Shoulder assessment_HANDOUTS.pptx
Transcription
Shoulder assessment_HANDOUTS.pptx
3/3/14 Shoulder Assessment Tony Kochhar Introduc9on -‐ TK Overview Anatomy of the Shoulder General Examina9on of the shoulder Tips and tricks – The Key is in the History Shoulder condi9ons – Impingement and RC tears -‐ Frozen Shoulder -‐Throwing arm injuries -‐ AC Joint Osteolysis – weightliNer’s shoulder -‐ Calcific Tendoni9s -‐ ?The Unstable Shoulder When to Operate? Shoulder Doctor Ques9ons 1 3/3/14 Shoulder injuries second only to back pain Top 4 musculoskeletal complaints presented to GPs (%) Shoulder pain 21 Lower back pain 27 Neck pain 20 Knee pain 16 0 5 10 15 20 25 30 Source: Picavet, H, Schouten J. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC study. Pain 2003;102(1): 167-‐178. Anatomy: bones Anatomy: ligaments 2 3/3/14 Shoulder examina9on Anatomy: muscles (not all of them) Shoulder examina9on 3 3/3/14 General shoulder examina9on Look Feel Move was9ng swelling asymmetry prominent ACJ scars bony landmarks SCJ Clavicle ACJ SA Bursa/cuff inser9on scapula temperature abduc9on forward flexion external rota9on internal rota9on Rotator cuff tears Group of tendons that connect the muscles that rotate the shoulder to the humerus Wear and tear injury Poor blood supply Insidious onset Trauma9c cause: acute onset Overuse aNer inac9vity Type I and Type II acromion Associated with impingement Impingement Usually enough room for tendons to slide under acromion Arm raised small amount of rubbing and pinching of tendons & bursa This is called impingement. It is normal Impingement becomes problema9c when it causes irrita9on/damage to tendons Con9nuous work with arms overhead/ throwing/repe99ve shoulder movements leads to problem Bone spurs caused by wear and tear of AC joint rub on tendons Type I and II acromion 4 3/3/14 History Affects sleep, dressing, pumng on a jacket Complains of jerky movement Pain on abduc9on and forward flexion Pain worse when reaching behind, outward, overhead Sharp pain when reaching into back pocket Unable to sleep on affected arm Weakness & inability to raise the arm total cuff tear Complete rotator cuff tear Trauma9c cause: listen in history for fast strong force applied on shoulder e.g.: – trying to catch heavy falling object – LiNing very heavy object with arm extended Inability to ac9vely abduct the arm Full passive range of mo9on Special tests: RCT/Impingement Painful arc in abduc9on: 80-‐120˚ Arm drop test Pain and weakness in External rota9on External rota9on lag test Recent systema9c review found Neer’s test and Hawkin’s-‐Kennedy test not of diagnos9c u9lity* * Hegedus E et al. "Physical examina9on tests of the shoulder: a systema9c review with meta-‐analysis of individual tests." Brit J Sport Med 42.2 (2008):80-‐92. 5 3/3/14 Painful arc in abduc9on: 80-‐120o +ve test: When pa9ent abducts arm there is pain from 80-‐120˚ Indicates rotator cuff disorder 80.5% sensi9vity* * Çalış M, et al. "Diagnos9c values of clinical diagnos9c tests in subacromial impingement syndrome." Annals of the rheuma9c diseases 59.1 (2000): 44-‐47. Arm drop test Arm abducted passively by examiner Pa9ent instructed to keep arm up Examiner releases arm +ve test pa9ent unable to keep arm up Confirms rotator cuff tear Considered highly specific* * Hegedus, E et al. "Physical examina9on tests of the shoulder: a systema9c review with meta-‐analysis of individual tests." Brit J Sport Med42.2 (2008): 80-‐92. Resisted external rota9on Instruct pa9ent on external rota9on Examiner resists pa9ents movement Compare both sides to gauge differences +ve result pain and weakness Indicates rotator cuff disorder 6 3/3/14 External rota9on lag test Pa9ents arm passively held in near maximal external rota9on by examiner Pa9ent instructed to hold arm in ER posi9on Examiner releases arm +ve test pa9ent unable to hold arm in same posi9on (as livle as 5˚ change in ER) Indicates rotator cuff disorder 100% posi9ve predic9on* 56% nega9ve predic9on* * Tennent T et al. "Clinical sports medicine update. A review of the special tests associated with shoulder examina9on Part I: the rotator cuff tests." Am J Sport Med 31.1 (2003): 154-‐160. RC Tears -‐ Non-‐surgical treatment In trauma9c injury, generally pa9ents with <50% tear will not need surgery Painkillers and an9-‐inflammatory meds Physiotherapy Strengthening exercises Recovery 6-‐8 weeks Surgical treatment Pa9ents with >50% tear