An Approach to the Patient with Shoulder Pain. Greg I. Nakamoto MD, FACP Department of Orthopedics and Sports Medicine Virginia Mason Medical Center

Transcription

1 An Approach to the Patient with Shoulder Pain Greg I. Nakamoto MD, FACP Department of Orthopedics and Sports Medicine Virginia Mason Medical Center

2 35 y/o female soccer player fell onto her left arm and shoulder one month ago. She had immediate pain, but was able to keep playing. Now she has worsening shoulder pain, stiffness, and weakness. CASE 1

3 CASE 1 PE: Diffuse anterior shoulder tenderness. Decreased ROM throughout. Mild weakness secondary to pain. Impingement signs are positive. X-rays: normal. Diagnosis:?

4 CASE 1 A: Arthritis B: Adhesive capsulitis C: Impingement syndrome D: Rotator cuff tendinitis E: Rotator cuff tear

5 CASE 2 S: 45 y/o male develops 2 months right lateral shoulder pain in the setting of remodeling his home. Denies trauma. Pain particularly with overhead activities. Now developing night pain. Denies stiffness and weakness.

6 CASE 2 O: Shoulder normal to inspection. No tenderness to palpation. Range of motion is a little stiff and painful at end forward flexion and internal rotation. 5/5 strength with trace discomfort in supraspinatous. Positive impingement signs. Xrays: mild AC degenerative changes A/P: Diagnosis?

8 CASE 3 S: 53 y/o male starts a new volleyball league after a hiatus from exercise. He slowly develops right shoulder pain, which continues to worsen, eventually causing him difficulty sleeping.

9 CASE 3 O: Shoulder without deformity or tenderness to palpation. Full range of motion, but painful forward flexion. Has give way weakness on supraspinatous strength testing. Positive impingement signs. X-Ray: normal A/P: Diagnosis?

11 OVERVIEW Differential diagnosis Anatomy Physical Exam range of motion rotator cuff strength testing Conceptual model for interpreting the physical exam hinge problems rope problems Adhesive capsulitis Impingement syndrome Rotator cuff tendinitis and rotator cuff tears

12 Differential Diagnosis of Traumatic and Atraumatic Shoulder Pain

13 Focused Differential of Shoulder Pain Fracture Dislocation Arthritis AC Glenohumeral Impingement syndrome Rotator Cuff Tendinitis or Tears Adhesive Capsulitis Biceps tendinitis Instability Sprain Referred pain

14 ANATOMY

15 ANATOMY

16 Hoppenfeld s Physical Examination of the Spine and Extremities

17 Focused Exam of the Shoulder Neck Inspection Palpation Range of motion Strength Provocative maneuvers Impingement AC joint Biceps Instability

18 Neck Active ROM Spurling s maneuver

19 Deformity Inspection

20 Palpation Clavicle AC joint Coracoid Lateral acromium Biceps tendon

23 Range of Motion Forward flexion painful arc External rotation 0-80 Internal rotation

24 Range of Motion Forward flexion External rotation Internal rotation T2 T4 T7 L-spine Hip pocket

25 Strength Supraspinatus External rotators Internal rotators

26 Strength Supraspinatus External rotators infraspinatous teres minor Internal rotators

27 Strength Supraspinatus External rotators Internal rotators (subscapularis) Gerber s liftoff

28 Provocative Maneuvers Impingement signs Hawkins Neer s AC joint compression Biceps tendon maneuvers

29 Provocative Maneuvers Impingement signs Hawkins Neer s AC joint compression Biceps tendon maneuvers

30 Provocative Maneuvers Impingement signs AC joint compression Biceps tendon maneuvers

31 Provocative Maneuvers Impingement signs AC joint compression Biceps tendon maneuvers Speed s Yergason s

32 Provocative Maneuvers Impingement signs AC joint compression Biceps tendon maneuvers Speed s Yergason s

33 Instability Sulcus sign Apprehension and relocation

34 Instability Sulcus sign Apprehension and relocation

35 Summary: Focused Exam of the Shoulder Neck Inspection Palpation Range of motion Strength Provocative maneuvers Impingement AC joint Biceps Instability

36 HINGE AND ROPE MODEL OF THE The hinge glenohumeral joint joint capsule SHOULDER

37 HINGE AND ROPE MODEL OF THE SHOULDER The rope rotator cuff tendons (primarily supraspinatous) biceps tendon

38 HINGE AND ROPE MODEL OF THE SHOULDER

39 Focused Differential of Shoulder Pain Fracture tenderness, weakness, xrays Dislocation deformity, weakness, xrays Arthritis AC tenderness, cross arm adduction, xrays Glenohumeral ROM, weakness 2 to pain, xrays Impingement ROM, impingement signs Rotator Cuff Tendonitis or Tears ROM, weakness Adhesive Capsulitis - ROM Biceps tendonitis tenderness, biceps tendon signs Instability sulcus sign, apprehension and relocation Sprain tenderness, ROM, weakness Referred pain Spurling s maneuver

