shoulder 101 …and then some evan d. ellis md rebound orthopaedics and sports medicine

Shoulder 101 Shoulder 101 …and Then Some…and Then Some

Evan D. Ellis MDEvan D. Ellis MD

Rebound Orthopaedics Rebound Orthopaedics and Sports Medicineand Sports Medicine

Why Shoulder 101?Why Shoulder 101?

Multiple studies: High percentage Multiple studies: High percentage of visits to see PCP are for of visits to see PCP are for musculoskeletal painmusculoskeletal pain

2 studies2 studies**: Large gap in PCP : Large gap in PCP confidence in evaluating and confidence in evaluating and treating musculoskeletal injuriestreating musculoskeletal injuries

Studies in both a rural and Studies in both a rural and tertiary academic settingtertiary academic setting

*Lynch et al JBJS AM 2006 and AJO 2005*Lynch et al JBJS AM 2006 and AJO 2005

The ShoulderThe Shoulder ANATOMYANATOMY

HISTORY HISTORY

PHYSICAL EXAMPHYSICAL EXAM

IMAGINGIMAGING

CASES/CASES/TREATMENTTREATMENT

AnatomyAnatomy

Not a ball and Not a ball and socketsocket

More of a ball More of a ball on a dishon a dish

Static Static RestraintsRestraints

Dynamic Dynamic RestraintsRestraints

AnatomyAnatomy

Glenoid Concavity:Glenoid Concavity:• BoneBone• CartilageCartilage• LabrumLabrum

AnatomyAnatomy LabrumLabrum: :

Deepens glenoid by 50%Deepens glenoid by 50% 9 mm superoinferior*9 mm superoinferior*

5 mm anteroposterior*5 mm anteroposterior*

Contributes to 20% of Contributes to 20% of stability in A-P directionstability in A-P direction

Loss of labral integrity may Loss of labral integrity may result in instabilityresult in instability

*McMahon et al. JSES. 2004. Jan-Feb;13(1):39-44.*Howell SM, Galinat BJ. The glenoid-labral socket: a constrained articular surface. Clin Orthop. 1989

AnatomyAnatomy

Static RestraintsStatic Restraints Glenohumeral LigamentsGlenohumeral Ligaments

Superior: Prevents inferior Superior: Prevents inferior translation with arm at sidetranslation with arm at side

Middle: Important for mid-Middle: Important for mid-range abductionrange abduction

Inferior: Critical for ABD/ERInferior: Critical for ABD/ER Anterior band prevents anterior Anterior band prevents anterior

inferior translationinferior translation

AnatomyAnatomy• Ligaments do not center Ligaments do not center the head. the head. • Limit its translation and Limit its translation and rotation.rotation.• Think Check-RainsThink Check-Rains

AnatomyAnatomyDynamic RestraintsDynamic Restraints Muscular StabilizersMuscular Stabilizers

Anterior: SubscapularisAnterior: Subscapularis

Superior: SupraspinatusSuperior: Supraspinatus

Posterior: Teres minor and Posterior: Teres minor and InfraspinatusInfraspinatus

Lateral: DeltoidLateral: Deltoid

Scapular stabilizersScapular stabilizers

History BasicsHistory Basics

Painful shoulders can be:Painful shoulders can be: UnstableUnstable StiffStiff WeakWeak Rough/PainRough/Pain

““What bothers you about What bothers you about your shoulder?your shoulder?””

HistoryHistory

AgeAge GenderGender Was there an Was there an

injury?injury? Injury mechanismInjury mechanism Prior problemPrior problem Dominant armDominant arm

HistoryHistory

ChronicityChronicity Location of PainLocation of Pain Pain at nightPain at night Stiffness/UnstableStiffness/Unstable Prior treatment Prior treatment

Physical ExamPhysical Exam Goal: Reproduce SymptomsGoal: Reproduce Symptoms

Inspection, Palpation, ROM, Inspection, Palpation, ROM, neurovascular exam, special neurovascular exam, special teststests

Compare to contralateral sideCompare to contralateral side

Cervical spineCervical spine

Note provocative positionsNote provocative positions

Physical ExamPhysical Exam

EXPOSE:EXPOSE: NeckNeck ShouldersShoulders ArmsArms

Physical ExamPhysical Exam

EXPOSE:EXPOSE: NeckNeck ShouldersShoulders ArmsArms

Women need gown Women need gown or tank top!or tank top!

