7/23/2013 Diagnosis and Management of At the end of this hour you will know Common Shoulder and Hip 1. The differential diagnosis for patients with Complaints decreased AROM and PROM of shoulder. 2. The key difference between impingement syndrome and rotator cuff tear. 3. How to diagnose a shoulder labral tear. 4. The key exam finding in hip OA. 5. The 2 exam maneuvers to bring out hip impingement and/or labral tear. UCSF Essentials of Primary Care August 8, 2013 Carlin Senter, M.D. Musculoskeletal work ‐ up Shoulder Problems • H istory • I nspection • P alpation • R ange of motion • O ther T ests 1
7/23/2013 Shoulder keys Shoulder examination • History • Inspection • Palpation – Hand dominance • ROM – Occupation – Abduction – H/o dislocation – Forward flexion – ER – Pain that wakes patient from sleep – IR • Exam • Strength – Supra – Always perform neck exam with shoulder – Infra and teres minor – Inspection: gown tied under arms or shirt off – Subscapularis – Always examine unaffected side • Other tests http://www.aafp.org/afp/20000515/3079.html Shoulder: diagnosis driven exam Case #1 • 50 y/o RHD woman with DM2 and Active ROM hypothyroidism presenting with R shoulder Normal Decreased pain. No injury. Waking up at night during sleep. Shoulder feels very stiff, having trouble Impingement RC tear reaching behind and raising above head. Passive ROM Labral tear Biceps tendinitis Normal AC joint OA Decreased Frozen GH joint Xray shoulder OA Abnormal Normal 2
7/23/2013 Range of motion Range of motion Internal rotation Abduction External rotation Flexion Supine shoulder PROM Physical exam: AROM Internal Unable to lift External rotation rotation the shoulder so uses entire shoulder girdle to abduct and FF. http://www.belmarpt.com/newwordpress/wp-content/uploads/2009/03/img_0294.jpg 3
7/23/2013 Physical examination: PROM Shoulder: diagnosis driven exam Active ROM Normal Decreased Impingement RC tear Passive ROM Labral tear Biceps tendinitis Normal AC joint OA Decreased Forward flexion Abduction Frozen GH joint Xray shoulder OA Abnormal Normal http://www.youtube.com/watch?v=p52IdSVqvjo Weighted abduction: diagnose Shoulder xrays glenohumeral joint OA • Evaluate etiology of decreased passive and active ROM 1# weight No weight AP Glenohumeral joint Scapular Y view Xrays courtesy of Ben Ma. 4
7/23/2013 Case #1: decreased AROM, PROM, but Shoulder: diagnosis driven exam normal xrays A. Adhesive capsulitis Active ROM B. Rotator cuff tear Normal Decreased C. Impingement syndrome Impingement D. Glenohumeral joint osteoarthritis RC tear Passive ROM Labral tear Biceps tendinitis Normal AC joint OA Decreased Frozen GH joint Xray shoulder OA Abnormal Normal Adhesive capsulitis Associated with • Diabetes • Hyper and hypothyroidism • Hypoadrenalism • Parkinson’s disease • Cardiac disease • Pulmonary disease • Stroke • Surgery (cardiac, cardiac cath, neurosurgery, radical neck dissection) http://www.aurorahealthcare.org/healthgate/images/si55551230.jpg 5
7/23/2013 Adhesive capsulitis is a clinical Active ER key finding diagnosis • No need for MRI • Xrays helpful to r/o GH joint OA 3 stages of adhesive capsulitis Treatment for adhesive capsulitis • Pain control: NSAIDs, oral or injected corticosteroids (either in GH joint or subacromial bursa) Freezing Frozen Thawing Does not change disease course • • +/- physical therapy to help restore ROM • Capsular distention injections Resolution 3-9 months 4-12 months 12-42 months • Surgery Average time ↑ pain ↓ pain Gradual ↑ ROM to resolution: Manipulation under anesthesia ↓ ROM Stable, • 1-3 years Pain at rest, decreased ROM Arthroscopic release and repair • sleep Manske and Prohaska, Curr Rev Musculoskeletal Med, 2008. 6
7/23/2013 Case #2 Case #3 Exam • 57 y/o RHD man presents with R shoulder pain • I: no atrophy that started after he fell 3 months ago. Pain at • P: mild ttp deltoid, nontender biceps and AC R deltoid. He tried physical therapy without joint benefit. Waking at night from sleep due to • ROM: Unable to actively abduct past 120 pain. degrees 2/2 pain. Full PROM. Shoulder: diagnosis driven exam Rotator cuff anatomy Active ROM Normal Decreased Impingement RC tear Passive ROM Labral tear Biceps tendinitis Normal AC joint OA Decreased Frozen GH joint Xray shoulder OA Abnormal Normal 7
7/23/2013 Rotator cuff anatomy Supraspinatus = abduction Supraspinatus Subscapularis Supraspinatus Infraspinatus Teres minor Empty can Photos from Dr. Christina Allen Infraspinatus and teres minor = Subscapularis = internal rotation external rotation Infraspinatus Teres minor Subscapularis Lift ‐ Off Photos from Dr. Christina Allen 8
