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Evaluating shoulder injuries in primary care
Bethany Reed, MSn, AGPCNP-BC One Medical Group
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Disclosures
• There has been no commercial support or sponsorship for this program.
• The planners and presenters have declared that no conflicts of interest exist.
• The program co-sponsors do not endorse any products in conjunction with any educational activity.
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https://www.hss.edu/pcp.asp
https://www.hss.edu/professional-conditions_musculoskeletal-medicine-for-the-primary-care-physician-shoulder-exam.asp
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How often do you assess shoulder injuries in your practice?
A. Daily
B. Weekly
C. Monthly
D. Yearly
E. Never
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Session objectives
• Discuss anatomy of the shoulder joint.
• Identify common injuries/conditions of shoulder injuries in the primary care setting—including typical presentation and mechanisms of injury.
• Review physical examination skills and orthopedic testing.
• Participation analysis case scenarios for your reference to test your skills.
• Discuss operative and non-operative approaches for the treatment and rehabilitation process.
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Common shoulder injuries
• Acute Onset • Fractures • Dislocations/subluxations
• Sprains/strains • Contusions • Rotator cuff tears
• Bicep tendon ruptures • Calcific tendonitis
• Adhesive capsulitis
• Chronic • Osteoarthritis
• Rotator cuff impingement • Cervical disease
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Case Study
• 38 yo female right shoulder pain worsening 3 weeks after starting CrossFit program with heavy lifting. Pain began 2/10 and has progressed to 7/10. Pain comes and goes with overhead and cross body reach.
• Also c/o pain w/ sleeping on right side. Denies trauma. Doesn’t recall acute injury.
• Denies numbness, tingling in right extremity.
• Mild improvement w/ rest, ice, Advil.
• PMH: Asthma, HLD
• ROS: As above, all others negative
• VS: HR 78, RR 14, B/P 130/85, T 99.1
• Exam: Visual inspection unremarkable for edema, erythema, deformity. Tenderness over anterior GH joint. ROM limited flexion, abduction, and external rotation. (+) painful arc. (-) empty can, neurovascular intact
• (-) imaging
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Diagnosis
A. Acute rotator cuff tear
B. Labrum tear
C. AC separation
D. Osteoarthritis
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Shoulder anatomy
• Bony • Humerus
• Scapula
• Clavicle
• Joints • Scapulothoracic
• Glenohumeral
• Acromioclavicular
• Coracoclavicular
• Soft tissue • Trapezius, rhomboids, serratus,
pectoralis minor/major, latissimus dorsi, deltoids, SCM
• Rotator cuff—supraspinatus, infraspinatus, teres minor, subscapularis
• Capsule and ligaments
• Labrum
• Tendons • Rotator cuff tendons, long
head of biceps
• Subacromial and subdeltoid bursa
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http://hospitalforspecialsurgery.interactive.understand.
com/view/shoulder/rotator-cuff-anatomy
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Shoulder pain: Differential diagnoses
• Traumatic disorders
• Instability
• AC joint disease
• Rotator cuff disease • Tears • Bursitis/tendonitis
[impingement] • Calcific tendonitis
• Adhesive capsulitis (frozen shoulder)
• Osteoarthritis
• Cervical disease
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Rotator cuff pathology
• Impingement syndrome • Calcific tendonitis
• Rotator cuff tears • Partial thickness tears
• Full thickness tears
• Massive tears
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Musculoskeletal work-up
• History
• Inspection
• Palpation
• Range of Motion
• Other Tests
• Strength
• Neurovascular • Resisted wrist extension tests radial nerve, Resisted opposition of thumb test median
nerve, Resisted digit abduction tests the ulnar nerve
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history
• Age
• Hand dominance (RHD, LHD)
• Occupation
• CC: pain, weakness, instability, strength
• Location—where is the pain?
• What is the quality of the pain?
• Onset
• Precipitating and alleviating factors
• Associated medical conditions and social history • Most importantly
smoking!
