the sore shoulder: how to evaluate, when to scan, when to refer randy wroble md ray tesner do dave...
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The Sore Shoulder: How The Sore Shoulder: How To Evaluate, When To To Evaluate, When To Scan, When To ReferScan, When To Refer
Randy Wroble MDRandy Wroble MD
Ray Tesner DORay Tesner DO
Dave Weil MDDave Weil MD
Team Physicians, Columbus Blue Team Physicians, Columbus Blue JacketsJackets
Case 1Case 1
HistoryHistory
• 25 yo right-handed female presents 25 yo right-handed female presents with pain and weakness in her left with pain and weakness in her left shouldershoulder
• She works in an office but is involved in She works in an office but is involved in several recreational sports including several recreational sports including volleyball, water-skiing and snow skiingvolleyball, water-skiing and snow skiing
• She has had problems with her She has had problems with her shoulder since high school but shoulder since high school but symptoms have worsened in the last symptoms have worsened in the last few monthsfew months
• Her pain is anterior, posterior, and Her pain is anterior, posterior, and laterallateral
• She denies any specific injury but She denies any specific injury but notes that her arm would feel notes that her arm would feel momentarily weak at various times momentarily weak at various times with her athletic activitieswith her athletic activities
• She has had similar but milder She has had similar but milder symptoms in her opposite shouldersymptoms in her opposite shoulder
• She was treated in high school with an She was treated in high school with an exercise program but no supervised exercise program but no supervised therapy. This seemed to relieve her therapy. This seemed to relieve her symptomssymptoms
• She has never had an x-ray or She has never had an x-ray or MRIMRI
• Occasionally she describes Occasionally she describes tingling in her whole armtingling in her whole arm
• She takes oral contraceptives She takes oral contraceptives but is otherwise healthy. She but is otherwise healthy. She had knee arthroscopy for a had knee arthroscopy for a “patella problem” 4 years ago“patella problem” 4 years ago
What Are the Key Points What Are the Key Points Learned From the History?Learned From the History?
What Is Your Differential What Is Your Differential Diagnosis?Diagnosis?
ExamExam
• No significant tendernessNo significant tenderness• ROM –fullROM –full• Impingement tests – negativeImpingement tests – negative• Instability testsInstability tests
– Positive load-shift and drawer Positive load-shift and drawer teststests
– Equivocal sulcus sign & relocation Equivocal sulcus sign & relocation testtest
• Apprehension tests produce Apprehension tests produce discomfort onlydiscomfort only
• Strength full in all muscle groups Strength full in all muscle groups • No crepitus, no atrophy or No crepitus, no atrophy or
swellingswelling• Neurocirculatory exam – normalNeurocirculatory exam – normal• Cervical spine exam - normalCervical spine exam - normal
DemonstrationDemonstration
• Apprehension testsApprehension tests• Relocation testRelocation test• Load-shiftLoad-shift• Drawer testDrawer test• Sulcus signSulcus sign
On Physical Exam, How Do On Physical Exam, How Do You Tell Apart Uni- Versus You Tell Apart Uni- Versus Multi-directional Instability Multi-directional Instability and Why Is That Important?and Why Is That Important?
When Do You Order X-rays When Do You Order X-rays and What Views?and What Views?
Imaging - X-raysImaging - X-rays
•Possible positive Possible positive findingsfindings– Bony Bankart lesionBony Bankart lesion– Hill-Sachs lesionHill-Sachs lesion
Hill-Sachs LesionHill-Sachs Lesion
When Do You Order an MRI?When Do You Order an MRI?
MRIMRI
• Possible positive findingsPossible positive findings– Labrum tearsLabrum tears– Capsular abnormalities – Capsular abnormalities –
increased volume, avulsionsincreased volume, avulsions
Normal LabrumNormal Labrum
Bankart LesionBankart Lesion
Enlarged CapsuleEnlarged Capsule
Describe Your Initial TreatmentDescribe Your Initial Treatment
How Long Should You How Long Should You Continue Non-operative Continue Non-operative
Treatment?Treatment?
Initial TreatmentInitial Treatment
• No labrum tearNo labrum tear– Physical therapy – supervised TIW Physical therapy – supervised TIW
– 6 weeks minimum– 6 weeks minimum• StrengtheningStrengthening• Neuromuscular controlNeuromuscular control• Scapular stabilizationScapular stabilization• Core stabilizationCore stabilization
Labrum Tear PresentLabrum Tear Present
• Referral for surgical Referral for surgical consultationconsultation
ResultsResults
• Multidirectional instability Multidirectional instability without labrum tearwithout labrum tear– Very high success rate with non-Very high success rate with non-
operative managementoperative management• May require prolonged and May require prolonged and
specialized therapy programspecialized therapy program
Instability With Labrum Instability With Labrum TearTear
• Very high rate of Very high rate of unsatisfactory results without unsatisfactory results without surgerysurgery– Early referralEarly referral
What Is the Surgical What Is the Surgical Decision-making Process in Decision-making Process in
This Case?This Case?
