Common Problems of the Shoulder

Part OneAge >40

First, a little Anatomy

Shoulder Girdle Muscles

Shoulder Pain

Rule out Extrinsic Sources Referred

Abdomen: subdiaphragmatic Pulmonary disease: Pancoast tumor

Radicular Cervical Spine

Cervicogenic Pain

Spondylosis: “degeneration” Ache into shoulders Pain reproduced with ROM

Radiculopathy (weakness) C 4-5: 5 root, pain to shoulder, (deltoid) C 5-6: 6 root, lat forearm, thumb (biceps, ECRL) C 6-7: 7 root, middle finger (triceps) C 7-8: 8 root, small finger (finger flexion) C8-T1: T1 root, medial arm (finger abduction)

Common Diagnoses

Impingement Rotator cuff tear AC joint disease Frozen shoulder Rare: Glenohumeral arthritis,

contusion, infection.

Shoulder Pain

Symptoms: Pain overhead Pain and weakness Pain with anything

Duration of symptoms

Duration of Symptoms

If pain is acute (<12weeks), you can cure the patient with activity modification (no activity with elbow away from side), once a day stretch fully overhead, ice, and +/- NSAID or narcotic.

Pain > 12weeks is harder. Pain > 6 months will need a miracle.

ImpingementThe most common diagnosis

Friction Overuse--rare to get it in the history Bursitis-->Tendinitis-->Rotator Cuff

Tear

Impingement

Bursitis= pain but not when testing cuff

Tendinitis=hurts when cuff muscles are tested

Rotator cuff tear=weakness, frequently without pain

Impingement/BursitisPain with overhead activity

Pain felt at lateral shoulder Pain at night Can also be coming from the AC joint EXAM: Impingement Sign vs AC joint

tenderness and Cross Arm Adduction Test

TestsImpingement Sign

TestsCross Arm Adduction(pain must be at AC joint, not posterior capsule)

AC Joint

Tenderness directly over joint. Pain increased with adduction,

overhead activity Treat like arthritis anywhere else. Injections are frequently helpful

diagnostically and therapeutically.

AC Joint Arthritis

Impingement Treatment

Activity modification: no activity with elbow away from side, in the gym, or at the computer.

Once a day stretch fully overhead. NSAID and Ice Injection in 3-6 wks prn. Physical Therapy: After pain subsides:

Regain ROM, strengthen rotator cuff

Keeping shoulder healthy

Once pain subsides, start rotator cuff strengthening.

Continue cuff program at the gym and at home.

BOTH shoulders.

Pain and Weakness

Does this mean a Rotator Cuff Tear? Can’t assess rotator cuff when there is pain Treat pain first: NSAID, PT, ice, rest-4 wks Cortisone shot (once) if above doesn’t work Test cuff when pain subsides. Refer after 6 weeks of treatment, not

symptoms.

Rotator Cuff Tests

Best single test is External Rotation Strength (Infraspinatus and Teres Minor).

Can get extra credit testing Supraspinatus

Advanced placement if massive tear picked up testing Subscapularis (hand push off test with hand dorsum resting on low back)

TestsRotator CuffExternal Rotation

TestsRotator CuffSupraspinatus

Rotator Cuff Treatment

Cuff tear is rare in age<50. Autopsy and MRI studies show most

males over have RC tear and never had symptoms

Beware of the Repeat Injectee who has weakness.

Surgery decision is based on pain

Biceps Tendon RuptureProximal

Special Case: Rupture of long head of Biceps

Usually occurs without much trauma Rupture of attrition (like a rope rubbing

over a rock), remember long (lateral) head is intra-articular and part of the cuff.

Problem is the shoulder, not the tendon Some supination power lost, not elbow

flexion

Pain with Anything

Usually severe symptoms, not acute Motion usually very restricted, passive

and active (really can’t examine patient) Frozen vs. “freezing” shoulder PT, PT, PT (pain isn’t harmful) Lots of support needed, injection might

help.

Frozen Shoulder

Not an “-itis”, more like Dupuytrens contracture in the hand.

DDx: Shoulder joint infection (GH joint), Shoulder joint arthritis (DX with XR)

Best Dx test: no passive external rotation.

Frozen shoulder vs. Arthritis

Age XR:

Shoulder Infection

Red, angry looking shoulder=septic arthritis of AC joint, not glenohumeral joint.

Aspirate point of maximal angriness (over superior AC joint), get labs, xray, and refer

Glenohumeral Joint Infection

Very rare Increased incidence in diabetics,

immuno-compromised patients. Shoulder looks normal, just bigger. SEVERE pain. Any motion hurts. Often a fever. Get labs (CBC, blood

cultures, ESR, CRP), XR, then: Get a consult.

Who needs an Xray?

1st visit, routine Hx/PE: No No improvement after Tx: Yes Odd Hx or PE, h/o fracture or injury:

Yes Pre-referral: Yes Recommended XR: AP/outlet views

Shoulder Xrays

What about a MRI?

If it will change what you do, order it. False positives Helpful if cervical spine is bemuddling. Some orthopedists like it prior to

referral; doesn’t hurt to check for local customs.

Shoulder MRI