Complete cuff repairs never heal without surgery A tear does not usually happen without a coexis9ng problem Likely problems e.g. impingement or AC joint osteoarthri9s may also need to be addressed Arthroscopic repair with suture anchors Ac9ve physiotherapy 6 weeks post-‐op Strengthening exercises 12 weeks post-‐op Full recovery around 6 months 7 3/3/14 Arthroscopic RC repair Adhesive capsuli9s/Frozen shoulder Affects 3% of the popula9on More common in diabe9cs and women* Ae9ology unknown but it is an inflammatory condi9on Can occur aNer injury, disloca9on, fracture, surgery, immobilisa9on Capsule surrounding joint contracts Contrac9on and scar forma9on restricts movement Spending 9me in a sling can cause frozen shoulder Maintain movement of joint aNer injury/surgery to prevent frozen shoulder * Mitchell C, Adebajo A, Hay E, et al; Shoulder pain: diagnosis and management in primary care. BMJ. 2005 Nov 12;331(7525):1124-‐8. History Insidious onset: shoulder became gradually s9ffer Trauma induced: injury lead to pain so did not move joint now s9ff Surgery: Shoulder immobilised in sling Unable to move shoulder around Can’t comb hair Dressing difficult, especially upper garments 8 3/3/14 3 stages 1. Painful or Freezing Stage: 6-‐12 weeks (can take months) + +Pain with onset of restricted movement 2. Frozen or restricted stage: 4-‐6 months. During this stage pain usually sevles, but s9ffness worsens 3. Thawing stage: >1 year. Gradual, mo9on steadily improves over a lengthy period of 9me 80% pa9ents have complete pain resolu9on Some have permanent slight loss of ROM Source: Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975; 4:193–196. Examina9on Range of mo9on limited with ac9ve and passive movement Loss of passive external rota9on & abduc9on X-‐ray and arthrogram can eliminate other differen9als DDX: In rotator cuff disease ac2ve range of mo2on is limited but passive ROM is good. Frozen Shoulder -‐Non-‐surgical treatment Frustra9ng and slow – takes many months Rest and an9-‐inflammatory medica9on Steroid injec9on Physiotherapy 90% success rate over 4 months for physio & injec9on combina9on1 Hydrodilata9on and post-‐injec9on stretching – Surgeon distends shoulder joint with fluid, and break down contractures – Accelerates staging process breaks down capsule for physio – Effec9ve if done in early stages of frozen shoulder2 1 Levine W et al. Nonopera9ve management of idiopathic adhesive capsuli9s. J Shoulder Elbow Surg. 2007; 16:569–573 2 Dacre J et al Injec9ons and physiotherapy for the painful s9ff shoulder. Ann Rheum Dis. 1989; 48:322–325. 9 3/3/14 Surgical treatment Surgery for more severe cases Arthroscopic surgery to remove scar and fibrous 9ssue Coracohumeral ligament cut Small part of joint capsule removed Gentle joint manipula9on This helps free the capsule Physiotherapy required Source: Warner J, Allen A, Marks P, Wong P. Arthoscopic release for chronic, refractory adhesive capsuli9s of the shoulder. J Bone Joint Surg Br. 1996; 78(12):1808-‐1816. SLAP lesions – internal impingement Injury to where the biceps tendon avaches to labrum Labrum is a cuff of car9lage that surrounds the socket of the shoulder joint Without the labrum, the ball and socket joint is extremely shallow and inherently unstable A sharp pulling on the bicep tugs on the labrum (e.g. chest fly or biceps exercise) This can cause it to tear and pull away from the glenoid Flap of labral tear can catch in the joint internal impingement History Plays racquet sports, swimming, climbing, throwing sports Catch of pain when throwing/serving/swimming Symptoms of impingement but less signs A recent systema9c review suggests current tests for diagnosing SLAP lesions are of limited u9lity* Thus arthroscopic inves9ga9on considered gold standard * Calvert E et al. "Special physical examina9on tests for superior labrum anterior posterior shoulder tears are clinically limited and invalid: a diagnos9c systema9c review." J Clin Epidemiol 62.5 (2009): 558-‐563. 