shoulder 101 …and then some evan d. ellis md rebound orthopaedics and sports medicine
TRANSCRIPT
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Shoulder 101 Shoulder 101 …and Then Some…and Then Some
Evan D. Ellis MDEvan D. Ellis MD
Rebound Orthopaedics Rebound Orthopaedics and Sports Medicineand Sports Medicine
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Why Shoulder 101?Why Shoulder 101?
Multiple studies: High percentage Multiple studies: High percentage of visits to see PCP are for of visits to see PCP are for musculoskeletal painmusculoskeletal pain
2 studies2 studies**: Large gap in PCP : Large gap in PCP confidence in evaluating and confidence in evaluating and treating musculoskeletal injuriestreating musculoskeletal injuries
Studies in both a rural and Studies in both a rural and tertiary academic settingtertiary academic setting
*Lynch et al JBJS AM 2006 and AJO 2005*Lynch et al JBJS AM 2006 and AJO 2005
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The ShoulderThe Shoulder ANATOMYANATOMY
HISTORY HISTORY
PHYSICAL EXAMPHYSICAL EXAM
IMAGINGIMAGING
CASES/CASES/TREATMENTTREATMENT
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AnatomyAnatomy
Not a ball and Not a ball and socketsocket
More of a ball More of a ball on a dishon a dish
Static Static RestraintsRestraints
Dynamic Dynamic RestraintsRestraints
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AnatomyAnatomy
Glenoid Concavity:Glenoid Concavity:• BoneBone• CartilageCartilage• LabrumLabrum
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AnatomyAnatomy LabrumLabrum: :
Deepens glenoid by 50%Deepens glenoid by 50% 9 mm superoinferior*9 mm superoinferior*
5 mm anteroposterior*5 mm anteroposterior*
Contributes to 20% of Contributes to 20% of stability in A-P directionstability in A-P direction
Loss of labral integrity may Loss of labral integrity may result in instabilityresult in instability
*McMahon et al. JSES. 2004. Jan-Feb;13(1):39-44.*Howell SM, Galinat BJ. The glenoid-labral socket: a constrained articular surface. Clin Orthop. 1989
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AnatomyAnatomy
Static RestraintsStatic Restraints Glenohumeral LigamentsGlenohumeral Ligaments
Superior: Prevents inferior Superior: Prevents inferior translation with arm at sidetranslation with arm at side
Middle: Important for mid-Middle: Important for mid-range abductionrange abduction
Inferior: Critical for ABD/ERInferior: Critical for ABD/ER Anterior band prevents anterior Anterior band prevents anterior
inferior translationinferior translation
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AnatomyAnatomy• Ligaments do not center Ligaments do not center the head. the head. • Limit its translation and Limit its translation and rotation.rotation.• Think Check-RainsThink Check-Rains
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AnatomyAnatomyDynamic RestraintsDynamic Restraints Muscular StabilizersMuscular Stabilizers
Anterior: SubscapularisAnterior: Subscapularis
Superior: SupraspinatusSuperior: Supraspinatus
Posterior: Teres minor and Posterior: Teres minor and InfraspinatusInfraspinatus
Lateral: DeltoidLateral: Deltoid
Scapular stabilizersScapular stabilizers
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History BasicsHistory Basics
Painful shoulders can be:Painful shoulders can be: UnstableUnstable StiffStiff WeakWeak Rough/PainRough/Pain
““What bothers you about What bothers you about your shoulder?your shoulder?””
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HistoryHistory
AgeAge GenderGender Was there an Was there an
injury?injury? Injury mechanismInjury mechanism Prior problemPrior problem Dominant armDominant arm
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HistoryHistory
ChronicityChronicity Location of PainLocation of Pain Pain at nightPain at night Stiffness/UnstableStiffness/Unstable Prior treatment Prior treatment
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Physical ExamPhysical Exam Goal: Reproduce SymptomsGoal: Reproduce Symptoms
Inspection, Palpation, ROM, Inspection, Palpation, ROM, neurovascular exam, special neurovascular exam, special teststests
Compare to contralateral sideCompare to contralateral side
Cervical spineCervical spine
Note provocative positionsNote provocative positions
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Physical ExamPhysical Exam
EXPOSE:EXPOSE: NeckNeck ShouldersShoulders ArmsArms
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Physical ExamPhysical Exam
EXPOSE:EXPOSE: NeckNeck ShouldersShoulders ArmsArms
Women need gown Women need gown or tank top!or tank top!
