Shoulder pain may 2014 ppt

Shoulder Pain Donna Guthery AOMA Graduate School of Integrative Medicine 2014

Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.

http://orthoinfo.aaos.org/topic.cfm?topic=a00071

Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

See Hand out Left Shoulder Pain

HPI• 48 Yom accountant, former swimmer, Shoulder pain x 2

months

• No pain at rest, pain with abducting Left arm

• Achy, non radiating 6-7/10 with movement only, no numbness or tingling

• Pain over anterior and medial deltoid muscles

• Wakes him at night if arm is too adducted

• Ibuprofen 800 mig bid, not much relief, PT exercises

• Also h/o upper back pain x years, achy non radiating, comes and goes

Exam• 110/68, p: 66 rr: 18, AA, O x 3

• L shoulder ROM decreased, abduct to 30-40 º pain is 6/10 with movement, able to internally externally rotate at lesser degree, uses accessory muscles when attempting abduction

• Can place L arm behind back but unable to raise it to scapula

• Unable to assess resisted ROM d/t pain

• Shrugs shoulders without pain

neck• Rom 75º ish bil, flexion/ extension ok, some tension with

flexion chin to chest

• Lateral flexion shoulder to ear no pain

• Few myofascial knots bil splenius capitus C 2-5, levator scapula tension, large myofascial knot R medial trapezius

• Motor strength: 5/5 bil hand grasp, RUE 5/5 C 5-8, LUE C 5/6 difficult to assess d/t pain

Treatment

• Initially St 38 L and passive ROM with traction able to abduct L arm 10º more

• Added SI 4, SJ 5 , Lu 6, 7, LI 4 on Left with local trigger points

• GB 20 bil./e SI 13 bil/e, SI 10, 11,12 L, JJ C3 bil, C 5 bil, C 6 bil, T 1 bil, T 2 bil, T 3 bil,Jianqian L x 30 minutes using micro current

• Followed by cupping massage

• End of treatment: able abduct L arm to 80 degrees

• Rec: twice a week for two weeks, if responding well, once a week and re-eval prior/after to each tx for follow up

FreezingIn the "freezing" stage, slowly have more and more pain. As the pain worsens, shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

FrozenPainful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

ThawingShoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

http://orthoinfo.aaos.org/topic.cfm?topic=a00071

Examination• Pain scale 0 – 10/10

• May find tenderness at bicipital groove

• May also have pain in upper back and neck d/t overuse of shoulder girdle muscles

• At rest may brace affected extremity against body

• Assess alignment of bones and soft tissues

• Assess postural alignment of cervical, thoracic, lumbar and humeral/scapular position (may find head forward, protracted scapula and thoracic kyphosis)

Brigham and Women’s Hospital Inc. Dept. of Rehabilitation Services 2010

Differential Diagnoses Biceps Rupture Biceps Tendinopathy Brachial Neuritis Cervical Disc Disease Cervical Myofascial Pain Cervical Spondyliosis Cervical Sprain and Strain Complex Regional Pain Syndromes Heterotopic Ossification Myelomeningocele

Neoplastic Brachial Plexopathy Parkinson Disease Psoriatic Arthritis Rheumatoid Arthritis Rotator Cuff Disease Shoulder and Hemiplegia Thoracic Outlet Syndrome Traumatic Brachial Plexopathy

http://orthoinfo.aaos.org/topic.cfm?topic=a00071

Muscle Origin on scapulaAttachment on

humerusFunction Innervation

Supraspinatus muscle

supraspinous fossasuperior and middle facet of the greater tuberosity

abducts the armSuprascapular nerve (C5)

Infraspinatus muscle

infraspinous fossaposterior facet of the greater tuberosity

externally rotates the arm

Suprascapular nerve (C5-C6)

Teres minor muscle

middle half of lateral border

inferior facet of the greater tuberosity

externally rotates the arm

Axillary nerve (C5)

Subscapularis muscle

subscapular fossalesser tuberosity (60%) or humeral neck(40%)

internally rotates the humerus

Upper and Lower subscapular nerve (C5-C6)

http://orthoinfo.aaos.org/topic.cfm?topic=a00071

Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

FINDING PROBABLE DIAGNOSIS

Scapular winging, trauma, recent viral illness Serratus anterior or trapezius dysfunction

Seizure and inability to passively or actively rotate affected arm externally

Posterior shoulder dislocation

Supraspinatus/infraspinatus wasting

Rotator cuff tear; suprascapular nerve entrapment

Pain radiating below elbow; decreased cervical range of motion

Cervical disc disease

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

Shoulder pain in throwing athletes; anterior glenohumeral joint pain and impingement

Glenohumeral joint instability

Pain or “clunking” sound with overhead motion

Labral disorder

Nighttime shoulder pain Impingement

Generalized ligamentous laxity Multidirectional instability

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

 Apley scratch test. The patient attempts to touch the opposite scapula to test range of motion of the shoulder. (Left) Testing abduction and external rotation. (Right) Testing adduction and internal rotation.

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

Supraspinatus examination (“empty can” test). The patient attempts to elevate the arms against resistance while the elbows are extended, the arms are abducted and the thumbs are pointing downward.

Infraspinatus/teres minor examination. The patient attempts to externally rotate the arms against resistance while the arms are at the sides and the elbows are flexed to 90 degrees.

