Download - Shoulder pain may 2014 ppt
Shoulder Pain Donna Guthery AOMA Graduate School of Integrative Medicine 2014
Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008
Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008
In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.
http://orthoinfo.aaos.org/topic.cfm?topic=a00071
Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008
See Hand out Left Shoulder Pain
HPI• 48 Yom accountant, former swimmer, Shoulder pain x 2
months
• No pain at rest, pain with abducting Left arm
• Achy, non radiating 6-7/10 with movement only, no numbness or tingling
• Pain over anterior and medial deltoid muscles
• Wakes him at night if arm is too adducted
• Ibuprofen 800 mig bid, not much relief, PT exercises
• Also h/o upper back pain x years, achy non radiating, comes and goes
Exam• 110/68, p: 66 rr: 18, AA, O x 3
• L shoulder ROM decreased, abduct to 30-40 º pain is 6/10 with movement, able to internally externally rotate at lesser degree, uses accessory muscles when attempting abduction
• Can place L arm behind back but unable to raise it to scapula
• Unable to assess resisted ROM d/t pain
• Shrugs shoulders without pain
neck• Rom 75º ish bil, flexion/ extension ok, some tension with
flexion chin to chest
• Lateral flexion shoulder to ear no pain
• Few myofascial knots bil splenius capitus C 2-5, levator scapula tension, large myofascial knot R medial trapezius
• Motor strength: 5/5 bil hand grasp, RUE 5/5 C 5-8, LUE C 5/6 difficult to assess d/t pain
Treatment
• Initially St 38 L and passive ROM with traction able to abduct L arm 10º more
• Added SI 4, SJ 5 , Lu 6, 7, LI 4 on Left with local trigger points
• GB 20 bil./e SI 13 bil/e, SI 10, 11,12 L, JJ C3 bil, C 5 bil, C 6 bil, T 1 bil, T 2 bil, T 3 bil,Jianqian L x 30 minutes using micro current
• Followed by cupping massage
• End of treatment: able abduct L arm to 80 degrees
• Rec: twice a week for two weeks, if responding well, once a week and re-eval prior/after to each tx for follow up
FreezingIn the "freezing" stage, slowly have more and more pain. As the pain worsens, shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.
FrozenPainful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.
ThawingShoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.
http://orthoinfo.aaos.org/topic.cfm?topic=a00071
Examination• Pain scale 0 – 10/10
• May find tenderness at bicipital groove
• May also have pain in upper back and neck d/t overuse of shoulder girdle muscles
• At rest may brace affected extremity against body
• Assess alignment of bones and soft tissues
• Assess postural alignment of cervical, thoracic, lumbar and humeral/scapular position (may find head forward, protracted scapula and thoracic kyphosis)
Brigham and Women’s Hospital Inc. Dept. of Rehabilitation Services 2010
Differential Diagnoses Biceps Rupture Biceps Tendinopathy Brachial Neuritis Cervical Disc Disease Cervical Myofascial Pain Cervical Spondyliosis Cervical Sprain and Strain Complex Regional Pain Syndromes Heterotopic Ossification Myelomeningocele
Neoplastic Brachial Plexopathy Parkinson Disease Psoriatic Arthritis Rheumatoid Arthritis Rotator Cuff Disease Shoulder and Hemiplegia Thoracic Outlet Syndrome Traumatic Brachial Plexopathy
http://orthoinfo.aaos.org/topic.cfm?topic=a00071
Muscle Origin on scapulaAttachment on
humerusFunction Innervation
Supraspinatus muscle
supraspinous fossasuperior and middle facet of the greater tuberosity
abducts the armSuprascapular nerve (C5)
Infraspinatus muscle
infraspinous fossaposterior facet of the greater tuberosity
externally rotates the arm
Suprascapular nerve (C5-C6)
Teres minor muscle
middle half of lateral border
inferior facet of the greater tuberosity
externally rotates the arm
Axillary nerve (C5)
Subscapularis muscle
subscapular fossalesser tuberosity (60%) or humeral neck(40%)
internally rotates the humerus
Upper and Lower subscapular nerve (C5-C6)
http://orthoinfo.aaos.org/topic.cfm?topic=a00071
Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008
Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008
FINDING PROBABLE DIAGNOSIS
Scapular winging, trauma, recent viral illness Serratus anterior or trapezius dysfunction
Seizure and inability to passively or actively rotate affected arm externally
Posterior shoulder dislocation
Supraspinatus/infraspinatus wasting
Rotator cuff tear; suprascapular nerve entrapment
Pain radiating below elbow; decreased cervical range of motion
Cervical disc disease
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
Shoulder pain in throwing athletes; anterior glenohumeral joint pain and impingement
Glenohumeral joint instability
Pain or “clunking” sound with overhead motion
Labral disorder
Nighttime shoulder pain Impingement
Generalized ligamentous laxity Multidirectional instability
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
Apley scratch test. The patient attempts to touch the opposite scapula to test range of motion of the shoulder. (Left) Testing abduction and external rotation. (Right) Testing adduction and internal rotation.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
Supraspinatus examination (“empty can” test). The patient attempts to elevate the arms against resistance while the elbows are extended, the arms are abducted and the thumbs are pointing downward.