Physical ExamPhysical Exam

Motion: Active/PassiveMotion: Active/Passive Forward ElevationForward Elevation External RotationExternal Rotation ER in AbductionER in Abduction Internal RotationInternal Rotation IR in AbductionIR in Abduction X-BodyX-Body

Range of MotionRange of Motion FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine

X-Body: 60X-Body: 60

Range of MotionRange of Motion

FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine

X-Body: 60X-Body: 60

Range of MotionRange of Motion

FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine

X-Body: 60X-Body: 60

Range of MotionRange of Motion

FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine

X-Body: 60X-Body: 60

Range of MotionRange of Motion

FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine

X-Body: 60X-Body: 60

Range of MotionRange of Motion

FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine

X-Body: 60X-Body: 60

Rotator Cuff ExamRotator Cuff Exam

MOTOR MOTOR SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor

Rotator Cuff ExamRotator Cuff Exam

MOTOR MOTOR SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor

Rotator Cuff ExamRotator Cuff Exam

MOTOR MOTOR SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor

Rotator Cuff ExamRotator Cuff Exam

MOTOR MOTOR SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor

Rotator Cuff ExamRotator Cuff Exam

MOTOR MOTOR SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor

Neurologic ExamNeurologic Exam

NEURONEURO SensationSensation MotorMotor ReflexesReflexes SpurlingSpurling’’ss

Neurologic ExamNeurologic Exam

NEURONEURO SensationSensation MotorMotor ReflexesReflexes SpurlingSpurling’’ss

Special Tests - CuffSpecial Tests - Cuff

CUFFCUFF Neer Impingement Neer Impingement

SignSign Neer Impingement Neer Impingement

TestTestSubacromial Subacromial

injectioninjection Hawkins Test Hawkins Test

Special Tests - CuffSpecial Tests - Cuff

CUFFCUFF Neer Impingement Neer Impingement

SignSign Neer Impingement Neer Impingement

TestTestSubacromial Subacromial

injectioninjection Hawkins TestHawkins Test

Special Tests - CuffSpecial Tests - Cuff CUFFCUFF

Neer Impingement Neer Impingement SignSign

Neer Impingement Neer Impingement TestTestSubacromial Subacromial

injectioninjection Hawkins Test Hawkins Test

Special Tests - InstabilitySpecial Tests - Instability Apprehension/RelocationApprehension/Relocation

Supine positionSupine position Stabilizes scapulaStabilizes scapula

Abduct to 90Abduct to 90°° Increase ER graduallyIncrease ER gradually

Positive:Positive: Apprehension w/ Apprehension w/

increasing amounts of increasing amounts of ERER

Apprehension relieved Apprehension relieved by posterior force on by posterior force on the humerusthe humerus

Special Tests - InstabilitySpecial Tests - Instability

Seated Load & ShiftSeated Load & Shift Assess A & P translationAssess A & P translation

Grade Grade 1+: to rim1+: to rim 2+: over rim 2+: over rim

w/reductionw/reduction 3+: over rim & locked3+: over rim & locked

Compare to other sideCompare to other side

Assess for pain, click, & Assess for pain, click, & instabilityinstability

Special Tests - InstabilitySpecial Tests - Instability

Supine Load & ShiftSupine Load & Shift Arm position: Arm position:

45-6045-60°° abduction abduction

Ant/Post directed force Ant/Post directed force applied to humerusapplied to humerus

AssessAssess StabilityStability PainPain Palpable clickPalpable click

Special Tests - InstabilitySpecial Tests - Instability

Sulcus Sign: Sulcus Sign: Arm at sideArm at side

To look for multi-directional To look for multi-directional instabilityinstability GradeGrade

1+ = 1 cm1+ = 1 cm 2+ = 1-2 cm2+ = 1-2 cm 3+ = > 2 cm3+ = > 2 cm

Look for generalized Look for generalized hypermobilityhypermobility

RadiographsRadiographs

Never order an MRI before X-RaysNever order an MRI before X-Rays

Everyone deserves a normal set of X-Rays!Everyone deserves a normal set of X-Rays!

