shoulder pain: evidence based evaluation & management frank j. domino, m.d. professor department...
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Shoulder Pain:Shoulder Pain:Evidence Based Evidence Based
Evaluation & ManagementEvaluation & Management
Frank J. Domino, M.D.Frank J. Domino, M.D.
ProfessorProfessor
Department Family Medicine & Community HealthDepartment Family Medicine & Community Health
University of Massachusetts Medical School University of Massachusetts Medical School
DisclosureDisclosure
Editor in Chief: Editor in Chief:
5 Minute Clinical Consult5 Minute Clinical Consult
Author and Editor for Author and Editor for Up To DateUp To Date
Pri Med Curriculum CommitteePri Med Curriculum Committee
Author/Editor: Author/Editor:
www.Epocrates.comwww.Epocrates.com, Rxpalm, Inc., , Rxpalm, Inc.,
www.Familydoctor.orgwww.Familydoctor.org
By the end of this session, you By the end of this session, you will:will:
1 Understand the normal and abnormal anatomy 1 Understand the normal and abnormal anatomy of the shoulderof the shoulder
2. Learn to use the 2. Learn to use the historyhistory and physical and physical examination to narrow the differential diagnosisexamination to narrow the differential diagnosis
3. Develop an evidence based diagnostic and 3. Develop an evidence based diagnostic and
treatment algorithm for usetreatment algorithm for use
Causes of Shoulder Pain in the Causes of Shoulder Pain in the Primary Care Setting:Primary Care Setting:
Impingement Syndrome >70%
Adhesive Capsulitis 12%
Bicipital Tendonitis 4%
A/C Joint OA 7%
Other (Instability, Infection) 7%
Smith, J Gen Intern Med 1992
Stats 101Stats 101
SensitivitySensitivity: : % of % of PeoplePeople with with Disease who Test + Disease who Test +
(TP / (TP + FN)) = a/(a+c)(TP / (TP + FN)) = a/(a+c)
SpecificitySpecificity: : % of % of PeoplePeople without Disease who test Negative without Disease who test Negative (TN/(TN+FN) = b/(b+d)(TN/(TN+FN) = b/(b+d)
PPVPPV: : Percent of + Percent of + Test ResultsTest Results that are truly positive that are truly positive
TP/(TP+FP) = a/(a+b)TP/(TP+FP) = a/(a+b)
Disease + -T E + a b S T - c d
1. Impingement Syndrome1. Impingement Syndromeaka Rotator Cuff Tendonitis aka Rotator Cuff Tendonitis
1. Impingement Syndrome1. Impingement SyndromeTypically Age > 25 YearsTypically Age > 25 YearsSupraspinatous TendonSupraspinatous TendonInsidious OnsetInsidious Onset
2. 2. Adhesive CapsulitisAdhesive Capsulitis aka: aka: “Frozen Shoulder”“Frozen Shoulder”
RCT Pain -> RCT Pain -> ↓ ROM ↓ ROM ---> Contracture of joint capsule ---> Contracture of joint capsule
3. Biceps Tendonitis3. Biceps TendonitisInflammation of long head of biceps tendonInflammation of long head of biceps tendonRepetitive lifting, overhead reaching or supinationRepetitive lifting, overhead reaching or supinationAnterior humeral pain; tenderness bicipital grooveAnterior humeral pain; tenderness bicipital groove
Tear of Biceps Tendon:Tear of Biceps Tendon:Chronically inflamed tendonChronically inflamed tendonLoss of flexion/supinationLoss of flexion/supination““Popeye Sign”—proximal to Popeye Sign”—proximal to antecubital fossaantecubital fossa
Holtby, Arthroscopy 2004
LongShort
Instability (Laxity)Instability (Laxity)4. INSTABILITY4. INSTABILITY
Age < 25 & TraumaAge < 25 & TraumaDerangement of G/H Joint Derangement of G/H Joint Capsule Capsule Dysfunction of Shoulder Dysfunction of Shoulder Stabilizers Stabilizers Pain, subluxation or Pain, subluxation or dislocation.dislocation.Labral Tear:Labral Tear:
SLAPSLAP: : SSuperior uperior LLabrum abrum from from AAnterior to nterior to PPosterior; osterior; --damage to superior labrum --damage to superior labrum --deep pain; clunking with --deep pain; clunking with overheadoverhead
7% Other7% Other
Cervical Radiculopathy Cervical Radiculopathy (neck pain, pain that (neck pain, pain that radiates to the elbow)radiates to the elbow)
Infection (G/N, Lyme)Infection (G/N, Lyme)
Left Sided: CVD/Anginal Left Sided: CVD/Anginal EquivalentEquivalent
Introduction to ExaminationIntroduction to Examination
The shoulder is a The shoulder is a multiaxial ball-and-multiaxial ball-and-socket synovial jointsocket synovial joint
Depends on muscles Depends on muscles and ligaments rather and ligaments rather than bones for than bones for support and stabilitysupport and stability
Easily Easily forgettableforgettable terms/anatomyterms/anatomy
Shoulder Flexion & ExtensionShoulder Flexion & Extension
Flexion is moving the Flexion is moving the arm FORWARDarm FORWARD
Extension (like Extension (like reaching for you reaching for you wallet) extending wallet) extending behind youbehind you
The Rotator Cuff Muscles
UpToDate, 2006Rotator Cuff
Supraspinatus: AbductionInfraspinatus: External rotationTeres Minor: External rotationSubscapularis: Internal rotation
3. Range of Motion3. Range of Motion
Active and PassiveActive and Passive– AbductionAbduction– Internal RotationInternal Rotation– External RotationExternal Rotation
Impingement:Impingement: Pain w/ Pain w/ activeactive Abduction Abduction
(Supraspinatus Tendon) (Supraspinatus Tendon)
Adhesive Capsulitis:Adhesive Capsulitis: Pain w: Pain w: both both activeactive & & passivepassive ROMROM
4. Provocative Testing4. Provocative Testing
Thanks: Thanks: J. Herb Stevenson, M.D.J. Herb Stevenson, M.D.Lee Mancini, M.D. Lee Mancini, M.D.