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Physical ExamPhysical Exam
Motion: Active/PassiveMotion: Active/Passive Forward ElevationForward Elevation External RotationExternal Rotation ER in AbductionER in Abduction Internal RotationInternal Rotation IR in AbductionIR in Abduction X-BodyX-Body
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Range of MotionRange of Motion FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine
X-Body: 60X-Body: 60
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Range of MotionRange of Motion
FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine
X-Body: 60X-Body: 60
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Range of MotionRange of Motion
FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine
X-Body: 60X-Body: 60
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Range of MotionRange of Motion
FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine
X-Body: 60X-Body: 60
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Range of MotionRange of Motion
FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine
X-Body: 60X-Body: 60
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Range of MotionRange of Motion
FE: 180FE: 180 ERS: 60ERS: 60 ERA: 90ERA: 90 IRA: 70IRA: 70 IRB: T-IRB: T-spinespine
X-Body: 60X-Body: 60
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Rotator Cuff ExamRotator Cuff Exam
MOTOR MOTOR SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor
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Rotator Cuff ExamRotator Cuff Exam
MOTOR MOTOR SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor
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Rotator Cuff ExamRotator Cuff Exam
MOTOR MOTOR SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor
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Rotator Cuff ExamRotator Cuff Exam
MOTOR MOTOR SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor
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Rotator Cuff ExamRotator Cuff Exam
MOTOR MOTOR SubscapularisSubscapularis SupraspinatusSupraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor
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Neurologic ExamNeurologic Exam
NEURONEURO SensationSensation MotorMotor ReflexesReflexes SpurlingSpurling’’ss
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Neurologic ExamNeurologic Exam
NEURONEURO SensationSensation MotorMotor ReflexesReflexes SpurlingSpurling’’ss
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Special Tests - CuffSpecial Tests - Cuff
CUFFCUFF Neer Impingement Neer Impingement
SignSign Neer Impingement Neer Impingement
TestTestSubacromial Subacromial
injectioninjection Hawkins Test Hawkins Test
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Special Tests - CuffSpecial Tests - Cuff
CUFFCUFF Neer Impingement Neer Impingement
SignSign Neer Impingement Neer Impingement
TestTestSubacromial Subacromial
injectioninjection Hawkins TestHawkins Test
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Special Tests - CuffSpecial Tests - Cuff CUFFCUFF
Neer Impingement Neer Impingement SignSign
Neer Impingement Neer Impingement TestTestSubacromial Subacromial
injectioninjection Hawkins Test Hawkins Test
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Special Tests - InstabilitySpecial Tests - Instability Apprehension/RelocationApprehension/Relocation
Supine positionSupine position Stabilizes scapulaStabilizes scapula
Abduct to 90Abduct to 90°° Increase ER graduallyIncrease ER gradually
Positive:Positive: Apprehension w/ Apprehension w/
increasing amounts of increasing amounts of ERER
Apprehension relieved Apprehension relieved by posterior force on by posterior force on the humerusthe humerus
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Special Tests - InstabilitySpecial Tests - Instability
Seated Load & ShiftSeated Load & Shift Assess A & P translationAssess A & P translation
Grade Grade 1+: to rim1+: to rim 2+: over rim 2+: over rim
w/reductionw/reduction 3+: over rim & locked3+: over rim & locked
Compare to other sideCompare to other side
Assess for pain, click, & Assess for pain, click, & instabilityinstability
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Special Tests - InstabilitySpecial Tests - Instability
Supine Load & ShiftSupine Load & Shift Arm position: Arm position:
45-6045-60°° abduction abduction
Ant/Post directed force Ant/Post directed force applied to humerusapplied to humerus
AssessAssess StabilityStability PainPain Palpable clickPalpable click
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Special Tests - InstabilitySpecial Tests - Instability
Sulcus Sign: Sulcus Sign: Arm at sideArm at side
To look for multi-directional To look for multi-directional instabilityinstability GradeGrade
1+ = 1 cm1+ = 1 cm 2+ = 1-2 cm2+ = 1-2 cm 3+ = > 2 cm3+ = > 2 cm
Look for generalized Look for generalized hypermobilityhypermobility
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RadiographsRadiographs
Never order an MRI before X-RaysNever order an MRI before X-Rays
Everyone deserves a normal set of X-Rays!Everyone deserves a normal set of X-Rays!