Most important X-Rays: Most important X-Rays: True APTrue AP (Grashey) (Grashey) and and Axillary LateralAxillary Lateral

These two X-Rays are almost always omitted These two X-Rays are almost always omitted from a from a ““shoulder seriesshoulder series””!!

RadiographsRadiographsTrue AP or Grashey View:• Arthritis• Fracture• Massive Rotator Cuff tear

RadiographsRadiographs

True APTrue AP

RadiographsRadiographs Axillary LateralAxillary Lateral

ArthritisArthritis InstabilityInstability FractureFracture

RadiographsRadiographs Axillary LateralAxillary Lateral

RadiographsRadiographs

Additional ViewsAdditional Views Outlet Outlet Internal/ExternalInternal/External Stryker NotchStryker Notch West Point ViewWest Point View

The ShoulderThe ShoulderA.A. Diagnosable & TreatableDiagnosable & Treatable

Rotator cuff tearsRotator cuff tears Shoulder instability Shoulder instability ArthritisArthritis SLAP tearSLAP tear

B.B. Diagnosable & UntreatableDiagnosable & Untreatable Brachial neuritisBrachial neuritis Voluntary instability/MDIVoluntary instability/MDI Rib fracturesRib fractures

Age is KeyAge is Key

Age is KeyAge is Key

Case #1Case #1

History:History: 16 year old RHD 16 year old RHD

male football playermale football player Shoulder Shoulder ““poppedpopped””

out of place while out of place while getting tackledgetting tackled

To ER for reductionTo ER for reduction Has happened 2 Has happened 2

previous timesprevious times

Case #1Case #1

Physical Exam:Physical Exam: Full Range of MotionFull Range of Motion Full rotator cuff Full rotator cuff

strength strength + Apprehension Test+ Apprehension Test + Relocation Test+ Relocation Test + Anterior Load & + Anterior Load &

ShiftShift

Case #1Case #1

Case #1Case #1

What do you do?What do you do?

Place him in a slingPlace him in a sling Refer to OrthoRefer to Ortho If first time dislocater – Physical If first time dislocater – Physical

TherapyTherapy If 2 or more dislocations – MRI and If 2 or more dislocations – MRI and

surgerysurgery

SlingSlingRegular Sling vs. External RotationRegular Sling vs. External Rotation

Which is better?Which is better?

Itoi, JBJS 2007Itoi, JBJS 2007 159 patients159 patients Avg follow up of 25.6 monthsAvg follow up of 25.6 months 74 immobilized in IR74 immobilized in IR

31 recurred (42%)31 recurred (42%) 85 immobilized in ER85 immobilized in ER

22 recurred (26%)22 recurred (26%) *Effect on labral position for *Effect on labral position for

healinghealing

Case #1Case #1

Case #1Case #1Arthroscopic Repair

Case #2Case #2History:History: 41 yo female with gradual onset 41 yo female with gradual onset

pain/stiffness over 6 weekspain/stiffness over 6 weeks No history of traumaNo history of trauma Similar problem with other shoulder 2 years Similar problem with other shoulder 2 years

priorprior Hx of DiabetesHx of Diabetes CanCan’’t brush hair or fasten brat brush hair or fasten bra

Case #2Case #2

Physical Exam:Physical Exam: Forward Elevation – 80Forward Elevation – 80 External Rotation – NeutralExternal Rotation – Neutral Internal Rotation – Back PocketInternal Rotation – Back Pocket Full strength of rotator cuffFull strength of rotator cuff CanCan’’t get arm to side to check for instabilityt get arm to side to check for instability

Case #2Case #2

RadiographsRadiographs

Case #2Case #2 Diagnosis???Diagnosis??? Adhesive Capsulitis/Frozen ShoulderAdhesive Capsulitis/Frozen Shoulder

Treatment???Treatment??? If nothing done, may take 2 years to resolveIf nothing done, may take 2 years to resolve PT, PT, PTPT, PT, PT If fails: Intraarticular cortisone shot and If fails: Intraarticular cortisone shot and

more PTmore PT If fails: Manipulation under anesthesiaIf fails: Manipulation under anesthesia If fails: Arthroscopic capsular releaseIf fails: Arthroscopic capsular release

Case #2Case #2 What would MRI show with adhesive What would MRI show with adhesive

capsulitis?capsulitis?

