Shoulder SyndromesVOMA

September 2011

P. Gunnar Brolinson, DO, FAOASM, FACOFP, FAAFPHead Team Physician, Virginia Tech

Chief of Sports MedicineEdward Via Virginia College of Osteopathic Medicine

Director Primary Care Sports Medicine Fellowship

Objectives

• Review anatomy of the shoulder complex

• Review motions of the shoulder complex• Describe the functional biomechanical

evaluation of the shoulder• Understand and be able to perform an

evaluation of shoulder using various functional and special tests

• Review some common shoulder problems

Introduction

• Shoulder injury is very common in the active patient population.

• It is a complex joint and presents unique challenges to diagnosis and subsequent treatment.

Introduction• Shoulder Pain is the third most

common MS complaint in primary care offices– Second to knee pain for referrals

to ortho/sports medicine physicians

• Incidence 25/1000 patients– Peak incidence in 50-70 year

olds

• 8-13% of athletic injuries involve the shoulder

Introduction

• The shoulder complex is a loosely constructed highly mobile complex of bones, muscles and ligaments.

• It is designed for increased mobility to the upper extremity with only sufficient stability to provide a proper foundation for muscular function which is vital for the performance of sports or activities of daily living (ADL)

Introduction

• Effective diagnosis and treatment of the shoulder requires a mastering of the relationship of structure and function of this complicated joint.

Anatomy

• It is composed of 3 joints (sternoclavicular, acromioclavicular and glenohumeral) and one articulation (scapulothoracic).

• All four work together in a synchronous rhythm for full range dynamic motion.

Anatomy…SC Joint

• The sternoclavicular joint (SCJ) enables the humerus to achieve 180 degrees of Abduction.

• It is a saddle shaped joint made up of the medial end of the clavicle, the manubrium sternum and the cartilage of the 1st rib.

• There is an articular disc separating the surfaces which adds strength to the joint.

SC Joint

Anatomy…AC Joint

• A plane synovial joint that augments the range of motion (ROM) in the humerus.

• It is made up of the acromiom process of the scapula and the lateral edge of the clavicle.

Anatomy…AC Joint

• It is surrounded by a fibrous capsule and an articular disc separates the surfaces.

• Primary strength is supplied by the acromioclavicular and coracoclavicular ligaments– trapezoid ligament – conoid ligaments

AC Joint

AC Joint

• Type I 17%• Type II 43%• Type III 40%

• Type III found in up to 80% of RC tears

• Compared with 3% in Type I

AC Joint/Subacromial Articulation

• Impingement– Greater tubercle– Acromion– Coracoacromial ligaments– Supraspinatus tendon

• Between 48-72% of shoulder pain in PCP office is subacromial impingement

Anatomy…GH Joint

• A multi-axial ball and socket joint surrounded by a capsule.

• Most of the support is provided by the rotator cuff muscles.

Anatomy of GH Joint

• The glenoid labrum is a ring of fibrocartilage that surrounds and deepens the glenoid fossa which increases the available contact area by approximately 70%.

Functional Anatomy…GH Joint

• The relaxed position of the humerus has it placed in the upper portion of the glenoid cavity.

• Contraction of the rotator cuff muscles pulls the humerus down into the lower/wider portion of the glenoid cavity.

• Without the “dropping down”, full Abduction is impossible.

GH Joint• Static stabilizers

– Labrum– Capsule– Adhesion-cohesion

• Intra-articular pressure

• Dynamic stabilizers– RC muscles– Deltoid– Long head of biceps– Scapulothoracic muscles– Proprioceptive feedback

GH Joint…Static Restraints

• Labrum– Ring of fibrocartilage – Deepens the glenoid fossa– Increases contact area ~70%

• Ligaments– Superior Glenohumeral– Middle Glenohumeral– Inferior Glenohumeral (important

when shoulder is abducted and externally rotated)

The Scapulothoracic Articulation

• The scapula serves as a mobile platform from which the upper limb operates.

• It is made up of the body of the scapula and the muscles covering the posterior chest wall.

The Scapulothoracic Articulation

• The GHJ moves 120 degrees as the scapula swings about 60 degrees around the chest wall in a smooth 2:1 ratio.

The Scapulothoracic Articulation

• The articulation allows the scapula to glide medially, laterally, superiorly and inferiorly and rotate over the posterolateral chest cage.

• Asymmetry of position usually indicates asymmetry of motion.

The Scapulothoracic Articulation

• In any given arm position, the scapula aligns itself to allow the glenoid cavity to be in the best position to receive the head of the humerus.

• The apparent simple motion of the scapula is neurologically complex due to relatively little “direct” muscle action.

