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  1. Introduction to Shoulder Injuries OHSU Andrea Herzka, MD Associate Professor OHSU Orthopaedic Sports Surgery

  2. Shoulder OHSU • Acromioclavicular joint • Sternoclavicular joint • Subacromial space • Glenohumeral joint

  3. The Scapula scapula?OHSU • The key to comfortable and powerful shoulder range of motion • How many muscles insert on the

  4. Musculoskeletal anatomy OHSU • Key = history! – Where does it hurt? – When does it hurt? • With use? • Night pain? • Positional pain? – Any injury? (Instability?) – Is it improving/worsening?

  5. Musculoskeletal anatomy OHSU • “Trauma” – Higher energy, acute – Lower energy, overuse

  6. Musculoskeletal anatomy OHSU • “Degeneration” – Cartilage • Labrum • Articular cartilage – Tendons – How does glenohumeral arthritis present?

  7. Musculoskeletal anatomy OHSU • Don’t forget referred pain! – Shoulder  arm – Cervical spine  shoulder/UE

  8. Physical Examination useOHSU • Visualization – Comfortable environment – Exposure of both shoulders • Scars • Asymmetry • Stigmata of steroid

  9. Neck Exam • Reflexes OHSU • Range of motion • Spurling’s sign • Distal sensation and strength

  10. Sensory Exam OHSU

  11. Observation OHSU • Posture • Symmetry – Atrophy – SC and AC joints, clavicle – Muscular contour • Scapular kinetics – Winging • Subtypes?

  12. Palpation OHSU • SC joint • Clavicle • AC joint • Acromion • Biceps tendon • Greater tuberosity • Axilla (pectoralis major)

  13. Range of Motion OHSU • Scapular plane* – Forward flexion – Abduction • External rotation – Neutral/90 • Internal rotation – Neutral/90

  14. Passive Range of Motion OHSU • Supine examination

  15. Signs and Symptoms OHSU • Crepitus – Think arthritis

  16. Signs and symptoms OHSU • Positional pain – Shoulder: • Subacromial impingement • Labral pathology

  17. Signs and symptoms capsulitis OHSU • Stiffness – Passive motion vs. active motion in the shoulder • Passive better? Think rotator cuff • Active better? Anxiety, Instability, Voluntary • Both affected? “Frozen shoulder” = adhesive

  18. Adhesive capsulitis/Frozen shoulder OHSU • Chronic inflammation of the capsule subsynovial layer • Associated conditions: – Diabetes – Thyroid disease – Heart disease, CVA – Prolonged immobilization – Previous surgery

  19. “Impingement” Testing OHSU • Subacromial impingement – Hawkins – Neer • AC joint – Cross-body

  20. Strength OHSU • Deltoid • Pectoralis major • Rotator cuff – Subscapularis – Supraspinatus – Infraspinatus – Teres minor

  21. Strength: Deltoid OHSU

  22. Strength: Pectoralis Major OHSU

  23. Strength: Rotator Cuff OHSU • Subscapularis

  24. Strength: Rotator Cuff OHSU • Supraspinatus:

  25. Strength: Rotator Cuff OHSU • Infraspinatus and Teres Minor

  26. Tendon injuries OHSU • The rotator cuff – 60% of patients over 60 years old!

  27. Biceps/Superior Labrum OHSU

  28. Speed’s Test OHSU

  29. Yergason’s Sign OHSU

  30. O’Brien Sign OHSU

  31. Thrower’s Test OHSU

  32. Shoulder instability OHSU

  33. Multidirectional Instability OHSU • The sulcus sign

  34. Anterior Instability OHSU • Apprehension/relocation tests

  35. Posterior Instability OHSU • Circumduction test • Posterior apprehension/Jerk test

  36. Evaluate Humeral Head Excursion OHSU • Seated examination • Load and shift

  37. Putting It All Together OHSU • Take a thorough history – Posterior pain: • Scapulothoracic dyskinesia • Posterior instability • Cuff pathology/impingement – Anterior pain: • Anterior instability • Biceps pathology • (Subcoracoid impingement) – Lateral pain: • AC separation • Cuff pathology/impingement • Scapular plane = home base!

  38. Thank you! OHSU • Andrea Herzka, MD • herzkaa@ohsu.edu • 503-494-4000 • OHSU Orthopaedic Sports Medicine