The Shoulder



The Shoulder

David J. Rolnick, M.D.

MedEx, LLC

5th Annual Worker’s Compensation Symposium ~ June 2, 2006

Questions to Answer

4 Is This a Legitimate Work Injury?

5 Is This a Workplace Exposure?

6 Manifestation of a Preexisting Condition?

Large # of WC Claims

1 Natural History of Shoulder Symptoms

1 Occur as we age

2 MRI positive in large # of asymptomatic individuals

3 Can respond to non-surgical treatment

4 Aggressive and Rapid Surgery may not be indicated

Where Is The Shoulder?

1 The glenohumeral joint

1 The true shoulder joint

2 The scapula

1 Part of the shoulder girdle

3 The trapezius

4 The neck

Shoulder Pain

1 Acromioclavicular joint arthritis

2 Impingement and Cuff Tendinopathy

3 Rotator cuff tear—partial/complete

4 Biceps tendon

5 Glenohumeral instability

6 SLAP lesions

7 Glenohumeral arthritis

The History

1 Mechanism of Injury

1 Is the type of problem consistent with the mechanism of injury?

2 Symptoms—onset, location, characteristics

1 Are the symptoms consistent with the problem and the injury?

3 Previous shoulder symptoms or injury

4 Diagnostic Tests Performed

5 Treatment Already Given

Acute Shoulder Problems

1 Fracture — Humerus, Glenoid, Clavicle, Acromion, Scapula, Coracoid

2 Dislocation — Glenohumeral

3 Acromioclavicular Separation

4 Acute Rotator Cuff Tears

5 Strains and Sprains

6 Nerve Injuries

Fractures

1 In normal bone, require significant force

2 Usually a good history of injury

3 Immediate pain—a broken bone hurts right away

4 X-rays necessary to confirm diagnosis

5 Stress fractures rare in shoulder

6 Os acromiale

Acute Rotator Cuff Tears

1 History of a specific incident

2 Immediate pain in appropriate location

3 Often difficult to move the shoulder due to pain or muscle weakness/inhibition

4 Can occur in a preexisting degenerative cuff

5 MRI needed to confirm

6 Can also have arthrogram or ultrasound

The Examination

1 Begins with observation

1 How does the person use the shoulder?

2 Muscle atrophy

2 Examine “painful” areas last

3 Go back to a part of the exam if you feel there is pathology or an inconsistency

4 Ends with observation

Shoulder Anatomy

1 Acromion

2 Clavicle

3 Acromioclavicular Joint

4 Biceps Tendon

5 Rotator Cuff

6 Scapula

The Shoulder Outlet (images)

Normal Shoulder Degeneration

1 Involves all parts of the shoulder

2 Advances with age

3 Is common in asymptomatic individuals

4 Is usually unrelated to heavy lifting with the exception of the acromioclavicular joint

5 Is progressive over time

Shoulder Degeneration

1 Biceps Tendon Degeneration

2 Acromioclavicular Degeneration

3 Rotator Cuff Degeneration

4 Glenohumeral Degeneration — Arthritis

Shoulder Degeneration — Arthritis

1 Etiology

1 Part of the normal degenerative process

2 Increases with age and time from onset

3 Rate of progression unpredictable

4 Commonly ASYMPTOMATIC

5 Symptoms can come on quickly even without an injury or work exposure

Bicipital Tendinitis

1 Tendon of the long head of the biceps

2 The long head tendon goes through the shoulder joint

3 Can be caused by impingement upon acromial spurs

4 Degeneration occurs with age

5 Can rupture spontaneously—no repair needed!

Biceps Tendons

1 Long and short heads

2 Long head almost always the problem

3 Proximal Rupture of the long head

1 Rarely traumatic, part of a degenerative process

2 “Popeye” muscle

3 Symptomatic treatment

4 Tendonitis—SLAP lesion

1 Yergason’s and Speed’s tests

5 Usually DEGENERATIVE

Acromioclavicular Joint

1 A-C Separations

1 Mechanism of injury

2 Physical findings

1 Localized tenderness and/or prominent clavicle

3 Diagnostic studies—routine plain x-rays

4 Treatment—early and late

5 Long term consequences

Acromioclavicular Arthrosis

1 Occurs with age and is progressive

2 Known association between AC Joint arthrosis and weight lifters

3 Can assume that long term heavy lifting of weight on the job is at least contributory

4 Can have symptoms with shoulder motion

5 Crossed arm adduction test

Acromioclavicular Joint Arthritis

1 Can occur with single or repeated trauma

2 Does not occur after complete (3°) acromioclavicular separation

3 Weight lifters at high risk

1 Can be occupational exposure

4 Crossed arm adduction test

Acromioclavicular Joint

1 Degeneration can occur without trauma or work exposure

2 Degeneration can follow a traumatic event such as an acromioclavicular separation

3 Increased incidence in competitive weight lifters—may have some bearing on occupation

Acromioclavicular Joint

1 Can get symptoms from the arthritic joint

2 Can cause “impingement”

3 Easy to examine:

1 Local Tenderness

2 Positive Crossed Arm Adduction Test

3 Can appear swollen

4 Hallmark of diagnosis is injection of local anesthetic leading to pain relief

Acromioclavicular Arthritis

1 TREATMENT

1 Injection

1 Local Anesthetic—mandatory pre-surgical trial

2 Steroids

2 Nonsteroidals

3 Observation

4 Surgical Partial Clavicle Resection—Mumford

Rotator Cuff Degeneration

1 Involves complete and partial tears which are degenerative

2 54% of asymptomatic individuals at age 60 have complete or partial rotator cuff tears on MRI