Scapulothoracic Articulation

Extrinsic Muscles of the Shoulder Region• Deltoid

– Anterior (Flex/IR)– Mid-portion (ABd)– Posterior (Ext/ER)

• Pectoralis Major (ADd/flex/IR)

• Biceps (Flex)• Triceps (Ext)• Teres Major (ADd/IR)• Latissimus dorsi

(Ext/ADd/IR)

Intrinsic Muscles of the Shoulder Region

• Rotator Cuff• Supraspinatus (ABd)• Infraspinatus (ER)• Teres Minor (ER)• Subscapularis (IR)

Muscles of the Scapulothoracic Articulation“Scapular Stabilizers”

• Trapezius– Superior (Elev)– Middle (Retract)– Inferior (Depress)

• Levator Scapulae (Elev)• Pectoralis Minor (Depress)• Rhomboids (Retract)• Serratus anterior (Protract)

Shoulder Stability

• The shoulder consists of passive and dynamic stabilizers.

Static Shoulder Stability

• The static stabilizers are:– Glenoid– glenoid labrum – capsule – ligaments

• (superior glenohumeral, middle glenohumeral and inferior glenohumeral),

– joint cohesion – Intra-articular negative

pressure.

Dynamic Shoulder Stability

• The dynamic stabilizers are the rotator cuff muscles along with the long head of the biceps.

• The scapulothoracic stabilizers are the rhomboids, trapezius, serratus anterior, and the pectoralis minor.

Ultimately Our Goal is Joint Congruence

• Maintenance of the articular surfaces’ apposition is the keystone to avoiding injury

• Altered engrams (motor activation patterns) increases loads on tissues, resulting in a singular macrotrauma or repetitive microtraumas

• More than a tight capsule and strong rotator cuff…

Shoulder ExaminationHISTORY

“Listen to the patient long enough and they will tell you what is wrong with them”

• Where/when/what/how/why• Specific mechanism of injury (MOI) (if any?)• Chronic vs. acute• What makes symptoms better or worse• Instability/weakness• Pain (0/10) • Crepitation• Radicular symptoms (pain radiation)

Shoulder ExaminationHISTORY

• Pain in shoulder coming from rotator cuff or bursa radiates to lateral deltoid – NOT past elbow!

• Pain that wakes on rolling over in bed suggests bursitis

• Pain that wakes from sleep suggests rotator cuff tear– 88% sensitive, 20% specific

Shoulder Exam • Physical exam should be done in the same manner

each time so that nothing is forgotten:– Inspection– Palpation– ROM

• Active and Passive– Strength and Neurologic Testing– Regional Osteopathic Structural Examination– Special Testing

Shoulder Pain Diagram

Shoulder Exam

• Inspect– Expose the area– Step offs– Deformities– Ecchymosis– Asymmetry

ROM• Forward flexion 1800

• Extension 450 • ABduction 1800

• ADduction 450

• IR 550

• ER 40-450

A/PROM tests

• Apley “scratch” test:• ER and aBduction (C7)• IR and aDduction (T7)• Asymmetry can be indicative

of:– limited GH adduction– internal/external rotation– scapular movement

• Painful arc of motion– 33% sensitive– 81% specific

Scapular Dyskinesis

• Functional base for shoulder• Alterations in the resting position

affects timing and magnitude of:– Acromial upward rotation– Excessive movement of the glenoid– Decrease maximal RC activation

• Often associated with other upper extremity disorders

Range of Motion

• Asymmetry is the Key!• Master the feel of normal/abnormal endpoints and

restrictions of motion.• Extra-articular blockage: rubbery feel and gives

slightly under pressure• Intra-articular blockage: inflexible and ROM ends

abruptly

Physical Exam• Neurologic exam• Muscle & tendon pain worse

with:– Passive stretch– Active contraction in a neutral

position– Palpation

• Ligaments/capsule pain worse with:– Passive & active loading,

usually only at the end ROM– Palpation

Reflex and Sensory Testing

Spurling’s Test• Puts pressure on

posterolateral complex (articular pillars, facets, & neural foramina

• Could be a ligament, muscle/tendon, disc, osteoarthritis, nerve root inflammation (virus, etc.), or tumor

Lhermitte’s Sign/Test

• the “Barber Chair” phenomenon• Trauma to cervical spinal cord• Space occupying lesion (tumor,

disc)• Multiple sclerosis• Cervical spondylosis• Vitamin B12 deficiency

Muscle Testing

• Range of “normal” muscle strength.

• When testing for strength, keep in mind that you are also testing for neurological function.

Special Testing

• Special testing can be done to add information for the diagnosis of the problem.

• Structured to uncover a specific type of pathology or dysfunction.