Infraspinatus/teres minor examination. The patient attempts to externally rotate the arms against resistance while the arms are at the sides and the elbows are flexed to 90 degrees.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
TEST MANEUVER
DIAGNOSIS SUGGESTED BY POSITIVE RESULT
Apley scratch test Patient touches superior and inferior aspects of opposite scapula
Loss of range of motion: rotator cuff problem
Neer's sign Arm in full flexion Subacromial impingement
Hawkins' test Forward flexion of the shoulder to 90 degrees and internal rotation
Supraspinatus tendon impingement
Drop-arm test Arm lowered slowly to waist
Rotator cuff tear
Cross-arm test Forward elevation to 90 degrees and active adduction
Acromioclavicular joint arthritis
Spurling's test Spine extended with head rotated to affected shoulder while axially loaded
Cervical nerve root disorder
Apprehension test Anterior pressure on the humerus with external rotation
Anterior glenohumeral instability
Relocation test Posterior force on humerus while externally rotating the arm
Anterior glenohumeral instability
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
Sulcus sign Pulling downward on elbow or wrist
Inferior glenohumeral instability
Yergason test Elbow flexed to 90 degrees with forearm pronated
Biceps tendon instability or tendonitis
Speed's maneuver Elbow flexed 20 to 30 degrees and forearm supinated
Biceps tendon instability or tendonitis
“Clunk” sign Rotation of loaded shoulder from extension to forward flexion
Labral disorder
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
08
Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008
Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008
Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008
Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008
Hawkins' test for subacromial impingement or rotator cuff tendonitis. The arm is forward elevated to 90 degrees, then forcibly internally rotated.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
Cross-arm test for acromioclavicular joint disorder. The patient elevates the affected arm to 90 degrees, then actively adducts it.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
Apprehension test for anterior instability. The patient's arm is abducted to 90 degrees while the examiner externally rotates the arm and applies anterior pressure to the humerus.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
Yergason test for biceps tendon instability or tendonitis. The patient's elbow is flexed to 90 degrees, and the examiner resists the patient's active attempts to supinate the arm and flex the elbow
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
Sulcus test for glenohumeral instability. Downward traction is applied to the humerus, and the examiner watches for a depression lateral or inferior to the acromion.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
Spurling's test for cervical root disorder. The neck is extended and rotated toward the affected shoulder while an axial load is placed on the spine.
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
LIGAMENTS OR JOINT GRADE 1 GRADE 2 GRADE 3 GRADE 4 GRADE 5 GRADE 6
Acromioclavicular ligaments
Sprained Disrupted Disrupted Disrupted Disrupted Disrupted
Acromioclavicular joint
Intact Disrupted or slight vertical separation
Disrupted Disrupted Separated Ruptured
Coracoclavicular ligaments
Intact Sprained Disrupted or slight vertical separation
Disrupted Disrupted Disrupted
Woodward MD, T. & Best MD, T. The painful shoulder: Part II. Clinical evaluation. AM Fam Physician, 2000
IMAGING MODALITY ADVANTAGES DISADVANTAGES
MRI 95% sensitivity and specificity in detecting complete rotator cuff tears, cuff degeneration, chronic tendonitis and partial cuff tears
Often identifies an apparent “abnormality” in an asymptomatic patient
No ionizing radiation
Arthrography Good at identifying complete rotator cuff tear or adhesive capsulitis (frozen shoulder)
Invasive
Relatively poor at diagnosing a partial rotator cuff tear
Ultrasonography Accurately diagnoses complete rotator cuff tears
Less useful in identifying partial cuff tears
Operator-dependent interpretation
MRI arthrography Reliably identifies full-thickness rotator cuff tears and labral tears
Invasive
CT scanning May be useful in diagnosis of subtle dislocation
Ionizing radiation
RADIOGRAPH ABNORMALITY BEST VISUALIZED
AP view of glenohumeral joint Degenerative glenohumeral changes
AC joint AC degenerative changes
AC joint separation
Distal clavicle fracture
Axillary lateral view of shoulder Glenohumeral dislocation
Bony Bankart lesion*
Supraspinatus outlet (arch) Abnormality of acromion process
Degenerative changes of anterior acromion
Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000
Burbank et al, Chronic shoulder pain part I, Am Fam Physician
2008
References
Burbank MD, K., Stevenson MD, J, Czarnecki DO, G. &
Dorfman, DO, J. Chronic shoulder pain: Part I. evaluation and
diagnosis. Am Fam Physician. 2008 Feb 15:77(4):453-460.
Burbank MD, K., Stevenson MD, J, Czarnecki DO, G. &
Dorfman, DO, J. Chronic shoulder pain: Part II. Treatment.
Am Fam Physician. 2008 Feb 15:77(4):493-497.
Cheng, I. 2013 Thawing frozen shoulder-A case study and
clinical recommendations for the use of acupuncture in
treatment of adhesive capsulitis. The American Acupuncturist
V62, 25-29.
Deily DC, S. 2013 Class Notes
Hammer, D. 2012. Chinese scalp acupuncture relieves
pain and restores function in complex regional pain syndrome.
Military Medicine, vol. 177, Oct 2012.
He, D., Hostmark, A., Viersted, K., & Medbo, J. 2005.
Acupuncture in Medicine. 23(2):52-61.
Ma, T., Kao, M., Liu, I., Chiu, Y., Chien, C., Ho, T., Chu,
B. and Chang, Y. 2006. A study on the clinical effects of
physical therapy and acupuncture to treat spontaneous frozen
shoulder. The American Journal of Chinese Medicine, Vol. 34,
NO 5, 759-775.
Peilin, S. 2011. The Treatment of Pain with Chinese
Herbs and Acupuncture, Churchill Livingstone, Edinburgh.