Fam med case 25

When evaluating pain that seems musculoskeletal, what are some key "red flags" to watch out for?

"Red flags:" Patient reports of local complaints such as redness or swelling and/or systemic complaints such fever, chills, and myalgias.

What are key neurological causes of shoulder pain?

1. Cervical disc disease-particularly involving compression of C5 and C6 nerve roots--may cause pain to radiate to the shoulder. Unless there is coincident disorder affecting the shoulder then the shoulder exam itself should be unremarkable. 2. Brachial plexus injury or compression (such as may occur in thoracic outlet syndrome) may produce altered sensation and pain in the region of the shoulder. Brachial plexus injuries may also occur in the setting of trauma; or, less commonly due to local invasion of breast or lung cancers. Neurovascular assessments are particularly important in the setting of trauma.

What is "Neer test"

A special maneuver to test for nerve impingement in an acute shoulder injury. As you reach the end of this range of motion, several structures are pinched between the humerus and the arch formed by the acromion and the ligament that attaches it to the coracoid process. You may remember that the structures in that space include the supraspinatous tendon, the long head of the biceps muscle, and the subacromial bursa.

What is Hawkins-Kennedy test?

A special maneuver to test for nerve impingement in an acute shoulder injuy. This test is slightly more specific than the Neer test

What are the major anatomic stabilizers of the shoulder joint? Select all that apply. • A. Labrum • B. Teres major muscle • C. Rotator muscle group • D. Glenohumeral ligaments • E. Brachial plexus

A, C, D have been selected by the expert.

When inspecting someone with an acute shoulder injury, how might someone present if they have Fracture of the clavicle or sprain of the acromioclavicular (AC) joint?

Bony deformity in the area of the clavicle or AC joint

When inspecting someone with an acute shoulder injury, how might someone present if they have Posterior dislocation?

Patient carries the arm in an adducted and internally rotated position

What does the teres minor do?

Rotator cuff muscle. Assists the infraspinatous in external rotation of the shoulder

What is adhesive capsulitis and in who is it common?

• In adhesive capsulitis there is contracture of the joint capsule. It is common in patients with metabolic diseases such as diabetes and hypothyroidism

What are the 4 muscles of the rotator cuff?

• Supraspinatous, infraspinatous, teres minor, subscapularis.

What is "O'brien test"?

1. Special maneuver to test for labral injuries. 1. Have the patient stand with hands on his hips. Place one of your hands over the shoulder and the other hand behind the elbow. Apply anterior-superior force and ask the patient to push back against the force. 2. 2. Have the patient hold his shoulder in 90-degrees of forward flexion, 30 to 45-degrees of horizontal adduction, and maximal internal rotation. Grab his wrist and resist his attempt to horizontally adduct and forward flex the shoulder.

When you come across red flags when evaluating musculoskeletal pain (ie, fever, chills), what steps should you take?

1. Urgent evaluation (with ultrasound or MRI) and immediate, same day consultation with an orthopedic surgeon. 2. Definitive evaluation will include aspiration and culture of related fluid. 3. Definitive treatment of confirmed septic arthritis or bursitis

A 72-year-old female presents to the clinic one year after having suffered a stroke that left her with some residual left sided weakness/paralysis. On exam, the left shoulder demonstrates a severe decrease in both active and passive ROM and significant pain. The patient has a history of hypertension, hyperlipidemia, and diabetes. What is the most likely diagnosis? • A. Adhesive capsulitis • B. Osteoarthritis • C. Rotator cuff tear • D. Biceps tendonitis • E. Subacromial bursitis

A has been selected by the expert. The correct answer is A. Adhesive capsulitis, also known as frozen shoulder, is characterized by pain and stiffness in the shoulder joint.Symptoms usually appear gradually and the majority will resolve in 1-3 years. The risk of developing adhesive capsulitis increases with conditions that limit the mobility of the arm, such as recovery from injury, stroke or mastectomy and also in diabetics. Adhesive capsulitis demonstrates a decrease in both active and passive ROM. Loss of active and passive ROM is more likely due to joint disease, whereas loss of only active ROM is more likely due to muscle tissue pathology. While osteoarthritis can present with decrease in both passive and active ROM, it is less common in the shoulder than in the hip and knee and the history is classic for adhesive capsulitis.

What is the labrum?

A main anatomic stabilizer of the shoulder joint. Adds stability by increasing the articulating surface area and depth of the glenoid fossa.

What is the rotator muscle group?

A main anatomic stabilizer of the shoulder joint. Essential dynamic stabilizer of shoulder joint.

What are the Glenohumeral or "capsular" ligaments?

A main anatomic stabilizer of the shoulder joint. Provide added support and static stability to the shoulder joint.

How do you distinguish a joint disease from an issue that is purely related to muscle tissue?

