chronic scapulothoracic pain or chronic shoulder pain

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Chronic Scapulothoracic Pain or Chronic Shoulder Pain. Steve Moll, DO Senior Medical Officer USS SAIPAN (LHA-2). Chronic Scapulothoracic Pain. At the conclusion of this activity, you should: - PowerPoint PPT Presentation

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  • Chronic Scapulothoracic Painor Chronic Shoulder PainSteve Moll, DOSenior Medical OfficerUSS SAIPAN (LHA-2)

  • Chronic Scapulothoracic Pain At the conclusion of this activity, you should: Appreciate the degree to which myofascial pain syndromes from the scapulothoracic region can cause shoulder pain. Understand the importance of treating predisposing factors in myofascial pain syndromes. Know that successful treatment requires a multi-factorial approach.

  • The Shoulder...The shoulder consists of four joints:GlenohumeralAcromioclavicularSternoclavicularScapulothoracicIts not just a Joint, but a Complex.

  • Differential DiagnosisShoulder pain arising from problems:Intrinsic to the A-C / glenohumeral joints, orExtrinsic (referred pain patterns) Somatic Visceral

  • Differential Diagnosisacromioclavicular arthritisacromioclavicular separationadhesive capsulitisadhesive capsulitisapical lung tumorsavascular necrosisaxillary vein thrombosisbicipital tendonitisbiliary tract diseasebrachial neuritisbrachial plexopathycalcific tendonitiscephalobrachialgiacervical root compression (esp.C5)

    cervicodorsal sympathalgiacoronary artery disease & anginacostoclavicular syndromedislocationfibromyalgiaforward head syndromefractures: clavicle, scapula, humerusglenohumeral arthritis - crystal-induced - osteoarthritis - post-traumatic - rheumatoid - septic

  • Differential Diagnosisglenohumeral instability - AMBRI - TUBSimpingement syndromelabral tears (SLAP tear)levator scapulae syndromelumbar facet syndromemyofascial pain syndromeParsonage-Turner syndromepneumoniapolymyalgia rheumaticareflex sympathetic dystrophyrotator cuff tearscapulocostal syndromeshoulder instabilitysnapping shoulder syndromespinal cord lesionssplenic lesionssubacromial bursitissupraspinatus nerve compressionsupraspinatus tendonitisswimmers shoulderthoracic outlet syndrometumor

  • History & Physical Exam

  • HistoryWhats new or different in the 6 months prior to the onset of pain?

  • HistoryWhats new or different in the 6 months prior to the onset of pain?- New job? Longer hours in front of the computer? - New car? Longer commute? - New duty station (shipboard)? Running shoes? - Raked leaves? - More stress? Less/poorer sleep? - Marital conflict? - Different pillow? - Pregnancy?

  • HistoryWhat occupies the majority of your day?How much time do you spend - sitting? - talking on the phone?- driving?, or - being driven nuts?

  • HistoryIs there a time of the day when your is pain better? Worse?

    How well do you sleep?

  • Physical Exam- ROM (active & passive) - Strength - Special tests (lift off; Neer; Hawkins; cross-body adduction; empty can)

  • Physical Exam- ROM (active & passive) - Strength - Special tests (e.g. lift off; Neer; Hawkins; cross-body adduction; empty can)- Palpate- Posture

  • Travell Trigger Points (TrPs) & Myofascial Pain Syndrome

    TrP: "a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is tender when pressed and can give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena.

    Palpation is a reliable diagnostic criterion for locating TrPs.

  • Travell Trigger Points (TrPs) & Myofascial Pain Syndrome

    Etiology of TrPs:1. Local myofascial tissues- Motor end plate dysfunction cascade5 - from genetic defects, or - acquired defects (nicotine, caffeine, psychological & physiological stress2. CNS factors (central sensitization)4,53. Biomechanical factors

  • Referred pain patterns

  • Treatment

    Direct Tx of TPs- pressure- injection- dry needling- massageTreatment of Perpetuating Factors

  • Treatment of Perpetuating Factors

    Postural stressesPsychological stressMechanical factorsConstriction of musclesSocial habits

  • Treatment of Perpetuating Factors

    Postural stresses - poor posture - misfitting furniture - immobility - frequent repetitive movements

  • Treatment of Perpetuating Factors

    Psychological stress- hopelessness- depression- anxiety & tension

  • Treatment of Perpetuating Factors

    Mechanical factors- SI dysfunctions- hemipelvic disparities - limb length discrepancy- Morton's foot (long second metatarsal)

  • Treatment of Perpetuating Factors

    Social habits - nicotine- caffeine- alcohol abuse

  • ConclusionThe Family Practice Physicianis eminently qualified to successfully manage the multifactorial problems which plague the chronic pain patient.

