Shoulder 101 …and Then Some Evan D. Ellis MD Rebound Orthopaedics and Sports Medicine

Why Shoulder 101? Multiple studies: High percentage of visits to see PCP are for musculoskeletal pain Multiple studies: High percentage of visits to see PCP are for musculoskeletal pain 2 studies * : Large gap in PCP confidence in evaluating and treating musculoskeletal injuries 2 studies * : Large gap in PCP confidence in evaluating and treating musculoskeletal injuries Studies in both a rural and tertiary academic setting Studies in both a rural and tertiary academic setting *Lynch et al JBJS AM 2006 and AJO 2005

The Shoulder ANATOMY ANATOMY HISTORY HISTORY PHYSICAL EXAM PHYSICAL EXAM IMAGING IMAGING CASES/TREATMENT CASES/TREATMENT

Anatomy Not a ball and socket Not a ball and socket More of a ball on a dish More of a ball on a dish Static Restraints Static Restraints Dynamic Restraints Dynamic Restraints

Anatomy Glenoid Concavity: Bone Bone Cartilage Cartilage Labrum Labrum

Anatomy Labrum: Labrum: Deepens glenoid by 50% Deepens glenoid by 50% 9 mm superoinferior* 9 mm superoinferior* 5 mm anteroposterior* 5 mm anteroposterior* Contributes to 20% of stability in A-P direction Contributes to 20% of stability in A-P direction Loss of labral integrity may result in instability Loss of labral integrity may result in instability *McMahon et al. JSES Jan-Feb;13(1): *Howell SM, Galinat BJ. The glenoid-labral socket: a constrained articular surface. Clin Orthop. 1989

Anatomy Static Restraints Glenohumeral Ligaments Glenohumeral Ligaments Superior: Prevents inferior translation with arm at side Superior: Prevents inferior translation with arm at side Middle: Important for mid- range abduction Middle: Important for mid- range abduction Inferior: Critical for ABD/ER Inferior: Critical for ABD/ER Anterior band prevents anterior inferior translation Anterior band prevents anterior inferior translation

Anatomy Ligaments do not center the head. Ligaments do not center the head. Limit its translation and rotation. Limit its translation and rotation. Think Check-Rains Think Check-Rains

Anatomy Dynamic Restraints Muscular Stabilizers Muscular Stabilizers Anterior: Subscapularis Anterior: Subscapularis Superior: Supraspinatus Superior: Supraspinatus Posterior: Teres minor and Infraspinatus Posterior: Teres minor and Infraspinatus Lateral: Deltoid Lateral: Deltoid Scapular stabilizers Scapular stabilizers

History Basics Painful shoulders can be: Painful shoulders can be: Unstable Unstable Stiff Stiff Weak Weak Rough/Pain Rough/Pain “ What bothers you about your shoulder? ”

History Age Age Gender Gender Was there an injury? Was there an injury? Injury mechanism Injury mechanism Prior problem Prior problem Dominant arm Dominant arm

History Chronicity Chronicity Location of Pain Location of Pain Pain at night Pain at night Stiffness/Unstable Stiffness/Unstable Prior treatment Prior treatment

Physical Exam Goal: Reproduce Symptoms Goal: Reproduce Symptoms Inspection, Palpation, ROM, neurovascular exam, special tests Inspection, Palpation, ROM, neurovascular exam, special tests Compare to contralateral side Compare to contralateral side Cervical spine Cervical spine Note provocative positions Note provocative positions

Physical Exam EXPOSE: EXPOSE: Neck Neck Shoulders Shoulders Arms Arms

Physical Exam EXPOSE: EXPOSE: Neck Neck Shoulders Shoulders Arms Arms Women need gown or tank top! Women need gown or tank top!

