Refer to Specialist. The Diagnosis and Management of Shoulder Pain 1. SLAP lesions, types 1 through 4

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Kelley McDowell
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1 The Diagnosis Management of Shoulder Pain 1 Significant Hisry -Age -Extremity Dominance -Hisry of trauma, dislocation, subluxation -Weakness, numbness, paresthesias -Sports participation -Past medical hisry (Diabetes, thyroid disease, cancer) -Previous hisry of joint problems (Rheumaid disorders) -Stiffness, Range of motion limitation -Night pain (Continuous or related position) -Occupation, position of arm when working -Aggravating facrs -Alleviating facrs -Previous treatment (Therapy,, surgery) -Pain location - anterior arm, upper arm, superior shoulder, interscapular -Hisry of malignancy Significant Shoulder Examination -Observation (swelling, atrophy, deformity) -Tenderness localized bursa, AC joint, glenohumeral joint -Range of motion (active & passive) in planes of elevation, external rotation, internal rotation, cross body adduction -Provocative tests for impingement & instability -Mor & sensory upper extremity assessment -n-contribury cervical spine exam -NB: exam should be bilateral each side compared for symmetry -Distal upper extremity examination (Check reflexes) Significant Imaging -True AP in internal external rotation -Axillary view -Lateral in scapular plane -If concerned about impingement syndrome -Caudally tilted AP (25 degrees) Critical Exclusionary Diagnoses -Acute trauma (fracture, dislocation, AC separation) -Tumor -Infection -red pain from cervical spine, chest, abdomen Exclusionary Diagnosis Needs specialized care SLAP lesions, types 1 through 4 Differential Diagnosis 1. Rotar Cuff Disorders 2. Frozen Shoulder 3. Glenohumeral Instability 4. Arthritis of Glenohumeral Joint 5. Acromioclavicular Joint Disorder page 2 Continue treatment if expertise available

-Occupation, position of arm when working -Aggravating facrs -Alleviating facrs -Previous treatment (Therapy,, surgery) -Pain location - anterior arm, upper arm, superior shoulder, interscapular

2 The Diagnosis Management of Shoulder Pain 2 Rotar Cuff Disorders Frozen Shoulder Glenohumeral Instability Glenohumeral Joint Arthritis Acromioclavicular Joint Disorder Findings Consistent with Diagnosis Age usually > 40yrs. Weakness, atrophy, tenderness Painful arc of motion Night pain Impingement signs Upper arm pain Painful crepitation Progressive pain stiffness of spontaneous onset Loss of ROM in all planes localized tenderness Pain at end range Age usually <40 yrs. Hisry of dislocation or subluxation, Apprehension sign relocation tests (tests for shoulder instability) Generalized ligamenus laxity Age usually > 50 yrs. Progressive pain Known arthritis (e.g.. RA) Tender GH joint posteriorly Crepitus Decreased ROM AC joint deformity AC joint tenderness Pain with cross-body adduction Superior clavicular pain Plain x-ray series Impingement Series -True AP (Grashey) view in internal rotation -True AP (Grashey) view in external rotation -Transaxillary view -25 O caudally tilted view Impingement Series -True AP (Grashey) view in internal rotation -True AP (Grashey) view in external rotation -Transaxillary view -25 O caudally tilted view Instability Series -AP view - True AP (Grashey) -Scapulolateral Y-view -Transaxillary view May also need the following views: -West Point view -Stryker notch view -Velpeau axillary view GH DJD Series -True AP (Grashey) view -Transaxillary lateral Impingement series plus -AP of AC joint -Zanca (15 degree cephalic tilt) view -Trans axillary lateral Plain X-ray Findings X-rays may be normal or may demonstrate the following: -Acromial spur -Greater tuberosity sclerosis &/or cysts -Loss of acromiohumeral interval n-specific x-rays May show osteopenia Hill-Sachs deformity Anterior inferior glenoid calcification X-rays may be normal Humeral osteophytes Humeral head flattening Irregular or narrow joint space Bone cysts Irregular or narrowed joint space Lysis or sclerosis of distal clavicle Additional studies Consider MRI early for acute weakness or for chronic pain /or weakness not responding appropriate nonsurgical treament MRI is of no value in diagnosing frozen shoulder which should be diagnosed by hisry, examination negative x-ray findings. MR arthrogram is more valuable than plain MRI in the evaluation of labral pathology such as SLAP o Bankart lesions. CT scan with 3D reconstructions may be helpful in assessing glenoid or humeral head damage glenoid version. Diagnosis of arthritis should be made on plain x-ray alone. MRI may be helpful in evaluating the integrity of the rotar cuff but is usually no necessary. CT scan is helpful in determining glenoid version posterior wear of the glenoid. MRI CT scan are usually not necessary evaluate conditions of the AC joint related arthritis, osteolysis or dislocation. Findings Inconsistent with Diagnosis Age < 30 yrs. upper arm pain weakness impingement signs rmal range of motion of shoulder hisry of dislocation or subluxation, no apprehension or relocation tests rmal ROM rmal x-rays swelling or tenderness of AC joint Rank Differential Diagnoses Continue if expertise available 1 O Diagnosis Confirmed Needs Specialized Care