• Shoulder special testing includes but not limited to the following….

Specific Special Tests• Biceps tendonitis

– Yergason’s– Speed’s

• Rotator Cuff– Empty Can– Full Can– Lift Off/Napolean– Scapular Retraction

• Instability– Apprehension– Jobe relocation– Anterior Release – Glide/Load and Shift– Sulcus Test

• Impingement– Hawkins– Neer’s

• Cross Arm Adduction• SLAP lesion

– O’Brien’s– Clunk or Crank– Resisted Supination/ER– Biceps load I and II– Zaslav

• TOS– Adson’s– Roos

Biceps TendonitisYergason’s Test

• Patient flexes elbow to 900

• Physician grasps the elbow with one hand and the wrist with the other

• The examiner resists as patient attempts to supinate and flex the elbow

• The test is positive if pain is elicited as the biceps tendon or bicipital groove

Biceps TendonitisSpeed’s Test

• Patient fully extends the elbow, flexes the shoulder and supinates the forearm

• Physician resists further flexion

• The test is positive when there is tenderness in the bicipital groove

Supraspinatus Testing• Position the arms in a position of 900

ABduction and 300 forward flexion with the thumbs pointing down

• Apply a downward force as the patient resists

• The test is positive with weakness or pain– 89% sensitive; 68% specific

• “Full Can Test”– Less impingement– Minimized infraspinatus– 86% sensitive; 74% specific

Supraspinatus TestScapular Retraction Test

• Scapular dyskinesis may decrease maximum RC activation

• With arm in empty can test position, scapula is lightly held in retraction by forearm pressure on the medial scapular border while the patient exerts maximum resistance

• Strength values increased by 24% in injured group, and 13% in control

Subscapularis Test Gerber Lift Off Test/Napoleon Test

• Internal rotation• Minimal activation of

pectoralis and latisimus• Ability to “lift off” • 62% sensitive• 100% specific

Infraspinatus Test

• 00 abduction and 450 IR of humerus

• Minimal activation of supraspinatus and deltoid– Contribute more from 00 to

450 ER

GH Instability• Apprehension Test

– Causes anterior translation (subluxation)– Sens 40%, Spec 87%

• Jobe Relocation Test– Posterior pressure on the head alleviates

the discomfort (relocation)– Sens 56%, Spec 93%

• Anterior Release Test– Allows for quick anterior

translation/apprehension returns– Sens 92%, Spec 89%

GH InstabilityGlide Test

• This test is performed to assess of A/P instability

• Compare bilaterally• The test is positive if

there is excessive mobility

GH InstabilityLoad and Shift Test

• Patient lie flat on the back so that the center of the scapula is on the edge of the table

• The physician holds the arm out 900 abduction

• Assess movement in the shoulder joint in the anterior and posterior directions

• Grade 0-3• “Lachman” of the shoulder

0 1

2 3

Inferior GH InstabilitySulcus Test

• Apply traction in an inferior direction with the arm relaxed

• The test is positive if it causes inferior subluxation of the humeral head and widening of the sulcus between the humerus and the acromion

• About 25% of patients with MDI will have sulcus of 2cm or more

Multidirectional Instability (MDI)• Usually not difficult to

diagnose• Laxity in at least the anterior

and posterior planes, inferior is usually lax as well

• Can be overlaid by another pathology

• Often a laxity in a joint is the compensatory result of restriction elsewhere

• Imaging not usually necessary or helpful

Multidirectional Instability (MDI) Treatment considerations

• Neuromuscular retraining• Maintenance of joint

congruence• Kinetic chain• TX Somatic Dysfunction• Reduction of capsule laxity

– Prolotherapy – Bankhart or capsular

plication

Impingement Syndrome• Primary

– Repetitive overhead motion– Supraspinatus impinges on acromion– Prominent coracoacromial ligament

• Secondary– GH laxity and instability of shoulder– Cephalad migration of humeral head– Labral lesion possible

• Internal (posterior-superior glenoid)– Inferior supraspinatus trapped between greater tuberosity and posterior

superior labrum– Posterior superior synovitis and partial under-surface tears

• Tensile failure– Often as a result of fatigue and tears with eccentric loading

Impingement TestsNeer’s Test

• Patient seated, passively IR arm so that thumb is downward

• Flex the arm while stabilizing scapula

• The test is positive if discomfort or pain is elicited

• Impingement of the humerus against the coracoacromial arch

• 81% sensitive• 50% specific

Impingement TestsHawkins Test

• Tests supraspinatus impingement against the coracoacromial ligament

• Elevate the patients shoulder to 900, flex the elbow to 900 and place the forearm in neutral position