ImpingementImpingement:+ Empty Can, Neer, Hawkin’s:+ Empty Can, Neer, Hawkin’s– Adhesive Capsulitis Loss of ROM Adhesive Capsulitis Loss of ROM
Instability ”Laxity”:Instability ”Laxity”: Apprehension Testing Apprehension TestingBiceps TendonitisBiceps Tendonitis: Speed’s: Speed’s
Testing/ProvocationTesting/ProvocationImpingement: Empty CanImpingement: Empty Can
Resist Forward Flexion Resist Forward Flexion & Internal Rotation& Internal Rotation
Test of SupraspinatusTest of Supraspinatus ImpingementImpingement
Impingement: NeerImpingement: Neer
Neer Impingement Neer Impingement TestTest– Passive forward Passive forward
flexion of the flexion of the forearm resulting in forearm resulting in painpain
Instability TestingInstability TestingApprehensionApprehension
Apprehension TestApprehension Test– laxity most common laxity most common
source shoulder pain source shoulder pain <25<25
– Passive external Passive external rotation that results in rotation that results in discomfort and the discomfort and the feeling “that the feeling “that the shoulder will pop out”shoulder will pop out”
– Indicative of Indicative of glenohumeral laxity glenohumeral laxity
Biceps Tendonitis
Speed’s Test
With elbow extended and hand supinated, palpate bicipital groove while patient attempts to forward flex shoulder 30 degrees against resistance
Siegel, Am Fam Phys 1999
Spurling’s ManeuverSpurling’s ManeuverCervical RadiculopathyCervical Radiculopathy
Extend NeckExtend Neck
Rotate toward Side Rotate toward Side with Painwith Pain
Axial LoadAxial Load
Plain X-RaysPlain X-RaysImpingementImpingement: AP, Int/Ext Rotation: AP, Int/Ext Rotation
LaxityLaxity: “Y” view: “Y” view
Clavicle
Acromion
Humerus
Glenoid Fossa
Basic Approach to TreatmentBasic Approach to Treatment
1.1. Eliminate CauseEliminate Cause
2.2. Pain ControlPain ControlNSAIDs/AcetaminophenNSAIDs/Acetaminophen
Corticosteroid InjectionCorticosteroid Injection
3.3. StretchingStretching
4.4. RehabilitationRehabilitation
Don’t Do it
Case 1. Doc, why does my Case 1. Doc, why does my shoulder hurt?shoulder hurt?
55 year old carpenter presents with 3 55 year old carpenter presents with 3 month history of right shoulder pain. month history of right shoulder pain. Gradual onset without h/o trauma. Gradual onset without h/o trauma. Pain at night when he lies on affected side Pain at night when he lies on affected side Pain with overhead activityPain with overhead activity
Pain w/AROM, + Empty Can, Hawkins Pain w/AROM, + Empty Can, Hawkins
Rotator Cuff Tendonitis: Rotator Cuff Tendonitis: TreatmentTreatment
Reduce offending activitiesReduce offending activitiesPhysical TherapyPhysical TherapyNSAIDs or subacromial steroid injectionNSAIDs or subacromial steroid injection– Each is better than placeboEach is better than placebo– Little long term differenceLittle long term difference– No benefit in combination treatmentNo benefit in combination treatment
Obtain X-rays: AP w/Internal & External Obtain X-rays: AP w/Internal & External RotationRotation
Materials for Glenohumeral Materials for Glenohumeral Joint injectionJoint injection
5-10 cc Syringe5-10 cc Syringe
22 or 25 g 1 ½ needle22 or 25 g 1 ½ needle
3-5 ml of 1% or 2% Lidocaine w/o Epi.3-5 ml of 1% or 2% Lidocaine w/o Epi.
