Presentation Transcript

  1. COMMON PROBLEMS OF THE SHOULDER, EXAMINATION AND OMT Richard Margaitis DO Assistant Professor Family Medicine/NMM/SM Florida Hospital October 19th2015

  2. Objectives • At the conclusion of this lecture, the attendee should be able to: Identify basic anatomic landmarks of the shoulder Identify typical patient symptoms/complaints Differentiate various medical diagnoses of the shoulder Perform & understand the indications of specific shoulder tests Identify various diagnostic and treatment modalities Perform various OMT techniques for shoulder dysfunctions

  3. Pre-Test Question #1 1) Which nerve is most commonly injured with a gleno- humeral shoulder dislocation? a) Axillary Nerve b) Suprascapular Nerve c) Musculo-cutaneous Nerve d) Radial Nerve c) Ulnar Nerve Answer: A) Axillary Nerve

  4. Pre-Test Question #2 2) How many ligaments make up the Coraco-clavicular Ligament? a) One b) Two c) Three d) Four c) Five Answer: B) Two The Conoid and Trapezoid Ligaments

  5. Pre-Test Question #3 3) Which of the following tests is used to evaluate for Bicipital Tendonitis? a) Jobe b) Apprehension c) Hawkins’ d) Apleys e) Speeds Answer: E) Speeds

  6. Pre-Test Question #4 4) How many muscles either attach or originate on the Scapula? a) 7 b) 10 c) 15 d) 17 e) 21 Answer: D) 17

  7. Muscles attaching to or originating on the Scapula Serratus Anterior Supraspinatus Subscapularis Trapezius Teres Major Teres Minor Triceps Brachii (long head) Biceps Brachii (short & long heads) Rhomboid Major Rhomboid Minor Coracobrachialis Omohyoid (inferior belly) Latiissimus Dorsi Deltoid Levator Scapula Infraspinatus Pectoralis Minor

  8. Pre-Test Question #5 5) What is the name of the (true AP) radiographic view that is taken in the plane of the scapula (30-45omedial to lateral) a) Scapular Y b) Swimmers c) Zanca d) Serendipity e) Grashey Answer: E) Grashey a) Scapular Y – Lateral view for dislocations b) Swimmers – Lateral view for better visualization of C7-T3 c) Zanca – AP view with Cephalic tilt to view AC joint d) Serendipity – 40oCephalic tilt to view SC joint

  9. Pre-Test Question #6 6) Which of the following Osteopathic Manipulative Medicine Techniques will work best at improving ROM of the Glenohumeral Joint? a) Miller Pump b) Dalrymple Pump c) Spencers Technique d) AC Joint Counterstrain e) Myofascial Release of the Scapulothoracic Joint Answer: C) Spencers Technique

  10. History and Physical Exam are Key • Is this problem Acute or Chronic (> 3 mos)? • Was there a History of Trauma/MOI or did it come on slowly? • Has this problem occurred before? • What activities exacerbate the symptoms? • Does the pain radiate from any other area? • Does this prevent you from doing certain things? • Are the symptoms getting worse? • What alleviates the symptoms? • On a pain scale 1-10, how severe is your pain now and what is it at it’s worst? • Have you seen anyone else for this problem before? • Have you tried anything to self treat or done anything at the advice of another physician?

  11. Anterior Shoulder

  12. Posterior Shoulder

  13. Lateral Shoulder

  14. Acute vs Chronic • Triggered by Trauma: Dislocation of Humeral Head from Glenoid Fossa Fracture to the Humerus/Clavicle/Scapula Sprain/Strain: AC Joint Injury or Traumatic Rotator Cuff Tear • Slow and Progressive (Repetitive Trauma/Overuse): Sub-acromial Impingement Bursitis Tendinitis: Bicipital, Rotator Cuff Progressing to Adhesive Capsulitis???

