“My Sore Shoulder!”
Guide to Diagnosis and Conservative Treatment
Shoulder Anatomy Acromioclavicular
(AC) joint Glenohumeral joint Glenoid labrum Humerus Rotator cuff Biceps muscle/tendon Deltoid muscle
Common Shoulder Conditions Rotator cuff injuries Impingement Instability Labral tears Bicipital tendonitis AC joint disorders Suprascapular nerve entrapment
Rotator Cuff Injuries Rotator cuff serves as a stabilizer for the
shoulder Cuff is comprised of the supraspinatus,
infraspinatus, subscapularis and teres minor muscles
Common rotator cuff injuries occur to the underside of the supraspinatus tendon
Increase in risk of tear at age 40
Impingement (Bursitis/Tendonitis) Can include inflammation of the bursa
overlying the rotator cuff, inflammation within the rotator cuff tendons, or calcium deposits within the rotator cuff tendons caused by wear and tear
Can be caused by frequent extension of the arm at high speed under high load (i.e. throwing a baseball)
Potential outcome is a rotator cuff tear
Instability Shoulder laxity needs to be differentiated from
frank instability Laxity is common in the swimmer and
throwing athlete, as the shoulder must be loose enough to allow excessive external rotation
Instability is unwanted translation of the humeral head on the glenoid, and compromises the comfort and function of the shoulder
Labral Tears Frequently seen in
throwing athletes Glenohumeral joint
receives compressive and shearing forces during the movement of the humeral head, anteriorly to posteriorly
Bicipital Tendonitis Inflammation of the biceps tendon Diagnosis made principally by palpation
of the tendon during clinical examination Occurs frequently in the throwing athlete:
• Modest biceps activity during cocking and acceleration phase
• High level of biceps activity during follow-through phase
AC Joint Disorders Most sprains to the
AC joint occur as the result of a fall or a blow to the lateral acromion
Symptoms of a separation may range from pain over the AC joint to a frank deformity
Suprascapular Nerve Entrapment Suprascapular nerve supplies the
supraspinatus and infraspinatus muscles of the rotator cuff
The nerve can be compromised by traction injuries or compression injuries
Athlete may present with subtle weakness and vague complaints of posterior shoulder girdle pain
The Subjective Evaluation
What? How? When? Where?
Pain? Instability? Weakness? Deformity?
The Clinical Examination Inspection Examination of the cervical spine Palpation Range of motion assessment Strength assessment Glenohumeral stability assessment Neurovascular examination Special tests
Inspection Should be performed from different
perspectives (front, side, back, top) Should assess for symmetry, atrophy,
hypertrophy, deformities, bruising and swelling
Note scars as evidence of prior surgical procedures
Examination of the Cervical Spine Have the patient look up at the ceiling,
touch his chin to his chest, look over each shoulder
Any numbness, tingling or pain referred to the affected shoulder points to the cervical spine as the etiology of the shoulder pain
PalpationBony Landmarks:
SC joint Clavicle AC joint Acromion Bicipital groove Scapula
Soft Tissue:
Biceps tendon Supraspinatus
insertion to the proximal humerus
Deltoid Posterior capsule
Range of Motion
Includes testing of both active and passive range of motion
For example, in the setting of a rotator cuff tear, passive range of motion will be normal but active range of motion will be diminished due to the tear in the muscle
Range of Motion (norms) External rotation in a 0° plane (90°) External rotation in a 90° plane (90°) Abduction (150°) Internal rotation (90°) Forward flexion (180°)
ALWAYS compare both shoulders!