Weakness, atrophy, tenderness Painful arc of motion Night pain Impingement signs Upper arm pain Painful crepitation Progressive pain stiffness of spontaneous onset Loss of ROM in all planes localized

3 The Diagnosis Management of Shoulder Pain 3 Rotar Cuff Disorders Severity of Problem Severe: Marked or sudden loss of strength manifested by either drop arm sign or loss of active elevation, loss of external rotation strength Manageable: ADL function without sudden loss of strength Manageable Severe Frozen Shoulder Initial treatment 3-4 weeks (However, patients with diabetes or hyperthyroidism may require more prolonged treatment) unless contraindicated Exercise program -Stretching resre full elevation rotation -Strengthen rotar cuff scapular stabilizers after ROM is resred Acromioclavicular Joint Disorder -Osteoarthritis -Osteolysis Initial 3-4 weeks Corticosteroid injection if appropriate Glenohumeral Instability Patient Requiring Reduction of Dislocation Glenohumeral Arthritis Initial 3-4 weeks ROM Strengthening exercises -Stretching improve forward flexion, extension rotation -Strengthen delid, rotar cuff scapular stabilizers as ROM is improving Initial (3-6 weeks) unless contraindicated ROM strengthening exercises -Stretching resre full elevation rotation -Strengthen rotar cuff scapular stabilizers after ROM is resred treatment Partial Partial or Poor Incomplete or not maintained improvement in pain, motion strength or ADL Minimal or no resration of activities Inability work Patient dissatisfied with outcome Resration of full range of motion -ADL -Work related tasks -Sleep Activities as lerated Return as needed Poor or Partial compliance (hisry, physical examination x- ray data) Modify Initial 3-4 weeks -Proper period, technique position of immobilization -Post immobilization physical therapy for selective muscle strengthening Initial Partial or Poor Activities as lerated Return as needed compliance (hisry, physical exam, x-ray data) Consider a subacromial injection Partial/Poor Initial Assessment Needs Specialized Care Modified (3-4 weeks) Supervised physical therapy Second Partial or Poor Incomplete or not maintained improvement in pain, motion, strength or ADL Minimal or no resration of activities Inability work Patient dissatisfied with outcome, compliance (hisry, physical exam, x-ray data) Resration of full range of motion -ADL -Work related tasks -Sleep Initial Assessment Partial or Poor Activity as lerated Return as needed compliance (hisry, physical examination x-ray data) Modify Repeat or Continue initial treatment

may require more prolonged treatment) unless contraindicated Exercise program -Stretching resre full elevation rotation -Strengthen rotar cuff scapular stabilizers after ROM is resred

4 The Diagnosis Management of Shoulder Pain 4

5 The Diagnosis Management of Shoulder Pain 5

6 The Diagnosis Management of Shoulder Pain 6 Initial 3-4 weeks ROM Strengthening exercises -Stretching improve forward flexion, extension rotation -Strengthen delid, rotar cuff scapular stabilizers as ROM is improving compliance (hisry, physical examination x-ray data) Modify

extension rotation -Strengthen delid, rotar cuff scapular

A Patient s Guide to Shoulder Pain

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