10 3/3/14 SLAPprehension test Arm held in horizontal flexion across the body Elbow extended Forearm is pronated +ve test pain in the bicipital groove With or without audible click Indicates SLAP lesion 87.5% sensi9vity for unstable SLAP lesion Source: Berg E and Ciullo J. "The SLAPprehension test." Journal of the Southern Orthopaedic Associa8on 4.3 (1995): 237. Speed test Pa9ent standing Arm held at side of body Elbow full extension, forearm supinated Pa9ent instructed to ac9vely flex arm forward Examiner resists arm movement by pressing down on forearm +ve test: pain felt in bicipital groove Indicates biceps tendon pathology or possible SLAP lesion 32% specificity, 79% sensi9vity of biceps tendon inflamma9on or SLAP lesion* * Karlsson J. "Physical examina9on tests are not valid for diagnosing SLAP tears: a review." Clin J Sport Med 2010;20(2): 134. Yergason’s test Pa9ent’s arm adducted to side of body Elbow flexed to 90o and forearm pronated Examiner holds wrist Pa9ent instructed to supinate wrist Examiner resists movement +ve test: pain felt in bicipital groove Indicates pathology of the biceps tendon 43% sensi9vity, 75% specificity for biceps tendon pathology or SLAP lesion* * Holtby R et al"Accuracy of the Speed’s and Yergason’s tests in detec9ng biceps pathology and SLAP lesions: comparison with arthroscopic findings." Arthroscopy 2004;20.3:231-‐236. 11 3/3/14 Non-‐surgical treatment Most pa9ents with SLAP tears respond well to non-‐ surgical treatments These treatments may include an9-‐inflammatory medica9on, rest, and physical therapy Some9mes cor9sone injec9ons are performed Surgical treatment Several procedures may have to be performed Labral debridement SLAP repair Biceps tenodesis (repair) 2-‐4 weeks in sling Physiotherapy Full recovery 12-‐16 weeks Success rate 87%* * Brockmeier, Stephen F., et al. "Outcomes aNer arthroscopic repair of type-‐II SLAP lesions." The Journal of Bone and Joint Surgery (American) 91.7 (2009): 1595-‐1603. Surgical treatment – SLAP repair 12 3/3/14 Distal clavicular osteolysis – WeightliNer’s Shoulder Repe99ve training/stress causes fractures at distal end of clavicle Bench-‐press and chest fly exercises to blame Places shoulders in excessive extension causing excessive trac9on on AC joint Bone doesn’t heal before next session Bone starts to dissolve Chronic inflamma9on Cyst forma9on, ↑ osteoclast ac9vity, car9lage disrup9on History of AC joint osteolysis Uses weights (bench-‐press, chest fly) Goes to gym Involved in lots of manual ac9vity Catching pain over AC joint Especially when reaching across or behind body Scarf test Hand from affected side is placed on contralateral shoulder Examiner then pushes elbow towards pa9ents body Hand should slide backwards over scapula +ve test: Pain in AC joint Indicates AC joint problem (DDX arthri9s) No evalua9on of accuracy available 13 3/3/14 Cross body adduc9on Pa9ents arm is passively moved across their body +ve test: elicits ACJ pain complained of in history Indicates AC joint problem (DDX arthri9s) 77% sensi9vity* * Chronopoulos E et al . Diagnos9c value of physical tests for isolated chronic acromioclavicular lesions. Am J Sports Med 2004;32:655–61. Non-‐surgical treatment ACJ osteolysis Rest to allow joint to heal Permanent changes in training and technique – Narrow hand spacing on bench-‐press – End bench press 2 inches above chest – Prevents over extension and takes load off distal clavicle Strongly advise against ‘working through the pain’ ac9vity modifica9on essen9al Stress avoidance of overtraining, allow for recovery 9me Stop smoking! Smoking impairs bone healing Non steroid an9-‐inflammatory medica9on May require steroid injec9on to reduce pain Resolu9on within 1-‐2 years with ac9vity modifica9on Surgical treatment ACJ osteolysis For those who refuse to change regime or limit ac9vi9es For when conserva9ve treatment has failed ‘Arthroscopic resec9on of distal clavicle’ Damaged por9on of clavicle removed (4-‐7mm) 91% success rate* * Schwarzkopf R et al. Distal clavicular osteolysis: a review of the literature. Bull NYU Hosp Jt Dis. 2008;66(2):94-‐101. 14 3/3/14 Calcific tendoni9s Calcium deposits form on rotator cuff (supraspinatus tendon) Degenera9ve calcifica9on, wear and tear Reac9ve calcifica9on, calcium crystals deposit (pain) then reabsorbed (pain subsides) Reac9ve Unknown ae9ology History Classic signs of impingement But X-‐ray finds calcium deposits OR Acute severe pain Pa9ent ~30-‐40yrs Can’t sleep – almost systemically unwell No movement DDX sep9c arthri9s check for fever, hot joint Special tests false posi9ves Same as impingement/RCT Painful arc in abduc9on: 80-‐120o Arm drop test Pain and weakness in External rota9on External rota9on lag test Revealed on X-‐ray to be calcifica2on 15 3/3/14 Non-‐surgical treatment First aim: to control pain Rest and An9-‐inflammatory