NormalNormal

Case #2Case #2

Case #3Case #3

History:History: 49 yo male fell down stairs and grabbed 49 yo male fell down stairs and grabbed

railing on way down.railing on way down. Felt ripping sensation in shoulderFelt ripping sensation in shoulder Pain on lateral aspect of shoulderPain on lateral aspect of shoulder Pain with overhead activityPain with overhead activity Night painNight pain PoppingPopping Feels weakFeels weak

Case #3Case #3Physical Exam:Physical Exam: Pain/crepitus with Pain/crepitus with

forward elevationforward elevation Positive Impingement Positive Impingement

SignSign Positive Hawkins TestPositive Hawkins Test Weakness with Weakness with

supraspinatus testingsupraspinatus testing No instabilityNo instability

Case #3Case #3

Case #3Case #3

Case #3Case #3Diagnosis??Diagnosis?? Acute rotator cuff tearAcute rotator cuff tear

Treatment??Treatment?? Refer to orthoRefer to ortho Acute, full-thickness Acute, full-thickness

cuff tear in a cuff tear in a ““youngyoung”” patient = surgical patient = surgical repairrepair

Case #4Case #4

History:History: 48 yo RHD male48 yo RHD male 6 months shoulder pain6 months shoulder pain No injuryNo injury Pain at nightPain at night Pain with reaching overheadPain with reaching overhead NSAIDS no helpNSAIDS no help No neck pain/numbness/tinglingNo neck pain/numbness/tingling

Case #4Case #4

Physical Exam:Physical Exam: Full ROMFull ROM + Impingement Sign+ Impingement Sign + Hawkins Test+ Hawkins Test Full Strength of CuffFull Strength of Cuff Pain with Pain with

supraspinatus supraspinatus testingtesting

Case #4Case #4

Case #4Case #4

Diagnosis?Diagnosis? Rotator Cuff Tendonitis vs. Rotator Cuff Tendonitis vs.

Partial Thickness TearPartial Thickness Tear

Treatment?Treatment? Physical TherapyPhysical Therapy If no improvement = Refer to If no improvement = Refer to

Ortho Ortho

Case #4Case #4

What do we do?What do we do? MRIMRI If MRI = If MRI = Cortisone Cortisone

injectioninjection If MRI = If MRI = Possible Possible

SurgerySurgery

Partial Thickness Cuff Partial Thickness Cuff TearsTears

Increasing prevalence with ageIncreasing prevalence with age 30 – 60% Incidence in Age > 6030 – 60% Incidence in Age > 60 Over 80% Incidence in Age > 70Over 80% Incidence in Age > 70

Often asymptomatic Often asymptomatic If painful and fail therapy = SurgeryIf painful and fail therapy = Surgery Supraspinatus is 11 mm thickSupraspinatus is 11 mm thick

If < 50% torn = Debridement + DecompressionIf < 50% torn = Debridement + Decompression If > 50% torn = Complete the tear and RepairIf > 50% torn = Complete the tear and Repair

Case #5Case #5

History:History: 66 yo male with progressive pain/stiffness 66 yo male with progressive pain/stiffness

shouldershoulder Pain is constant and unable to do ADLSPain is constant and unable to do ADLS Feels like itFeels like it’’s popping with motions popping with motion NSAIDS – Some reliefNSAIDS – Some relief

Case #5Case #5

Physical Exam:Physical Exam: FE: 100FE: 100 ER: NeutralER: Neutral IR: Back PocketIR: Back Pocket ““RatchetingRatcheting”” motion motion Cuff Strength Cuff Strength

NormalNormal

Case #5Case #5Radiographs

Case #5Case #5

Diagnosis?Diagnosis? Endstage Shoulder OsteoarthritisEndstage Shoulder Osteoarthritis

