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

Supination & PronationSupination & Pronation

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

Approach to ExamApproach to Exam1. Observe1. Observe2. Palpate2. Palpate

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

Impingement: Hawkins’ Test

Hawkins, Am J Sports Med 1980

Woodward, Am Fam Phys 2000

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

DemonstrationDemonstrationObserve, Palpate, ROM, ProvocationObserve, Palpate, ROM, Provocation

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)

Subacromial Bursa InjectionSubacromial Bursa Injection

http://familydoctor.org/268.xml; http://www.orthoassociates.com/shoulder1.htm

DemonstrationDemonstrationPhysical Therapy/RehabPhysical Therapy/Rehab

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)

Thank youThank you

Frank.domino@umassmemorial.orgFrank.domino@umassmemorial.org