Assessment and Treatment of Common Orthopedic Problems Indiana

Assessment and Treatment of Common Orthopedic Problems Mary Bennett FNP-S N664 Summer 2004 Common Shoulder Problems Rotator Cuff and Impingment Thoracic Outlet Syndrome Dislocation Tendonitis Bursitis Basic Shoulder Exam Technique Compare with opposite arm Test isometric strength (resisted) – Use standard Strength Grading in Motor Exam Interpretation Pain suggests tendonitis Weakness suggests Rotator Cuff Tear ROM Shoulder Exam Basic Exam Inspection from front and back Asymmetry – Disuse atrophy – Neurologic compromise Swelling and bruising Technique – Both shoulders exposed – Palpate for atrophy or swelling – Assess contour of shoulder – Palpate for tenderness over Acromioclavicular (AC) joint Biceps Tendon tenderness Greater tuberosity of Humerus (and supraspinatus) Grading of pain – No pain: 0 Mild pain: 1 Moderate: 2 Severe: 4 Specific Shoulder Tests Shoulder Range of Motion Shoulder Strength Exam Shoulder Instability Exam Shoulder Impingement Signs Basic ROM Tests Abduction and External Rotation Test Technique Compare both sides Reach over shoulders to "scratch" between scapulae – Measure to which vertebrae thumb can reach Actively resist moving scratching hand away from back – Tests Subscapularis strength Adduction and Internal Rotation Test Technique Compare both sides Reach behind back as if to scratch low back – Measure to which vertebrae thumb can reach Full or Empty Cans Test Hold arms to side as if holding cans bilaterally – Empty Cans test (original test) Wrists pronated as if emptying cans – Full Cans Test Wrists supinated as if holding cans upright May be more specific for Supraspinatus impingement Hold arm abducted at 50 degrees against resistance Speed’s Test for biceps tendinitis Arm is fully extended anteriorly, palm facing up. The examiner pushes down on the hand as the patient resists. Pain in the anterior shoulder is a positive test for biceps tendinitis. http://www.aafp.org/afp/980215ap/fongemie.html Rotator Cuff Four muscles--the subscapularis, the supraspinatus, the infraspinatus and the teres minor--and their tenndinous attachments. A bursa in the subacromial space provides lubrication for the rotator cuff Tests for rotator cuff tears Drop arm test: – – – – – Patient abducts arm to 90 degrees Patient slowly lowers arm Interpretation: Signs of Rotator Cuff Tear Arm drops to side quickly and not smoothly Gentle tap over abducted arm may force arm to give way Strength Test Have patient hold arm straight out, level with the shoulder, with palm facing down (hand in a fist). Press down on patient fists to determine strength in this position. Empty Can Test Client may stand or sit. Position the shoulders at 45 degrees of horizontal abduction with the shoulder fully internal rotated (thumbs down) Apply 5 pounds of pressure at the wrist Ask the client to maintain the position Inability to maintain the position may indicate a tear of the rotator cuff and involvement of the supraspinatus. http://www.medfitcd.com/empty_can_test.htm Lift Off Test The subscapularis lift-off test of Gerber and Krushell is performed with the arm internally rotated behind the back with the elbow flexed. The patient pushes away from the back against resistance, keeping the elbow flexed; inability to push away indicates subscapularis injury. X-Ray Testing Plain radiographs, while not as useful for detecting soft tissue damage, can be useful in ruling out calcific tendonitis and predisposing factors such as type III acromions or acromioclavicular joint arthritis. The three recommended views – anteroposterior view with the arm at 30 degrees external rotation, – outlet Y view – axillary view. Other Tests Ultrasonography Non- invasive relatively inexpensive, but may not show what you are looking for. Arthrography (invasive and expensive). Magnetic resonance imaging, although expensive, provides the best imaging mode for rotator cuff pathology Ultimately, arthroscopy is the best diagnostic modality, but is expensive and invasive. Impingement The space between the undersurface of the acromion and the humeral head is called the impingement interval. This space is normally narrow and is maximally narrow when the arm is abducted. Any condition that further narrows this space can cause impingement. Impingement can result from extrinsic compression or from loss of competency of the rotator cuff. Symptoms of Impingement Pain, weakness and loss of motion are the most common symptoms reported. Pain is exacerbated by overhead or above-theshoulder activities. A frequent complaint is night pain, often disturbing sleep, particularly when the patient lies on the affected shoulder. The onset of symptoms may be acute, following an injury, or insidious, particularly in older patients, where no specific injury occurs. Stages of Impingement Stage I – – – – edema and/or hemorrhage. Usually less than 25 YO frequently associated with overuse Usually reversible. Stage II – patients 25 to 40 years of age. – Fibrosis and irreversible tendon changes. Stage III – generally over 50 years of age – frequently involves a tendon rupture or tear. – process of attrition and the culmination of fibrosis and tendinosis that have been present for many years. Assessment for signs of impingement All the impingement tests involve moving the shoulder passively with approximately 5 to 10 lb of force directed down on the top of the shoulder which narrows the subacromial space. The examiner tests to see if pain appears with these maneuvers and disappears when the examiner removes the downward acromial push. Impingement I Passive forward elevation with slight internal rotation while applying pressure to top of shoulder. Impingement II Passive Abduction 90 degree external rotation while applying downward pressure on shoulder Impingement III Passive abduction 90 degree internal rotation while applying downward pressure Impingement IV Passive Adduction (Crossover) with 90 degree bend and downward pressure. Crossover Exam Indication Shoulder Exam Differentiates AC joint disease from impingement Technique Adduct arm across front of chest Touch opposite shoulder Interpretation: Pain indicates a positive test Acromioclavicular joint disease Sternoclavicular joint disease Differential Diagnosis Calcific tendinitis – 30 to 50 years of age. – usually in the supraspinatus tendon. Acromioclavicular arthritis – Radiographs show the degenerative changes. Dislocated shoulder Adhesive capsulitis (frozen shoulder) – Capsule of the joint becomes fibrosed. X-Ray Findings and Treatment of Impingement Radiographs may be normal or may show outlet obstruction (spurs, type 2 or type 3 acromion), aided with lidocaine injection Conservative treatment involves resting and stopping the offending activity. It may also involve prolonged physical therapy. Sport and job modifications may be beneficial. Nonsteroidal anti-inflammatory drugs (NSAIDS) and ice treatments can relieve pain. Ice packs applied for 20 minutes three times a day may help. A sling is never used, because adhesive capsulitis can result from immobilization. Indications for Therapeutic injectionsLidocaine plus a corticosteroid Impingement that does not improve with conservative treatment Older patients with clearly operable lesions, such as subacromial spurs, who are not good surgical candidates. As a diagnostic technique. If a patient fails to improve following a subacromial space injection and has normal radiographs the rotator cuff may not be the problem. For temporary pain relief in a patient with an operable lesion. Injection Medication 8 to 9 mL of lidocaine (Xylocaine), 1 percent, mixed with either – 20 mg of triamcinolone (20 mg per mL) – Or methylprednisolone (Depo-Medrol), 20 mg per mL, – Or betamethasone (Celestone), 6 mg per mL. – The large volume floods the rotator cuff surface. – 1.5-in, 22-gauge needle usually works well. Injection Technique Posterior subacromial approach is perhaps the easiest. By angling the needle to the underside of the acromion, the physician can easily verify that the needle is properly positioned and there is no danger of hitting the humoral head. It is important not to inject directly into the tendon and, if resistance to flow is encountered, the needle should be directed away from the site. Use a maximum of two injections at least 3 months apart, Prescribe 1 week of rest from resistance exercises after an injection. Surgery A rotator cuff tear is not, in itself, an indication for surgery. Survey studies using MRI have shown a high incidence of unsuspected full or partial tears of the rotator cuff in asymptomatic adults. Most older patients with impingement and rotator cuff tears actually do well without surgery. Surgery might be considered in a patient who has failed to improve after six months of conservative treatment or in a patient less than 60 years of age with a debilitating tear that impairs function. Dislocation Patient's Start Position – Elbow flexed 90 degrees – Shoulder abducted 90 degrees Apprehension Maneuver – Examiner holds patient's wrist – Apply forward pressure from behind shoulder – Externally rotate shoulder – Positive if produces pain Relocation http://www.umm.edu/ outdoor/shoulder_disl ocation.htm This site has information on relocation of a dislocated shoulder if you are in a field setting without access to standard medical care. Relocation Maneuver – – – – Perform if Apprehension Test Positive Continue external rotation as above Apply backward pressure from front of shoulder Positive if pain reduced from Apprehension Test Interpretation Positive Apprehension Test – Pain reduced on Relocation Test Anterior Shoulder Instability – Pain NOT relieved on Relocation Test Acromioclavicular Impingement Negative Apprehension Test – No obvious anterior Disability Shoulder References Management of Shoulder Impingement Syndrome and Rotator Cuff Tears ALLEN FONGEMIE, M.D., DANIEL BUSS, M.D., & SHARON ROLNICK, PH.D. American Family Physician, Feb 15, 1998 http://www.aafp.org/afp/980215ap/fongemie.html Family Practice Notebook: http://www.fpnotebook.com/ORT114.htm Shoulder Exam