• Previous treatments: surgeries, medications, PT, injections
• Neurological complaints: numbness, tingling, weakness
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Shoulder disorders by age
• Age 12-30 • Labral tears • Instability • Traumatic disorders
• Age 30-50 • Rotator cuff disease • Calcific tendonitis • Adhesive capsulitis
• Age 50-90 • Rotator cuff • Tears • Impingement • Calcific tendonitis
• Osteoarthritis • Adhesive capsulitis
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Algorithm
• History of severe trauma? Deformity? Severe acute pain? Fracture? Dislocation? • If Yes, refer for X-ray, A&E, specialist. • If No, do they have referred pain?
• Cervical pathology—degenerative disc disease, costochondritis, cardiac—myocardial ischemia, pericarditis, pulmonary—pneumonia, diaphragmatic irritation—ulcer
• If No, do they have systemic illness? Polymyalgia rheumatica, malignant tumor, brachial neuritis, Herpes Zoster, Paget’s Disease, Fibromyalgia
• If Yes, refer, investigate, treat accordingly
• If No. . . . .
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Algorithm
Acute
• Fractures of clavicle, humerus and scapula
• Glenohumeral dislocations
• AC joint sprain separation
• Rotator cuff injury/tear
Chronic
• Rotator cuff tendonitis (including biceps tendon/bursitis/tears)
• Frozen Shoulder (Adhesive Capsulitis)
• Arthritis of the glenohumeral joint
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Physical examination
• Observation/Inspection • Erythema
• Swelling
• Ecchymosis
• Deformity
• Bony or soft tissue
• Asymmetry
• Atrophy
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Shoulder and physical exam
• Palpation
• C spine
• Upper trapezius
• AC joint
• Long head of the bicep
• Greater tuberosity
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Shoulder and physical exam
• Range of Motion • Neck and shoulders
• Always compare bilaterally
• Active and passive
• Forward elevation
• External rotation
• Internal rotation with adduction (to vertebral level)
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Shoulder physical exam
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The empty can test should be done with the thumbs pointing up
toward the ceiling?
A. True
B. False
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Rotator cuff testing
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What is the name of this useful assessment test?
A. Empty Can test
B. Lachman test
C. Hawkins-Kennedy test
D. Neers test
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Testing • Infraspinatus and teres minor muscle
strength test—resisted external rotation—pain or weakness + for tendonopathy or tear
• Subscapularis muscle strength test—resisted internal rotation or push off test—adduct arm and internally rotate behind back resist patient’s hand as pushes hand away from back
• Hawkin’s-assesses for rotator cuff impingement—stabilize scapula, passively abduct shoulder to 90, flex shoulder to 30, flex elbow to 90 and internally rotate the shoulder--+ if painful . . . Also,
• Neer’s-stabilize scapula with thumb pointing down and passively flex arm--+ if painful
• Cross arm flexion test—AC arthritis or subluxation—flex shoulder 90 and adduct across body--+ pain at AC joint.
• Active ROM shoulder—flexion, extension, abduction, adduction, external rotation, internal rotation, posterior scratch test (adduction/external rotation) and (adduction/internal rotation)
• Assess strength of rotator cuff muscles—drop arm test—evaluates for supraspinatus muscle tear—abduct shoulder to 90, flex to 30, and point thumbs down—test is + if patient is unable to keep arm up after examiner releases
• Resistance known as Empty Can (Jobe’s test) test evaluates supraspinatus muscle strength--+ result indicates tendonopathy or tear
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Rotator cuff testing
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External rotation
• Positive findings: Decreased strength or pain on resisted testing.
• Significant weakness-suprascapular nerve palsy secondary to trauma, ganglion cyst or injury
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What shoulder muscle is this test assessing strength of?
A. Infraspinatus and teres minor
B. Pectoralis minor and serratus anterior
C. Supraspinatus and teres minor
D. All of the above
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Subscapularis lift-off test
• Evaluates the muscular strength of the subscapularis
• Positive findings: Inability to lift the dorsum of hand off the back
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Impingement/rotator cuff (Special Tests)
Neer’s Impingement
• Assesses the presence of impingement of the rotator cuff, primarily the supraspinatus, as it passes under the subacromial arch during forward flexion
• Positive findings: Pain in the anterior should or reproduction of the patient’s symptoms
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Hawkins Kennedy Impingement Test
• Evaluates impingement of rotator cuff and subacromial bursa.
