shoulder pain2017/10/31 · drop arm test purpose: tears in the rotator cuff, primarily...
TRANSCRIPT
SHOULDER PAINA Real Pain in the Neck
Michael Wolk, MDNortheastern Rehabilitation Associates
October 31, 2017
THE SHOULDER JOINT (S)
1. glenohumeral
2. suprahumeral
3. acromioclavicular
4. scapulocostal
5. sternoclavicular
6. costosternal
7. costovertebral
ROTATOR CUFF MUSCLES
Supraspinatusattach to greater tubercle from above
(Abduct)
Infraspinatusattach to greater tubercle posteriorly (Ext. Rot.)
Teres Minorattach to greater tubercle posteriorly (Ext. Rot.)
Subscapularisattach to lesser tubercle anterior (Int. Rot.)
RANGE OF MOTION
MOVEMENT NORMAL RANGE
Forward Flexion 180o
Extension (behind back) 40o
Abduction 180o (with palms up)
Adduction 0o
External rotation* 45o (arm at side, elbow flexed)
Internal rotation* 55o (arm at side, elbow flexed)
FORWARD FLEXION
Arm straight and brought upward through frontal plane, and move as far as patient can go above his head
0° is defined as straight down at patient's side, & 180° is straight up
ABDUCTION
Arm straight
Hand – palm up (arm
supinated)
ROM measured in degrees
as for forward flexion
EXTERNAL AND INTERNAL ROTATION
Arm at side, elbow flexed to 90° and held at waist
Examiner externally or internally rotates arm
APLEY SCRATCH TEST FOR ER/IR*
• Internal rotation and adduction
• Reach for lower scapula• Compare bilaterally –
note level reached
• External rotation and abduction
• Reach for upper scapula• Compare bilaterally –
note level reached
STRENGTH TESTS
Flexion Extension
STRENGTH TESTS*
External rotation
• Infraspinatus
• Teres minor
Internal rotation
• Subscapularis
STRENGTH TESTS
Empty can test*
• Supraspinatus
Lift off test*
• Subscapularis
SPECIAL TESTS
•Drop arm testRotator cuff
•Neer’s sign
•Hawkin’s test
Impingement tests
•Biceps tendonSpeed’s test
•O’Brien’s test
•Crank testLabral tear
•Anterior release
•Relocation testInstability tests
ROTATOR CUFF
Empty Can Test
•Supraspinatus
Lift off test
•Subscapularis integrity
Drop Arm Test
•Rotator cuff tear or supraspinatus dysfunction
DROP ARM TEST Purpose: tears in the rotator cuff,
primarily supraspinatus muscle
Method: patient abducts (or examiner passively abducts) arm and then slowly lowers it May be able to lower arm slowly to 90° (deltoid
function)
Arm will then drop to side if rotator cuff tear
Positive test: patient unable to lower arm further with control If able to hold at 90º, pressure on wrist will
cause arm to fall
IMPINGEMENT – NEER’S SIGN*
Patient seated with arm at side, palm down (pronated)
Examiner standing
Examiner stabilizes scapula and raises the arm (between flexion and abduction)
Positive test = pain
IMPINGEMENT – HAWKIN’S TEST*
Patient standing
Examiner forward flexes shoulder to 90°, then forcibly
internally rotates the arm
Positive test = pain in area of
superior GH joint or AC joint
SPEED’S TEST - BICEPS TENDON
Forward flex shoulder against
resistance while maintaining
elbow in extension and
forearm in supination
Positive test = tender in
bicipital groove (bicipital tendinitis)
LABRAL TEAR (SLAP) O'Brien's Active Compression Test
Patient standing
Arm forward flexed 90°, adducted 15° to 20°with elbow straight
Full internal rotation so thumb pointing down
Examiner applies downward force on arm -patient resists
Patient externally rotates arm so thumb pointing up
Examiner applies downward force on arm -patient resists
Positive test = Pain or painful clicking elicited with thumb down and decreased or eliminated with thumb up
LABRAL TEAR Crank Test
Shoulder elevated to 160° in the
scapular plane
A gentle axial load is applied through
glenohumeral joint with one hand,
while other hand does IR and ER
Positive test = pain, catching, or
clicking in the shoulder
ROTATOR CUFF TEAR MRI ULTRASOUND
SHOULDER PATHOLOGY
1. 90 asymptomatic adults between the ages of 30 and 99
years using ultrasound
2. No statistically significant difference in the dominant arms
or between genders
3. Increased prevalence as age
Continued…
J Bone & Joint Surgery. 1995 March;77B(2):296-298.
