c. christopher smith, m.d. 1011-22/4... · biceps tendonitis • inflammation of long head of the...
TRANSCRIPT
Evaluation and Treatment of the
Painful Shoulder
in the Primary Care Setting
C. Christopher Smith, M.D. Associate Professor of Medicine
Harvard Medical School Beth Israel Deaconess Medical Center
A 65-year-old woman with a history of type II
DM presents for evaluation of new left shoulder
pain. The pain is in her anterior and lateral
shoulder and has gradually worsened over the
last three weeks. It is dull and constant and
keeps her up at night. She also notices marked
discomfort when she combs her hair and
cannot get sweaters from the top of her closet
due to pain and weakness. She denies any
trauma or prior injuries. She works as an
investment banker.
The Painful Shoulder
• Recognize, diagnose and treat the most common cause of shoulder pain in the primary care setting
• Know how to differentiate it from other common causes of shoulder pain
The Painful Shoulder
• Anatomy
• History
• Differential based on patient’s age and location of pain
• Physical exam maneuvers
• Initial treatment
Anatomy of the Shoulder
UpToDate, 2006
The Rotator Cuff Muscles
UpToDate, 2006
Causes of Shoulder Pain
• Acromioclavicular Osteoarthritis
• Adhesive Capsulitis
• Biceps Tendonitis
• Brachial Plexus Neuritis
• Cervical Radiculopathy
• Glenohumeral Arthritis
• Instability
• Impingement Syndrome
• Systemic Inflammatory Disorders
• Referred Pain - Diaphragmatic, Subdiaphragmatic and Intrathoracic Causes
In the primary care setting, what is the most common cause of nontraumatic shoulder pain?
A. Bicipital Tendonitis
B. Impingement Syndrome
C. Adhesive Capsulitis (Frozen Shoulder)
D. Osteoarthritis of the Glenohumeral Joint
E. Acromioclavicular Joint Osteoarthritis
In the primary care setting, what is the most common cause of nontraumatic shoulder pain?
A. Bicipital Tendonitis
B. Impingement Syndrome
C. Adhesive Capsulitis (Frozen Shoulder)
D. Osteoarthritis of the Glenohumeral Joint
E. Acromioclavicular Joint Osteoarthritis
Causes of Shoulder Pain in the
Primary Care Setting:
Impingement Syndrome > 70%
Adhesive Capsulitis 12%
Bicipital Tendonitis 4%
A/C Joint OA 7%
Other 7%
Smith, J Gen Intern Med, 1992
So what is impingement
syndrome?
Impingement Syndrome
UpToDate, 2006
Typical History of Impingement Syndrome
• Any age, but risk increases with age
• Anterior or lateral shoulder pain
• Pain exacerbated by abduction and forward flexion
• Night pain common
Age and Shoulder Pain
Young (< 30 y.o.) • Dislocations/Instability of Glenohumeral Joint • Separation of AC joint • Overuse injury
Less Young (30-60 y.o.) • Impingement Syndrome • Adhesive Capsulitis (especially in diabetics) • Separation/Overuse as above
Older (> 60 y.o.)
• Impingement Syndrome (non-traumatic tears) • Adhesive Capsulitis • Systemic Conditions (if bilateral, PMR, RA)
Physical Examination
• Inspection
• Palpation
Physical Examination
• Inspection
• Palpation
• Range of Motion
– Passive and Active
• Strength and Sensation
• Specific Maneuvers to Confirm Diagnosis
Painful arc
http://www.clinicalexams.co.uk/painful-arc-syndrome.asp
Maneuvers to Verify Impingement Syndrome
Maneuvers to Verify Impingement Syndrome
Empty Can Test
Maneuvers to Verify Impingement Syndrome
Neer’s Test Neer, Clin Orthop 1983
Maneuvers to Verify Impingement Syndrome
Hawkins’ Test Hawkins, Am J Sports Med 1980
©
A 65-year-old woman with a history of type
II DM presents for evaluation of new left
shoulder pain. The pain is in her anterior
and lateral shoulder and has gradually
worsened over the last three weeks. It is
dull and constant and keeps her up at
night. She also notices marked
discomfort when she combs her hair and
cannot get her sweaters from the top of
her closet due to pain and weakness. She
denies any trauma or prior injuries. She
works as an investment banker.
