Itz very much helpful to detect and treat shoulder pathology and their management

1. CME on Approach to Shoulder
Pain Assessment&Evaluation
Presenter:
Dr. Fahad Islam
Honorary Medical Officer, CMCH
Physical Medicine &Rehabilitation Department

2. SHOULDER JOINT
Patient Evaluation

3. SHOULDER JOINT
*Multiaxial Ball& Socket type of
synovial joint
*Most flexible joint in the entire human
body due to limited interface
*Formed by the articulation between
the glenoid fossa of scapula& Head
of Humerus

4. ANATOMY..
• Shoulder Girdle: humerus, clavicle,
scapula & sternum
• Physiologic area: subacromial space
• Muscles
• Non-contractile structures (ligament,
capsule, bursa, labrum, nerves &
blood vessels)

5. Bursa around Shoulder
1.Subdeltoid Bursa
2.Subcoracoid Bursa
3.Coracobrachial Bursa
4.Subacromial Bursa
5.Subscapular Bursa

6. Ligaments
1.Superior, middle and inferior
glenohumeral Ligaments
2.Coracohumeral Ligaments
3.Transeverse humeral ligaments
4.Coraco-acromial Ligaments

7. Nerve Supply
1.Suprascapular N
2.Axillary N
3.Lateral Pectoral N

8. Blood Supply
The glenohumeral joint is supplied with
blood by branches of the-
1.Anterior and Posterior circumflex
humeral,
2.Suprascapular arteries and
3.The scapular circumflex arteries.

9. PURPOSE OF SHOULDER
ASSESSMENT
• Verify the nature and extent of
impairments (e.g. pain,
movement restriction,
impaired proprioception etc.)

10. • Ascertain the degree of the
resulting disability (e.g. difficulty
throwing, inability to perform
freestyle stroke etc.)
• Gather significant information
about the patient (e.g. level of
motivation, expectations,
occupation, sport activities etc.)

11. SUBJECTIVE EXAMINATION
• Patient’s profile
– Age
– Occupation
– Hand dominance
– Recreational pursuits
– Work requirements
– ADL

12. Continue..
• Comfortable/ Preferred limb
position
• Mechanism of Injury
– Overhead exertion involving
repetitive motion
– Fall or blow to tip of shoulder or
land on elbow
– Shoulder feels unstable or “coming
out”

13. • Body Chart
– Symptomatic representation of pt’s
complaints
– Most important element of subj
examination
• Movements that cause pain or
problems?
– Lateral rotation- ant. Dislocation
– Dead Arm Syndrome – ant. instability
– Night & Resting pain- rotator cuff tear
– Activity related pain- tendinitis
– Pain greater than 90 degrees of ABD-
AC joint

14. • Extent & behavior of patient’s pain
(e.g. deep, boring, toothache-like
pain – TOS)
• Activities that causes or
aggravates pain (e.g. overhead
elevation – impingement)
• Pain relieving positions (e.g.
overhead – nerve root pain)
• Functional capabilities of the
patient
• Onset and duration of sx? (e.g.
frozen shoulder – 3 stages)

15. • Any indication of muscle
spasm, deformity, wasting,
bruising, paresthesia or
numbness?
• Any feeling of heaviness and
weakness of the limb after
activity? (e.g. TOS – coolness
& pallor)
• Any indication of nerve injury?
(paresthesia, numbness,
weakness)

16. Chief Complaints
1.Pain-True/referred
*AC joint/Referred pain=Top of the Shoulder
*Glenohumeral Joint/rotatory cuff= Front&
outer aspect of joint as far as the middle of the
arm.
*Rotatory cuff impingment=pain in
Window cleaning position
*Shoulder instability=Sudden

17. Continue..
2.Weakness
*True Loss of power=Neurological
disorder
*Sudden&
Surprising inability to abduct=Rotatory
cuff Tear

18. Continue..
3.Instability-Feeling of shoulder jumps out
of its socket when raising arm, Click/Jerk
when arm is held over headed.
4.Stiffness-May be
Severe/progressive---Frozen Shoulder
5.Swelling-may be Joint/Muscle/Bone

19. Continue..
6.Deformity-May be either Muscle
wasting,AC jt prominence,Winging of
scapula,or an abnormal position of the arm
7.Loss
of Function-Expressed as difficulty with
dressing &grooming or inability to lift
objects or work with the arm above
shoulder height.