SHOULDER PATHOLOGY
4. Partial of Full thickness tears present in:➢ 15% 40-49 year old
➢ 35% 50-59 year old
➢ 55% 60-69 year old
➢ 75% 70-79 year old
➢ 85% 80-99 year old
5. Regard RTC tears as normal part of aging
6. Recommend treatment based on clinical findings,
not on imaging results
J Bone & Joint Surgery. 1995 March;77B(2):296-298.
SHOULDER PATHOLOGY
J Shoulder Elbow Surgery. 1999 Jul-Aug;8(4):296-9.– 411 asymptomatic volunteers – u/s
– Tears RTC 23% overall
Number Age - yrs % RTC tears
Group 1 167 50 - 59 13
Group 2 108 60 - 69 20
Group 3 87 70 - 79 31
Group 4 49 >= 80 51
SHOULDER PATHOLOGY
• Regard RTC tears as normal part of degeneration
• Not a cause of pain or functional impairment
J Shoulder Elbow Surgery. 1999 Jul-Aug;8(4):296-9.
J Bone Joint Surg Br. 2009 Feb;91(2):196-200.
Moosmayer S, Smith HJ, Tariq R, Larmo A.
• Clinical and ultrasonographic examination of shoulders of
420 asymptomatic volunteers aged between 50 and 79
years. MRI was performed in selected cases
• Full-thickness tears of the rotator cuff were detected in 32
subjects (7.6%)
SHOULDER PATHOLOGY
"Prevalence and characteristics of asymptomatic tears of
the rotator cuff: an ultrasonographic and clinical study“
• Prevalence increased with age:
– 50 to 59 years, 2.1%
– 60 to 69 years, 5.7%
– 70 to 79 years, 15%
• Tear localization was limited to the supraspinatus tendon in most
cases (78%)
• Asymptomatic tears of the rotator cuff should be regarded as
part of the normal aging process
SHOULDER PATHOLOGY
DIAGNOSIS
Recommend treatment based on clinical findings and not on imaging results
Consider other diagnosis of shoulder weakness
PHYSICAL EXAM The Power Of “P”
d
NERVES
• All shoulder joint muscles are innervated from the brachial plexus
• Lateral pectoral nerve arising from C5, C6, & C7– Pectoralis major (clavicular head)
• Medial pectoral nerve arising from C8 & T1– Pectoralis major (sternal head)
• Thoracodorsal nerve arising from C6, C7, & C8– Latissimus dorsi
NERVES
• Axillary nerve branching from C5 & C6– Deltoid
– Teres minor
– Sensation to lateral patch of skin over deltoid region of arm
• Upper subscapular nerves arising from C5 & C6– Subscapularis
NERVES• Lower subscapular nerve arising from C5 & C6
– Subscapularis
– Teres major
• Suprascapula nerve originating from C5 & C6
– Supraspinatus
– Infraspinatus
NERVES
• Musculotaneous nerve
branching from C5, C6, & C7
– Coracobrachialis
– Sensation to radial aspect of
forearm
NERVE ROOTBrachial Plexus Injuries
The common mechanism for traction injuries of the brachial plexus is violent distraction of the entire arm from the rest of the body.
These injuries usually result from a motorcycle accident or a high-speed motor vehicle accident.
A fall from a significant height may also result in brachial plexus injury, either traction type or from a direct blow.
SYMPTOMS
Pain, especially of the neck and shoulder.
Pain in a nerve distribution is common with rupture, as opposed to lack of percussion
tenderness with avulsion
Paresthesias and dysesthesias
Weakness or heaviness in the extremity
NERVE ROOTBrachial Plexus Injuries
Cervical
RootClinically Relevant Gross Motor Function
C5 Shoulder abduction, extension, and external rotation; some
elbow flexion
C6 Elbow flexion, forearm pronation and supination, some wrist
extension
C7 Diffuse loss of function in the extremity without complete paralysis of a specific muscle group, elbow extension,
consistently supplies the latissimus dorsi
C8 Finger extensors, finger flexors, wrist flexors, hand intrinsics
T1 Hand intrinsics
NERVE ROOTBrachial Plexus Injuries
Numbness and weakness in the upper extremity may persist.
Symptoms are reproduced by extending, and side bending
the neck.
Function gradually returns from the proximal muscle groups to
the distal muscle groups.
OUTLINE OF THE CAUSES OF PAIN FELT
IN THE UPPER EXTREMITY
OUTLINE OF THE CAUSES
OF PAIN FELT IN THE UPPER
EXTREMITY
OUTLINE OF THE CAUSES
OF PAIN FELT IN THE UPPER
EXTREMITY
OUTLINE OF THE CAUSES
OF PAIN FELT IN THE
UPPER EXTREMITY