# Presentation: 099279

## Shoulder Symposium4th Annual Federal Worker’sCompensation Conference

## The Shoulder 

- Ann Dew DO
- Grace Stringfellow MD

## Course Objectives

- Review of shoulder anatomy and physiology
- Review of evaluation, diagnosis, and treatment of common shoulder injuries
- Review of mechanism of injury and prevention of work related injuries

## Anatomy and Physiology

- Bones
- Muscles
- Joints
- Tendons
- Nerves

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## A Brief Examination of the Shoulder and Upper Extremity

- Dr. Philip Reisweg, MD
- Chief of Orthopedics
- Loma Linda VA Medical Center

## Common Conditions

- Impingement Syndrome
- Rotator cuff tendinitis
- Rotator cuff tear
- Frozen shoulder
- Acromioclavicular Strain/Osteoarthritis
- Biceps tendinitis
- Subscapular bursitis
- Glenohumeral osteoarthritis
- Instability

## Impingement Syndrome

- Description:
- Compression of the rotator cuff tendons and the subacromial bursa between the greater tubercle of the humeral head and the undersurface of the acromial process
- “*I feel like my bones are rubbing together”*
*“**It’s too painful to raise my arm up”*

## Exam Summary

- 1.  Positive painful arc maneuver
- 2.  Focal subacromial tenderness
- 3.  *Painless *testing of resisted abduction (supraspinatus), external rotation (infraspinatus), adduction (subscapularis) and elbow flexion (biceps)
- 4.  Normal ROM of Glenohumeral joint
- 5.  Preserved strength all directions

## Diagnosis

- History of lateral shoulder pain
- Abnormal signs of local subacromial tenderness – below middle of acromion
- Painful arc
- Absence of signs of active tendinitis
- Initial xrays optional

## Treatment

- Goal: Increase subacromial space
- Rest and restriction of overhead positioning and reaching
- Weighted pendulum stretching exercises using 5-10 lb, 5 min x 1-2 q d with passive stretching
- Ice to control pain
- Avoid simple slings and immobilizers
- Isometric toning of infraspinatus

## Rotator Cuff Tendinitis

- Inflammation of the supraspinatus and infraspinatus tendons lying between the humeral head and the acromial process.
- Aggrevated by repetitive overhead reaching, pushing, pulling and lifting with the arms outstretched – repeated abduction, elevation and torque to the shoulder

## Exam Summary

- 1.  Focal subacromial tenderness
- 2.  Painful arc maneuver
- 3.  Pain with resisted midarc abduction and external rotation, isometrically performed
- 4.  Normal range of motion of the glenohumeral joint
- 5.  Preserved strength of midarc abduction and external rotation (lidocaine test)

## Diagnosis

- History of shoulder pain aggravated by reaching, evidence of subacromial impingement, and pain with isometric testing of the supraspinatus, infraspinatus, or subscapularis.
*“**I can’t sleep on my shoulder – if I roll over it wakes me up”*
*“**I can’t reach up or back anymore”*

## Treatment

- Goals:  reduce tendon swelling and inflammation, increase subacromial space, and prevent progressive damage to tendons
- NSAIDS
- Weighted pendulum stretching exercises
- Ice to control pain
- Toning infraspinatus and supraspinatus tendons
- Avoid slings and immobilizers

## Frozen Shoulder

- Stiff shoulder joint – a glenohumeral joint that has lost significant range of motion
- Common causes:  rotator cuff tendinitis, acute subacromial bursitis, fractures of humeral head and neck, and paralytic stroke
- May be accompanied by reflex sympathetic dystrophy (RSD)

## Exam Summary

- Abnormal Apley scratch test (inability to scratch lower back)
- Restricted abduction and external rotation, measured passively
- No xray evidence of glenohumeral arthritis
*“**It’s getting hard to put on my coat”*
*“**I can’t comb my hair”*

## Diagnosis

- Demonstrated loss of range of motion of glenohumeral joint
- Xrays ruling out arthritis of the glenohumeral joint – however, most plain films are nondiagnostic

