The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave...

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Transcript of The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave...

  • The Sore Shoulder: How To Evaluate, When To Scan, When To Refer

    Randy Wroble MDRay Tesner DODave Weil MDTeam Physicians, Columbus Blue Jackets

  • Case 1

  • History25 yo right-handed female presents with pain and weakness in her left shoulderShe works in an office but is involved in several recreational sports including volleyball, water-skiing and snow skiingShe has had problems with her shoulder since high school but symptoms have worsened in the last few months

  • Her pain is anterior, posterior, and lateralShe denies any specific injury but notes that her arm would feel momentarily weak at various times with her athletic activitiesShe has had similar but milder symptoms in her opposite shoulderShe was treated in high school with an exercise program but no supervised therapy. This seemed to relieve her symptoms

  • She has never had an x-ray or MRIOccasionally she describes tingling in her whole armShe takes oral contraceptives but is otherwise healthy. She had knee arthroscopy for a patella problem 4 years ago

  • What Are the Key Points Learned From the History?

  • What Is Your Differential Diagnosis?

  • ExamNo significant tendernessROM fullImpingement tests negativeInstability testsPositive load-shift and drawer testsEquivocal sulcus sign & relocation test

  • Apprehension tests produce discomfort onlyStrength full in all muscle groups No crepitus, no atrophy or swellingNeurocirculatory exam normalCervical spine exam - normal

  • DemonstrationApprehension testsRelocation testLoad-shiftDrawer testSulcus sign

  • On Physical Exam, How Do You Tell Apart Uni- Versus Multi-directional Instability and Why Is That Important?

  • When Do You Order X-rays and What Views?

  • Imaging - X-raysPossible positive findingsBony Bankart lesionHill-Sachs lesion

  • Hill-Sachs Lesion

  • When Do You Order an MRI?

  • MRIPossible positive findingsLabrum tearsCapsular abnormalities increased volume, avulsions

  • Normal Labrum

  • Bankart Lesion

  • Enlarged Capsule

  • Describe Your Initial Treatment

  • How Long Should You Continue Non-operative Treatment?

  • Initial TreatmentNo labrum tearPhysical therapy supervised TIW 6 weeks minimumStrengtheningNeuromuscular controlScapular stabilizationCore stabilization

  • Labrum Tear PresentReferral for surgical consultation

  • ResultsMultidirectional instability without labrum tearVery high success rate with non-operative managementMay require prolonged and specialized therapy program

  • Instability With Labrum TearVery high rate of unsatisfactory results without surgeryEarly referral

  • What Is the Surgical Decision-making Process in This Case?

  • Case 2

  • Patient History47 yo female complains of pain in her dominant right shoulder. Onset was about 3 months ago. She thought her pain may have started after she caught herself from falling in the shower, but the incident was so mild she quickly had forgotten about it. Since that time, she has steadily worsened.

  • She feels weak and has a lot of pain when she lifts her arm overhead. She describes the pain as being deep within the shoulder. Some ADLS have become difficult, including fastening her bra. She has no paresthesias or neck pain.

  • She went to an urgent care facility and had x-rays. She was told these were normal. An NSAID was given at that time and it helped a little. She takes Lipitor, Wellbutrin, and Glucophage.

  • What Are the Key Points Learned From the History?

  • What Is Your Differential Diagnosis?

  • ExamTenderness anteriorly and posteriorly around the acromionROM FF 90 degrees, ER 20 degrees with arm at the side, IR to about the SI jointImpingement tests all cause pain at end range of motionStrength near normal in all groups

  • Mild crepitusNo atrophy or swellingNeurocirculatory exam normalInstability tests negativeCervical spine exam normal

  • DemonstrationROM testingC-spine and other ancillary testing

  • How Does Your Exam Eliminate Rotator Cuff Problems From the Differential?

  • When Do You Order X-rays and What Views?

  • Imaging - X-raysPossible positive findingsGenerally normal x-raysOsteopenia?

  • When Do You Order an MRI?

  • MRIPossible positive findingsNeed to know cuff and labrum statusMany false positives in older age group

  • Describe Your Initial Treatment

  • What Is the Role of Corticosteroid Injections?

  • How Long Should You Continue Non-operative Treatment?

  • Initial TreatmentAlways non-operativeUnless history of contralateral frozen shoulder unresponsive to therapyGet control of painNSAIDsSupplemental non-narcotic analgesicsTENS

  • Physical therapy supervised TIWSpecify aggressive ROM/stretchingMyofascial/trigger point approachAquatic programCombine with home programReassess in 4 weeksInsurance often limits visits save visits for post-op PTReferral if no progress

  • What Is the Surgical Decision-making Process in This Case?

  • Results Majority respond to PTFirst operative intervention is manipulation under anesthesia

  • Case 3

  • Patient History54 yo male maintenance supervisor and recreational softball player complains of a 6 month history of dominant shoulder painPain is localized to the anterior aspect of the shoulder with radiation to the deltoid insertion He recalls no specific injury but has had several similar bouts of pain over the last 5 or 6 years. Each of these episodes resolved with activity modification alone

  • His current pain is worse with overhead activities and with reaching. He is occasionally wakened from sleep by his shoulder painHe notes no numbness, tingling, or neck painHe has mild treated hypertension but has no other significant medical history

  • What Are the Key Points Learned From the History?

  • What Is Your Differential Diagnosis?

  • ExamTenderness anteriorly acromion, AC joint, and anterior deltoidROM near full,mild restriction of IRImpingement tests positive in full forward flexion, internal rotation at 90 degrees flexion, and in adduction

  • Strength decreased to external rotation and forward flexion Painful arc of motion 60 to 100 degrees forward flexionMild crepitusNo atrophy or swelling, neurocirculatory exam normal, instability tests negative, cervical spine exam normal

  • DemonstrationEmphasize proper exposureInspectionPalpationStrength testsImpingement signs

  • What Is the Most Reliable Physical Exam Finding to Differentiate Cuff Tendinitis From Cuff Tear?

  • How Do You Tell If the AC Joint Is Involved?

  • When Do You Order X-rays and What Views?

  • Imaging - X-raysPossible positive findingsAcromial hookSclerosis acromial & greater tuberosityAC joint narrowing & spurringCalcific deposits

  • Acromial Hook

  • AC Arthritis

  • Rotator Cuff Tear

  • When Do You Order an MRI?

  • MRIPossible positive findingsIncreased signal in cuffFluid in bursaDiscontinuityMuscle atrophy

  • RC Tendinitis

  • RC Tear

  • Describe Your Initial Treatment

  • Initial TreatmentTendinitis/partial rotator cuff tearNSAIDsActivity modificationPhysical therapy supervised TIWStrengtheningStretchingModalities

  • How Long Should You Continue Non-operative Treatment?

  • What Is the Role of Corticosteroid Injections?

  • ResultsTendinitis/partial rotator cuff tearNon-operative treatment successful 60 to 70% of casesMaintenance exercise programGradual progression to full activityAssessment of workplaceTransitional work programNon-operative treatment not successful after 6 weeksReferral

  • Full Thickness Rotator Cuff TearReferral to orthopaedic surgeon

  • What Is the Surgical Decision-making Process in This Case?

  • Full Thickness Rotator Cuff TearArthroscopic cuff repair Some tears are irreparable!

  • Thanks and enjoy the game!