shoulder and hip for the disclosures primary care clinician

7/27/2017

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Shoulder and Hip for the Primary Care Clinician

Carlin Senter, MDAssociate ProfessorPrimary Care Sports MedicineUCSF Medicine and Orthopaedics

UCSF Essentials of Primary Care August 10, 2017

Disclosures

I have nothing to disclose.

Objectives

Upon completion of this session, participants should be able to:

1. Name 2 causes of shoulder pain when both active and passive range of motion are limited.

2. Identify a full thickness rotator cuff tear on physical exam.

3. Explain treatment for rotator cuff disease.

4. Identify intraarticular hip pathology by history and exam.

5. Provide a differential diagnosis for intraarticular hip pathology based on patient age.

Shoulder Problems

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Case #1

50 y/o RHD woman with type 2 diabetes presents with 3 months of severe R shoulder pain. No injury. Waking up at night due to pain. Shoulder feels very stiff. She is having trouble reaching behind and raising arm above head.

On exam she has no muscle atrophy and no point tenderness. There is decreased active and passive range of motion of the right shoulder. Her rotator cuff strength is 5/5 though difficult to perform due to limited range of motion and pain. A R shoulder xray is normal.

How would you treat this patient?

A. Provide R shoulder sling to use for comfort.

B. Provide shoulder steroid injection to reduce pain.

C. Obtain shoulder MRI.

D. Obtain PET CT.

E. Refer to surgeon for arthroscopy.

Adhesive capsulitis

http://www.aurorahealthcare.org/healthgate/images/si55551230.jpg

Shoulder: diagnosis driven exam

Active ROM

DecreasedNormal

Passive ROM

Normal

Decreased

XrayFrozen shoulder

Normal

GH joint arthritis

Abnormal

Rotator cuff diseaseLabral tear

Biceps tendinitisAC joint OA

Adapted from: O'Kane and Toresdahl.

The evidenced-based shoulder evaluation. Cur Sports Med Rep. 2014.

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Abduction

Flexion

Shoulder active range of motion

External rotation

Internal rotation

Shoulder active range of motion

Limited ER key finding Shoulder passive range of motion

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Adhesive capsulitis is associated with

• Diabetes screen for this if hasn’t been done recently• Hyper and hypothyroidism• Hypoadrenalism• Parkinson’s disease• Cardiac disease• Pulmonary disease• Stroke• Surgery (cardiac, cardiac cath, neurosurgery, radical neck

dissection)

Adhesive capsulitis is a clinical diagnosis

No need for MRI

X-rays helpful to r/o glenohumeral joint arthritis

3 stages of adhesive capsulitis

Freezing Frozen Thawing

3-9 months↑ pain↓ ROMPain at rest, sleep

4-12 months↓ painStable, decreased ROM

12-42 monthsGradual ↑ ROM Resolution

Average time to resolution: 1-3 years

Treatment for adhesive capsulitis

Pain control: NSAIDs, oral or injected corticosteroids

• Does not change disease course

• Does help significantly with pain control

+/- physical therapy to help restore ROM

Capsular distention injections

Surgery

• Manipulation under anesthesia

• Arthroscopic release and repair

Manske and Prohaska, Curr Rev Musculoskeletal Med, 2008.Griesser MJ et al. Adhesive capsulitis …a systematic review of intraarticular

injections. J Bone Joint Surg Am. Sep 2011.

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Case #2

57 y/o RHD man presents with R shoulder pain that started after he slipped and fell 3 months ago. Pain at R deltoid. He tried physical therapy without benefit. Waking at night from sleep due to pain.

Exam: Point tenderness just below the acromion. AROM intact with pain on abduction between 60 and 120 degrees. Difficulty fully abducting the R arm. Moderate pain with resisted internal and external rotation of the shoulder. (+) External rotation lag test, (+) internal rotation lag test.

What is the most likely cause of his shoulder pain?

A. Frozen shoulder

B. Glenohumeral joint arthritis

C. Rotator cuff tendinitis (tendinopathy)

D. Partial thickness rotator cuff tear

E. Full thickness rotator cuff tear

Shoulder: diagnosis driven exam

Active ROM

DecreasedNormal

Passive ROM

Normal

Decreased

XrayFrozen shoulder

Normal

GH joint arthritis

Abnormal

Rotator cuff diseaseLabral tear

Biceps tendinitisAC joint OA

Adapted from: O'Kane and Toresdahl.

The evidenced-based shoulder evaluation. Cur Sports Med Rep. 2014.

Rotator cuff disease in primary care

The 3rd most frequent musculoskeletal reason patients present to the office

The most common cause of shoulder pain in patients in the US primary care settings

Whittle S, Buchbinder R. In the clinic. Rotator cuff disease. Ann Intern Med. 2015 Jan 6;162(1):ITC1-15.

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What is rotator cuff disease?