1-2 ml of1-2 ml of– 1 to 2 mL Triamcinolone (Kenalog) 40 mg/mL 1 to 2 mL Triamcinolone (Kenalog) 40 mg/mL
oror– betamethasone sodium phosphate and betamethasone sodium phosphate and
acetate (Celestone Soluspan)acetate (Celestone Soluspan)
Adhesive Capsulitis: Adhesive Capsulitis: TreatmentTreatment
Pain w/ AROM & PROM:Pain w/ AROM & PROM:
Reduce offending activitiesReduce offending activities
Physical TherapyPhysical TherapyNSAIDs or subacromial steroid injectionNSAIDs or subacromial steroid injection
– Most resolve with conservative treatment: Most resolve with conservative treatment: Stretching/Exercises x 18 monthsStretching/Exercises x 18 months; ;
– Orthopedic ReferralOrthopedic Referral
Case 2: “What happened to my Case 2: “What happened to my arm?”arm?”
Just started working Just started working out againout again
Lifting weights; curls Lifting weights; curls with free weightswith free weights
Went to driving range, Went to driving range, felt a sharp pain and felt a sharp pain and
pop in arm.pop in arm.
Now “lump” in middle Now “lump” in middle of forearm.of forearm.
Biceps TendonitisBiceps Tendonitis
Eliminate Offending ActivityEliminate Offending Activity
NSAIDs/Steroid Injection (Subacromial NSAIDs/Steroid Injection (Subacromial after age 50 – tendon rupture) after age 50 – tendon rupture)
Ice/Physical Therapy/ExercisesIce/Physical Therapy/Exercises
Biceps Tendon Rupture; ? surgical repair. Biceps Tendon Rupture; ? surgical repair. Orthopedic referral.Orthopedic referral.
5 to 10 pounds; Arm kept vertical and close to the body Swing arm back and forth or in a small diameter circle (no greater than one foot in any direction).
20 biceps curls 1-2 x/day
Increase weight every 5 days as tolerated
Biceps Tendonitis Exercise
Case 3: Doc, my shoulder and arm hurts
45 year old transcriptionist
Now needs reading glasses to see computer screen
No pain with ROM of shoulder
+ Spurling’s
Spurling’s ManeuverSpurling’s ManeuverCervical RadiculopathyCervical Radiculopathy
Extend NeckExtend Neck
Rotate toward Side Rotate toward Side with Painwith Pain
Axial LoadAxial Load
Cervical RadiculopathyCervical RadiculopathyTreatmentTreatment
Change Work EnvironmentChange Work Environment
X-RaysX-Rays
NSAID’sNSAID’s
Physical TherapyPhysical Therapy
? Meditation? Meditation
48 Year Old Painter falls off 48 Year Old Painter falls off ladderladder
““My Shoulder is killing me”My Shoulder is killing me”
““Feels like it is going to pop out”Feels like it is going to pop out”
No pain at restNo pain at rest
DX: Instability: + ApprehensionDX: Instability: + Apprehension
Instability/LaxityInstability/Laxity
NSAIDsNSAIDsAggressive strengthening and neuro-Aggressive strengthening and neuro-
muscular rehabmuscular rehabSurgery if fails conservative careSurgery if fails conservative care
Shoulder SummaryShoulder SummaryHistoryHistory PhysicalPhysical DiagnosisDiagnosis
<25, new Activity, Trauma, <25, new Activity, Trauma, Overhead Sports, Acute or Overhead Sports, Acute or ChronicChronic
+ Apprehension+ Apprehension Shoulder InstabilityShoulder Instability
25-40, gradual onset, pain 25-40, gradual onset, pain overhead activityoverhead activity
+ Empty Can + Empty Can + Neer+ Neer
Stage I ImpingementStage I Impingement (Supraspinatous (Supraspinatous Tendonopathy) Tendonopathy)
>40, gradual onset, pain >40, gradual onset, pain overhead activity, night overhead activity, night painpain
+ Empty Can+ Empty Can+ Neer+ Neer+ Hawkins+ Hawkins
Stage II/III ImpingementStage II/III Impingement (partial/complete rotator (partial/complete rotator cuff tear)cuff tear)
Gradual onset painful stiff Gradual onset painful stiff shoulder. Often no h/o shoulder. Often no h/o traumatrauma
+ Decrease active + Decrease active andand passive ROMpassive ROM+Neer+Neer
Adhesive CapsulitisAdhesive Capsulitis
Repetitive motion, new Repetitive motion, new lifting regimen, OAlifting regimen, OA
+ Speed+ Speed+ Yergason+ Yergason
Biceps TendonitisBiceps Tendonitis(if Popeye, Biceps Tendon (if Popeye, Biceps Tendon Rupture)Rupture)