead positioning and reaching
• Weighted pendulum done passively for 5 min BID
• Cautious isometric toning
• No relief in 2-4 wks, add NSAID for 3-4 wk

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Prognosis

• Small to medium tears with loss of 25-50
  strength and function can be treated medically
  restrictions, PT for up to 6 mos
• No response in 4 wks refer to ortho
• Medium to large refer immediately
• Risk factors age gt62, fall onto outstretched arm
  or direct blow to shoulder, recurrent tendinitis,
  weakness, lt1 cm subacromial space on plain film

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Acromioclavicular Strain or Osteoarthritis

• The AC, coracoclavicular, and coracoacromial
  ligaments, binding the acromion, clavicle, and
  coracoid process together, can be strained,
  partially torn, or completely disrupted.
• Repeated strain or injury to the supporting
  ligaments may progress to osteoarthritis
• Repetitive reaching (esp across chest or over
  head), trauma

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Exam Summary

• 1. AC joint enlargement or deformity
• 2. AC joint tenderness (with or without
  swelling)
• 3. Pain aggravated by downward traction or
  forced adduction, performed passively
• 4. AC joint widening with downward traction of
  the arm
• 5. Xrays recommended w/o and w weights

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Diagnosis

• AC joint disease is easily made from the physical
  examination
• Osteoarthritis of the AC joint or AC separation
  is made by xray
• Degenerative changes narrowing, sclerosis,
  squaring off of bones of clavicle or proximal
  acromion, spurring.
• Separation gt5mm between clavicle and acromion
  process

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Treatment

• Goals To reduce direct pressure and traction at
  the AC joint to allow ligament to reattach to
  respective bony insertions
• Restrict reaching and direct pressure over the
  shoulder
• Limit lifting to 10 20 lb held close to the
  body
• Immobilization for 3-4 wks
• Ice to control swelling and pain
• Avoid sleeping on either side
• General shoulder conditioning

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Biceps Tendinitis

• Inflammation of the long head tendon as it passes
  through the bicipital groove of the anterior
  humerus. Repeated irritation leads to
  microtearing and degenerative change.
• Vigorous or unusual lifting can lead to
  spontaneous rupture 10 12
• My shoulder used to hurt a lot. Two days ago it
  stopped hurting. Now I have this big bruise near
  my elbow and the muscle seems bigger.

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Exam Summary

• 1. Local tenderness in the bicipital groove
• 2. Pain aggravated by flexion of the elbow,
  isometrically performed
• 3. Painful arc often positive
• 4. A bulge in the anticubital fossa, signifying
  long head tendon rupture

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Diagnosis

• History of anterior humeral pain and an exam
  showing local tenderness in the bicipital groove
  aggravated by resisted elbow flexion.

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Treatment

• Goals reduce inflammation and swelling in the
  tendon, to strengthen the biceps muscle and
  tendon, and to prevent rupture.
• Eliminate lifting
• Restrict over-the-shoulder positions and reaching
• Ice to anterolateral shoulder, NSAID,
  phonophoresis
• Weighted pendulum, passive
• Toning exercises for the short head biceps and
  brachioradialis tendons (with rupture)

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Subscapular Bursitis

• Constant friction (to and fro motions of the arm)
  and direct pressure (lying on hard surfaces)
  cause irritation and inflammation to develop
  between the scapula and the underlying rib
• Diff Dx rhomboid or levator scapular muscle
  irritation (posture, stress, whiplash) and
  referred pain from lower cervical roots.

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Exam Summary

• 1. Local tenderness under the superomedial angle
  of the scapula, directly over rib
• 2. Full ROM of the shoulder
• 3. No evidence of cervical root irritation or
  rhomboid or trapezius strain
• Every time I roll my shoulder, it pops
• I cant sleep on my back anymore, there is a
  spot of pain over my shoulder blade

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Diagnosis

• Focal tenderness just under the superomedial
  angle of the scapula over 2nd or 3rd rib
• Full shoulder range of motion
• Negative neck examination w full ROM
• Normal upper extremity neuro exam

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Treatment

• Goals To reduce acute inflammation and to
  prevent further episodes by improvement in
  posture and in shoulder muscle tone
• Local injection of Kenalog 40
• Limit to-and-fro motions and overhead reaching
  with the affected arm
• Good posture
• Avoid direct pressure over the scapula

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Glenohumeral Osteoarthritis

• Wear and tear of the articular cartilage of the
  glenoid labium and humeral head is uncommon.
  Usually trauma precedes the condition, I.e.,
  previous dislocation, humeral head or neck
  fracture, large rotator cuff tears and RA

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Exam Summary

• 1. Local tenderness located anteriorly, just
  under the coracoid process
• 2. Restricted abduction and external rotation,
  measured passively
• 3. Crepitation with circumduction or clunking on
  release of isometric tension
• 4. Swelling of the infraclavicular fossa or
  general fullness to the shoulder

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Diagnosis

• History of progressive loss of range of motion
• Crepitation or crunching with circumduction
• Loss of external rotation and abduction
• Plain xrays of shoulder show narrowing of the
  articular cartilage and irreg inferior glenoid
  fossa, spurring and finally, flattening of the
  humeral head with obliteration of the articular
  cartilage at the inferior glenoid

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Treatment

• Goals improve range of motion and muscular
  support
• Elimination of heavy work, overhead reaching, and
  forceful pushing and pulling.
• NSAID
• Weighted pendulum exercises once daily with heat
  to anterior shoulder prior to exercise
• Passive stretching

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Multidirectional Instability of the Shoulder

• Synonymous with subluxation, loose, or
  partial dislocation.
• More common in young women with poor muscular
  support of the shoulder, patients with large
  rotator cuff tendon tears, and athletic patients
  lt 40 yr.
• Uncommon after 40 due to natural stiffening of
  the shoulder

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Exam Summary

• 1. Downward traction on the arm causing the
  sulcus sign
• 2. Increased anteroposterior mobility of the
  humeral head (relative to the glenoid fossa)
• 3. Painful arc may be positive
• 4. Positive apprehension sign with are placed at
  70-80 degrees abduction and passively rotated
  externally

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Diagnosis

• Diagnosis of hypermobility made by history and
  physical exam
• It feels like my shoulder is going to pop out
• My shoulder makes a crunching sound
• Every time I try to lift something heavy, my
  shoulder seems to slip

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Treatment

• Goals similar to recommendations for rotator
  cuff tendinitis and to improve stability of
  glenohumeral joint to prevent OA
• Advise rest and restriction of overhead
  positioning, reaching, pushing, pulling and
  lifting
• Isometric toning exercises in external and
  internal rotation
• Ice initially, NSAID added if no improvement
• At about 3 mos cautious overhead reaching

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Prevention

• Wellness
• Exercise stretching, toning, strengthening
• Weight management
• Nutrition
• Ergonomics
• Devices
• Personal