  15. Acromion Types • Type I – {FLAT} least likely to cause impingement • Type II – {CURVED} more likely to cause impingement • Type III – {BEAKED} most likely to cause impingement, usually requires surgical debridement prior to rehabilitation • Subacromial impingement of the Supraspinatus with overhead activities

  16. Gross Shoulder Anatomy Landmarks

  17. Functional Shoulder Articulations • Structural • Thoracic cage • Scapula • Clavicle • Humerus • Functional • Scapulothoracic • Acromioclavicular • Sternoclavicular • Glenohumeral Hoppenfeld

  18. Common Ailments of the Shoulder • Tendonitis (Supraspinatus, Biceps) • Bursitis (Sub-acromial) • Dislocation/Subluxation (Gleno-humeral) • Sprain (AC Joint) • Strain/Tear (Rotator Cuff – SITS muscles, Biceps tendon) • Osteoarthritis (AC Joint) • Fracture (Clavicular, Scapular, Humeral) • * Adhesive Capsulitis • Rule out Cervical Radiculopathy with Spurling’s maneuver and Neurologic Examination: DTRs, Sensory Testing, and Motor Strength

  19. Case #1 • 54 yo female environmental engineer presents for re-evaluation of right shoulder pain x 1 week after falling on the same shoulder. She was initially seen in the ER and x-rays were negative, she was sent home with a sling. Pain has become progressively worse and she now has limited ROM in all planes (sling use x 1 week). No prior injury or shoulder issues reported. She has been taking Cataflam with limited relief. Pain 7/10 on pain scale. • Exam is very limited due to pain • Suspected Frozen Shoulder 2/2 trauma • CS injection done of the sub-acromial space • Slight improvement of pain, 5/10, and handout given w/ instructions for ROM exercises and advised discontinued use of sling

  20. Case #1 Continued • Patient returns in one week with little to no improved pain and continued very limited ROM and limited exam 2/2 guarding. • MRI performed demonstrating • Massive full thickness tear of the supraspinatus, infraspinatus and subscapularis muscles, also the biceps tendon is not seen and appears completely torn • Surgery referral place • * Review of history showing Poorly controlled asthma and taking Prednisone 20 mg daily • **No OMT done in this case

  21. Frozen Shoulder • Adhesive Capsulitis - refers to a stiffened GH joint that has lost significant ROM - shoulder motion is more scapulothoracic than GH - persistent dull ache, unable to lift arm above head or internally rotate GH joint - Due to lack of use from shoulder pain, mcc rotator cuff tendinopathy • Tx: OMT, Physical Therapy and Pain Relief (NSAIDs), CS injections * Consider MUA if not better in 6-18 mos

  22. Rotator Cuff Muscles*** Rotator Cuff Muscles Proximal Attachment of Scapula Distal Attachment on Humerus Innervations Muscle Action Supraspinatus Supraspinous fossa Superior facet of greater tubercle Suprascapular N (C4, C5, C6) Initiates & assists deltoid in ABDuction Infraspinatus Infraspinous fossa Middle facet of greater tubercle Suprascapular N (C5, C6) External (laterally) rotation Teres Minor Middle part of lateral border Inferior facet of greater tubercle Axillary N (C5, C6) External (laterally) rotation Subscapularis Subscapular fossa (most of the anterior surface) Lesser tubercle Upper & lower subscapular N ( C5, C6, C 7) Internal (medially) rotation

  23. Rotator Cuff Muscles  Remember {SITS}  Stabilizes humeral head in glenoid fossa along with many ligaments  Supraspinatus – mc tear, attaches to the greater tubercle of the superior-lateral humeral head * Mainly involved w/ ABduction  Infraspinatus – attaches to the greater tubercle and Externally Rotates Arm  Teres Minor - attaches to the greater tubercle and Externally Rotates Arm  Subscapularis – attaches to the lesser tubercle and Internally Rotates Arm * Pain commonly radiates to the Deltoid insertion with rotator cuff pathology

  24. Reference Material: Upper Extremity Muscles with Motion at the Gleno-humeral Joint • Extensors • Latissimus dorsi • Teres major • Deltoid (posterior) • Triceps • External Rotators (Lateral Rotation) • Infraspinatus • Teres minor • Deltoid (posterior) • Internal Rotators (Medial Rotation) • Subscapularis • Pectoralis major • Latissimus dorsi • Terers Major • Deltoid (anterior) • Flexors • Deltoid (anterior) • Coracobrachialis • Pectoralis major • Biceps • ABductors • Deltoid (midportion) • Supraspinatus • Serratus anterior • ADductors • Pectoralis major • Latissimus dorsi • Teres minor • Deltoid (anterior)

