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					AIM Workshop Series- Shoulder John MacKnight, M.D. 1. “IMPINGEMENT SYNDROME” -Encompasses subacromial bursitis, rotator cuff tendonitis, or partial rotator cuff tears -80-85% of primary care shoulder pain visits -Repetitive compression of bursae/tendons between humeral head and acromion -Deep pain with radiation to sub-deltoid area; often painful at night -Painful ROM complaints, particularly rotational movements -High degree of dysfunction for activities at or above the level of the shoulder

2. FULL THICKNESS/ COMPLETE ROTATOR CUFF TEAR -Usually with at least modest trauma, but can be subtle -More common with increased age -Loss of active ROM, variable pain 3. ADHESIVE CAPSULITIS/ “FROZEN SHOULDER” -Progressive loss of shoulder ROM due to shrinking of glenohumeral capsule -Associated with many other shoulder pain syndromes and immobilization -Associated with acute medical problems (pneumonia, MI) and diabetes -Middle-aged women -Loss of active and passive range of motion -Pain is prominent early, then generally painless

4. ACROMIOCLAVICULAR ARTHRITIS/ SPRAIN -The most common site for osteoarthritis in the shoulder -Begins in our 20’s! -Gnawing, progressive, deep pain; worse at night; often disabling, exacerbated by adduction motion

-Sprain, or “separation,” presents similarly but with an obvious source of prior traumathere may be a discernible bony “step-off” of the AC joint

5. BICEPS TENDONITIS -Inflammation of long head of biceps- important forearm supinator -Anterior shoulder pain primarily exacerbated by forearm supination -Often arises along with impingement syndrome (tendon attachment on glenoid) 6. REFERRED PAIN -Most commonly from cervical spine: -C4 trapezius, C5 deltoid, C6 biceps/cuff, C7 triceps -There may be no neck pain complaint -Consider for any patient who is failing what appears to be appropriate management for a shoulder condition


PHYSICAL EXAM 1. INSPECTION -Assess relative shoulder height/symmetry -Assess for muscular atrophy -Assess for relative scapular placement

2. RANGE OF MOTION -Patient should do everything actively with both arms -Compare functional ability; compare relative speed of motions -Flexion- forward to 180 -Extension- backward to 80 -Abduction- 0- 180 (0-70 deltoid; 70-180 rotator cuff) -“Painful arc of abduction”- 70-130 (associated with impingement syndrome) -Internal rotation- hand to upper or lower back- compare sides -Loss of active ROM? -Full thickness cuff tear -“Drop arm” test (release arm at 130 abduction) -“Shrug sign”

-Adhesive capsulitis (active AND passive ROM loss) -Severe impingement syndrome 3. PALPATION -AC Joint- just lateral to rise of distal clavicle; small joint; palpate deeply with tip of finger and assess for pain

-Long head of biceps- at junction of deltoid and pectoralis major; palpate deeply with index and middle fingers, “snap” tendon under fingers by moving them medial/lateral 4. ROTATOR CUFF TESTING -Weak supraspinatus stress test (90 abduction/30 flexion, thumbs down)“empty can test,” “beer can test” -Weak/painful resisted internal (subscapularis)/external (infraspinatus/ teres minor) rotational testing (control the elbow)

5. IMPINGEMENT TESTS -Hawkins test- shoulder flexion, then passive internal rotation -Neer test- shoulder internal rotation, then passive flexion

6. BICEPS/AC JOINT TESTS -Yergason test- resisted forearm supination, for biceps tendonitis

-Crossed adduction- for AC joint pathology

7. SPURLING’S MANEUVER - Cervical rotation + extension (passive) closes cervical neuroforamina- will reproduce shoulder pain if due to nerve compression

Management Impingement Syndrome 1. 2. 3. 4. Activity modification Physical therapy to address rotator cuff weakness and any impairment in ROM NSAID’s Subacromial corticosteroid injection a. Posterolateral approach b. 40 mg Triamcinolone (Kenalog) + 5 cc 1% lidocaine without epi, 21 G needle

Rotator Cuff Tears 1. MRI early and refer early 2. Tendons will retract and cuff muscles will become atrophic if tear is not identified and repaired quickly 3. Poor management leads to glenohumeral arthritis- “cuff arthropathy” 4. Surgery for full-thickness rotator cuff tears or symptomatic partial tears Adhesive Capsulitis 1. Aggressive restoration of ROM passively through PT 2. Recommend PT ONLY for pain-free shoulders; often too painful initially to make any progress with PT until pain is improved 3. May start with subacromial injection

4. Fluoro-guided glenohumeral injections can be very helpful for pain control and improvement in capsular/synovial tightness 5. If refractory, consider manipulation under anesthesia AC Joint Arthritis Activity modification NSAID’s, Tylenol, Glucosamine/chondroitin, MSM, SAM-e PT AC joint injections either in the office or by radiology a. 10-20 mg Triamcinolone (Kenalog) + 1 cc 1% lidocaine without epi, 23 G needle 5. Surgery-distal clavicle resection with acromioplasty- if symptoms persist Biceps Tendonitis 1. 2. 3. 4. Activity modification Ice NSAID’s PT focusing on forearm supination strength and motion 1. 2. 3. 4.

Referred Pain/Cervical Spine 1. 2. 3. 4. 5. Plain x-rays of cervical spine +/- MRI NSAID’s Consider oral corticosteroids PT to optimize cervical strength and ROM If root compression seen on MRI, consider fluoroscopically-guided nerve block injection

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