medica9on Cor9sone injec9on may be used Physio – ultrasound therapy Lavage may be useful – 2 large needles into the shoulder – Flush area with sterile saline – Calcium deposits may be washed out Surgical treatment Arthroscope used to locate calcifica9ons on RC Calcium deposits resected Area rinsed Loose calcium deposits removed 92% success rate* Physio starts immediately Aim to strengthen RC as this causes less pain from deposits * Seil, Romain, et al. "Arthroscopic treatment of chronically painful calcifying tendini9s of the supraspinatus tendon." Arthroscopy: The Journal of Arthroscopic & Related Surgery 22.5 (2006): 521-‐527. When to Operate Failure of Conserva9ve Treament Defini9ve Repair required Pa9ent requirements/logis9cs – 50/50 – eg. ACJ separa9on GIII 16 3/3/14 Shoulder Doctor Prac9ce Best prac9ce MOST PATIENTS DON’T NEED SURGERY Efficient -‐ eg. One Stop Clinic Latest techniques – eg. PRP University of Greenwich – development of Strength and Condi9oning Thanks for listening Shoulder instability Head of humerus held in place by muscles and ligaments of the shoulder If strength of soN 9ssue anchors is lowered joint more suscep9ble to disloca9ons Instability caused by structural weakness or muscle paverning Structural weakness can be caused by trauma i.e. disloca9on Disloca9ons tearing of the support structures Minor trauma and wear and tear instability Muscle paverning: the voluntary dislocator 17 3/3/14 Bankart tear & Hill-‐Sach’s lesion Bankart’s tear is a tear to the labrum ONen happens in disloca9ons Can cause recurrent disloca9ons & instability Hill-‐Sachs lesion is a compression fracture of the humeral head Can some9mes cause shoulder instability History and Examina9on Trauma9c cause: history of disloca9ons History of subluxa9on ( joint slips out and in again) Shoulder feels loose Shoulder feels like it might dislocate upon movement Predisposed: Hypermobility in joints (Beighton score) Muscle paverning cause: history of ‘party trick’ disloca9on Special tests for instability Load and shiN test Gold standard for posterior and anterior instability Provide axial load on humerus, compressing the glenohumeral joint Move head of humerus anteriorly and posteriorly +ve test: Humeral head displacement Test can be repeated with pa9ent supine Diagnos9c of instability When posi9ve, test is extremely predic9ve for instability Likelihood ra9o > 80* * Tzannes A, &Murrell G. "Clinical examina9on of the unstable shoulder." Sports Medicine 2002;32.7: 447-‐457. 18 3/3/14 Jobe’s reloca9on test Pa9ent lies supine with arm in abduc9on, elbow at 90o flexion External rota9on un9l apprehension noted then stop Posteriorly directed force over humerus, test repeated +ve test if ER with posterior force > than when there is no posterior force applied – Indicates anterior instability Differen9ates between anterior instability and impingement 64% sensi9vity, 99% specificity for instability* * Lo I et al. "An evalua9on of the apprehension, reloca9on, and surprise tests for anterior shoulder instability." Am J Sport Med 32.2 (2004): 301-‐307. Biceps tendoni9s Overuse injury Con9nuous or repe99ve shoulder ac9ons Cells have no 9me to recuperate before next use Tendon fails to recover Fibroblasts produced collagen loses strength breaks down and forms scar 9ssue Tendon strands and fibres break Tendon strength compromised, can lead to rupture Can develop due to over shoulder condi9ons: RCT, impingement and instability History Engages in repe99ve shoulder ac9vity/ strain Especially overhead arm movements Athletes who throw, swim, or swing a racquet or club are at greatest risk Use Yergason and Speed test 19 3/3/14 Types of SLAP tear & internal impingement Type 1 (75% of Slap Lesions) Par9al tear of the top of the labrum Damage limited to a fraying of labrum-‐glenoid connec9on Surgery usually limited to debridement Type 2 Several types Vary between the loca9on of the tear in respect to the midpoint of where the biceps tendon avaches Type 3 Tear leaves flap of labrum that hangs into the ball and socket joint internal impingement Causes catching or impingement within the joint Surgical removal of flap then reavachment of remaining labrum Type 4 The tear of the labrum extends into the biceps tendon Surgical reavachment of labrum and repair of biceps tendon required Shoulder Anatomy-‐ Live General shoulder examina9on -‐ Live 20 3/3/14 Surgical treatment ACJ osteolysis 21