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

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The Sore Shoulder: How The Sore Shoulder: How To Evaluate, When To To Evaluate, When To Scan, When To Refer Scan, When To Refer Randy Wroble MD Randy Wroble MD Ray Tesner DO Ray Tesner DO Dave Weil MD Dave Weil MD Team Physicians, Columbus Blue Team Physicians, Columbus Blue Jackets Jackets

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

Page 1: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

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

Randy Wroble MDRandy Wroble MD

Ray Tesner DORay Tesner DO

Dave Weil MDDave Weil MD

Team Physicians, Columbus Blue Team Physicians, Columbus Blue JacketsJackets

Page 2: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Case 1Case 1

Page 3: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

HistoryHistory

• 25 yo right-handed female presents 25 yo right-handed female presents with pain and weakness in her left with pain and weakness in her left shouldershoulder

• She works in an office but is involved in She works in an office but is involved in several recreational sports including several recreational sports including volleyball, water-skiing and snow skiingvolleyball, water-skiing and snow skiing

• She has had problems with her She has had problems with her shoulder since high school but shoulder since high school but symptoms have worsened in the last symptoms have worsened in the last few monthsfew months

Page 4: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

• Her pain is anterior, posterior, and Her pain is anterior, posterior, and laterallateral

• She denies any specific injury but She denies any specific injury but notes that her arm would feel notes that her arm would feel momentarily weak at various times momentarily weak at various times with her athletic activitieswith her athletic activities

• She has had similar but milder She has had similar but milder symptoms in her opposite shouldersymptoms in her opposite shoulder

• She was treated in high school with an She was treated in high school with an exercise program but no supervised exercise program but no supervised therapy. This seemed to relieve her therapy. This seemed to relieve her symptomssymptoms

Page 5: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

• She has never had an x-ray or She has never had an x-ray or MRIMRI

• Occasionally she describes Occasionally she describes tingling in her whole armtingling in her whole arm

• She takes oral contraceptives She takes oral contraceptives but is otherwise healthy. She but is otherwise healthy. She had knee arthroscopy for a had knee arthroscopy for a “patella problem” 4 years ago“patella problem” 4 years ago

Page 6: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Are the Key Points What Are the Key Points Learned From the History?Learned From the History?

Page 7: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Is Your Differential What Is Your Differential Diagnosis?Diagnosis?

Page 8: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

ExamExam

• No significant tendernessNo significant tenderness• ROM –fullROM –full• Impingement tests – negativeImpingement tests – negative• Instability testsInstability tests

– Positive load-shift and drawer Positive load-shift and drawer teststests

– Equivocal sulcus sign & relocation Equivocal sulcus sign & relocation testtest

Page 9: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

• Apprehension tests produce Apprehension tests produce discomfort onlydiscomfort only

• Strength full in all muscle groups Strength full in all muscle groups • No crepitus, no atrophy or No crepitus, no atrophy or

swellingswelling• Neurocirculatory exam – normalNeurocirculatory exam – normal• Cervical spine exam - normalCervical spine exam - normal

Page 10: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

DemonstrationDemonstration

• Apprehension testsApprehension tests• Relocation testRelocation test• Load-shiftLoad-shift• Drawer testDrawer test• Sulcus signSulcus sign

Page 11: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

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

Page 12: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

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

Page 13: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Imaging - X-raysImaging - X-rays

•Possible positive Possible positive findingsfindings– Bony Bankart lesionBony Bankart lesion– Hill-Sachs lesionHill-Sachs lesion

Page 14: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Hill-Sachs LesionHill-Sachs Lesion

Page 15: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

When Do You Order an MRI?When Do You Order an MRI?

Page 16: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

MRIMRI

• Possible positive findingsPossible positive findings– Labrum tearsLabrum tears– Capsular abnormalities – Capsular abnormalities –

increased volume, avulsionsincreased volume, avulsions

Page 17: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Normal LabrumNormal Labrum

Page 18: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Bankart LesionBankart Lesion

Page 19: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Enlarged CapsuleEnlarged Capsule

Page 20: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Describe Your Initial TreatmentDescribe Your Initial Treatment

Page 21: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

How Long Should You How Long Should You Continue Non-operative Continue Non-operative

Treatment?Treatment?

Page 22: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Initial TreatmentInitial Treatment

• No labrum tearNo labrum tear– Physical therapy – supervised TIW Physical therapy – supervised TIW

– 6 weeks minimum– 6 weeks minimum• StrengtheningStrengthening• Neuromuscular controlNeuromuscular control• Scapular stabilizationScapular stabilization• Core stabilizationCore stabilization

Page 23: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Labrum Tear PresentLabrum Tear Present

• Referral for surgical Referral for surgical consultationconsultation

Page 24: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

ResultsResults

• Multidirectional instability Multidirectional instability without labrum tearwithout labrum tear– Very high success rate with non-Very high success rate with non-

operative managementoperative management• May require prolonged and May require prolonged and

specialized therapy programspecialized therapy program

Page 25: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Instability With Labrum Instability With Labrum TearTear

• Very high rate of Very high rate of unsatisfactory results without unsatisfactory results without surgerysurgery– Early referralEarly referral

Page 26: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Is the Surgical What Is the Surgical Decision-making Process in Decision-making Process in

This Case?This Case?