Range of Motion During range of motion assessment is a
reasonable time to test for impingement Impingement sign: with the arm abducted to
90° and the elbow flexed to 90°, externally rotate the patient’s arm
Impingement test: forward flex the patient’s arm to 180°
• Pain signifies a positive test
Strength Assessment Strength is easy to assess by standing behind
the patient who is seated on the exam table
Strength is graded 0 to 5 over 5:• 0/5 = total paralysis• 1/5 = palpable or visible contraction• 2/5 = full ROM with gravity eliminated• 3/5 = full ROM against gravity• 4/5 = full ROM with decreased strength• 5/5 = normal strength
Strength Assessment Supraspinatus: assessed at 90° of
forward flexion in the scapular plane with the thumbs pointed to the floor; downward pressure is resisted by the patient
• Test is specific for supraspinatus function, and evaluates cuff strength and integrity
Strength Assessment External rotators: with the patient’s arm
at his side and the elbow flexed to 90°, he will externally rotate as if hitting a tennis ball in a backhanded manner against resistance
• Test is specific for the teres minor and infraspinatus muscles
Strength Assessment Abduction: assessed in the coronal
plane against resistance• May be suggestive of either deltoid or cuff
deficiency Subscapularis: with the dorsum of the
patient’s hand on his ipsalateral back pocket, instruct him to push backward against resistance
Glenohumeral Stability Assessment Subtle anterior
instability is not uncommon in the throwing athlete
In addition, the hyperlax patient may have some element of multidirectional instability
Glenohumeral Stability Assessment Sulcus sign: distraction force is placed
on the elbow and the space created between the undersurface of the acromion and the apex of the humeral head is noted
• This distance is recorded in centimeters, and indicates laxity in the joint
Glenohumeral Stability Assessment “Load and shift” test: with the humeral head
reduced (“loaded”) into the glenoid fossa, the examiner steadies the limb girdle with one hand and translates the humeral head both anteriorly and posteriorly with the opposite hand• The amount of translation is graded as 1+, 2+, or 3+• This test is also repeated in the supine position• Glenohumeral translation depends upon the skill of the
examiner as well as the patient’s ability to relax
Glenohumeral Stability Assessment Apprehension test: evaluation of the
patient’s sense of pending anterior subluxation or dislocation with the arm in stressed external rotation abduction
• Can be performed sitting or supine, but works best with the patient supine
• In order for a test to be positive, apprehension must be present – pain alone does not indicate a positive test
Glenohumeral Stability Assessment Relocation test: following the supine
apprehension test, apply posterior pressure to the proximal humerus at the same level of external rotation noted in the apprehension test• A positive relocation test is described when
the patient’s apprehension disappears with the posterior stress
Neurovascular Examination Dermatomal sensory examination Deep tendon reflexes at the wrist and
elbow Cervical root testing – wrist extension,
finger abduction and adduction, thumb abduction, elbow flexion
Palpation of the brachial and radial pulses
Special Tests
Drop arm test: the patient’s arm is abducted to 90° and released
• A positive test is noted when the patient’s arm falls down from the position
• Indicative of a rotator cuff tear
Special Tests Speed’s test: with the shoulder in
forward flexion, elbow extended, and hand supinated, resistance is applied
• Pain in the location of the bicipital groove during resistance is indicative of bicipital tendonitis
Special Tests O’Brien’s test: with the arm adducted
across the midline, elbow extended and thumb down, the examiner applies downward pressure; the patient’s thumb is then turned up, and he again resists downward pressure• A positive test is indicative of a labral tear, and
is described when greater pain occurs with the thumb pointed downward
Special Tests Clunk test: while the patient lies supine
the examiner abducts the arm past 90° with one hand while pressing the proximal humeral head anteriorly; the examiner then rotates the shoulder internally and externally• A positive test is elicited when the patient feels a
deep “clunk” in the shoulder• Indicative of a labral tear
Radiographic findings X-rays – what to look
for:
• Bony tumors• Fracture lines• Hook to the acromion• Degenerative changes• Dislocation
Radiographic findings MRI
• Good for ruling out bad things
• Can be misleading• Must be correlated
with clinical exam – the radiologist does not have the benefit of examining the patient
Conservative treatment Physical therapy
• Excellent form of strengthening and rehabilitating weak or injured muscles
• Formal physical therapy will reassure you that the exercises are actually being done
• The most successful conservative form of therapy for the musculoskeletal system
Conservative treatment Oral anti-inflammatories
• Sometimes just a short course of anti-inflammatories can provide permanent relief
• Non-selective COX inhibitors still work great if the patient can tolerate them
• COX-2 inhibitors:• Celebrex 200 mg daily• Vioxx 25 mg daily • Bextra 20 mg daily
Conservative treatment Cortisone injection (short-acting + local)
• Can be a permanent cure, but is frequently a short-term fix
• Relief from the injection gives an excellent prognosis for surgical success
• Should only be given every 3 months
If the above fail… Refer to orthopedic surgeon Surgery is a measure of last resort! “There is no pain so terrible that surgery can’t
make worse.”