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

TEST MANEUVER

DIAGNOSIS SUGGESTED BY POSITIVE RESULT

Apley scratch test Patient touches superior and inferior aspects of opposite scapula

Loss of range of motion: rotator cuff problem

Neer's sign Arm in full flexion Subacromial impingement

Hawkins' test Forward flexion of the shoulder to 90 degrees and internal rotation

Supraspinatus tendon impingement

Drop-arm test Arm lowered slowly to waist

Rotator cuff tear

Cross-arm test Forward elevation to 90 degrees and active adduction

Acromioclavicular joint arthritis

Spurling's test Spine extended with head rotated to affected shoulder while axially loaded

Cervical nerve root disorder

Apprehension test Anterior pressure on the humerus with external rotation

Anterior glenohumeral instability

Relocation test Posterior force on humerus while externally rotating the arm

Anterior glenohumeral instability

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

Sulcus sign Pulling downward on elbow or wrist

Inferior glenohumeral instability

Yergason test Elbow flexed to 90 degrees with forearm pronated

Biceps tendon instability or tendonitis

Speed's maneuver Elbow flexed 20 to 30 degrees and forearm supinated

Biceps tendon instability or tendonitis

“Clunk” sign Rotation of loaded shoulder from extension to forward flexion

Labral disorder

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

08

Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

Burbank et al, Chronic shoulder pain part I, Am Fam Physician 2008

Hawkins' test for subacromial impingement or rotator cuff tendonitis. The arm is forward elevated to 90 degrees, then forcibly internally rotated.

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

Cross-arm test for acromioclavicular joint disorder. The patient elevates the affected arm to 90 degrees, then actively adducts it.

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

Apprehension test for anterior instability. The patient's arm is abducted to 90 degrees while the examiner externally rotates the arm and applies anterior pressure to the humerus.

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

Yergason test for biceps tendon instability or tendonitis. The patient's elbow is flexed to 90 degrees, and the examiner resists the patient's active attempts to supinate the arm and flex the elbow

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

Sulcus test for glenohumeral instability. Downward traction is applied to the humerus, and the examiner watches for a depression lateral or inferior to the acromion.

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

Spurling's test for cervical root disorder. The neck is extended and rotated toward the affected shoulder while an axial load is placed on the spine.

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

LIGAMENTS OR JOINT GRADE 1 GRADE 2 GRADE 3 GRADE 4 GRADE 5 GRADE 6

Acromioclavicular ligaments

Sprained Disrupted Disrupted Disrupted Disrupted Disrupted

Acromioclavicular joint

Intact Disrupted or slight vertical separation

Disrupted Disrupted Separated Ruptured

Coracoclavicular ligaments

Intact Sprained Disrupted or slight vertical separation

Disrupted Disrupted Disrupted

Woodward MD, T. & Best MD, T. The painful shoulder: Part II. Clinical evaluation. AM Fam Physician, 2000

IMAGING MODALITY ADVANTAGES DISADVANTAGES

MRI 95% sensitivity and specificity in detecting complete rotator cuff tears, cuff degeneration, chronic tendonitis and partial cuff tears

Often identifies an apparent “abnormality” in an asymptomatic patient

No ionizing radiation

Arthrography Good at identifying complete rotator cuff tear or adhesive capsulitis (frozen shoulder)

Invasive

Relatively poor at diagnosing a partial rotator cuff tear

Ultrasonography Accurately diagnoses complete rotator cuff tears

Less useful in identifying partial cuff tears

Operator-dependent interpretation

MRI arthrography Reliably identifies full-thickness rotator cuff tears and labral tears

Invasive

CT scanning May be useful in diagnosis of subtle dislocation

Ionizing radiation

RADIOGRAPH ABNORMALITY BEST VISUALIZED

AP view of glenohumeral joint Degenerative glenohumeral changes

AC joint AC degenerative changes

AC joint separation

Distal clavicle fracture

Axillary lateral view of shoulder Glenohumeral dislocation

Bony Bankart lesion*

Supraspinatus outlet (arch) Abnormality of acromion process

Degenerative changes of anterior acromion

Woodward MD, T. & Best MD, T. The painful shoulder: Part I. Clinical evaluation. AM Fam Physician, 2000

Burbank et al, Chronic shoulder pain part I, Am Fam Physician

2008

References

Burbank MD, K., Stevenson MD, J, Czarnecki DO, G. &

Dorfman, DO, J. Chronic shoulder pain: Part I. evaluation and

diagnosis. Am Fam Physician. 2008 Feb 15:77(4):453-460.

Burbank MD, K., Stevenson MD, J, Czarnecki DO, G. &

Dorfman, DO, J. Chronic shoulder pain: Part II. Treatment.

Am Fam Physician. 2008 Feb 15:77(4):493-497.

Cheng, I. 2013 Thawing frozen shoulder-A case study and

clinical recommendations for the use of acupuncture in

treatment of adhesive capsulitis. The American Acupuncturist

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Deily DC, S. 2013 Class Notes

Hammer, D. 2012. Chinese scalp acupuncture relieves

pain and restores function in complex regional pain syndrome.

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Ma, T., Kao, M., Liu, I., Chiu, Y., Chien, C., Ho, T., Chu,

B. and Chang, Y. 2006. A study on the clinical effects of

physical therapy and acupuncture to treat spontaneous frozen

shoulder. The American Journal of Chinese Medicine, Vol. 34,

NO 5, 759-775.

Peilin, S. 2011. The Treatment of Pain with Chinese

Herbs and Acupuncture, Churchill Livingstone, Edinburgh.