Most important X-Rays: Most important X-Rays: True APTrue AP (Grashey) (Grashey) and and Axillary LateralAxillary Lateral
These two X-Rays are almost always omitted These two X-Rays are almost always omitted from a from a ““shoulder seriesshoulder series””!!
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RadiographsRadiographsTrue AP or Grashey View:• Arthritis• Fracture• Massive Rotator Cuff tear
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RadiographsRadiographs
True APTrue AP
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RadiographsRadiographs Axillary LateralAxillary Lateral
ArthritisArthritis InstabilityInstability FractureFracture
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RadiographsRadiographs Axillary LateralAxillary Lateral
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RadiographsRadiographs
Additional ViewsAdditional Views Outlet Outlet Internal/ExternalInternal/External Stryker NotchStryker Notch West Point ViewWest Point View
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The ShoulderThe ShoulderA.A. Diagnosable & TreatableDiagnosable & Treatable
Rotator cuff tearsRotator cuff tears Shoulder instability Shoulder instability ArthritisArthritis SLAP tearSLAP tear
B.B. Diagnosable & UntreatableDiagnosable & Untreatable Brachial neuritisBrachial neuritis Voluntary instability/MDIVoluntary instability/MDI Rib fracturesRib fractures
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Age is KeyAge is Key
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Age is KeyAge is Key
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Case #1Case #1
History:History: 16 year old RHD 16 year old RHD
male football playermale football player Shoulder Shoulder ““poppedpopped””
out of place while out of place while getting tackledgetting tackled
To ER for reductionTo ER for reduction Has happened 2 Has happened 2
previous timesprevious times
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Case #1Case #1
Physical Exam:Physical Exam: Full Range of MotionFull Range of Motion Full rotator cuff Full rotator cuff
strength strength + Apprehension Test+ Apprehension Test + Relocation Test+ Relocation Test + Anterior Load & + Anterior Load &
ShiftShift
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Case #1Case #1
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Case #1Case #1
What do you do?What do you do?
Place him in a slingPlace him in a sling Refer to OrthoRefer to Ortho If first time dislocater – Physical If first time dislocater – Physical
TherapyTherapy If 2 or more dislocations – MRI and If 2 or more dislocations – MRI and
surgerysurgery
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SlingSlingRegular Sling vs. External RotationRegular Sling vs. External Rotation
Which is better?Which is better?
Itoi, JBJS 2007Itoi, JBJS 2007 159 patients159 patients Avg follow up of 25.6 monthsAvg follow up of 25.6 months 74 immobilized in IR74 immobilized in IR
31 recurred (42%)31 recurred (42%) 85 immobilized in ER85 immobilized in ER
22 recurred (26%)22 recurred (26%) *Effect on labral position for *Effect on labral position for
healinghealing
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Case #1Case #1
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Case #1Case #1Arthroscopic Repair
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Case #2Case #2History:History: 41 yo female with gradual onset 41 yo female with gradual onset
pain/stiffness over 6 weekspain/stiffness over 6 weeks No history of traumaNo history of trauma Similar problem with other shoulder 2 years Similar problem with other shoulder 2 years
priorprior Hx of DiabetesHx of Diabetes CanCan’’t brush hair or fasten brat brush hair or fasten bra
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Case #2Case #2
Physical Exam:Physical Exam: Forward Elevation – 80Forward Elevation – 80 External Rotation – NeutralExternal Rotation – Neutral Internal Rotation – Back PocketInternal Rotation – Back Pocket Full strength of rotator cuffFull strength of rotator cuff CanCan’’t get arm to side to check for instabilityt get arm to side to check for instability
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Case #2Case #2
RadiographsRadiographs
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Case #2Case #2 Diagnosis???Diagnosis??? Adhesive Capsulitis/Frozen ShoulderAdhesive Capsulitis/Frozen Shoulder
Treatment???Treatment??? If nothing done, may take 2 years to resolveIf nothing done, may take 2 years to resolve PT, PT, PTPT, PT, PT If fails: Intraarticular cortisone shot and If fails: Intraarticular cortisone shot and
more PTmore PT If fails: Manipulation under anesthesiaIf fails: Manipulation under anesthesia If fails: Arthroscopic capsular releaseIf fails: Arthroscopic capsular release
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Case #2Case #2 What would MRI show with adhesive What would MRI show with adhesive
capsulitis?capsulitis?
