David J. Rolnick, M.D.
The Shoulder
Page 1
The Shoulder
David J. Rolnick, M.D.
MedEx, LLC
5th Annual Worker’s Compensation Symposium ~ June 2, 2006
Questions to Answer
oIs This a Legitimate Work Injury?
oIs This a Workplace Exposure?
oManifestation of a Preexisting Condition?
Large # of WC Claims
oNatural History of Shoulder Symptoms
oOccur as we age
oMRI positive in large # of asymptomatic individuals
oCan respond to non-surgical treatment
oAggressive and Rapid Surgery may not be indicated
Where Is The Shoulder?
oThe glenohumeral joint
oThe true shoulder joint
oThe scapula
oPart of the shoulder girdle
oThe trapezius
oThe neck
Shoulder Pain
oAcromioclavicular joint arthritis
oImpingement and Cuff Tendinopathy
oRotator cuff tear—partial/complete
oBiceps tendon
oGlenohumeral instability
oSLAP lesions
oGlenohumeral arthritis
The History
oMechanism of Injury
oIs the type of problem consistent with the mechanism of injury?
oSymptoms—onset, location, characteristics
oAre the symptoms consistent with the problem and the injury?
oPrevious shoulder symptoms or injury
oDiagnostic Tests Performed
oTreatment Already Given
Acute Shoulder Problems
oFracture — Humerus, Glenoid, Clavicle, Acromion, Scapula, Coracoid
oDislocation — Glenohumeral
oAcromioclavicular Separation
oAcute Rotator Cuff Tears
oStrains and Sprains
oNerve Injuries
Fractures
oIn normal bone, require significant force
oUsually a good history of injury
oImmediate pain—a broken bone hurts right away
oX-rays necessary to confirm diagnosis
oStress fractures rare in shoulder
oOs acromiale
Acute Rotator Cuff Tears
oHistory of a specific incident
oImmediate pain in appropriate location
oOften difficult to move the shoulder due to pain or muscle weakness/inhibition
oCan occur in a preexisting degenerative cuff
oMRI needed to confirm
oCan also have arthrogram or ultrasound
The Examination
oBegins with observation
oHow does the person use the shoulder?
oMuscle atrophy
oExamine “painful” areas last
oGo back to a part of the exam if you feel there is pathology or an inconsistency
oEnds with observation
Shoulder Anatomy
oAcromion
oClavicle
oAcromioclavicular Joint
oBiceps Tendon
oRotator Cuff
oScapula
The Shoulder Outlet (images)
Normal Shoulder Degeneration
oInvolves all parts of the shoulder
oAdvances with age
oIs common in asymptomatic individuals
oIs usually unrelated to heavy lifting with the exception of the acromioclavicular joint
oIs progressive over time
Shoulder Degeneration
oBiceps Tendon Degeneration
oAcromioclavicular Degeneration
oRotator Cuff Degeneration
oGlenohumeral Degeneration — Arthritis
Shoulder Degeneration — Arthritis
oEtiology
oPart of the normal degenerative process
oIncreases with age and time from onset
oRate of progression unpredictable
oCommonly ASYMPTOMATIC
oSymptoms can come on quickly even without an injury or work exposure
Bicipital Tendinitis
oTendon of the long head of the biceps
oThe long head tendon goes through the shoulder joint
oCan be caused by impingement upon acromial spurs
oDegeneration occurs with age
oCan rupture spontaneously—no repair needed!