7/23/2013 Subscapularis = internal rotation Impingement Supraspinatus Subacromial bursa • Inflammation of the subacromial space – The area under the acromion and above the glenohumeral joint – Structures in this space • Supraspinatus • Subacromial/subdeltoid Subscapularis bursa Impingement signs Case #2 exam, continued • Other tests: – 4/5 supraspinatus strength due to pain. – 5/5 infra and teres minor with pain. – 4/5 subscapularis with pain. – (+) Neers, (+) Hawkins. Hawkin’s Neer’s Photos from Dr. Christina Allen 9
7/23/2013 Diagnosis Rotator cuff tear more likely if… • Older patient A. Adhesive capsulitis • Traumatic mechanism B. Rotator cuff tear • Weak on exam C. Impingement syndrome D. Glenohumeral joint osteoarthritis Treatment Rotator cuff disease spectrum • Stage I: < 25 y/o. Bursitis A. Order MRI, confirm tear, refer for arthroscopic RTC repair • Stage II: 25 ‐ 40 y/o. Tendinitis and fibrosis of B. Repeat trial of physical therapy, f/u 3 months. rotator cuff • Stage III: > 40 y/o. Partial to complete tearing C. NSAIDs and activity modification, f/u 3 months of rotator cuff D. Subacromial injection, f/u 3 months 10
7/23/2013 AP shoulder Rotator cuff tear algorithm • If weak on testing of rotator cuff order xrays and MRI if (+) rotator cuff tear refer. • Greater likelihood tear if >40 y/o • Surgical outcomes better if cuff tears fixed earlier than later – Smaller tear – Less fatty infiltration – Less muscle atrophy – Less retraction Reduced acromiohumeral interval Saupe N, et al. AJR, 2006. Differential diagnosis Case #3 traumatic shoulder injury • 30 y/o RHD man fell off bike 9 months ago, • AC joint separation injured R shoulder • Labral tear • Went to PT but continues to have pain • Rotator cuff tear • Anterior shoulder • Shoulder dislocation • Only feels pain if moves shoulder in certain • Fracture directions quickly – Humerus or clavicle • Does not wake him from sleep at night 11
7/23/2013 O’Brien’s Test Physical examination To r/o Labral Tear • Arm forward flexed to • No atrophy 90° • Tender biceps tendon, nontender AC joint • Elbow fully extended • AROM R shoulder • Arm adducted 10° to 15° with thumb down – FF 0 ‐ 170 with pain at top • Downward pressure – Abd 0 ‐ 170 with pain at top • Repeat with thumb up – ER 45, IR L1 (Same as L shoulder) • Suggestive of labral • Strength 5/5 rotator cuff tear if more pain with • ( ‐ ) Neers and Hawkins thumb down • Sens = 59-94%, Spec • (+) O’Brien’s test = 28-92% Glenoid labrum SLAP tears • S uperior L abrum A nterior to P osterior – Many different types, classifications • Diagnosis: MR arthrogram • Treatment: surgery – Debridement – Repair • NOT a disease of older people (do not consider as etiology for shoulder pain in most >50 y/o as labrum degenerates naturally) 12
7/23/2013 Locate the hip pain • Anterior groin = hip joint, hip flexor • Buttock = SI joint, Hip Problems lumbar spine • Lateral hip = greater trochanteric bursitis, gluteus tendinopathy • Radiating to thigh = could be hip joint • Radiating to the foot = http://www.everydayhealth.com lumbar spine /hip ‐ pain/hip ‐ anatomy.aspx Hip inspection Hip palpation • Abdomen • Ecchymosis: fracture, • Pelvis hematoma – Iliac crest • Leg shortened and – ASIS externally rotated: – Inguinal canal fracture • Lymph nodes • Gait ‐ unable to weight – Pubic tubercles bear or sig limp: http://www.emedx.com/emedx/diagnosis_information/hip • Hip _pelvis_disorders/hip_fracture_leg_external_rotation.htm fracture, inflammatory – Greater trochanter arthritis • Back: SI joints, LS http://www.rush.edu/rumc/page ‐ 1098987346941.html 13
7/23/2013 Hip passive range of motion: Hip passive range of motion internal and external rotation Flexion External rotation Internal rotation normal 120 ° normal 40 ‐ 60 ° normal 30 ‐ 40 ° http://www.youtube.com/watch?v=5LNYdJIrWYo Hip neurovascular exam Signs of intra ‐ articular hip pathology • Strength • Pain with passive ROM – Hip flexion (T12 ‐ L3) • Most pain with IR of – Knee extension (L2 ‐ 4) affected hip – Plantar flexion (S1) – Narrows joint space – Foot dorsiflexion (L4) • Decreased IR of – Great toe extension (L5) affected compared to • Sensation to light touch unaffected side • Reflexes: patellar (L4) and achilles (S1) http://netterreference.com/ELSEVIER/netter_s_ atlas_of_human_anatomy/a/atlasbook/8 Netter online anatomy atlas, UCSF library. 14
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