20. Continue..
Examined from front, side, behind & above, both
upper limb, Neck ,upper chest& outline of
Scapula must be visible

21. OBSERVATION
• Observe
shoulder,
head, cervical
spine, thorax
(anterior &
posterior
aspects) &
entire UE

22. ANTERIOR VIEW
• Step Deformity
– Distal end of clavicle lying
superior over the Acromion
Process (AC dislocation)
• Sulcus Sign
– Sulcus below Acromion (GH
subluxation)
• Flattening of deltoid muscle:
ant dislocation of GH jt or
deltoid paralysis

23. STEP DEFORMITY

24. SULCUS SIGN

25. POSTERIOR VIEW
• Examine for bony contours &
alignment
• Atrophy: Upper trapz,
supra/infraspinatus
• Winging of the scapula: medial
border moves away from
posterior chest wall
• ROTARY WINGING- inf angle is
rotated farther from the spine

26. • DYNAMIC WINGING- with
mov’t caused by lesion in long
thoracic nerve & spinal
accessory nerve
• STATIC WINGING- at rest due
to structural deformity
• SCAPULAR TILT- superior/
inferior border tilt away from the
chest
• SPRENGEL’s DEFORMITY-
congenitally high or
undescended scapula

27. WINGING of the SCAPULA
Long Thoracic
Nerve Lesion

28. SPRENGEL’S DEFORMITY

29. FEEL
1.Skin-Temparature
2.Bony points
&Soft tissues
*6 Points= SC jt,trace clavicle, AC
jt, Ant. Edge of Acromion& Around acromion, Ant.&
Post.margin of glenoid, Bicipital groove

30. EXAMINATION

31. Range of Motion
3 CLASSIC SHOULDER
CASES
–JOINT PATHOLOGY
–MUSCLE/ TENDON
PATHOLOGY
–NERVE COMPRESSION
INJURIES

32. MOVEMENTS
Observed from Front, then behind, Pt either
standing/sitting
1.AROM
a. Abduction(0-170)&Adduction(0-50)
b.Flexion(0-165)& Extension(0-60)

33. AROM..continue
e. External rotation in abduction=0-100
degree
f.External rotation in extension=0-70 degree
g.Internal rotation in extension 0-70 degree
h.Shoulder Elevation=37 degree
i.Shoulder depression=8 degree

34. CONTINUE..
2.PROM-Examiner press Firmly down on
the Top of the shoulder with one hand while
the other hand moves the Pts arm
3.Power

35. COMMON CAUSES OF
SHOULDER PAIN
A. Joint patholgy- GH arthritis,AC arthritis
B. Rotatory cuff patholgy-Impingement,
Tendinitis, Tear, Frozen shoulder
C. Bone pathology-Infection,Tumor
D. Nerve patholgy-Suprascapular N
entrapment
E. Referred Pain-
C/Spondylosis,Mediastinal &Cardiac
Ischemia

36. Disorder of Rotatory Cuff
(Rotatory Cuff Syndrome)
Comprises at least 4 condition with distinct
clinical features& conditions:
1.Supraspinatus impingement syndrome&
Tendinitis
2.Rotatory cuff tear
3.Acute calcific Tendinitis
4.Biceps Tendinitis and,or/ Rupture

37. Impingement site
pics-1.lnk

38. Impingement Syndrome
Pathology:
1.Repetitive compression or rubbing of the
tendons under coracoacromial arch
specially in Impingement position
2.Osteoarthritic Thickening of AC joint

39. Impingement Syndrome-
pathology. continue
3.Osteophyte on the ant. Edge of acromion
4.Inflammatory swelling of rotatory cuff or
subacromial bursa.eg: Gout,RA
5.Acromial Morphology.

40. Pathology..continue
6.Friction in Old age may leads to minute tear
of cuff
7.Sudden strain-partial/full thickness tear,
associated with Biceps tendon tear.
8.Secondary arthropathy

41. Clinical features of Rotatory Cuff Syndrome
3 Pattern are encountered:
1.Subacute tendinitis-Painful arc syndrome
2.Chronic tendinitis
3.Cuff disruption

42. Impingement Test
1.The Painful arc-on active abduction
(60-120 degree)
2.Neer’s Impingement sign: 80 percent
sensitive. also (+)ve in Rotatory cuff tear,
AC joint OA, Glenohumeral instability&
SLAP lesions.

43. 1.PAINFUL ARC

44. 2.NEER IMPINGEMENT TEST

45. 3.HAWKINS-KENNEDY
IMPINGEMENT TEST

46. continue..
TEST FOR ISOLATED
MUSCLE WEAKNESS

47. 1.Supraspinatus-
EMPTY CAN TEST

48. 2.INFRASPINATUS TEST-
resisted external rotation

49. 3.DROP ARM TEST
-found in Infraspinatus &Post. cuff tear

50. 4.LIFT-OFF SIGN / TEST
subscapularis pathology

51. Investigations
1.X-ray examination- early stages found
normal, but in
*Ch. tendinitis= erosion, sclerosis& Cyst formation
at the site of cuff insertion
*In Ch. Case caudal tilt view show roughening or
overgrowth of ant. Edge of acromion& upward
displacement of humeral head

52. Investigations..
2.MRI-gives valuable information about
structures like lesion of glenoid labrum,
joint capsule or surrounding muscle, bone.
3.USG-identifying and measuring the size of
full thickness or partial thickness tear.