Impingement

Tendinitis/tendinopathy

Partial thickness tear

Full thickness tear

Rotator cuff disease treatment

Most do well with conservative treatment

Impingement

Tendinitis, tendinopathy

Partial thickness tear

Full thickness tear Consider ortho referral.

• Caveat: atraumatic full thickness tears can do well without surgery. (Kuhn JE et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013 Oct;22(10):1371-9.)

PT

+/- Injection+/- Medication

Physical exam maneuvers that increase likelihood of rotator cuff disease

1. Painful arc

2. Drop arm test

Pain test: Painful arc

If painful, positive LR 3.7 for rotator cuff disease.

If not painful, negative LR 0.36 for rotator cuff disease.

JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013.

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Pain/strength test: Drop arm test

Positive LR 3.3, negative LR 0.82 for rotator cuff disease.


Physical exam maneuvers that increase likelihood of full thickness rotator cuff tear

1. External rotation lag test

2. Internal rotation lag test

https://www.healthbase.com/hb/images/cm/procedures/orthopedics/rotator_cuff_tear.jpg

Strength test:External rotation lag test

Positive LR 7.2,

Negative LR 0.57 for full thickness rotator cuff tear


Strength test:Subscapularis = internal rotation lag test

Positive LR 5.6, negative LR 0.04 for full thickness rotator cuff tear


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Case #2

57 y/o RHD man presents with R shoulder pain that started after he slipped and fell 3 months ago. Pain at R deltoid. He tried physical therapy without benefit. Waking at night from sleep due to pain.

Exam: Point tenderness just below the acromion. AROM intact with pain on abduction between 60 and 120 degrees. Difficulty fully abducting the R arm. Moderate pain with resisted internal and external rotation of the shoulder. (+) External rotation lag test, (+) internal rotation lag test.

What is the most likely cause of his shoulder pain?

A. Frozen shoulder

B. Glenohumeral joint arthritis

C. Rotator cuff tendinitis (tendinopathy)

D. Partial thickness rotator cuff tear

E. Full thickness rotator cuff tear

Treatment

A. Refer for surgical consult

B. Repeat trial of physical therapy, f/u 3 months.

C. Give NSAIDs and activity modification, f/u 3 months

D. Give subacromial injection, f/u 3 months

Case #3

30 y/o RHD man fell off bike 9 months ago, injured R shoulder

Went to PT but continues to have pain

Anterior shoulder

Only feels pain if moves shoulder in certain directions quickly

Does not wake him from sleep at night

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Physical examination

No atrophy

Tender biceps tendon, nontender AC joint

AROM R shoulder

• FF 0-170 with pain at top

• Abd 0-170 with pain at top

• ER 45, IR L1 (Same as L shoulder)

Strength 5/5 rotator cuff

(-) Neers and Hawkins

(+) O’Brien’s test

Case #3 differential diagnosis

Labral tear

AC joint separation

Rotator cuff tear

Shoulder dislocation

Fracture

• Humerus or clavicle

http://www.frozenshoulderclinic.com/wp-content/uploads/2014/02/anterior-scapula-287x300.jpg

Glenoid labrum O’Brien’s Test for Labral Tear

• Arm forward flexed to 90°• Elbow fully extended• Arm adducted 10° to 15° with thumb down• Downward pressure• Repeat with thumb up• Suggestive of labral tear if more pain with thumb down• Sens = 59-94%, Spec = 28-92%

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SLAP tears

Superior Labrum Anterior to Posterior

• Many different types, classifications

Diagnosis: MR arthrogram

Treatment:

• Trial of physical therapy

• Surgery: debridement vs repair

NOT a disease of older people (do not consider as etiology for shoulder pain in most >50 y/o as labrum degenerates naturally)

Hip Problems

Locate the hip pain

Anterior groin = hip joint, hip flexor

Buttock = SI joint, lumbar spine

Lateral hip = greater trochanteric bursitis, gluteus tendinopathy

Radiating to thigh = could be hip joint

Radiating to the foot = lumbar spine

http://www.everydayhealth.com/hip-pain/hip-anatomy.aspx

Hip palpation

Abdomen

Pelvis

• Iliac crest

• ASIS

• Inguinal canal

‒ Lymph nodes

• Pubic tubercles

Hip

• Greater trochanter

Back: Sacroiliac joints, lumbar spine

http://www.rush.edu/rumc/page-1098987346941.html

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Hip palpation

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Hip passive range of motion

Flexionnormal 120°

External rotationnormal 40-60°

Internal rotationnormal 30-40°

http://www.youtube.com/watch?v=5LNYdJIrWYo

Hip passive range of motion:internal and external rotation

Hip passive range of motion

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Hip neurovascular exam

Strength

• Hip flexion (T12-L3)

• Knee extension (L2-4)

• Plantar flexion (S1)

• Foot dorsiflexion (L4)

• Great toe extension (L5)

Sensation to light touch

Reflexes: patellar (L4) and achilles (S1)

Netter online anatomy atlas, UCSF library.

