Approach To Overuse Related Shoulder Injuries

Approach to overuse Approach to overuse related shoulder injuriesrelated shoulder injuries

Dausen Harker MDDausen Harker MD

Family MedicineFamily Medicine

ObjectivesObjectives

Epidemiology ReviewEpidemiology Review Shoulder anatomy reviewShoulder anatomy review Common causes of shoulder painCommon causes of shoulder pain General approach to examGeneral approach to exam Special testsSpecial tests

EpidemiologyEpidemiology

22ndnd most common orthopedic problem in primary care most common orthopedic problem in primary care sports medicine (second to knee injury)sports medicine (second to knee injury)

Young athletes with overuse injuries is increasingYoung athletes with overuse injuries is increasing Overuse injuries common in military populationOveruse injuries common in military population Most common overuse injuriesMost common overuse injuries

Rotator Cuff PathologyRotator Cuff Pathology ImpingementImpingement Glenohumeral Instability/Labrum TearsGlenohumeral Instability/Labrum Tears Biceps Tendonitis Biceps Tendonitis AC Joint PathologyAC Joint Pathology

Anatomical structuresAnatomical structures

Please review images of shoulder anatomy prior Please review images of shoulder anatomy prior to or while viewing slidesto or while viewing slides

Major anatomical components involved in Major anatomical components involved in shoulder painshoulder pain Rotator cuff muscles and tendonsRotator cuff muscles and tendons AC jointAC joint Glenoid and labrumGlenoid and labrum Biceps tendonBiceps tendon Skeletal components of shoulderSkeletal components of shoulder Shoulder related bursaShoulder related bursa

EvaluationEvaluation

Every shoulder exam should include:Every shoulder exam should include: AppearanceAppearance Range of MotionRange of Motion

• Active vs PassiveActive vs Passive PalpationPalpation Neurological testingNeurological testing Special testsSpecial tests

Rotator Cuff InjuryRotator Cuff Injury

One of the most common causes of One of the most common causes of shoulder painshoulder pain

Involves “Involves “SITS minorSITS minor” muscles” muscles Includes tendonitis and tearsIncludes tendonitis and tears


TendonitisTendonitis::• Most common condition among pt’s with shoulder Most common condition among pt’s with shoulder

complaints—especially >30 y/ocomplaints—especially >30 y/o• Supraspinatous or infraspinatousSupraspinatous or infraspinatous• Repetitive over head activity most common causeRepetitive over head activity most common cause• PainPain

Worse with reaching and over head activityWorse with reaching and over head activity May awaken pt at nightMay awaken pt at night

• Associated with increased risk of tearAssociated with increased risk of tear


TearsTears::• <30 y/o: <1% of shoulder injury are complete tears<30 y/o: <1% of shoulder injury are complete tears• >45 y/o: ~35% of shoulder injury are tears >45 y/o: ~35% of shoulder injury are tears • Supraspinatous and InfraspinatousSupraspinatous and Infraspinatous• Common mechanisms of injuryCommon mechanisms of injury

Fall on an outstretched armFall on an outstretched arm direct blow to shoulderdirect blow to shoulder rapid accelerationrapid acceleration

• Associated with chronic impingement, tendon degeneration Associated with chronic impingement, tendon degeneration or traumaor trauma

• Clinical signs: Weakness, loss of shoulder function, and Clinical signs: Weakness, loss of shoulder function, and symptoms of tendonitissymptoms of tendonitis

Special TestsSpecial Tests

Drop Arm TestDrop Arm Test Supraspinatous Strength TestSupraspinatous Strength Test Lift Off TestLift Off Test 909000 elbow flexion with external arm elbow flexion with external arm

rotation and resistancerotation and resistance

Drop Arm TestDrop Arm Test

Slowly lower fully ABducted armSlowly lower fully ABducted arm Active pressure may be applied at 90Active pressure may be applied at 9000