53. Treatment of Cuff disorders
Conservative:
1.ADLs modification
2.Physiotherapy=UST
3.AROMs
4.NSAIDs,I/A depot corticosteroids

54. CONTINUE
Surgical management:
*When conservative treatment fails after 3
months
*Symptoms persist or worse after adequate
treatment

55. CONTINUE
1.Decompress rotatory cuff by excising
coracoacromial ligament,undercutting
the ant. Part of acromion
2.Open/Arthroscopic acromioplasty
3.Open/Arthroscopic repair of the rotatory
cuff

56. Calcification of the Rotatory cuff
Acute calcific tendinitis:
*deposition of CPPD crystal in critical zone, also occurs in
ankle, knee, hip, elbow
*Cause is unknown, supposed that ischemia leads to
fibrocartilaginous metaplasia& crystal deposition by
chondrocytes.
*Florid vascular reaction produces tension& swelling of the
tendons causes pain
*Resorbtion of calcific materials is rapid with in few weeks.

57. C/F of Acute calcific tendinitis
1.30-50 yrs age
2.Aching pain develops with in hours after
overuse, raising to an agonizing
3.After few days pain subside

58. X-ray findings
1.Calcification just above greater
tuberosity
2.Well demarcated deposit becomes more
woolly and then dissappears.

59. Treatment of Acute calcific tendinitis
Conservative Mx:
1.NSAIDs
2.Subacromial I/A steroids
3.Physiotherpay
4.Extra corporeal shock wave therapy
5.Needle aspiration& Irrigation

60. Management continue
Surgical Mx: after 6months of conservative
treatment
*Arthroscopic incision from bursal side
with fibre orientation of the tendon,then
curette to milk out the tooth paste
deposit.Sub-acromial decompression
may also done.

61. Lesions of the Biceps Tendon
1.Tendinitis
2.Rupture:Pop-Eye Bulge
3.Hypertrophy & Intra-articular entrapment
(The Hour glass Biceps)
4.Instability
*Subluxation-Partial&/transient loss of contact between the
tendons& its groove
*Dislocation-complete& permanent loss of contact between
the tendons& its groove

62. TEST FOR BICEPS TENDON
1.Speed’s Test
2.Yergason’s Test

63. 1.Speed’S Test

64. 2.Yergason’s Test

65. SLAP Lesions
Compressive loading of the shoulder in the
flexed abducted position like fall on the out-
stretched hand.4 main types:
1.Non-traumatic(degenerative) sup. labral tear
2.Avulsion of the sup.part of labrum(commonest)
3.A Bucket handle tear of Sup.labrum
4.Bucket handle tear with its extension into long
head of biceps

66. Special Test:O’Brien Test

67. SHOULDER INSTABILITY
1.Type I: Traumatic structural(Ant.) Instability
2.Type II: Atraumatic /minimally traumatic
structural instability, multidirectional
instability eg:repetitive microtrauma/overall
laxity like during swimmers, athelets, throwers
3.Type III: Atraumatic non-structural
instability(muscular dyskinesia)

68. Shoulder Instabilities
• Instability Anterior
– Crank (apprehension) test
– Anterior Drawer Test
• Instability Posterior
– Posterior Drawer Test
– Posterior Apprehension Test
• Instability Inferior
– Sulcus Sign

69. APPREHENSION TEST FOR
ANTERIOR SHOULDER
DISLOCATION

70. POSTERIOR
APPREHENSION TEST

71. DRAWER TEST

72. SULCUS SIGN

73. LOAD AND SHIFT TEST

74. FROZEN SHOULDER

75. Frozen Shoulder
* Progessive pain and stiffness of the shoulder
joint which spontaneously resolve after 18
months.
*Restricted both active &passive ROMs in all
planes.
*commonly associated with DM,
Hyperlipidaemia, Hyperthyroidism,
Dupuytren’s disease, IHD, Inflammatory
arthritis & C/Spondylosis

76. Continue..
Passes in 3 stages:
1.1st
stage/Freezing phase: 3-6months
2. 2nd
stage/Frozen phase/Progessive
stiffness: 3-18 months
3.Final stage/Resolution/Thawing phase: 3-
6 months

77. Test for Frozen shoulder

78. Treatment
Diagnosis is clinical. Rx combining:
1.ADLs modification
2.NSAIDs
3.I/A Steroid,or 50-200 sterile saline under
pressure
4.Codman pendulum ex is very effective
5.Physical agent: UST

79. Thank you ..