Physical Exam Motion: Active/Passive Forward Elevation Forward Elevation External Rotation External Rotation ER in Abduction ER in Abduction Internal Rotation Internal Rotation IR in Abduction IR in Abduction X-Body X-Body

Range of Motion FE: 180 FE: 180 ERS: 60 ERS: 60 ERA: 90 ERA: 90 IRA: 70 IRA: 70 IRB: T-spine IRB: T-spine X-Body: 60 X-Body: 60

Range of Motion FE: 180 FE: 180 ERS: 60 ERS: 60 ERA: 90 ERA: 90 IRA: 70 IRA: 70 IRB: T-spine IRB: T-spine X-Body: 60 X-Body: 60

Range of Motion FE: 180 FE: 180 ERS: 60 ERS: 60 ERA: 90 ERA: 90 IRA: 70 IRA: 70 IRB: T-spine IRB: T-spine X-Body: 60 X-Body: 60

Range of Motion FE: 180 FE: 180 ERS: 60 ERS: 60 ERA: 90 ERA: 90 IRA: 70 IRA: 70 IRB: T-spine IRB: T-spine X-Body: 60 X-Body: 60

Range of Motion FE: 180 FE: 180 ERS: 60 ERS: 60 ERA: 90 ERA: 90 IRA: 70 IRA: 70 IRB: T-spine IRB: T-spine X-Body: 60 X-Body: 60

Range of Motion FE: 180 FE: 180 ERS: 60 ERS: 60 ERA: 90 ERA: 90 IRA: 70 IRA: 70 IRB: T-spine IRB: T-spine X-Body: 60 X-Body: 60

Rotator Cuff Exam MOTOR MOTOR Subscapularis Subscapularis Supraspinatus Supraspinatus Infraspinatus Infraspinatus Teres Minor Teres Minor

Rotator Cuff Exam MOTOR MOTOR Subscapularis Subscapularis Supraspinatus Supraspinatus Infraspinatus Infraspinatus Teres Minor Teres Minor

Rotator Cuff Exam MOTOR MOTOR Subscapularis Subscapularis Supraspinatus Supraspinatus Infraspinatus Infraspinatus Teres Minor Teres Minor

Rotator Cuff Exam MOTOR MOTOR Subscapularis Subscapularis Supraspinatus Supraspinatus Infraspinatus Infraspinatus Teres Minor Teres Minor

Rotator Cuff Exam MOTOR Subscapularis Supraspinatus Infraspinatus Teres Minor

Neurologic Exam NEURO NEURO Sensation Sensation Motor Motor Reflexes Reflexes Spurling ’ s Spurling ’ s

Neurologic Exam NEURO NEURO Sensation Sensation Motor Motor Reflexes Reflexes Spurling ’ s Spurling ’ s

Special Tests - Cuff CUFF CUFF Neer Impingement Sign Neer Impingement Sign Neer Impingement Test Neer Impingement Test Subacromial injection Subacromial injection Hawkins Test Hawkins Test

Special Tests - Cuff CUFF CUFF Neer Impingement Sign Neer Impingement Sign Neer Impingement Test Neer Impingement Test Subacromial injection Subacromial injection Hawkins Test Hawkins Test

Special Tests - Cuff CUFF CUFF Neer Impingement Sign Neer Impingement Sign Neer Impingement Test Neer Impingement Test Subacromial injection Subacromial injection Hawkins Test Hawkins Test

Special Tests - Instability Apprehension/Relocation Apprehension/Relocation Supine position Supine position Stabilizes scapula Stabilizes scapula Abduct to 90° Abduct to 90° Increase ER gradually Increase ER gradually Positive: Positive: Apprehension w/ increasing amounts of ER Apprehension w/ increasing amounts of ER Apprehension relieved by posterior force on the humerus Apprehension relieved by posterior force on the humerus

Special Tests - Instability Seated Load & Shift Seated Load & Shift Assess A & P translation Assess A & P translation Grade Grade 1+: to rim 1+: to rim 2+: over rim w/reduction 2+: over rim w/reduction 3+: over rim & locked 3+: over rim & locked Compare to other side Compare to other side Assess for pain, click, & instability Assess for pain, click, & instability