ABductionABduction Positive test indicated by inability to keep Positive test indicated by inability to keep

arm ABducted at 90arm ABducted at 9000

Indicates rotator cuff tearIndicates rotator cuff tear

Supraspinatous Strength TestSupraspinatous Strength Test

Shoulder ABducted to 90Shoulder ABducted to 900 0 with 30with 300 0 of forward of forward flexion and arm pronation (thumb down) flexion and arm pronation (thumb down)

Isolates Isolates supraspinatoussupraspinatous Positive test if asymmetric weakness or inability Positive test if asymmetric weakness or inability

to maintain arm position to maintain arm position

Lift Off TestLift Off Test

Dorsum of hand on back and push outward Dorsum of hand on back and push outward against resistance (isolates internal rotation)against resistance (isolates internal rotation)

Isolates Isolates subscapularissubscapularis Positive test indicated by asymmetric inability Positive test indicated by asymmetric inability

to lift hand from backto lift hand from back

External RotationExternal Rotation

Elbow flexed to 90Elbow flexed to 9000 with active resistance to with active resistance to external rotationexternal rotation

Isolates Isolates infraspinatousinfraspinatous and and teres minorteres minor Positive test indicated by asymmetric Positive test indicated by asymmetric

weakness weakness

ImpingementImpingement

Describes compression of rotator cuff Describes compression of rotator cuff tendons and subacromial bursa between tendons and subacromial bursa between bony structuresbony structures

Mechanisms of injury: Rounded shoulders, Mechanisms of injury: Rounded shoulders, poor muscle development, repetitive over poor muscle development, repetitive over head motionhead motion

Presentation nearly identical to rotator cuff Presentation nearly identical to rotator cuff injuryinjury


Hawkins TestHawkins Test Neers TestNeers Test


Hawkins TestHawkins Test 909000 forward flexion, 45-90 forward flexion, 45-9000 elbow flexion and elbow flexion and

passive internal rotationpassive internal rotation Drives greater tuberosity into coracoacromial Drives greater tuberosity into coracoacromial

archarch Positive test indicated by painPositive test indicated by pain More sensitive than Neers test for More sensitive than Neers test for

impingementimpingement


Neer TestNeer Test Arm internally rotated while fully extended Arm internally rotated while fully extended

and forward flexion to 180and forward flexion to 18000

Positive test indicated by pain with motionPositive test indicated by pain with motion

Glenohumeral Instability/Labral Glenohumeral Instability/Labral tearstears

GHIGHI Characteristic group: Women, poor muscular Characteristic group: Women, poor muscular

development, large Rotator cuff tears, athletes < 40 development, large Rotator cuff tears, athletes < 40 (especially swimmers, throwers)(especially swimmers, throwers)

Clinical presentation: Vague symptoms, may see Clinical presentation: Vague symptoms, may see excessive ROMexcessive ROM

TUBS: Traumatic, Unidirectional instability, Bankart TUBS: Traumatic, Unidirectional instability, Bankart lesion (glenoid labrum tear), frequently require lesion (glenoid labrum tear), frequently require SurgerySurgery

AMBRI: Atraumatic, Multidirectional shoulder laxity AMBRI: Atraumatic, Multidirectional shoulder laxity Bilaterally, usually responds to Rehabilitation, when Bilaterally, usually responds to Rehabilitation, when sugery is necessary it involves tightening of Inferior sugery is necessary it involves tightening of Inferior capsulecapsule

Glenohumeral Instability/Labral Glenohumeral Instability/Labral TearsTears

LTLT Caused by similar mechanism as rotator cuff Caused by similar mechanism as rotator cuff

injuriesinjuries Greatest risk with repetitive overhead Greatest risk with repetitive overhead

activitiesactivities Clinical presentation: Deep shoulder pain, Clinical presentation: Deep shoulder pain,

catching sensation, instabilitycatching sensation, instability


GHIGHI Sulcus SignSulcus Sign Apprehension TestApprehension Test Anterior/Posterior Drawer TestAnterior/Posterior Drawer Test