Page 27: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Case 2Case 2

Page 28: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Patient HistoryPatient History

• 47 yo female complains of pain in 47 yo female complains of pain in her dominant right shoulder. Onset her dominant right shoulder. Onset was about 3 months ago. was about 3 months ago.

• She thought her pain may have She thought her pain may have started after she caught herself started after she caught herself from falling in the shower, but the from falling in the shower, but the incident was so mild she quickly incident was so mild she quickly had forgotten about it. Since that had forgotten about it. Since that time, she has steadily worsened. time, she has steadily worsened.

Page 29: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

• She feels weak and has a lot of She feels weak and has a lot of pain when she lifts her arm pain when she lifts her arm overhead. She describes the pain overhead. She describes the pain as being deep within the shoulder. as being deep within the shoulder.

• Some ADLS have become difficult, Some ADLS have become difficult, including fastening her bra. including fastening her bra.

• She has no paresthesias or neck She has no paresthesias or neck pain. pain.

Page 30: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

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

• She takes Lipitor, Wellbutrin, She takes Lipitor, Wellbutrin, and Glucophage.and Glucophage.

Page 31: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Are the Key Points What Are the Key Points Learned From the History?Learned From the History?

Page 32: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Is Your Differential What Is Your Differential Diagnosis?Diagnosis?

Page 33: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

ExamExam

• Tenderness anteriorly and Tenderness anteriorly and posteriorly around the acromionposteriorly around the acromion

• ROM – FF 90 degrees, ER – 20 ROM – FF 90 degrees, ER – 20 degrees with arm at the side, IR degrees with arm at the side, IR – to about the SI joint– to about the SI joint

• Impingement tests – all cause Impingement tests – all cause pain at end range of motionpain at end range of motion

• Strength near normal in all Strength near normal in all groups groups

Page 34: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

• Mild crepitusMild crepitus

• No atrophy or swellingNo atrophy or swelling

• Neurocirculatory exam – Neurocirculatory exam –

normalnormal

• Instability tests – negativeInstability tests – negative

• Cervical spine exam – normalCervical spine exam – normal

Page 35: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

DemonstrationDemonstration

• ROM testingROM testing• C-spine and other ancillary C-spine and other ancillary

testingtesting

Page 36: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

How Does Your Exam How Does Your Exam Eliminate Rotator Cuff Eliminate Rotator Cuff

Problems From the Problems From the Differential?Differential?

Page 37: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

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

Page 38: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Imaging - X-raysImaging - X-rays

•Possible positive Possible positive findingsfindings– Generally normal x-raysGenerally normal x-rays– Osteopenia?Osteopenia?

Page 39: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

When Do You Order an MRI?When Do You Order an MRI?

Page 40: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

MRIMRI

•Possible positive Possible positive findingsfindings– Need to know cuff and Need to know cuff and labrum statuslabrum status

– Many false positives in Many false positives in older age groupolder age group

Page 41: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Describe Your Initial Describe Your Initial TreatmentTreatment

Page 42: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Is the Role of What Is the Role of Corticosteroid Injections?Corticosteroid Injections?

Page 43: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

How Long Should You How Long Should You Continue Non-operative Continue Non-operative

Treatment?Treatment?

Page 44: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Initial TreatmentInitial Treatment

• Always non-operativeAlways non-operative– Unless history of contralateral frozen Unless history of contralateral frozen

shoulder unresponsive to therapyshoulder unresponsive to therapy

• Get control of painGet control of pain– NSAIDsNSAIDs– Supplemental non-narcotic Supplemental non-narcotic

analgesicsanalgesics– TENSTENS

Page 45: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

• Physical therapy – supervised TIWPhysical therapy – supervised TIW– Specify aggressive ROM/stretchingSpecify aggressive ROM/stretching

• Myofascial/trigger point approachMyofascial/trigger point approach• Aquatic programAquatic program• Combine with home programCombine with home program• Reassess in 4 weeksReassess in 4 weeks• Insurance often limits visits – Insurance often limits visits –

“save” visits for post-op PT“save” visits for post-op PT• Referral if no progressReferral if no progress

Page 46: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Is the Surgical What Is the Surgical Decision-making Process in Decision-making Process in

This Case?This Case?

Page 47: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Results Results

• Majority respond to PTMajority respond to PT• First operative intervention is First operative intervention is

manipulation under anesthesiamanipulation under anesthesia

Page 48: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Case 3Case 3

Page 49: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Patient HistoryPatient History

• 54 yo male maintenance supervisor and 54 yo male maintenance supervisor and recreational softball player complains of a recreational softball player complains of a 6 month history of dominant shoulder 6 month history of dominant shoulder painpain

• Pain is localized to the anterior aspect of Pain is localized to the anterior aspect of the shoulder with radiation to the deltoid the shoulder with radiation to the deltoid insertion insertion

• He recalls no specific injury but has had He recalls no specific injury but has had several similar bouts of pain over the last several similar bouts of pain over the last 5 or 6 years. Each of these episodes 5 or 6 years. Each of these episodes resolved with activity modification aloneresolved with activity modification alone

Page 50: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

• His current pain is worse with His current pain is worse with overhead activities and with overhead activities and with reaching. He is occasionally reaching. He is occasionally wakened from sleep by his wakened from sleep by his shoulder painshoulder pain

• He notes no numbness, tingling, He notes no numbness, tingling, or neck painor neck pain

• He has mild treated hypertension He has mild treated hypertension but has no other significant but has no other significant medical historymedical history

Page 51: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Are the Key Points What Are the Key Points Learned From the Learned From the

History?History?