40 35 y/o female soccer player fell onto her left arm and shoulder one month ago. She had immediate pain, but was able to keep playing. Now she has worsening shoulder pain, stiffness, and weakness. CASE1

41 CASE 1 PMH: DM, hypothyroidism Meds: metformin, levothyroxine PE: Diffuse anterior shoulder tenderness. Decreased ROM throughout. Weakness seems secondary to pain, but not too bad if tested within a limited ROM. Impingement signs, AC joint signs, and biceps tendon signs all positive. X-rays: normal. Diagnosis:?

42 Epidemiology also called frozen shoulder ADHESIVE CAPSULITIS characterized by gradual loss of active and passive glenohumeral motion prevalence slightly greater than 2% in the general population more common in persons older than 40 years approximately 70% of cases are female 20-30% will develop adhesive capsulitis in the opposite shoulder documented to be more common and difficult to treat in patients who have diabetes, thyroid disease, and autoimmune disease

43 Historical Perspective ADHESIVE CAPSULITIS Duplay first identified a stiff shoulder as a periarthritis in 1872 Codman labeled the condition frozen shoulder in 1934 Neviaser coined the term adhesive capsulitis in 1945, recognizing pathologic changes in the capsule Dr. Ernest Codman ( )

44 Pathology/Anatomy ADHESIVE CAPSULITIS inflammation and consequent stiffening of the glenohumeral joint capsule unclear what initiates this inflammatory process may occur in setting of recent trauma more common in diabetes disagreement remains as to whether the underlying process is actually inflammatory or fibrosing

45 Classification ADHESIVE CAPSULITIS Primary idiopathic, progressive, painful loss of active and passive shoulder motion Secondary similar presentation and progression as primary adhesive capsulitis, but results from a known intrinsic or extrinsic cause intrinsic: rotator cuff tears, bursitis, tendonitis extrinsic: trauma, surgery

46 ADHESIVE CAPSULITIS Stages of Adhesive Capsulitis: Stage 1 duration: symptoms generally less than 3 months symptoms: aches at rest, sharp with motion; night pain; progressive loss of motion exam after injection: significant improvement in range of motion to normal or minimal loss arthroscopic findings: diffuse hypervascular synovitis

47 ADHESIVE CAPSULITIS Stages of Adhesive Capsulitis: Stage 2 the freezing stage duration: symptoms present approximately 3 to 9 months symptoms: aches at rest, sharp with motion; night pain often significant; significant loss of motion exam after injection: partial improvement in range of motion; lost motion secondary to loss of capsular volume and a response to painful synovitis arthroscopic findings: diffuse hypervascular synovitis with a tight capsule and a rubbery feel with insertion of the arthroscope

48 ADHESIVE CAPSULITIS Stages of Adhesive Capsulitis: Stage 3 the frozen stage duration: symptoms present approximately 9 to 15 months symptoms: minimal pain at rest and at night, but still sharp at end range of motion; significant stiffness exam after injection: no improvement in range of motion; lost motion secondary to profound loss of capsular volume and fibrosis of the glenohumeral joint capsule arthroscopic findings: fibrotic synovium that is no longer hypervascular

49 ADHESIVE CAPSULITIS Stages of Adhesive Capsulitis: Stage 4 the thawing stage duration: symptoms present greater than 15 or more months symptoms: minimal pain at rest and progressive improvement in range of motion due to capsular remodeling exam after injection and arthroscopic findings: data is lacking as patients rarely undergo interventions once they have reached this stage I often simplify it to a 6 month inflammatory phase followed by an 18 month thawing phase

50 History pain and stiffness night pain pain with sudden movements possible antecedent trauma association with diabetes ADHESIVE CAPSULITIS

51 ADHESIVE CAPSULITIS Exam Palpation: may have tenderness over the anterior capsule of the shoulder Range of Motion: Pain at end range of motion in all directions Firm endpoints at end range of motion Increased pain with overpressure Strength: normal Provocative maneuvers: may have positive impingement signs or other provocative maneuvers

52 Imaging X-rays Normal ADHESIVE CAPSULITIS Obtained to rule out other potential causes of stiff shoulder, such as glenohumeral arthritis, calcific tendonitis, or rotator cuff disease MRI - normal