NormalNormal
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Case #2Case #2
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Case #3Case #3
History:History: 49 yo male fell down stairs and grabbed 49 yo male fell down stairs and grabbed
railing on way down.railing on way down. Felt ripping sensation in shoulderFelt ripping sensation in shoulder Pain on lateral aspect of shoulderPain on lateral aspect of shoulder Pain with overhead activityPain with overhead activity Night painNight pain PoppingPopping Feels weakFeels weak
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Case #3Case #3Physical Exam:Physical Exam: Pain/crepitus with Pain/crepitus with
forward elevationforward elevation Positive Impingement Positive Impingement
SignSign Positive Hawkins TestPositive Hawkins Test Weakness with Weakness with
supraspinatus testingsupraspinatus testing No instabilityNo instability
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Case #3Case #3
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Case #3Case #3
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Case #3Case #3Diagnosis??Diagnosis?? Acute rotator cuff tearAcute rotator cuff tear
Treatment??Treatment?? Refer to orthoRefer to ortho Acute, full-thickness Acute, full-thickness
cuff tear in a cuff tear in a ““youngyoung”” patient = surgical patient = surgical repairrepair
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Case #4Case #4
History:History: 48 yo RHD male48 yo RHD male 6 months shoulder pain6 months shoulder pain No injuryNo injury Pain at nightPain at night Pain with reaching overheadPain with reaching overhead NSAIDS no helpNSAIDS no help No neck pain/numbness/tinglingNo neck pain/numbness/tingling
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Case #4Case #4
Physical Exam:Physical Exam: Full ROMFull ROM + Impingement Sign+ Impingement Sign + Hawkins Test+ Hawkins Test Full Strength of CuffFull Strength of Cuff Pain with Pain with
supraspinatus supraspinatus testingtesting
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Case #4Case #4
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Case #4Case #4
Diagnosis?Diagnosis? Rotator Cuff Tendonitis vs. Rotator Cuff Tendonitis vs.
Partial Thickness TearPartial Thickness Tear
Treatment?Treatment? Physical TherapyPhysical Therapy If no improvement = Refer to If no improvement = Refer to
Ortho Ortho
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Case #4Case #4
What do we do?What do we do? MRIMRI If MRI = If MRI = Cortisone Cortisone
injectioninjection If MRI = If MRI = Possible Possible
SurgerySurgery
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Partial Thickness Cuff Partial Thickness Cuff TearsTears
Increasing prevalence with ageIncreasing prevalence with age 30 – 60% Incidence in Age > 6030 – 60% Incidence in Age > 60 Over 80% Incidence in Age > 70Over 80% Incidence in Age > 70
Often asymptomatic Often asymptomatic If painful and fail therapy = SurgeryIf painful and fail therapy = Surgery Supraspinatus is 11 mm thickSupraspinatus is 11 mm thick
If < 50% torn = Debridement + DecompressionIf < 50% torn = Debridement + Decompression If > 50% torn = Complete the tear and RepairIf > 50% torn = Complete the tear and Repair
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Case #5Case #5
History:History: 66 yo male with progressive pain/stiffness 66 yo male with progressive pain/stiffness
shouldershoulder Pain is constant and unable to do ADLSPain is constant and unable to do ADLS Feels like itFeels like it’’s popping with motions popping with motion NSAIDS – Some reliefNSAIDS – Some relief
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Case #5Case #5
Physical Exam:Physical Exam: FE: 100FE: 100 ER: NeutralER: Neutral IR: Back PocketIR: Back Pocket ““RatchetingRatcheting”” motion motion Cuff Strength Cuff Strength
NormalNormal
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Case #5Case #5Radiographs
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Case #5Case #5
Diagnosis?Diagnosis? Endstage Shoulder OsteoarthritisEndstage Shoulder Osteoarthritis
Treatment?Treatment? Physical Therapy and/or refer to OrthoPhysical Therapy and/or refer to Ortho Cortisone InjectionCortisone Injection Shoulder ReplacementShoulder Replacement
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Case #5Case #5
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Case #6Case #6