Case 2Case 2
Patient HistoryPatient History
• 47 yo female complains of pain in 47 yo female complains of pain in her dominant right shoulder. Onset her dominant right shoulder. Onset was about 3 months ago. was about 3 months ago.
• She thought her pain may have She thought her pain may have started after she caught herself started after she caught herself from falling in the shower, but the from falling in the shower, but the incident was so mild she quickly incident was so mild she quickly had forgotten about it. Since that had forgotten about it. Since that time, she has steadily worsened. time, she has steadily worsened.
• She feels weak and has a lot of She feels weak and has a lot of pain when she lifts her arm pain when she lifts her arm overhead. She describes the pain overhead. She describes the pain as being deep within the shoulder. as being deep within the shoulder.
• Some ADLS have become difficult, Some ADLS have become difficult, including fastening her bra. including fastening her bra.
• She has no paresthesias or neck She has no paresthesias or neck pain. pain.
• She went to an urgent care She went to an urgent care facility and had x-rays. She facility and had x-rays. She was told these were normal. was told these were normal. An NSAID was given at that An NSAID was given at that time and it helped “a little”. time and it helped “a little”.
• She takes Lipitor, Wellbutrin, She takes Lipitor, Wellbutrin, and Glucophage.and Glucophage.
What Are the Key Points What Are the Key Points Learned From the History?Learned From the History?
What Is Your Differential What Is Your Differential Diagnosis?Diagnosis?
ExamExam
• Tenderness anteriorly and Tenderness anteriorly and posteriorly around the acromionposteriorly around the acromion
• ROM – FF 90 degrees, ER – 20 ROM – FF 90 degrees, ER – 20 degrees with arm at the side, IR degrees with arm at the side, IR – to about the SI joint– to about the SI joint
• Impingement tests – all cause Impingement tests – all cause pain at end range of motionpain at end range of motion
• Strength near normal in all Strength near normal in all groups groups
• Mild crepitusMild crepitus
• No atrophy or swellingNo atrophy or swelling
• Neurocirculatory exam – Neurocirculatory exam –
normalnormal
• Instability tests – negativeInstability tests – negative
• Cervical spine exam – normalCervical spine exam – normal
DemonstrationDemonstration
• ROM testingROM testing• C-spine and other ancillary C-spine and other ancillary
testingtesting
How Does Your Exam How Does Your Exam Eliminate Rotator Cuff Eliminate Rotator Cuff
Problems From the Problems From the Differential?Differential?
When Do You Order X-rays When Do You Order X-rays and What Views?and What Views?
Imaging - X-raysImaging - X-rays
•Possible positive Possible positive findingsfindings– Generally normal x-raysGenerally normal x-rays– Osteopenia?Osteopenia?
When Do You Order an MRI?When Do You Order an MRI?
MRIMRI
•Possible positive Possible positive findingsfindings– Need to know cuff and Need to know cuff and labrum statuslabrum status
– Many false positives in Many false positives in older age groupolder age group
Describe Your Initial Describe Your Initial TreatmentTreatment
What Is the Role of What Is the Role of Corticosteroid Injections?Corticosteroid Injections?
How Long Should You How Long Should You Continue Non-operative Continue Non-operative
Treatment?Treatment?
Initial TreatmentInitial Treatment
• Always non-operativeAlways non-operative– Unless history of contralateral frozen Unless history of contralateral frozen
shoulder unresponsive to therapyshoulder unresponsive to therapy
• Get control of painGet control of pain– NSAIDsNSAIDs– Supplemental non-narcotic Supplemental non-narcotic
analgesicsanalgesics– TENSTENS
• Physical therapy – supervised TIWPhysical therapy – supervised TIW– Specify aggressive ROM/stretchingSpecify aggressive ROM/stretching
• Myofascial/trigger point approachMyofascial/trigger point approach• Aquatic programAquatic program• Combine with home programCombine with home program• Reassess in 4 weeksReassess in 4 weeks• Insurance often limits visits – Insurance often limits visits –
“save” visits for post-op PT“save” visits for post-op PT• Referral if no progressReferral if no progress
What Is the Surgical What Is the Surgical Decision-making Process in Decision-making Process in
This Case?This Case?