• Positive findings: Pain in the anterior shoulder or reproduction of the patient’s symptoms with the test.
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Rotator cuff disease impingement syndrome
• Tendonitis/bursitis • Subacromial • Supraspinatus
• History: • Pain reaching to side and
back, overhead • Pain sleeping
• Physical exam findings: • Little to no weakness • + Neer’s Impingement • + Hawkins Kennedy • + Jobe’s/Empty can • + Scapular retraction
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Rotator cuff disease impingement syndrome
• Treatment • NSAID’s • Rehabilitation
• Postural training, periscapular stabilization, strengthening of rotator cuff and scapular muscles
• Posterior stretching • Activity modification
• Injections • Lidocaine +
corticosteroid
• Surgical intervention
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Calcific tendonitis
• Calcification within rotator cuff tendon supraspinatus
• ACUTE onset, very painful
• Painful arc of motion
• Treatment: • NSAID’s
• Injection
• PT
• Surgery
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Rotator cuff tears
• Follow impingement
• Can start small and progress
• Trauma
• Physical exam findings • Weakness
• TREATMENT
• Rehabilitation
• Injections
• Surgery • Arthroscopic repair • Not all tears require surgery
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Adhesive capsulitis—frozen shoulder
• Painful shoulder
• Restricted ROM • Insidious • Active and passive
• X-ray is normal
• Shoulder capsule thickens r/t inflammation
• Etiology • Idiopathic • Diabetes Mellitus • Post traumatic • Post surgical
• Treatment: • NSAID’s, PT, intra-articular
injection, TIME.
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Ac separation
• Various types
• Fall on tip of shoulder
• Possible bony deformity
• Pain on palpation of AC joint
• Pain on cross body adduction
• Differential diagnoses include AC arthropathy, AC osteoarthritis
• Treatment: • Sling for comfort • NSAID’s • PT • Surgery in severe cases
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Labral tear
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Speed’s test
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• Suspected labral tear
• No real reason for acute MRI
• Start PT and NSAID
• If no improvement in 6 weeks obtain MRI
• MRI shows labral tear
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Glenohumeral osteoarthritis
• Degenerative process
• Progressive pain
• Limitation in ROM • Active and passive • Forward elevation • External rotation • Internal rotation • Abduction
• Treatment: • NSAID’s • PT • Injections • Surgery—joint replacement
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SUMMARY
• With careful history and physical examination the diagnosis can be made in most cases . . . not everyone needs an MRI.
• MRI if suspected large rotator cuff tear, or in patients who fail to progress with other treatment.
• Never too much of a downside to giving someone 1-2 weeks of therapy or rest and re-examining the shoulder.
• At least from a surgeon standpoint . . . • Immediate MRI in everyone with work injury may lead to
incidental findings
• i.e. ‘What am I supposed to do with this information?’
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Keep in mind . . .
• Thoracic outlet syndrome
• Additional labral tear tests
• Spurling’s for cervical root impingement
• Glenohumeral joint sulcus
• Impingement signs
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Case Study
• 38 yo female right shoulder pain worsening 3 weeks after starting CrossFit program with heavy lifting. Pain began 2/10 and has progressed to 7/10. Pain comes and goes with overhead and cross body reach.
• Also c/o pain w/ sleeping on right side. Denies trauma. Doesn’t recall acute injury.
• Denies numbness, tingling in right extremity.
• Mild improvement w/ rest, ice, Advil.
• PMH: Asthma, HLD
• ROS: As above, all others negative
• VS: HR 78, RR 14, B/P 130/85, T 99.1
• Exam: Visual inspection unremarkable for edema, erythema, deformity. Tenderness over anterior GH joint. ROM limited flexion, abduction, and external rotation. (+) painful arc. (-) empty can, neurovascular intact
• (-) imaging
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