LTLT Crank TestCrank Test


Sulcus SignSulcus Sign Arm relaxed, neutral position with downward Arm relaxed, neutral position with downward

traction at wristtraction at wrist Positive indicated by development of sulcusPositive indicated by development of sulcus Important to assess symmetry of test Important to assess symmetry of test Sulcus sign recorded as cm of sulcusSulcus sign recorded as cm of sulcus


Apprehension TestApprehension Test Supine position, 90Supine position, 9000 ABduction, neutral ABduction, neutral

rotationrotation Apply slight leverage at proximal humerus Apply slight leverage at proximal humerus

while externally rotatingwhile externally rotating Positive test indicated by pt apprehension that Positive test indicated by pt apprehension that

shoulder will give wayshoulder will give way


Anterior/Posterior Drawer TestAnterior/Posterior Drawer Test Best to have patient in supine positionBest to have patient in supine position Humeral head slid anteriorly and posteriorly Humeral head slid anteriorly and posteriorly

in glenoid while scapula is stabilizedin glenoid while scapula is stabilized Positive test with painful click/clunk, Positive test with painful click/clunk,

apprehension or increased movement apprehension or increased movement compared to other shouldercompared to other shoulder


Crank TestCrank Test Pt supine or seated with arm elevated to Pt supine or seated with arm elevated to

16016000 Force applied along axis with internal and Force applied along axis with internal and

external rotationexternal rotation Drives humeral head against labrumDrives humeral head against labrum Positive test if pain is reproduced or Positive test if pain is reproduced or

catching +/- click is notedcatching +/- click is noted

Biceps TendonitisBiceps Tendonitis

Inflammation of long head of biceps as it Inflammation of long head of biceps as it passes through bicipital groovepasses through bicipital groove

Assoc with repetitive lifting or overhead Assoc with repetitive lifting or overhead activity that leads to inflammationactivity that leads to inflammation

Can lead to spontaneous rupture (10%)Can lead to spontaneous rupture (10%) Pain aggravated by lifting, carrying bags or Pain aggravated by lifting, carrying bags or

overhead reaching; overhead reaching; pt often localizes pain directly to bicipital pt often localizes pain directly to bicipital

groovegroove


Speed TestSpeed Test Yergason TestYergason Test


Speed TestSpeed Test Shoulder forward flexed to 60Shoulder forward flexed to 600,0, arm flexed to arm flexed to

303000 and supinated and supinated Downward force applied to distal forearmDownward force applied to distal forearm Positive test indicated by pain or weaknessPositive test indicated by pain or weakness


Yergason TestYergason Test Arm neutral, elbow flexed to 90Arm neutral, elbow flexed to 9000

Pt attempts to supinate and flex elbow Pt attempts to supinate and flex elbow against resistanceagainst resistance

Positive test indicated pain or a “painful pop” Positive test indicated pain or a “painful pop”

AC Joint PathologyAC Joint Pathology

Injury type: Sprain, partial or complete tearInjury type: Sprain, partial or complete tear Associated with overuse (reaching across Associated with overuse (reaching across

chest or overhead) or trauma (especially chest or overhead) or trauma (especially falls on tip of shoulder) falls on tip of shoulder)

Associated with anterior shoulder painAssociated with anterior shoulder pain Pt usually localize pain directly to AC joint Pt usually localize pain directly to AC joint

(i.e. pt will point to AC joint)(i.e. pt will point to AC joint)

Special TestsSpecial Tests Cross Chest ADduction Test (Cross Arm Cross Chest ADduction Test (Cross Arm

Test)Test) Forward flexed to 90Forward flexed to 9000 and hand to opposite and hand to opposite

shouldershoulder Examiner hyperADducts shoulderExaminer hyperADducts shoulder Positive test indicated by pain at AC jointPositive test indicated by pain at AC joint May be false + with impingementMay be false + with impingement

SummarySummary

Shoulder injury common in primary care sports Shoulder injury common in primary care sports medicine medicine

Difficult exam due to complexity of shoulderDifficult exam due to complexity of shoulder Made easier by following step wise approachMade easier by following step wise approach