  25. Case #2 • 51 yo male presents for evaluation of right shoulder/arm pain x 1 day. He helped a driver who had got stuck with his corvette on the beach. While lifting the back end and pushing the car, with the driver hitting the accelerator, he felt a snap in his shoulder and arm. • He immediately feels pain and weakness in the right arm. • Examination reveals weakness in his right arm, 4/5 with arm flexion (biceps) • Tenderness to palpation of the bicipital tuberosity on the proximal radius • Pain and weakness with Speeds test and Yergasons test • Also noted, slight muscular deformity proximally

  26. Case #2 Continued • MRI performed confirming distal bicipital tendon rupture • Surgery consulted • No OMT performed

  27. Bicipital Tendinitis • Usually involves Long Head biceps tendon • L.H. of Biceps tendon passes through the Bicipital Groove of the anterior humerus {Anterior Shoulder Pain} L.H. attaches to supraglenoid tubercle on humeral head S.H. attaches to coracoid process of scapula • Frequently seen w/ Rotator Cuff pathology • Yergason’s Test – elbow flexed to 90oand wrist pronated, pt will attempt to externally rotate arm and supinate against resistance • Speed’s Test – Arm Flexed up to 90oand continued Flexion against physician resistance * (+) if pain in bicipital tendon or tendon slips out of bicipital groove (held in place by transverse humeral ligament)

  28. Speed’s Test Yergasons Test Testing for Bicipital tendonitis, bicipital tendon subluxation • Testing for Bicipital tendonitis, (long head) • Patient with Arm Flexed to 80- 90oand Forearm Supinated • Examiner Resists Forward Flexion from patient w/ downward force on patient’s wrist • Pain in the anterior shoulder, site of biceps tendon, = + TEST Patient with Arm Pronated and Elbow at 90o Examiner resists and externally rotates arm while the patient supinates and externally rotate the arm against resistance, can add elbow flexion Pain in the anterior shoulder, and/or subluxation of biceps tendon = + Test

  29. Steps to perform Counterstrain (of the shoulder) • Diagnose the somatic dysfunction by identifying significant tender points. • Test the regions and determine the worst. • Position the patient to reduce the tenderness. • First stage: place the patient in the classic position. • Second stage: Fine tune three times to attempt to reduce tenderness to O%. • Quantify your results each time you position the patient: • assign the initial value of tenderness to 10 on a scale of 0-10 • ask the patient how much tenderness is left on a scale of 0-10 each time you reposition • “If your original pain was a 10 on a scale of 0-10, what is it now on a scale of 0-10 when I press on it?”

  30. Principles: Treatment • While you hold the position of maximum comfort for a minimum of 90 seconds (120 sec. for ribs): • Remind the patient to relax. • Maintain your finger lightly on the tender point to: •Palpate/assess changes in the tender point •Re-assess the patient’s level of tenderness by pressing on the tender point and getting feedback after 30 seconds and after treatment •Assure your patient that you’re testing the same location

  31. Principles: Treatment • Return the patient to the neutral position. This must be done very slowly and totally passively (talk them out of the position). • “The only difference between the cause and the cure is the speed of return to the neutral position.” • Maintain your finger on the tender point while you return the patient to neutral.

  32. Principles: Treatment • In neutral position, retest the tender point for desired effect, i.e., resolution or significant reduction in tenderness. • reduction of pain to about 30% of the original tenderness level • Remaining tenderness of: • 3/10 on tenderness scale or 30% of original tenderness still present • resolution of “jump sign” Although some tenderness may be present, this is a significant reduction.

  33. LH Biceps • Tendon of the biceps muscle’s long head in the bicipital groove

  34. • Flexion of elbow, flexion of shoulder • Slight abduction • Internal rotation of shoulder • Patient should be lying comfortably in the supine position as seen below with their dorsal wrist/forearm placed on their forehead LH Biceps

  35. Case #3 • 49 yo female county office worker presents with h/o 3 months worsening right shoulder pain. Denies any specific trauma, but states pain came on after having a two week duration of shifting boxes/files in a storage area. She notes having difficulty with putting her bra strap on now, unable to talk on phone while holding phone on the right side. Pain is 9/10 on pain scale and responds somewhat to Naproxen. Pain resolves when the shoulder is being held still and not moving.