Special Tests - Instability Supine Load & Shift Supine Load & Shift Arm position: Arm position: 45-60° abduction 45-60° abduction Ant/Post directed force applied to humerus Ant/Post directed force applied to humerus Assess Assess Stability Stability Pain Pain Palpable click Palpable click

Special Tests - Instability Sulcus Sign: Sulcus Sign: Arm at side Arm at side To look for multi-directional instability To look for multi-directional instability Grade Grade 1+ = 1 cm 1+ = 1 cm 2+ = 1-2 cm 2+ = 1-2 cm 3+ = > 2 cm 3+ = > 2 cm Look for generalized hypermobility Look for generalized hypermobility

Radiographs Never order an MRI before X-Rays Never order an MRI before X-Rays Everyone deserves a normal set of X-Rays! Everyone deserves a normal set of X-Rays! Most important X-Rays: True AP (Grashey) and Axillary Lateral Most important X-Rays: True AP (Grashey) and Axillary Lateral These two X-Rays are almost always omitted from a “ shoulder series ” ! These two X-Rays are almost always omitted from a “ shoulder series ” !

Radiographs True AP or Grashey View: Arthritis Fracture Massive Rotator Cuff tear

Radiographs True AP True AP

Radiographs Axillary Lateral Axillary Lateral Arthritis Arthritis Instability Instability Fracture Fracture

Radiographs Axillary Lateral Axillary Lateral

Radiographs Additional Views Additional Views Outlet Outlet Internal/External Internal/External Stryker Notch Stryker Notch West Point View West Point View

The Shoulder A. Diagnosable & Treatable Rotator cuff tears Rotator cuff tears Shoulder instability Shoulder instability Arthritis Arthritis SLAP tear SLAP tear B. Diagnosable & Untreatable Brachial neuritis Brachial neuritis Voluntary instability/MDI Voluntary instability/MDI Rib fractures Rib fractures

Age is Key

Case #1 History: 16 year old RHD male football player 16 year old RHD male football player Shoulder “ popped ” out of place while getting tackled Shoulder “ popped ” out of place while getting tackled To ER for reduction To ER for reduction Has happened 2 previous times Has happened 2 previous times

Case #1 Physical Exam: Full Range of Motion Full Range of Motion Full rotator cuff strength Full rotator cuff strength + Apprehension Test + Apprehension Test + Relocation Test + Relocation Test + Anterior Load & Shift + Anterior Load & Shift

Case #1

What do you do? What do you do? Place him in a sling Place him in a sling Refer to Ortho Refer to Ortho If first time dislocater – Physical Therapy If first time dislocater – Physical Therapy If 2 or more dislocations – MRI and surgery If 2 or more dislocations – MRI and surgery

Sling Regular Sling vs. External Rotation Which is better? Which is better? Itoi, JBJS 2007 Itoi, JBJS patients 159 patients Avg follow up of 25.6 months Avg follow up of 25.6 months 74 immobilized in IR 74 immobilized in IR 31 recurred (42%) 31 recurred (42%) 85 immobilized in ER 85 immobilized in ER 22 recurred (26%) 22 recurred (26%) *Effect on labral position for healing *Effect on labral position for healing

Case #1

Arthroscopic Repair

Case #2 History: 41 yo female with gradual onset pain/stiffness over 6 weeks 41 yo female with gradual onset pain/stiffness over 6 weeks No history of trauma No history of trauma Similar problem with other shoulder 2 years prior Similar problem with other shoulder 2 years prior Hx of Diabetes Hx of Diabetes Can ’ t brush hair or fasten bra Can ’ t brush hair or fasten bra

Case #2 Physical Exam: Forward Elevation – 80 Forward Elevation – 80 External Rotation – Neutral External Rotation – Neutral Internal Rotation – Back Pocket Internal Rotation – Back Pocket Full strength of rotator cuff Full strength of rotator cuff Can ’ t get arm to side to check for instability Can ’ t get arm to side to check for instability