53 ADHESIVE CAPSULITIS Treatment Nonoperative Watchful waiting Anticipate resolution over approximately 2 years Physical therapy sometimes frustrating Consider Dynasplint X-ray guided intra-articular cortisone injection Closed manipulation under anesthesia with simultaneous intra-articular cortisone injection

54 ADHESIVE CAPSULITIS Treatment Operative Arthroscopic capsular release Open surgical capsular release

55 ADHESIVE CAPSULITIS Summary Progressive and painful stiffening of the shoulder Self-limited, often resolving over about 2 years More common and more difficult to treat in diabetes Examination is characterized by decreased range in all directions, with firm endpoints, with increased pain with overpressure Optimal treatment likely depends on the stage at which the patient presents

56 CASE 2 S: 45 y/o male develops 2 months right lateral shoulder pain in the setting of remodeling his home. Denies trauma. Pain particularly with overhead activities. Now developing night pain. No stiffness or weakness.

57 CASE 2 O: Shoulder normal to inspection. No tenderness to palpation. Range of motion is a little stiff and painful at end forward flexion and internal rotation. 5/5 strength with trace discomfort in supraspinatous. Positive impingement signs. X-rays: mild AC degenerative changes A/P: Diagnosis?

58 Pathology/Anatomy IMPINGEMENT compression of the rotator cuff tendon between the humeral head and acromial roof, causing tendinitis subacromial bursa also gets inflamed, resulting in bursitis most commonly occurs in position of forward flexion and/or internal rotation can ultimately lead to rotator cuff tears can be primary (bony) or secondary

59 IMPINGEMENT History pain in lateral arm with overhead activities night pain repetitive use in overhead activity weakness secondary to pain range of motion usually OK

60 Exam IMPINGEMENT Palpation: may have tenderness at the lateral acromion ROM: full, but may have pain in forward flexion and/or internal rotation Strength: 5/5 but may have pain in supraspinatous and/or internal rotation Provocative maneuvers: may have one or more positive impingement signs

61 IMPINGEMENT Exam Impingement signs: Hawkins and Neers

62 IMPINGEMENT Exam Impingement signs: Hawkins and Neers

63 X-rays normal x-rays possibly decreased clearance on acriomial outlet view IMPINGEMENT

64 IMPINGEMENT MRI MRI: not usually necessary, but may show impingement of the soft tissues

65 Treatment Non-operative NSAIDS, cortisone physical therapy IMPINGEMENT Operative: subacromial decompression (acriomioplasty with bursectomy) +/- distal clavicle resection

66 CASE 3 S: 53 y/o male starts a new volleyball league after a hiatus from exercise. He slowly develops right shoulder pain, which continues to worsen, eventually causing him difficulty sleeping.

67 O: Shoulder without deformity or tenderness to palpation. Full range of motion, but painful forward flexion. Has give way weakness on supraspinatous strength testing. Positive impingement signs. X-Ray: normal A/P: Diagnosis? CASE 3

68 ROTATOR CUFF TENDINITIS AND TEARS Pathology/Anatomy injury to the rotator cuff tendon painful to actively pull on the injured tendon can be traumatic or atraumatic/degenerative can be acute or chronic

69 ROTATOR CUFF TENDINITIS AND TEARS

70 ROTATOR CUFF TENDINITIS AND TEARS History trauma, sudden disability overuse or change in activity level pain, weakness especially overhead pain with eccentric lowering of the arm night pain range of motion usually OK

71 ROTATOR CUFF TENDINITIS AND TEARS Exam Palpation: may have tenderness at the lateral acromiom ROM: full, but painful in forward flexion; less pain passively than actively Strength: pain and weakness with rotator cuff strength testing Provocative maneuvers: may have positive impingement signs

72 Exam ROTATOR CUFF TENDINITIS AND TEARS Supraspinatus testing: pain and/or weakness

73 ROTATOR CUFF TENDONITIS AND TEARS X-rays often normal may show calcific tendonitis chronically: high riding humeral head, rotator cuff arthropathy Ultrasound, MRI

74 ROTATOR CUFF TENDONITIS AND TEARS X-rays often normal may show calcific tendonitis chronically: high riding humeral head, rotator cuff arthropathy Ultrasound, MRI

75 ROTATOR CUFF TENDONITIS AND TEARS Other imaging Ultrasound MRI

76 ROTATOR CUFF TENDINITIS AND TEARS Treatment Tendinitis: NSAIDS, cortisone; physical therapy Partial thickness tears: NSAIDS, cortisone; physical therapy; surgery Full thickness tears: early surgery for the young; elective surgery (versus symptomatic treatment) for the elderly

77 THE END