Biceps Tendons
oLong and short heads
oLong head almost always the problem
oProximal Rupture of the long head
oRarely traumatic, part of a degenerative process
o“Popeye” muscle
oSymptomatic treatment
oTendonitis—SLAP lesion
oYergason’s and Speed’s tests
oUsually DEGENERATIVE
Acromioclavicular Joint
oA-C Separations
oMechanism of injury
oPhysical findings
oLocalized tenderness and/or prominent clavicle
oDiagnostic studies—routine plain x-rays
oTreatment—early and late
oLong term consequences
Acromioclavicular Arthrosis
oOccurs with age and is progressive
oKnown association between AC Joint arthrosis and weight lifters
oCan assume that long term heavy lifting of weight on the job is at least contributory
oCan have symptoms with shoulder motion
oCrossed arm adduction test
Acromioclavicular Joint Arthritis
oCan occur with single or repeated trauma
oDoes not occur after complete (3°) acromioclavicular separation
oWeight lifters at high risk
oCan be occupational exposure
oCrossed arm adduction test
Acromioclavicular Joint
oDegeneration can occur without trauma or work exposure
oDegeneration can follow a traumatic event such as an acromioclavicular separation
oIncreased incidence in competitive weight lifters—may have some bearing on occupation
Acromioclavicular Joint
oCan get symptoms from the arthritic joint
oCan cause “impingement”
oEasy to examine:
oLocal Tenderness
oPositive Crossed Arm Adduction Test
oCan appear swollen
oHallmark of diagnosis is injection of local anesthetic leading to pain relief
Acromioclavicular Arthritis
oTREATMENT
oInjection
oLocal Anesthetic—mandatory pre-surgical trial
oSteroids
oNonsteroidals
oObservation
oSurgical Partial Clavicle Resection—Mumford
Rotator Cuff Degeneration
oInvolves complete and partial tears which are degenerative
o54% of asymptomatic individuals at age 60 have complete or partial rotator cuff tears on MRI
oIs often referred to as a partial tear or tendinopathy
oShould be treated conservatively if possible
Glenohumeral Arthrosis
oUncommon site of arthrosis or arthritis
oOccurs after trauma
oCan occur idiopathically
oNo definite association with heavy work
oRare with rotator cuff tears
oLoss of motion, crunching, pain with motion and stiffness
Glenohumeral Arthritis
oA degenerative arthritis
oCan occur over time after trauma that alters the architecture of the glenoid or humeral head
oFracture
oNo evidence it is associated with long term heavy use of the upper extremities
Impingement
oWhen the rotator cuff or sub-acromial bursa strikes a nearby structure in certain positions of the arm
oOccurs during overhead activities or reaching
oAcromial types—Bigliani
Impingement
oNeer Impingement Sign
oImpingement test
oHawkins sign
Impingement Tests
oNeer Impingement Test
oPassively forward elevate the arm while depressing the scapula
oImpingement Test
oInject subacromial bursa to eliminate impingement pain and test cuff strength
oHawkins Sign
oShoulder and elbow flexed 90° then shoulder internally rotated
Impingement Treatment
oNSAIDS
oAvoidance of overhead activities
oPhysical therapy—stretch and strengthen
oJobes exercises OK
oNo iontophoresis, ultrasound, etc
oSub-acromial injection—steroid and local anesthetic. Avoid multiple injections which weaken the rotator cuff tissue
oSurgery—minority of cases
Rotator Cuff Pathology
oDiagnostic Studies Can Show:
Tendinopathy
Tendinitis—Increased Incidence in Obesity
Partial Thickness Rotator Cuff Tears
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
oOccurs from impingement
oTreated conservatively as outlined for impingement
oSometimes requires surgical debridement and decompression
Full Thickness Rotator Cuff Tears
oRarely occur without a significant traumatic event in young people
o54% of asymptomatic individuals at age 60 have complete or partial rotator cuff tears on MRI
Treatment of Full Thickness Rotator Cuff Tears
oFor tears that are clearly chronic and in older age group, can begin with non-surgical treatment.
oExercises, NSAIDS and Injections
Treatment of Full Thickness Rotator Cuff Tears
oAcute tears and repairable tears should be fixed—especially in a young, physically active person.
oOpen
oArthroscopic
Treatment of Full Thickness Rotator Cuff Tears
oAfter surgical repair of a rotator cuff tear, there is an extended period of healing.
oIt 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
oSuperior Labral Anterior-Posterior
oThe labrum contributes to shoulder stability by increasing the depth and concavity of the glenoid.
oSLAP lesions may be unrecognized for some time—a careful history of recent or remote trauma is important.