## Treatment

- Goals:  treat any underlying periarticular or bony process, stretch GH joint lining, and restore normal range of motion
- Heat
- Weighted pendulum exercises BID, performed passively
- Daily stretching exercises, performed passively
- When improved, rotator cuff muscle toning, isometrically

## Rotator Cuff Tendon Tear

- Loss of the normal integrity of the infraspinatus or supraspinatus tendons or both, occur as the end result of chronic subacromial impingement and progressive tendon degeneration or from traumatic injury or both.
- Falls onto the outstretched arm, directly onto outer shoulder, vigorous pulling, unusual heaving pushing and pulling

## Exam Summary

- Loss of smooth overhead motion
*Weakness* and pain with isometric testing of midarc abduction, external rotation, or both
- Painful arc usually positive
- Subacromial tenderness
- Atrophy of the infraspinatus and/or supraspinatus noted over the scapula

## Diagnosis

- Requires special testing
- Lidocaine injection test, persistent weakness
- MRI, good for large tears but cannot distinguish a small tear from active tendinitis
- Arthrography demonstrates subtendinous tears, small splits, and large tendon tears
- Plain xrays – subacromial space measurement of < 1 cm is highly suggestive of degenerative thinning, tear, or both

## Treatment

- Goals:  recover and improve lost strength in external rotation and abduction, to improve the global function of the shoulder, and to treat any rotator cuff tendinitis
- Small and medium tears:  physical therapy toning exercises of external rotation and abduction
- 50-62 year olds with large tear: surgery referral

## Initial Care

- Ice to control pain or swelling
- Plain xrays
- Restrict overhead positioning and reaching
- Weighted pendulum done passively for 5 min BID
- Cautious isometric toning
- No relief in 2-4 wks, add NSAID for 3-4 wk

## Prognosis

- Small to medium tears with loss of 25-50% strength and function can be treated medically: restrictions, PT for up to 6 mos
- No response in 4 wks – refer to ortho
- Medium to large: refer immediately
- Risk factors: age >62, fall onto outstretched arm or direct blow to shoulder, recurrent tendinitis, weakness, <1 cm subacromial space on plain film

## Acromioclavicular Strain or Osteoarthritis

- The AC, coracoclavicular, and coracoacromial ligaments, binding the acromion, clavicle, and coracoid process together, can be strained, partially torn, or completely disrupted.
- Repeated strain or injury to the supporting ligaments may progress to osteoarthritis
- Repetitive reaching (esp across chest or over head), trauma

## Exam Summary

- 1.  AC joint enlargement or deformity
- 2.  AC joint tenderness (with or without swelling)
- 3.  Pain aggravated by downward traction or forced adduction, performed passively
- 4.  AC joint widening with downward traction of the arm
- 5.  Xrays recommended w/o and w weights

## Diagnosis

- AC joint disease is easily made from the physical examination
- Osteoarthritis of the AC joint or AC separation is made by xray
- Degenerative changes:  narrowing, sclerosis, “squaring off of bones” of clavicle or proximal acromion, spurring.
- Separation: >5mm between clavicle and acromion process

## Treatment

- Goals:  To reduce direct pressure and traction at the AC joint to allow ligament to reattach to respective bony insertions
- Restrict reaching and direct pressure over the shoulder
- Limit lifting to 10 – 20 lb held close to the body
- Immobilization for 3-4 wks
- Ice to control swelling and pain
- Avoid sleeping on either side
- General shoulder conditioning

## Biceps Tendinitis

- Inflammation of the long head tendon as it passes through the bicipital groove of the anterior humerus.  Repeated irritation leads to microtearing and degenerative change.
- Vigorous or unusual lifting can lead to spontaneous rupture – 10 – 12%
*“**My shoulder used to hurt a lot. Two days ago it stopped hurting.  Now I have this big bruise near my elbow and the muscle seems bigger.”*

## Exam Summary

- 1.  Local tenderness in the bicipital groove
- 2.  Pain aggravated by flexion of the elbow, isometrically performed
- 3.  Painful arc often positive
- 4.  A bulge in the anticubital fossa, signifying long head tendon rupture

## Diagnosis

- History of anterior humeral pain and an exam showing local tenderness in the bicipital groove aggravated by resisted elbow flexion.