Case #2 Radiographs Radiographs

Case #2 Diagnosis??? Diagnosis??? Adhesive Capsulitis/Frozen Shoulder Adhesive Capsulitis/Frozen Shoulder Treatment??? Treatment??? If nothing done, may take 2 years to resolve If nothing done, may take 2 years to resolve PT, PT, PT PT, PT, PT If fails: Intraarticular cortisone shot and more PT If fails: Intraarticular cortisone shot and more PT If fails: Manipulation under anesthesia If fails: Manipulation under anesthesia If fails: Arthroscopic capsular release If fails: Arthroscopic capsular release

Case #2 What would MRI show with adhesive capsulitis? What would MRI show with adhesive capsulitis? Normal Normal

Case #2

Case #3 History: 49 yo male fell down stairs and grabbed railing on way down. 49 yo male fell down stairs and grabbed railing on way down. Felt ripping sensation in shoulder Felt ripping sensation in shoulder Pain on lateral aspect of shoulder Pain on lateral aspect of shoulder Pain with overhead activity Pain with overhead activity Night pain Night pain Popping Popping Feels weak Feels weak

Case #3 Physical Exam: Pain/crepitus with forward elevation Pain/crepitus with forward elevation Positive Impingement Sign Positive Impingement Sign Positive Hawkins Test Positive Hawkins Test Weakness with supraspinatus testing Weakness with supraspinatus testing No instability No instability

Case #3

Diagnosis?? Acute rotator cuff tear Acute rotator cuff tearTreatment?? Refer to ortho Refer to ortho Acute, full-thickness cuff tear in a “ young ” patient = surgical repair Acute, full-thickness cuff tear in a “ young ” patient = surgical repair

Case #4 History: History: 48 yo RHD male 48 yo RHD male 6 months shoulder pain 6 months shoulder pain No injury No injury Pain at night Pain at night Pain with reaching overhead Pain with reaching overhead NSAIDS no help NSAIDS no help No neck pain/numbness/tingling No neck pain/numbness/tingling

Case #4 Physical Exam: Physical Exam: Full ROM Full ROM + Impingement Sign + Impingement Sign + Hawkins Test + Hawkins Test Full Strength of Cuff Full Strength of Cuff Pain with supraspinatus testing Pain with supraspinatus testing

Case #4

Diagnosis? Diagnosis? Rotator Cuff Tendonitis vs. Partial Thickness Tear Rotator Cuff Tendonitis vs. Partial Thickness Tear Treatment? Treatment? Physical Therapy Physical Therapy If no improvement = Refer to Ortho If no improvement = Refer to Ortho

Case #4 What do we do? What do we do? MRI MRI If MRI = If MRI = Cortisone injection Cortisone injection If MRI = If MRI = Possible Surgery Possible Surgery

Partial Thickness Cuff Tears Increasing prevalence with age Increasing prevalence with age 30 – 60% Incidence in Age > – 60% Incidence in Age > 60 Over 80% Incidence in Age > 70 Over 80% Incidence in Age > 70 Often asymptomatic Often asymptomatic If painful and fail therapy = Surgery If painful and fail therapy = Surgery Supraspinatus is 11 mm thick Supraspinatus is 11 mm thick If < 50% torn = Debridement + Decompression If < 50% torn = Debridement + Decompression If > 50% torn = Complete the tear and Repair If > 50% torn = Complete the tear and Repair

Case #5 History: History: 66 yo male with progressive pain/stiffness shoulder 66 yo male with progressive pain/stiffness shoulder Pain is constant and unable to do ADLS Pain is constant and unable to do ADLS Feels like it ’ s popping with motion Feels like it ’ s popping with motion NSAIDS – Some relief NSAIDS – Some relief

Case #5 Physical Exam: Physical Exam: FE: 100 FE: 100 ER: Neutral ER: Neutral IR: Back Pocket IR: Back Pocket “ Ratcheting ” motion “ Ratcheting ” motion Cuff Strength Normal Cuff Strength Normal