• IR the humerus• The test is positive when there is

pain or discomfort• 90% sensitive, 60% specific

Impingement SyndromeTreatment

• Injection– Diagnostic– Therapeutic– Larger volume

• PT– Up to 6 mos– 60-90% resolve

• OMT

AC Joint/Posterior CapsuleCross Arm Test

• With the patient seated, bring the arm across the chest as far as possible

• The test is positive if there is pain elicited at the AC joint

• By comparison with the opposite side one can ascertain the tightness or laxity of the posterior capsule

Superior Labral Anterior Posterior Lesions (SLAP)

• Anterior pain• Posterior tightness• Clicking or popping• Dominant arm• Mechanisms

– Eccentric loading of biceps during throwing

– Fall with compressive load– Forced Abd/ER– Excessive traction from weight lifting– MVA from seatbelt

SLAP - O’Brien’s Test• Shoulder 900 flexion, 10-200

adduction, thumb pointed down

• Patient resists downward pressure

• Rotate to supination and resist flexion

• Test is positive if pain alleviated in palm-up position

• Sensitivity 67%• Specificity 49%

SLAP - Crank Test

• Patient shoulder aBducted to 900

• Axial load placed by examiner• Humerus then IR• The test is positive if pain is

noted with or without an “clunk”, or reproduction of activity related symptoms

• Sensitivity 59%• Specificity 82%

SLAP - Resisted Supination ER Test

• Patient is supine with scapula near the edge

• Examiner supports the limb in 900 aBduction, elbow flexed 60-700, forearm in neutral

• Patient attempts to supinate, as examiner resists and then gently externally rotated to the maximal point

• The test is positive if anterior or deep pain, clicking, or reproduction of activity related symptoms

• 83% sensitive, 82% specific

SLAP - Biceps Load Test

• Loads the superior labrum via stress on the biceps tendon during resisted flexion force

• Positive test is pain or apprehension• Test I is 900/900 Sens 91%, Spec 97%• Test II is 1200/900 Sens 90%, Spec 97%

SLAP - Zaslav Test• Helps to differentiate labral tears from impingement

syndrome• Positive test denoted by weakness, NOT pain• Sensitivity 88%, Specificity 96%

Thoracic Outlet Syndrome (TOS)• Compression of the neurovascular structures at the superior

aperture of the thorax• Etiology

– Neurologic• Brachial plexus (95%)

– Vascular• Subclavian vein (4%)• Subclavian artery (1%)

• Neurologic - Female-to-male ratio approximately 3.5:1• Venous - More common in males than in females• Arterial - No sexual predilection

TOS - Etiology• Anatomic

– Scalene triangle (most common)– Cervical ribs (more common in arterial)– Congenital fibromuscular bands (up to 80% in neurologic)– Transverse process of C7 is elongated

• Trauma or repetitive activities– MVA, hyperextension injury, with subsequent fibrosis and scarring– Effort vein thrombosis (ie, spontaneous thrombosis of the axillary veins

following vigorous arm exertion)– Playing a musical instrument: maintain the shoulder in abduction or extension for

long periods• Neurovascular entrapment

– Costoclavicular space between the 1st rib and the head of the clavicle– C8-T1 (90%)-ulnar n. distribution

TOS - Adson’s Test• Patency of subclavian artery• “Classic” maneuver• Patient’s arm aBducted, extend and

ER• Patient then takes a deep breath and

holds it while turning the head towards the side being tested

• Then turn head to the opposite direction

• Test is positive if diminished or absent pulse or reproduces symptoms

TOS - Roos Test

• Patient aBducts the shoulders to 900, ER, and flex the elbows to 900

• Then patient then slowly opens and closes the hands for 3 minutes• The test is positive if the arm becomes heavy or there are

paresthesia of the hand• Compression of subclavian artery and vein and the brachial plexus

Diagnostic Work-Up• Depending on the

injury, there are many diagnostic tests that can be done to evaluate an injury:• X-rays• CT Scan• MRI• CT/MR Arthrograms

• Selective injections– Using anesthetic and/or

steroids

• Serial exams in office• Ultrasound• Dynamic ultrasound

– In office– US guided injections

Imaging• X-rays

– AP– GH dislocation best seen

on axillary views, also on scapular Y view

Imaging

• X-rays– Outlet views are obtained

to evaluate impingement– For instability, West Point

view or the Stryker notch view are used to better detect Bankart and Hill Sachs' lesions

Imaging

• Arthrogram– Detailed anatomical

information is obtained when combined with CT or MRI of the shoulder

– Excellent detail of capsular attachments and of the labrum

Thought for the Day…

• “Education is what

you remember after

you have forgotten

what you studied for

the test."

-Emerson