3 Is often referred to as a partial tear or tendinopathy

4 Should be treated conservatively if possible

Glenohumeral Arthrosis

1 Uncommon site of arthrosis or arthritis

2 Occurs after trauma

3 Can occur idiopathically

4 No definite association with heavy work

5 Rare with rotator cuff tears

6 Loss of motion, crunching, pain with motion and stiffness

Glenohumeral Arthritis

1 A degenerative arthritis

1 Can occur over time after trauma that alters the architecture of the glenoid or humeral head

1 Fracture

2 No evidence it is associated with long term heavy use of the upper extremities

Impingement

1 When the rotator cuff or sub-acromial bursa strikes a nearby structure in certain positions of the arm

2 Occurs during overhead activities or reaching

3 Acromial types—Bigliani

Impingement

1 Neer Impingement Sign

2 Impingement test

3 Hawkins sign

Impingement Tests

1 Neer Impingement Test

1 Passively forward elevate the arm while depressing the scapula

2 Impingement Test

1 Inject subacromial bursa to eliminate impingement pain and test cuff strength

3 Hawkins Sign

1 Shoulder and elbow flexed 90° then shoulder internally rotated

Impingement Treatment

1 NSAIDS

2 Avoidance of overhead activities

3 Physical therapy—stretch and strengthen

1 Jobes exercises OK

2 No iontophoresis, ultrasound, etc

4 Sub-acromial injection—steroid and local anesthetic. Avoid multiple injections which weaken the rotator cuff tissue

5 Surgery—minority of cases

Rotator Cuff Pathology

1 Diagnostic Studies Can Show:

1 Tendinopathy

2 Tendinitis—Increased Incidence in Obesity

3 Partial Thickness Rotator Cuff Tears

4 Full Thickness Rotator Cuff Tears

WHAT IS “NORMAL”?

Rotator Cuff Degeneration

AT AGE SIXTY, 54% OF ASYMPTOMATIC INDIVIDUALS HAVE COMPLETE OR PARTIAL THICKNESS ROTATOR CUFF TEARS ON MRI

Partial Thickness Cuff Tear

1 Occurs from impingement

2 Treated conservatively as outlined for impingement

3 Sometimes requires surgical debridement and decompression

Full Thickness Rotator Cuff Tears

1 Rarely occur without a significant traumatic event in young people

2 54% of asymptomatic individuals at age 60 have complete or partial rotator cuff tears on MRI

Treatment of Full Thickness Rotator Cuff Tears

1 For tears that are clearly chronic and in older age group, can begin with non-surgical treatment.

2 Exercises, NSAIDS and Injections

Treatment of Full Thickness Rotator Cuff Tears

1 Acute tears and repairable tears should be fixed—especially in a young, physically active person.

2 Open

3 Arthroscopic

Treatment of Full Thickness Rotator Cuff Tears

1 After surgical repair of a rotator cuff tear, there is an extended period of healing.

2 It is reasonable to avoid any strenuous activity for a period of at least 3 months to allow the cuff repair to heal and become strong.

SLAP Lesions

1 Superior Labral Anterior-Posterior

2 The labrum contributes to shoulder stability by increasing the depth and concavity of the glenoid.

3 SLAP lesions may be unrecognized for some time—a careful history of recent or remote trauma is important.

SLAP Lesions

1 Incidence is from 3.9% to 11.8%

2 Biceps tendon also contributes to stability

3 Secondary problems from instability can include bursitis, impingement and A-C arthritis

SLAP Lesions

1 The mechanism of injury is very important

2 Frequently results from a fall onto the elbow or outstretched hand with the elbow adducted or extended

3 There may be a history of remote trauma

4 Sometimes the SLAP lesion is old, and secondary symptoms bring the patient in for care

SLAP Lesion Causes

1 Acute compression force or traction pull on the shoulder

2 Fall onto the shoulder

3 Sudden upward traction

SLAP Lesion Causes

1 84 patients reviewed

1 15% fall onto the shoulder

2 13% lifting a heavy object

3 13% traumatic dislocation

4 9% insidious onset

5 8% abduction and external rotation force

6 8% fall onto the outstretched arm

7 6% occurred gradually from repetitive lifting

8 6% motor vehicle accidents

Shoulder Stability Exam

1 Sulcus test

1 Arm at the side

2 Shoulder at 90° abduction

2 Anterior and Posterior drawer

3 Anterior apprehension test

4 Relocation Test

5 Posterior instability test

Testing for SLAP Lesions - The O’Brien Test

1 Suddenly internally rotating the shoulder as it is adducted 30° in 90° of forward flexion

2 Positive test

1 Clicking in the shoulder and/or

2 Pain radiating down the biceps tendon or posterior joint

Routine Radiographs

1 Always get plain radiographs before MRI, CT, or Arthrogram for any shoulder complaints

2 Look at Acromioclavicular join for arthritis which can be a late sign of a SLAP lesion and superior instability and migration