  36. Special Tests Apley Scratch Test The position at the upper left arm tests for external rotation and abduction of the shoulder. The patient reaches behind his or her head to attempt to touch the superior medial angle of the opposite scapula. The positions at the lower left test for internal rotation and adduction of the shoulder. The patient reaches behind his back to touch the inferior angle of the opposite scapula.

  37. Apley’s Scratch Test Notice the limited internal rotation on the right side *

  38. Normal ROM • Flexion – 160-180 degrees • Extension – 45 degrees • Abduction – 160-180 degrees • External Rotation – 45-90 degrees • The Apley Scratch Test used to assess rotation of the shoulder joint. Patients with normal glenohumeral motion should be able to scratch the midback ( T8 to T10 level) *patients with glenohumeral osteoarthritis (or frozen shoulder and possibly acute rotator cuff tendinitis) have limited ROM when compared with the healthy arm

  39. Normal Shoulder ROM • Neutral flexion (N ≈ 150-170°) • Neutral extension (N ≈ 40°) • Neutral external rotation (N ≈ 60°) • Neutral internal rotation stage 1 (N ≈ 70°) • Neutral internal rotation stage 2 (hand behind the back-95°) • Adduction (N ≈ 20-40°)-arm front of body • Abduction (N ≈ 180°)-along coronal plane • Horizontal flexion (N ≈ 130-160°)-from coronal plane • Horizontal extension (N ≈ 40-50°)-from coronal plane • Horizontal internal rotation (N ≈ 70°)-from coronal plane • Horizontal external rotation (N ≈ 90°)-from coronal plane

  40. Case #3 Continued • Pain with Hawkins and Neers tests • Pain with Flexion and Abduction > 90oof motion

  41. Dx •Sub-acromial Bursitis/Tendonitis •leading to Adhesive capsulitis

  42. CS injection (sub-acromial)

  43. 1 2 3 7 Spencer Technique 6 4 4 5b 5a

  44. Case #4 • 21 yo softball pitcher with c/o right shoulder pain and a heaviness with right upper extremity tingling which occurs after throwing 40-50 pitches. Pain and numbness/tingling has been getting worse over the past 4 months. Pain and tingling resolve shortly after a pitching sensation has ended. She denies any specific injuries to the shoulder. No h/o prior shoulder trauma, including subluxation/dislocation. Meds don’t help with the pain. • Examination (+) Roos, (+) Adsons, (+) Wrights tests • Dx: ? • Thoracic Outlet Syndrome (TOS) • To confirm Dx of TOS; EMG/NCS is commonly performed to determine

  45. Thoracic Outlet Syndrome (TOS) Tests • Roos Test – Shoulder Abduction/External Rotation; Elbows flexed to 90 degrees, hands perform repetitive opening/closing of hands x 3 mins (Paresthesias) Numbness/Tingling + test • Adsons Test – Shoulder/Arm held in Slight Extension and Abduction, slight extension of head turned toward affected side, physician palpates wrist for Weakened radial pulse or paresthesias + test (Scalene Triangle Impingement) • Wrights Test – Hyperabduct arm above the head in the coronal plane, palpate radial pulse, notice change in pulse with patient turning head away Weakened radial pulse or Paresthesias + test (Pectoralis Minor Impingement)

  46. Thoracic Outlet Syndrome (TOS) Etiology • Borders include: Middle & Anterior Scalenes, Anterior 1stRib and Clavicle, also cervical rib • Neurovascular Structures affected include: • Brachial Plexus • Subclavian Artery • Subclavian Vein

  47. Pectoralis Minor Lift Physician pulls traction on the anterior axillary fold towards patient’s head while the patient inhales and resists the axillary fold retracting during exhalation. The thumb applies a counter-force on the supero-lateral aspect of the pectoralis minor muscle

  48. Facilitated Positional Release Inhalation Rib/Elevated 1stRib

  49. Still Technique (seated) Superior 1stRib, Left A B D C