Page 52: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Is Your Differential What Is Your Differential Diagnosis?Diagnosis?

Page 53: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

ExamExam

• Tenderness anteriorly – acromion, Tenderness anteriorly – acromion, AC joint, and anterior deltoidAC joint, and anterior deltoid

• ROM – near full,mild restriction of ROM – near full,mild restriction of IRIR

• Impingement tests – positive in Impingement tests – positive in full forward flexion, internal full forward flexion, internal rotation at 90 degrees flexion, and rotation at 90 degrees flexion, and in adductionin adduction

Page 54: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

• Strength decreased to external Strength decreased to external rotation and forward flexion rotation and forward flexion

• Painful arc of motion 60 to 100 Painful arc of motion 60 to 100 degrees forward flexiondegrees forward flexion

• Mild crepitusMild crepitus• No atrophy or swelling, No atrophy or swelling,

neurocirculatory exam – neurocirculatory exam – normal, instability tests – normal, instability tests – negative, cervical spine exam – negative, cervical spine exam – normalnormal

Page 55: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

DemonstrationDemonstration

• Emphasize proper exposureEmphasize proper exposure• InspectionInspection• PalpationPalpation• Strength testsStrength tests• Impingement signsImpingement signs

Page 56: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Is the Most What Is the Most Reliable Physical Exam Reliable Physical Exam Finding to Differentiate Finding to Differentiate

Cuff Tendinitis From Cuff Cuff Tendinitis From Cuff Tear?Tear?

Page 57: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

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

Page 58: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

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

Page 59: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Imaging - X-raysImaging - X-rays

• Possible positive findingsPossible positive findings– Acromial hookAcromial hook– Sclerosis – acromial & Sclerosis – acromial &

greater tuberositygreater tuberosity– AC joint narrowing & AC joint narrowing &

spurringspurring– Calcific deposits Calcific deposits

Page 60: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Acromial HookAcromial Hook

Page 61: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

AC ArthritisAC Arthritis

Page 62: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Rotator Cuff TearRotator Cuff Tear

Page 63: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

When Do You Order an When Do You Order an MRI?MRI?

Page 64: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

MRIMRI

• Possible positive findingsPossible positive findings– Increased signal in cuffIncreased signal in cuff– Fluid in bursaFluid in bursa– DiscontinuityDiscontinuity– Muscle atrophyMuscle atrophy

Page 65: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

RC TendinitisRC Tendinitis

Page 66: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

RC TearRC Tear

Page 67: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Describe Your Initial TreatmentDescribe Your Initial Treatment

Page 68: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Initial TreatmentInitial Treatment

• Tendinitis/partial rotator cuff Tendinitis/partial rotator cuff teartear– NSAIDsNSAIDs– Activity modificationActivity modification– Physical therapy – supervised TIWPhysical therapy – supervised TIW

• StrengtheningStrengthening• StretchingStretching• ModalitiesModalities

Page 69: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

How Long Should You How Long Should You Continue Non-operative Continue Non-operative

Treatment?Treatment?

Page 70: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Is the Role of What Is the Role of Corticosteroid Injections?Corticosteroid Injections?

Page 71: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

ResultsResults

• Tendinitis/partial rotator cuff tearTendinitis/partial rotator cuff tear– Non-operative treatment successful – 60 Non-operative treatment successful – 60

to 70% of casesto 70% of cases• Maintenance exercise programMaintenance exercise program• Gradual progression to full activityGradual progression to full activity• Assessment of workplaceAssessment of workplace

– Transitional work programTransitional work program

• Non-operative treatment not successful Non-operative treatment not successful after 6 weeksafter 6 weeks– ReferralReferral

Page 72: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Full Thickness Rotator Full Thickness Rotator Cuff TearCuff Tear

• Referral to orthopaedic Referral to orthopaedic surgeonsurgeon

Page 73: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

What Is the Surgical What Is the Surgical Decision-making Process in Decision-making Process in

This Case?This Case?

Page 74: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

Full Thickness Rotator Full Thickness Rotator Cuff TearCuff Tear

• Arthroscopic cuff repairArthroscopic cuff repair • Some tears are irreparable!Some tears are irreparable!

Page 75: The Sore Shoulder: How To Evaluate, When To Scan, When To Refer Randy Wroble MD Ray Tesner DO Dave Weil MD Team Physicians, Columbus Blue Jackets.

ThanksThanks……

and enjoy the and enjoy the game!game!


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