Special Studies for SLAP

1 MRI Arthrogram

1 The MRI arthrogram is considered the definitive test for SLAP tears with an accuracy of 95-100%

2 MRI without contrast

1 Less sensitive and less specific than MRI arthrogram

Treatment of SLAP Lesions

1 Arthroscopy is the preferred method of diagnosis and treatment

2 Snyder identified 4 types of SLAP lesions

3 Maffet identified 7 types of SLAP lesions

Types of SLAP Lesions

1 Type I—11%

1 Fraying of the superior labrum

2 Type II—41%

1 Detachment of the biceps tendon with or without fraying

3 Type III—33%

1 Bucket handle tear of the superior labrum

4 Type IV—15%

1 Similar to type III but there was extension of the tear up into the biceps tendon

Repair of SLAP Lesions

1 Various devices are used for arthroscopic repair

2 Post-Operative Rehabilitation is often prolonged for 6-12 weeks

Suprascapular Neuropathy

1 Nerve to the supraspinatus and infraspinatus

2 Can be compressed by:

1 Ganglion cyst—associated with labral tear

2 Thickened spinoglenoid ligament

3 Viral Neuritis

4 Direct trauma

Shoulder Dislocations

1 Can occur in any direction

2 Can damage:

1 Rotator Cuff

2 Humeral Head

3 Glenoid

4 Labrum

5 Axillary Nerve or Brachial Plexus

CASE STUDIES

55-Year-Old Truck Driver

1 Female, right-hand dominant

2 Employed as a truck driver

3 Does not load or unload cargo

4 3-month history of left shoulder pain

5 Worse with overhead activity

6 Night pain

7 No traumatic event

55-Year-Old Truck Driver…

1 X-ray—Acromioclavicular Arthritis

2 MRI—Supraspinatus Tendinopathy with Partial Thickness Rotator Cuff Tear

3 Treatment?

1 Physical Therapy

2 Injection

3 Surgery

30-Year-Old Parts Inspector

1 Male; right-hand dominant

2 Works on a conveyer belt at waist level

3 Lift up to 5 pounds frequently

4 No overhead or floor level reaching

5 Acute right shoulder pain while at work

6 MRI shows full thickness RC Tear

7 Outside activities: baseball, basketball, skiing

30-Year-Old Parts Inspector…

1 Is the full thickness rotator cuff tear caused by:

1 A work related single event?

2 A work exposure?

2 Are symptoms:

1 A manifestation of the tear?

2 Aggravated by work? permanent or temporary?

30-Year-Old Forklift Driver

1 Male; right-hand dominant

2 No lifting at work

3 Fell at work landing on right shoulder

4 Acute onset of pain at time of fall

5 Primary care MD diagnosis of “Sprain”

6 Routine x-rays negative

7 Weak rotator cuff muscles

30-Year-Old Forklift Driver…

1 MRI shows a full thickness rotator cuff tear

1 Work Related?

60-Year-Old Secretary

1 Right-hand dominant

2 Uses mouse all day with right hand

3 Has an ergonomically correct work station

4 Slow onset of right shoulder pain

5 X-rays negative

6 MRI—Rotator cuff tendinopathy or partial thickness tear

7 Scheduled for surgery—never had PT

60-Year-Old Secretary…

1 Is The Condition Work Related?

1 Caused by work exposure?

2 Aggravated by work exposure?

3 Just a manifestation?

2 What is the appropriate treatment, regardless of causation?

50-Year-Old Receptionist

1 Female, right-hand dominant

2 Height 5’2” - Weight 240 lbs

3 Spontaneous Onset of Left Shoulder Pain

4 Severe Night Pain

5 X-ray—Negative

6 MRI—Mild tendinopathy

7 Limited active and passive motion

50-Year-Old Receptionist…

1 What is the diagnosis?

2 What is the appropriate treatment?

50-Year-Old Construction Worker

1 Right-hand dominant

2 Long History of Right Shoulder Ache

3 Acute onset of right shoulder pain associated with a “pop”

4 Slow improvement in pain—less than before the “pop”

5 Normal Shoulder Motion

50-Year-Old Construction Worker…

1 X-ray—Mild AC Arthritis & Type II Acromion

2 Prominent Biceps Muscle

3 MRI shows intact rotator cuff and no biceps tendon in the bicipital groove

4 Diagnosis

1 Rupture of the long head of the biceps

5 Treatment?

6 Work Related?

Conclusions

1 The shoulder is a complex joint

2 Take a careful history

3 Examine the patient carefully

4 Consider what is “normal” (Cuff tears over age 60??)

5 Rehabilitate before and after surgery if possible

Questions?

Thank You!

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