  • Common ConcomitantsForward Head SyndromeMyofascial Pain (Scapulothoracic) SyndromeRotator Cuff SyndromeThoracic facet syndrome (somatic dysfunction)

  • Treatment (contd)Fix the SLEEP problem!No sleep. No relief. No hope.

    Raise SEROTONIN levels.

    Treat the depression &/or anxiety.

  • Treating InsomniaR/O Obstructive Sleep ApneaTrazodone (Desyrel)Allow self-titrationExplicit verbal & written instructionsTreatment failures? Bipolar until proven otherwise.TCAs (nortriptylene; amitriptyline)Gabapentin (Neurontin)Zolpidem (Ambien)SSRIs

  • Boosting Serotonin LevelsSSRIsStart earlyEscalate doses, as tolerated

    Yes this is an anti-depressant. No I dont think youre depressed. I am giving this to you as an adjunct

    *The SHOULDER... Its not just a joint, but a complex

    The shoulder consists of four joints:Glenohumeral2. Acromicoclavicular3. Sternoclavicular4. Scapulothoracic* The complexity of the shoulder, in addition to its large range of motion, are the setting for a wide range of problems. The presentation of shoulder pain has a very broad differential diagnosis. I like to break down the differential into those problems which are 1) intrinsic to the A-C/glenohumeral joints, and those extrinsic to this area. The extrinsic etiologies, for the most part, are those problems which elicit referred pain. These may be further subdivided into referred pain from a) somatic structures, and b) visceral organs.*Listed alphabetically, the differential is mind-boggling, and you might even have some additional problems that I havent included.

    *Naturally, when you put on your detective caps and go to work to figure out which of these is bothering the patient in your clinic, youll set about considering whether this is an acute or chronic problem, whether trauma was a factor, the age of the patient, their activities & occupation, and youll do a thorough physical just like you learned in your training.

    *I would like to focus the balance of the talk on chronic shoulder pain.

    When the pain has been going on for months, encompasses multiple muscles/locations in the shoulder & upper arm, the trapezius and, possibly, the neck, and radiates down the arm ... plain films fail to show OA/DDD... and the Pt has failed various NSAIDs and the muscle relaxer du jour... What are you gonna do next??? *Figuring out all the different variables contributing to someone's chronic pain will appear to be a daunting task. It doesn't have to be done in one 15 min appointment. What's important is that you know which route to take (have a game plan), what to look for, and what you need to do once you find problems.

    If its a chronic problem, chances are youve already covered many of the questions or done a significant portion of the exam in previous visits.

    *Although youve heard it countless times, it bears repeating that THE HISTORY IS EVERYTHING!

    One of my favorite questions is, Whats new or different in the 6 months prior to the onset of pain? (Why 6 mos? Its arbitrary. But, generally, chronic problems have a long build up phase which precedes the onset of pain. And most Pts probably wont be able to historically differentiate between 5, 6, or 7 mos.)

    If they respond with, Nothing, Doc. keep pressing them.*I can just about guarantee that there is something that plays a contributing role in their chronic pain.*Muscles dont like long periods of immobility.If you have your head cocked sideways talking on the phone for long periods, you may develop neck & trapezius pain.Sitting in a car for long periods, especially in bad traffic, is also a set-up for upper extremity & upper thoracic pain.*If pain is worse in the AM, the culprit may have something to do with sleeping arrangements. (A common problem with shipboard sailors.) You can often help them either get a new mattress or write a Rx chit to allow them to put a sheet of plywood under their mattress.Worse at the end of the day, some repetitive movement (or lack thereof).

    Insomnia is a frequent complaint, due to an inability to find a comfortable sleeping position.1 Although this may be a consequence of the pain, it may have existed prior to the onset of the problem. Regardless, insomnia must be treated as a separate entity but simultaneously with other musculoskeletal treatments if the chronic pain is to be mitigated **Your palpatory and postural exams are especially important in the patient with chronic scapulothoracic pain.

    Ideally, palpation is performed with the back exposed. The goal is to identify trigger points and palpable nodules within the muscle overlying the upper thorax.

    Is the patient kyphotic? Is the tragus directly over the clavicle? Or well forward of it?*Travell defined TrP as "a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is tender when pressed and can give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena.2Palpation is a reliable diagnostic criterion for locating TrPs.

    *This is why PALPATI