Case #5 Radiographs

Case #5 Diagnosis? Diagnosis? Endstage Shoulder Osteoarthritis Endstage Shoulder Osteoarthritis Treatment? Treatment? Physical Therapy and/or refer to Ortho Physical Therapy and/or refer to Ortho Cortisone Injection Cortisone Injection Shoulder Replacement Shoulder Replacement

Case #5

Case #6 History: History: 14 yo female with longstanding history of both shoulders going “ in and out ” 14 yo female with longstanding history of both shoulders going “ in and out ” No traumatic event No traumatic event Has never had them reduced in the ER Has never had them reduced in the ER Sometimes “ grosses friends out ” by dislocating her shoulder at parties Sometimes “ grosses friends out ” by dislocating her shoulder at parties

Case #6 Physical Exam: Physical Exam: Full Range of Motion Full Range of Motion Normal Cuff Strength Normal Cuff Strength Sulcus - Grade 3 Sulcus - Grade 3 Hypermobile Signs + Hypermobile Signs +

Case #6 Hypermobile Tests

Case #6 Radiographs – Normal Radiographs – Normal Diagnosis? Diagnosis? Atraumatic, bilateral shoulder instability Atraumatic, bilateral shoulder instability Treatment? Treatment? PT, PT, PT PT, PT, PT More PT More PT MRI – Normal or Enlarged joint capsule MRI – Normal or Enlarged joint capsule If absolutely fails everything – Capsular shift If absolutely fails everything – Capsular shift

Case #6 Capsular Shift

Case #7 History: History: 80 yo female with occasional ache in shoulder 80 yo female with occasional ache in shoulder Swims everyday Swims everyday No Injury No Injury Pain is minimal, but just wants to get it checked out Pain is minimal, but just wants to get it checked out Takes no pain meds Takes no pain meds

Case #7 Physical Exam: Physical Exam: Full ROM Full ROM Mild pain with reaching overhead Mild pain with reaching overhead + Impingement Sign + Impingement Sign + Hawkins Test + Hawkins Test Profound weakness of supra/infraspinatus Profound weakness of supra/infraspinatus

Case #7 Radiographs

Case #7 MRI

Case #7 Diagnosis? Diagnosis? Massive Rotator Cuff Tear Massive Rotator Cuff Tear Treatment? Treatment? No role for surgical repair No role for surgical repair Leave it alone Leave it alone Physical Therapy Physical Therapy Occasional cortisone injection Occasional cortisone injection

Summary A focused, thorough H&P is critical to correctly diagnosing a shoulder problem. A focused, thorough H&P is critical to correctly diagnosing a shoulder problem. Expose the shoulder for the exam and compare to the other side. Expose the shoulder for the exam and compare to the other side. Age, alone, is an important predictor of a patients ’ diagnosis. Age, alone, is an important predictor of a patients ’ diagnosis. Always order an x-ray series prior to ordering a shoulder MRI. Everyone deserves a normal set of x-rays! Always order an x-ray series prior to ordering a shoulder MRI. Everyone deserves a normal set of x-rays! X-ray series should always, at a minimum, include a true AP (grashey) and an axillary view. X-ray series should always, at a minimum, include a true AP (grashey) and an axillary view.

Summary Not all rotator cuff tears can, or should be, fixed. Not all rotator cuff tears can, or should be, fixed. Traumatic, unidirectional, recurrent dislocaters should be surgically repaired. Traumatic, unidirectional, recurrent dislocaters should be surgically repaired. Atraumatic, multidirectional, and/or voluntary shoulder dislocaters should almost never be surgically repaired. Atraumatic, multidirectional, and/or voluntary shoulder dislocaters should almost never be surgically repaired. Physical therapy is a tremendous adjunct to treatment for the majority of shoulder injuries. Physical therapy is a tremendous adjunct to treatment for the majority of shoulder injuries. If you have questions, please call or refer your patients. We are always happy to help! If you have questions, please call or refer your patients. We are always happy to help!

Thanks!!