History:History: 14 yo female with 14 yo female with
longstanding history of both longstanding history of both shoulders going shoulders going ““in and outin and out””
No traumatic eventNo traumatic event Has never had them reduced Has never had them reduced
in the ERin the ER Sometimes Sometimes ““grosses friends grosses friends
outout”” by dislocating her by dislocating her shoulder at partiesshoulder at parties
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Case #6Case #6
Physical Exam:Physical Exam: Full Range of MotionFull Range of Motion Normal Cuff Normal Cuff
StrengthStrength Sulcus - Grade 3Sulcus - Grade 3 Hypermobile Signs +Hypermobile Signs +
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Case #6Case #6
Hypermobile Tests
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Case #6Case #6 Radiographs – NormalRadiographs – Normal
Diagnosis?Diagnosis? Atraumatic, bilateral shoulder instabilityAtraumatic, bilateral shoulder instability
Treatment?Treatment? PT, PT, PTPT, PT, PT More PTMore PT MRI – Normal or Enlarged joint capsuleMRI – Normal or Enlarged joint capsule If absolutely fails everything – Capsular shiftIf absolutely fails everything – Capsular shift
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Case #6Case #6
Capsular Shift
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Case #7Case #7
History:History: 80 yo female with occasional ache in 80 yo female with occasional ache in
shouldershoulder Swims everydaySwims everyday No InjuryNo Injury Pain is minimal, but just wants to get it Pain is minimal, but just wants to get it
checked outchecked out Takes no pain medsTakes no pain meds
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Case #7Case #7
Physical Exam:Physical Exam: Full ROMFull ROM Mild pain with reaching overheadMild pain with reaching overhead + Impingement Sign+ Impingement Sign + Hawkins Test+ Hawkins Test Profound weakness of supra/infraspinatusProfound weakness of supra/infraspinatus
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Case #7Case #7Radiographs
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Case #7Case #7MRI
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Case #7Case #7
Diagnosis?Diagnosis? Massive Rotator Cuff TearMassive Rotator Cuff Tear
Treatment?Treatment? No role for surgical repairNo role for surgical repair Leave it aloneLeave it alone Physical TherapyPhysical Therapy Occasional cortisone injectionOccasional cortisone injection
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SummarySummary A focused, thorough H&P is critical to correctly A focused, thorough H&P is critical to correctly
diagnosing a shoulder problem. diagnosing a shoulder problem. Expose the shoulder for the exam and compare to Expose the shoulder for the exam and compare to
the other side. the other side. Age, alone, is an important predictor of a patientsAge, alone, is an important predictor of a patients’’
diagnosis. diagnosis. Always order an x-ray series prior to ordering a Always order an x-ray series prior to ordering a
shoulder MRI. Everyone deserves a normal set of shoulder MRI. Everyone deserves a normal set of x-rays! x-rays!
X-ray series should always, at a minimum, include X-ray series should always, at a minimum, include a true AP (grashey) and an axillary view.a true AP (grashey) and an axillary view.
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SummarySummary
Not all rotator cuff tears can, or should be, fixed. Not all rotator cuff tears can, or should be, fixed. Traumatic, unidirectional, recurrent dislocaters Traumatic, unidirectional, recurrent dislocaters
should be surgically repaired. should be surgically repaired. Atraumatic, multidirectional, and/or voluntary Atraumatic, multidirectional, and/or voluntary
shoulder dislocaters should almost never be shoulder dislocaters should almost never be surgically repaired. surgically repaired.
Physical therapy is a tremendous adjunct to Physical therapy is a tremendous adjunct to treatment for the majority of shoulder injuries. treatment for the majority of shoulder injuries.
If you have questions, please call or refer your If you have questions, please call or refer your patients. We are always happy to help!patients. We are always happy to help!
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Thanks!!Thanks!!
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