SLAP Lesions
oIncidence is from 3.9% to 11.8%
oBiceps tendon also contributes to stability
oSecondary problems from instability can include bursitis, impingement and A-C arthritis
SLAP Lesions
oThe mechanism of injury is very important
oFrequently results from a fall onto the elbow or outstretched hand with the elbow adducted or extended
oThere may be a history of remote trauma
oSometimes the SLAP lesion is old, and secondary symptoms bring the patient in for care
SLAP Lesion Causes
oAcute compression force or traction pull on the shoulder
oFall onto the shoulder
oSudden upward traction
SLAP Lesion Causes
o84 patients reviewed
o15% fall onto the shoulder
o13% lifting a heavy object
o13% traumatic dislocation
o9% insidious onset
o8% abduction and external rotation force
o8% fall onto the outstretched arm
o6% occurred gradually from repetitive lifting
o6% motor vehicle accidents
Shoulder Stability Exam
oSulcus test
oArm at the side
oShoulder at 90° abduction
oAnterior and Posterior drawer
oAnterior apprehension test
oRelocation Test
oPosterior instability test
Testing for SLAP Lesions - The O’Brien Test
oSuddenly internally rotating the shoulder as it is adducted 30° in 90° of forward flexion
oPositive test
oClicking in the shoulder and/or
oPain radiating down the biceps tendon or posterior joint
Routine Radiographs
oAlways get plain radiographs before MRI, CT, or Arthrogram for any shoulder complaints
oLook at Acromioclavicular join for arthritis which can be a late sign of a SLAP lesion and superior instability and migration
Special Studies for SLAP
oMRI Arthrogram
oThe MRI arthrogram is considered the definitive test for SLAP tears with an accuracy of 95-100%
oMRI without contrast
oLess sensitive and less specific than MRI arthrogram
Treatment of SLAP Lesions
oArthroscopy is the preferred method of diagnosis and treatment
oSnyder identified 4 types of SLAP lesions
oMaffet identified 7 types of SLAP lesions
Types of SLAP Lesions
oType I—11%
Fraying of the superior labrum
oType II—41%
Detachment of the biceps tendon with or without fraying
oType III—33%
Bucket handle tear of the superior labrum
oType IV—15%
Similar to type III but there was extension of the tear up into the biceps tendon
Repair of SLAP Lesions
oVarious devices are used for arthroscopic repair
oPost-Operative Rehabilitation is often prolonged for 6-12 weeks
Suprascapular Neuropathy
oNerve to the supraspinatus and infraspinatus
oCan be compressed by:
oGanglion cyst—associated with labral tear
oThickened spinoglenoid ligament
oViral Neuritis
oDirect trauma
Shoulder Dislocations
oCan occur in any direction
oCan damage:
oRotator Cuff
oHumeral Head
oGlenoid
oLabrum
oAxillary Nerve or Brachial Plexus
CASE STUDIES
55-Year-Old Truck Driver
oFemale, right-hand dominant
oEmployed as a truck driver
oDoes not load or unload cargo
o3-month history of left shoulder pain
oWorse with overhead activity
oNight pain
oNo traumatic event
55-Year-Old Truck Driver…
oX-ray—Acromioclavicular Arthritis
oMRI—Supraspinatus Tendinopathy with Partial Thickness Rotator Cuff Tear
oTreatment?
oPhysical Therapy
oInjection
oSurgery
30-Year-Old Parts Inspector
oMale; right-hand dominant
oWorks on a conveyer belt at waist level
oLift up to 5 pounds frequently
oNo overhead or floor level reaching
oAcute right shoulder pain while at work
oMRI shows full thickness RC Tear
oOutside activities: baseball, basketball, skiing
30-Year-Old Parts Inspector…
oIs the full thickness rotator cuff tear caused by:
oA work related single event?
oA work exposure?
oAre symptoms:
oA manifestation of the tear?
oAggravated by work? permanent or temporary?
30-Year-Old Forklift Driver
oMale; right-hand dominant
oNo lifting at work
oFell at work landing on right shoulder
oAcute onset of pain at time of fall
oPrimary care MD diagnosis of “Sprain”
oRoutine x-rays negative
oWeak rotator cuff muscles
30-Year-Old Forklift Driver…
oMRI shows a full thickness rotator cuff tear
oWork Related?
60-Year-Old Secretary
oRight-hand dominant
oUses mouse all day with right hand
oHas an ergonomically correct work station
oSlow onset of right shoulder pain
oX-rays negative
oMRI—Rotator cuff tendinopathy or partial thickness tear
oScheduled for surgery—never had PT
60-Year-Old Secretary…
oIs The Condition Work Related?
oCaused by work exposure?
oAggravated by work exposure?
oJust a manifestation?
oWhat is the appropriate treatment, regardless of causation?
50-Year-Old Receptionist
oFemale, right-hand dominant
oHeight 5’2” - Weight 240 lbs
oSpontaneous Onset of Left Shoulder Pain
oSevere Night Pain
oX-ray—Negative
oMRI—Mild tendinopathy
oLimited active and passive motion
50-Year-Old Receptionist…
oWhat is the diagnosis?
oWhat is the appropriate treatment?
50-Year-Old Construction Worker
oRight-hand dominant
oLong History of Right Shoulder Ache
oAcute onset of right shoulder pain associated with a “pop”
oSlow improvement in pain—less than before the “pop”
oNormal Shoulder Motion
50-Year-Old Construction Worker…
oX-ray—Mild AC Arthritis & Type II Acromion
oProminent Biceps Muscle
oMRI shows intact rotator cuff and no biceps tendon in the bicipital groove
oDiagnosis
oRupture of the long head of the biceps
oTreatment?
oWork Related?
Conclusions
oThe shoulder is a complex joint
oTake a careful history
oExamine the patient carefully
oConsider what is “normal” (Cuff tears over age 60??)
oRehabilitate before and after surgery if possible
Questions?
Thank You!