On inspection, her left humerus was
riding slightly higher than her right.
There was pain with palpation of the
lateral subacromial space. ROM
revealed pain with abduction and
forward flexion; it was worse with active
than passive movement. Positive empty
can, Neer and Hawkins test.
What is the most appropriate initial
treatment for this patient?
A. NSAIDs alone
B. NSAIDs with Physical Therapy
C. Subacromial Steroid Injection with PT
D. NSAIDs plus Steroid Injection
E. Orthopedic consultation
What is the most appropriate initial
treatment for this patient?
A. NSAIDs alone
B. NSAIDs with Physical Therapy
C. Subacromial Steroid Injection with PT
D. NSAIDs plus Steroid Injection
E. Orthopedic consultation
Treatment
• Reduce offending activities
• Physical Therapy
– Aimed at improving mechanical dysfunction and shoulder motion
• NSAIDs or Subacromial injection
– Each is better than placebo
– Little long term difference
– No benefit in combination treatment
White, J Rheumatol 1986
Petri, Arthritis Rheum 1987
You passively abduct the arm to 160
degrees and ask the patient to slowly lower
her arm. At approximately 90 degrees, she
is unable to continue to lower her arm due to
weakness and she drops it to her side.
What is your diagnosis now?
A. Bicipital Tendonitis
B. Impingement Syndrome
C. Adhesive Capsulitis (Frozen Shoulder)
D. Tear of Supraspinatus Tendon
E. Glenohumeral Joint Osteoarthritis
What is your diagnosis now?
A. Bicipital Tendonitis
B. Impingement Syndrome
C. Adhesive Capsulitis (Frozen Shoulder)
D. Tear of Supraspinatus Tendon
E. Glenohumeral Joint Osteoarthritis
Supraspinatus Tendon Tear
• Positive “Drop-Arm” Test
• Supraspinatus weakness
• External Rotation weakness
• Impingement Signs
• Greater than 60 years old
Murrell, Lancet 2001
Diagnosing Rotator Cuff Tear
# Positive signs* Age Probability of rotator cuff tear
All 3 Any 98%
Any 2 > 60 98%
Any 2 < 60 64%
Any 1 > 70 76%
Any 1 < 40 12%
None Any 5%
* supraspinatus weakness, weakness in external rotation,
positive impingement signs Murrell, Lancet 2001
Internal Rotation Lag Sign
Diagnosis of Rotator Cuff Tear
http://seattleclouds.com/myapplications/Albertosh/Shoulder/Exploramanguito.html
External Rotation Lag Sign
http://www.youtube.com/watch?v=7UsAcorKQUk
Test + LR - LR
Painful Arch (RCD) 3.7 0.36
Drop Arm (RCD) 3.3 0.82
External Resistance (RCD) 2.6 0.49
External Lag (Full Tear) 7.2 0.57
Internal Lag (Full Tear) 5.6 0.04
Hermans. JAMA, 2013 RCD=Rotator Cuff Disease
Clinical Tests for Rotator Cuff Disease and Tears
Internal Rotation Lag Sign
Diagnosis of Rotator Cuff Tear
External Rotation Lag Sign
A 55-year-old male with IDDM, HTN and
GERD presents with three months of
worsening left lateral shoulder pain,
which is worse at night. He reports pain
with most any movement. Range of
motion testing reveals pain and restricted
movement in most directions. Symptoms
are present with both passive and active
movement.
Adhesive Capsulitis or Frozen Shoulder
• Thickening and contraction of the capsule surrounding the glenohumeral joint
• Insidious onset of pain
• Night pain
• Pain in deltoid, but no tenderness to palpation
• Pain and limited active and passive ROM
• Need AP X-ray of glenohumeral joint to rule out glenohumeral arthritis
• Treatment: Physical Therapy
What is the most significant risk factor
for adhesive capsulitis?
A. Diabetes
B. Hypothyroidism
C. Immobility
D. AVN of glenohumeral head
E. Reflex sympathetic dystrophy
What is the most significant risk factor
for adhesive capsulitis?