Treatment?Treatment? Physical Therapy and/or refer to OrthoPhysical Therapy and/or refer to Ortho Cortisone InjectionCortisone Injection Shoulder ReplacementShoulder Replacement

Case #5Case #5

Case #6Case #6

History:History: 14 yo female with 14 yo female with

longstanding history of both longstanding history of both shoulders going shoulders going ““in and outin and out””

No traumatic eventNo traumatic event Has never had them reduced Has never had them reduced

in the ERin the ER Sometimes Sometimes ““grosses friends grosses friends

outout”” by dislocating her by dislocating her shoulder at partiesshoulder at parties

Case #6Case #6

Physical Exam:Physical Exam: Full Range of MotionFull Range of Motion Normal Cuff Normal Cuff

StrengthStrength Sulcus - Grade 3Sulcus - Grade 3 Hypermobile Signs +Hypermobile Signs +

Case #6Case #6

Hypermobile Tests

Case #6Case #6 Radiographs – NormalRadiographs – Normal

Diagnosis?Diagnosis? Atraumatic, bilateral shoulder instabilityAtraumatic, bilateral shoulder instability

Treatment?Treatment? PT, PT, PTPT, PT, PT More PTMore PT MRI – Normal or Enlarged joint capsuleMRI – Normal or Enlarged joint capsule If absolutely fails everything – Capsular shiftIf absolutely fails everything – Capsular shift

Case #6Case #6

Capsular Shift

Case #7Case #7

History:History: 80 yo female with occasional ache in 80 yo female with occasional ache in

shouldershoulder Swims everydaySwims everyday No InjuryNo Injury Pain is minimal, but just wants to get it Pain is minimal, but just wants to get it

checked outchecked out Takes no pain medsTakes no pain meds

Case #7Case #7

Physical Exam:Physical Exam: Full ROMFull ROM Mild pain with reaching overheadMild pain with reaching overhead + Impingement Sign+ Impingement Sign + Hawkins Test+ Hawkins Test Profound weakness of supra/infraspinatusProfound weakness of supra/infraspinatus

Case #7Case #7Radiographs

Case #7Case #7MRI

Case #7Case #7

Diagnosis?Diagnosis? Massive Rotator Cuff TearMassive Rotator Cuff Tear

Treatment?Treatment? No role for surgical repairNo role for surgical repair Leave it aloneLeave it alone Physical TherapyPhysical Therapy Occasional cortisone injectionOccasional cortisone injection

SummarySummary A focused, thorough H&P is critical to correctly A focused, thorough H&P is critical to correctly

diagnosing a shoulder problem. diagnosing a shoulder problem. Expose the shoulder for the exam and compare to Expose the shoulder for the exam and compare to

the other side. the other side. Age, alone, is an important predictor of a patientsAge, alone, is an important predictor of a patients’’

diagnosis. diagnosis. Always order an x-ray series prior to ordering a Always order an x-ray series prior to ordering a

shoulder MRI. Everyone deserves a normal set of shoulder MRI. Everyone deserves a normal set of x-rays! x-rays!

X-ray series should always, at a minimum, include X-ray series should always, at a minimum, include a true AP (grashey) and an axillary view.a true AP (grashey) and an axillary view.

SummarySummary

Not all rotator cuff tears can, or should be, fixed. Not all rotator cuff tears can, or should be, fixed. Traumatic, unidirectional, recurrent dislocaters Traumatic, unidirectional, recurrent dislocaters

should be surgically repaired. should be surgically repaired. Atraumatic, multidirectional, and/or voluntary Atraumatic, multidirectional, and/or voluntary

shoulder dislocaters should almost never be shoulder dislocaters should almost never be surgically repaired. surgically repaired.

Physical therapy is a tremendous adjunct to Physical therapy is a tremendous adjunct to treatment for the majority of shoulder injuries. treatment for the majority of shoulder injuries.

If you have questions, please call or refer your If you have questions, please call or refer your patients. We are always happy to help!patients. We are always happy to help!

Thanks!!Thanks!!

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