Results Results
• Majority respond to PTMajority respond to PT• First operative intervention is First operative intervention is
manipulation under anesthesiamanipulation under anesthesia
Case 3Case 3
Patient HistoryPatient History
• 54 yo male maintenance supervisor and 54 yo male maintenance supervisor and recreational softball player complains of a recreational softball player complains of a 6 month history of dominant shoulder 6 month history of dominant shoulder painpain
• Pain is localized to the anterior aspect of Pain is localized to the anterior aspect of the shoulder with radiation to the deltoid the shoulder with radiation to the deltoid insertion insertion
• He recalls no specific injury but has had He recalls no specific injury but has had several similar bouts of pain over the last several similar bouts of pain over the last 5 or 6 years. Each of these episodes 5 or 6 years. Each of these episodes resolved with activity modification aloneresolved with activity modification alone
• His current pain is worse with His current pain is worse with overhead activities and with overhead activities and with reaching. He is occasionally reaching. He is occasionally wakened from sleep by his wakened from sleep by his shoulder painshoulder pain
• He notes no numbness, tingling, He notes no numbness, tingling, or neck painor neck pain
• He has mild treated hypertension He has mild treated hypertension but has no other significant but has no other significant medical historymedical history
What Are the Key Points What Are the Key Points Learned From the Learned From the
History?History?
What Is Your Differential What Is Your Differential Diagnosis?Diagnosis?
ExamExam
• Tenderness anteriorly – acromion, Tenderness anteriorly – acromion, AC joint, and anterior deltoidAC joint, and anterior deltoid
• ROM – near full,mild restriction of ROM – near full,mild restriction of IRIR
• Impingement tests – positive in Impingement tests – positive in full forward flexion, internal full forward flexion, internal rotation at 90 degrees flexion, and rotation at 90 degrees flexion, and in adductionin adduction
• Strength decreased to external Strength decreased to external rotation and forward flexion rotation and forward flexion
• Painful arc of motion 60 to 100 Painful arc of motion 60 to 100 degrees forward flexiondegrees forward flexion
• Mild crepitusMild crepitus• No atrophy or swelling, No atrophy or swelling,
neurocirculatory exam – neurocirculatory exam – normal, instability tests – normal, instability tests – negative, cervical spine exam – negative, cervical spine exam – normalnormal
DemonstrationDemonstration
• Emphasize proper exposureEmphasize proper exposure• InspectionInspection• PalpationPalpation• Strength testsStrength tests• Impingement signsImpingement signs
What Is the Most What Is the Most Reliable Physical Exam Reliable Physical Exam Finding to Differentiate Finding to Differentiate
Cuff Tendinitis From Cuff Cuff Tendinitis From Cuff Tear?Tear?
How Do You Tell If the AC How Do You Tell If the AC Joint Is Involved?Joint Is Involved?
When Do You Order X-When Do You Order X-rays and What Views?rays and What Views?
Imaging - X-raysImaging - X-rays
• Possible positive findingsPossible positive findings– Acromial hookAcromial hook– Sclerosis – acromial & Sclerosis – acromial &
greater tuberositygreater tuberosity– AC joint narrowing & AC joint narrowing &
spurringspurring– Calcific deposits Calcific deposits
Acromial HookAcromial Hook
AC ArthritisAC Arthritis
Rotator Cuff TearRotator Cuff Tear
When Do You Order an When Do You Order an MRI?MRI?
MRIMRI
• Possible positive findingsPossible positive findings– Increased signal in cuffIncreased signal in cuff– Fluid in bursaFluid in bursa– DiscontinuityDiscontinuity– Muscle atrophyMuscle atrophy
RC TendinitisRC Tendinitis
RC TearRC Tear
Describe Your Initial TreatmentDescribe Your Initial Treatment
Initial TreatmentInitial Treatment
• Tendinitis/partial rotator cuff Tendinitis/partial rotator cuff teartear– NSAIDsNSAIDs– Activity modificationActivity modification– Physical therapy – supervised TIWPhysical therapy – supervised TIW
• StrengtheningStrengthening• StretchingStretching• ModalitiesModalities
How Long Should You How Long Should You Continue Non-operative Continue Non-operative
Treatment?Treatment?
What Is the Role of What Is the Role of Corticosteroid Injections?Corticosteroid Injections?
ResultsResults
• Tendinitis/partial rotator cuff tearTendinitis/partial rotator cuff tear– Non-operative treatment successful – 60 Non-operative treatment successful – 60
to 70% of casesto 70% of cases• Maintenance exercise programMaintenance exercise program• Gradual progression to full activityGradual progression to full activity• Assessment of workplaceAssessment of workplace
– Transitional work programTransitional work program
• Non-operative treatment not successful Non-operative treatment not successful after 6 weeksafter 6 weeks– ReferralReferral
Full Thickness Rotator Full Thickness Rotator Cuff TearCuff Tear
• Referral to orthopaedic Referral to orthopaedic surgeonsurgeon
What Is the Surgical What Is the Surgical Decision-making Process in Decision-making Process in
This Case?This Case?
Full Thickness Rotator Full Thickness Rotator Cuff TearCuff Tear
• Arthroscopic cuff repairArthroscopic cuff repair • Some tears are irreparable!Some tears are irreparable!
ThanksThanks……
and enjoy the and enjoy the game!game!