Signs of intra-articular hip pathology

Pain with passive ROM

Most pain with IR of affected hip

• Narrows joint space

Decreased IR of affected compared to unaffected side

http://netterreference.com/ELSEVIER/netter_s_atlas_of_human_anatomy/a/atlasbook/8

If pain with passive ROM be concerned about hip emergencies

Septic arthritis

Femoral neck fracture or stress fracture

• Xrays

• Make non weight bearing (crutches or wheelchair)

Non-emergent intraarticular hip pathology

Osteoarthritis ( >50 y/o)

Femoroacetabular impingement (< 50 y/o)

Labral tear (< 50 y/o)

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Case #4

29 y/o woman with R hip pain

Localizes to R groin

Started when running on sand

Was running 10 miles/week

Pain 2/10 sitting, 5/10 standing

Aleve helps

Groin pain can be sharp with certain movements

Did PT but didn’t help

No h/o amenorrhea, no eating disorder, no h/o stress fracture

http://www.aafp.org/afp/2009/1215/p1429.html

Case #4 exam

No ecchymosis

Tender R inguinal canal

ROM: bilateral flexion 130, IR 40 and ER 60 but R groin pain with flexion and IR.

FADIR and FABER R hip cause R groin pain

No pain with FADIR and FABER L hip

What’s the diagnosis?

A. Greater trochanteric bursitis

B. Sacroiliac joint dysfunction

C. Femoroacetabular impingement

D. Femoral neck stress fracture

E. Hip osteoarthritis

FADIR

Flexion

Adduction

Internal

Rotation


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FABER

Flexion

Abduction

External

Rotation

http://kurumiyama.web.fc2.com/PT/orthopedic_test.htm

Femoroacetabular Impingement (FAI)

Abnormal bony anatomy that forms during development

Age group 15 to 45 years old

More commonly chronic injury (can be acute)

Can lead to intra-articular injury to labrum and cartilage

Can lead to early arthritis

Slide courtesy of Alan Zhang, MD

FAI

• Cam-Type- femoral head neck asphericity• Pincer Type- acetabulum overcoverage• Mixed Type- both Cam and Pincer


Hip Labral Tear- can be acute event


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FAI X-rays

AP pelvis

Dunn view lateral

• Hip flexed 90 and abducted 20 degrees

Lateral can miss impingement


Hip labral tear imaging

Xrays: normal or impingement, r/o OA

MR arthrogram

• Contrast injected into hip joint

• 92% sensitivity (DeLee and Drez’s Orthpaedic Sports Medicine, 3rd ed)

http://www.currentprotocols.com/WileyCDA/CPUnit/refId-mia2602.html

Treatment FAI/labral tear

Physical therapy

• Core strengthening

• Hip muscle strengthening

Activity modification

Corticosteroid injection

• Short term pain relief

• Confirm that provides pain relief (right diagnosis)

Hip Arthroscopy


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Surgery for FAI/labral tear

Indications

• Pain with flexion and IR

• Labral tear on MRI or MR arthrogram

• Relief of pain after injection

• Failed physical therapy

Arthroscopy

• Labral debridement or repair

• Osteoplasty of femoral neck and/or acetabulum to restore normal bony alignment

• Higher pt satisfaction if no co-existing hip cartilage damage (chondropathy)

Kemp JL et al, Br J Sports Med 2012; 46:632-643.

Objectives

Upon completion of this session, participants should be able to:

1. Name 2 causes of shoulder pain when both active and passive range of motion are limited.

2. Identify a full thickness rotator cuff tear on physical exam.

3. Explain treatment for rotator cuff disease.

4. Identify intraarticular hip pathology by history and exam.

5. Provide a differential diagnosis for intraarticular hip pathology based on patient age.

Name 2 causes of shoulder pain when both active and passive range of motion are limited.

Identify a full thickness rotator cuff tear on physical exam.

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Explain treatment for rotator cuff disease

65

Identify intraarticular hip pathology

History

• Groin pain

• “C” sign

• Worse with hip flexion

• Worse when putting on shoe (or can’t put on shoe)

Physical exam

• Groin pain with

‒ PROM

Flexion

Internal rotation

• Limited PROM on affected side

• (+) FADIR groin pain

• (+) FABER groin pain

Differential dx intraarticular hip pain by age

Age < 50 yrs

• Femoroacetabular impingement

• Labral tear

• FAI + labral tear

• Femoral neck stress fracture

‒ Physical activity

‒ Bone health

Age > 50 yrs

• Osteoarthritis

• Fracture (trauma)

• Femoral neck or acetabular stress fracture

‒ Physical activity

‒ Bone health

Thank [email protected]

shoulder and hip for the disclosures primary care clinician

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