A. Diabetes
B. Hypothyroidism
C. Immobility
D. AVN of glenohumeral head
E. Reflex sympathetic dystrophy
46 year old male who moves furniture on the weekends and works as a handyman during the week, presents with right anterior shoulder pain. The pain began after a particularly heavy move, where he moved over a hundred boxes. No fever, chills, night sweats; no weakness or numbness. No prior injuries.
He points to his anterior shoulder with one finger. He has a normal ROM and good strength and positive Yergason and Speed’s tests.
What is your diagnosis?
A. Bicipital Tendonitis
B. Impingement Syndrome
C. Adhesive Capsulitis (Frozen Shoulder)
D. Tear of Supraspinatus Tendon
E. Glenohumeral Joint Osteoarthritis
What is your diagnosis?
A. Bicipital Tendonitis
B. Impingement Syndrome
C. Adhesive Capsulitis (Frozen Shoulder)
D. Tear of Supraspinatus Tendon
E. Glenohumeral Joint Osteoarthritis
Anterior View of Shoulder
UpToDate, 2006
Biceps Tendonitis
• Inflammation of long head of the biceps tendon – 95% associated with impingement syndrome
• Repetitive lifting, overhead reaching or forearm supination
• Anterior humeral pain
• Tenderness in bicipital groove – Exacerbated with resisted elbow flexion or forearm
supination
– Yergason and Speed’s Tests
– Impingement signs
• Treatment – Rest, restriction of lifting, reaching and supination
– Anti-inflammatory therapy & Ice
– Physical Therapy Holtby, Arthroscopy 2004
Yergason Test
• Evaluate biceps tendon by palpating bicipital groove while patient flexes elbow to 90 degrees and supinates against resistance
Woodward, Am Fam Phys 2000
Speed’s Test
With elbow extended and
hand supinated, palpate
bicipital groove while
patient attempts to forward
flex shoulder 30
degrees against
resistance
Siegel, Am Fam Phys 1999
Which is the most likely diagnosis?
A 62 year old man was pulling a dead branch from a
tree when he felt a sudden pain in his upper arm and
heard an audible snap. Now, two weeks later, he
has no pain and only minimal loss of strength. His
exam is significant for the finding below.
A. Rotator cuff strain
B. Proximal biceps tendon rupture
C. Distal biceps tendon rupture
D. Biceps tendonitis
Which is the most likely diagnosis?
A 62 year old man was pulling a dead branch from a
tree when he felt a sudden pain in his upper arm and
heard an audible snap. Now, two weeks later, he
has no pain and only minimal loss of strength. His
exam is significant for the finding below.
A. Rotator cuff strain
B. Proximal biceps tendon rupture
C. Distal biceps tendon rupture
D. Biceps tendonitis
Biceps Tendon Tear
• Proximal aspect of long head of biceps tendon
• After especially vigorous lifting
• Often in setting of chronically inflamed tendon
• Weakness of elbow flexion/supination
• “Popeye Sign” - bulge just proximal to antecubital fossa
• Risk Factors:
– Recurrent tendonitis
– Prior tear of rotator cuff or biceps
– Age > 50
– RA
A proximal bicipital tendon tear can usually be treated conservatively, avoiding surgery.
A. True
B. False
A proximal bicipital tendon tear can usually be treated conservatively, avoiding surgery.
A. True
B. False
Summary
• Impingement syndrome most common cause of shoulder pain in the primary care setting
• Systematic approach to physical exam
• Range of Motion: pain with abduction, forward flexion; active > passive; painful arc
• Empty can, Neer, Hawkins tests to confirm
• Drop arm, internal and external lag signs indicate a complete tear - especially in patients > 60 years old
Summary
• Adhesive Capsulitis
– DM or Immobile shoulder
– Limited ROM in most planes
– Pain with both active passive ROM
• Biceps Tendonitis
– Associated with impingement syndrome
– Reproduced with Yergason and Speed’s tests
– “Popeye” sign for biceps tendon tear
Summary
A careful history and physical examination can correctly diagnose most common causes of shoulder pain.
http://jama.jamanetwork.com/multimediaPlayer.aspx?mediaid=5975016
Questions from the
Audience?