The Big 5’s The Big 5’s Overuse Injuries: Rotator cuff pathology, Overuse Injuries: Rotator cuff pathology,

Impingement, GHI/LT, Biceps tendonitis, AC joint Impingement, GHI/LT, Biceps tendonitis, AC joint pathologypathology

Physical Exam: Appearance, ROM, Palpation, Physical Exam: Appearance, ROM, Palpation, Neurologic, Special TestsNeurologic, Special Tests

SummarySummarySpecial TestsSpecial Tests

Rotator CuffRotator Cuff Drop Arm TestDrop Arm Test Supraspinatous Strength Supraspinatous Strength

TestTest Lift Off TestLift Off Test External RotationExternal Rotation

ImpingementImpingement Hawkins TestHawkins Test Neer’s TestNeer’s Test

GHIGHI Sulcus SignSulcus Sign Apprehension TestApprehension Test Anterior/Posterior Drawer Anterior/Posterior Drawer

TestTest LTLT

Crank TestCrank Test Biceps TendonitisBiceps Tendonitis

Speed TestSpeed Test Yergason TestYergason Test

AC JointAC Joint Cross Arm TestCross Arm Test

ResourcesResourcesAnderson, Bruce. “Acromioclavicular Injury.” UpToDate®. Anderson, Bruce. “Acromioclavicular Injury.” UpToDate®. www.uptodate.comwww.uptodate.com. ©2006. Howard,. ©2006. Howard,

Anderson, Bruce. “Biceps Tendonitis and Rupture.” UpToDate®. Anderson, Bruce. “Biceps Tendonitis and Rupture.” UpToDate®. www.uptodate.comwww.uptodate.com. © 2006. . © 2006.

Anderson, Bruce. “Multidirectional Instability of the Shoulder.” UpToDate®. Anderson, Bruce. “Multidirectional Instability of the Shoulder.” UpToDate®. www.uptodate.comwww.uptodate.com. . ©2006. ©2006.

Anderson, Bruce. “Rotator Cuff Tendonitis.” UpToDate®. Anderson, Bruce. “Rotator Cuff Tendonitis.” UpToDate®. www.uptodate.comwww.uptodate.com. © 2006. © 2006

Anderson, Bruce and Michael Roberts. “Shoulder Impingement Syndrome.” UpToDate®. Anderson, Bruce and Michael Roberts. “Shoulder Impingement Syndrome.” UpToDate®. www.uptodate.comwww.uptodate.com. ©2006.. ©2006.

Anderson, Bruce and Ronald Anderson. “Evaluation of the Patient with Shoulder Complaints.” Anderson, Bruce and Ronald Anderson. “Evaluation of the Patient with Shoulder Complaints.” UpToDate®. UpToDate®. www.uptodate.comwww.uptodate.com. © 2006.. © 2006.

Anderson, Bruce, et. al. “Rotator Cuff Tear.” UpToDate®. Anderson, Bruce, et. al. “Rotator Cuff Tear.” UpToDate®. www.uptodate.comwww.uptodate.com. © 2006.. © 2006.

Cassas, Kyle J. and Amelia Cassettari-Wayhs. “Childhood and Adolescent Sports-Related Overuse Cassas, Kyle J. and Amelia Cassettari-Wayhs. “Childhood and Adolescent Sports-Related Overuse Injuries.” Injuries.” American Family Physician.American Family Physician. March 2006. Vol 73, No. 6. pp 1014-1022. March 2006. Vol 73, No. 6. pp 1014-1022.

Thomas M., Francis G. O’Conner. “The Injured Shoulder. Primary Care Assessment.” Thomas M., Francis G. O’Conner. “The Injured Shoulder. Primary Care Assessment.” Archives of Archives of Family MedicineFamily Medicine July/August 1997, Vol. 6. pp 376-384 July/August 1997, Vol. 6. pp 376-384

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Approach To Overuse Related Shoulder Injuries

Health & Medicine