## Treatment

- Goals:  reduce inflammation and swelling in the tendon, to strengthen the biceps muscle and tendon, and to prevent rupture.
- Eliminate lifting
- Restrict over-the-shoulder positions and reaching
- Ice to anterolateral shoulder, NSAID, phonophoresis
- Weighted pendulum, passive
- Toning exercises for the short head biceps and brachioradialis tendons (with rupture)

## Subscapular Bursitis

- Constant friction (to and fro motions of the arm) and direct pressure (lying on hard surfaces) cause irritation and inflammation to develop between the scapula and the underlying rib
- Diff Dx:  rhomboid or levator scapular muscle irritation (posture, stress, whiplash) and referred pain from lower cervical roots.

## Exam Summary

- 1.  Local tenderness under the superomedial angle of the scapula, directly over rib
- 2.  Full ROM of the shoulder
- 3.  No evidence of cervical root irritation or rhomboid or trapezius strain
*“**Every time I roll my shoulder, it pops”*
*“**I can’t sleep on my back anymore, there is a spot of pain over my shoulder blade”*

## Diagnosis

- Focal tenderness just under the superomedial angle of the scapula over 2nd or 3rd rib
- Full shoulder range of motion
- Negative neck examination w full ROM
- Normal upper extremity neuro exam

## Treatment

- Goals:  To reduce acute inflammation and to prevent further episodes by improvement in posture and in shoulder muscle tone
- Local injection of Kenalog 40
- Limit to-and-fro motions and overhead reaching with the affected arm
- Good posture
- Avoid direct pressure over the scapula

## Glenohumeral Osteoarthritis

- Wear and tear of the articular cartilage of the glenoid labium and humeral head is uncommon.  Usually trauma precedes the condition, I.e., previous dislocation, humeral head or neck fracture, large rotator cuff tears and RA

## Exam Summary

- 1.  Local tenderness located anteriorly, just under the coracoid process
- 2.  Restricted abduction and external rotation, measured passively
- 3.  Crepitation with circumduction or clunking on release of isometric tension
- 4.  Swelling of the infraclavicular fossa or general fullness to the shoulder

## Diagnosis

- History of progressive loss of range of motion
- Crepitation or crunching with circumduction
- Loss of external rotation and abduction
- Plain xrays of shoulder show narrowing of the articular cartilage and irreg inferior glenoid fossa, spurring and finally, flattening of the humeral head with obliteration of the articular cartilage at the inferior glenoid

## Treatment

- Goals:  improve range of motion and muscular support
- Elimination of heavy work, overhead reaching, and forceful pushing and pulling.
- NSAID
- Weighted pendulum exercises once daily with heat to anterior shoulder prior to exercise
- Passive stretching

## Multidirectional Instability of the Shoulder

- Synonymous with “subluxation,” “loose,” or partial dislocation.
- More common in young women with poor muscular support of the shoulder, patients with large rotator cuff tendon tears, and athletic patients < 40 yr.
- Uncommon after 40 due to natural stiffening of the shoulder

## Exam Summary

- 1.  Downward traction on the arm causing the sulcus sign
- 2.  Increased anteroposterior mobility of the humeral head (relative to the glenoid fossa)
- 3.  Painful arc may be positive
- 4.  Positive apprehension sign with are placed at 70-80 degrees abduction and passively rotated externally

## Diagnosis

- Diagnosis of hypermobility made by history and physical exam
*“**It feels like my shoulder is going to pop out”*
*“**My shoulder makes a crunching sound”*
*“**Every time I try to lift something heavy, my shoulder seems to slip”*

## Treatment

- Goals:  similar to recommendations for rotator cuff tendinitis and to improve stability of glenohumeral joint to prevent OA
- Advise rest and restriction of overhead positioning, reaching, pushing, pulling and lifting
- Isometric toning exercises in external and internal rotation
- Ice initially, NSAID added if no improvement
- At about 3 mos cautious overhead reaching

## Prevention

- Wellness
- Exercise:  stretching, toning, strengthening
- Weight management
- Nutrition
- Ergonomics
- Devices
- Personal