A patient with loss of active and passive ROM is more likely to have joint disease; whereas a patient with loss of only active ROM is more likely to have an issue with muscle tissue.

A patient presents with weakness on isolation of his supraspinatus muscle and tenderness to palpation of its insertion on the greater tuberosity. He also has positive impingement signs. In addition to physical therapy, what treatments do you plan to recommend for this condition? Select all that apply. • A. Relative rest from aggravating factors such as his softball playing and painting • B. Pain medication as needed in topical and/or oral form • C. Sling immobilization • D. Urgent orthopedic surgical consultation for suspected complete tear of the rotator cuff • E. X-ray of the shoulder • F. MRI of the shoulder • G. Subacromial injection

A, B have been selected by the expert. NOTE** If patient does not respond to treatment, x-rays of the shoulder are likely in order.

Mr. Chen is a 38-year-old man with subacute onset of moderate burning and aching right shoulder pain aggravated by movement. He plays softball in a community league but his pain has limited his participation. Physical exam is suggestive of rotator cuff tendinopathy and impingement syndrome. Which of the following conditions are most appropriate to include on the differential diagnosis of Mr. Chen's shoulder pain at this time? Choose the top four answers. • A. Rotator cuff tendinopathy • B. Impingement / Subacromial bursitis • C. Rotator cuff tear • D. Biceps tendinopathy • E. Degenerative glenohumeral arthritis • F. Shoulder instability • G. Acromioclavicular (AC) joint separation • H. Labral tear • I. Adhesive capsulitis

A, B, C, H have been selected by the expert. An appropriate differential diagnosis for Mr. Chen's shoulder pain includes: • Rotator cuff tendinopathy (A) • Impingement or subacromial bursitis (B) • Rotator cuff tear (C) • Labral tear (H) NOTE** Biceps tendinopathy: Would show more anterior shoulder pain with anterior tenderness to palpation (in the bicipital groove).; Degenerative glenohumeral arthritis would be rare in someone this young

• A patient demonstrates: • 1) Positive Apley's Scratch test; • 2) Weakness and pain with empty can testing; • 3) Limited active ROM due to pain. What is the most likely diagnosis? A) Rotator cuff tendinopathy B) Torn rotator cuff C) Impingement syndrome with bursitis D) Labral tear

Answer: A • NOTE** Positive Apley's Scratch test leads one towards this diagnosis, but is not definitive. • Weakness and pain with empty can testing strongly suggests supraspinatus (i.e., rotator cuff) pathology. Whether this pathology is tendonitis or a tear is often a matter of degree. • Limited active ROM due to pain supports this diagnosis.

• A patient demonstrates: Limited ROM with significant pain; Significant weakness with strength testing. What is the most likely diagnosis? A) Rotator cuff tendinopathy B) Torn rotator cuff C) Impingement syndrome with bursitis D) Labral tear

Answer: B) Torn rotator cuff • NOTE** Limited ROM with significant pain is a hallmark of the physical exam in the patient with a partial or complete rotator cuff tear. In a complete tear, the patient will likely not be able to raise his arm above his head. • Significant weakness with strength testing. • Young athletes tend to present with traumatic torn rotator cuff, whereas older people present with insidious onset because of the degenerative process that occurs.

While Mr. Chen's pain does not sound emergent, you are ever mindful of conditions within your differential that would require immediate treatment to avoid catastrophic outcomes. Which of the following musculoskeletal causes of shoulder pain would merit urgent diagnosis and management? Select all that apply. A. Calcific tendinopathy B. Septic glenohumeral arthritis C. Impingement of the supraspinatus tendon D. Septic subacromial bursitis E. Adhesive capsulitis

Answer: B, D have been selected by the expert. Because: Delay in recognition and treatment of a septic glenohumeral ("shoulder joint") arthritis or septic subacromial bursitis may lead to local tissue destruction and loss of function, extension of infection locally to deeper spaces such as bone (osteomyelitis) or more distant sites by way of bacteremia and that may progress to sepsis. NOTE**The other answer choices such as calcific tendinopathy (A), impingement of the supraspinatus tendon (C), and adhesive capsulitis (E) are much more common causes of shoulder pain-likely with chronic antecedents - but not in and of themselves cause for urgent attention and referral.

• A patient presents with: Apley's Scratch test causes pain and/or limited range of motion What is the most likely diagnosis? A) Rotator cuff tendinopathy B) Torn rotator cuff C) Impingement syndrome with bursitis D) Labral tear

Answer: C. • NOTE** Apley's Scratch test causes pain and/or limited range of motion with these conditions. • Neer and Hawkins-Kennedy tests used to rule out these conditions.

When inspecting someone with an acute shoulder injury, how might someone present if they have Torn rotator cuff or nerve impingement?

Atrophy of smaller muscles such as the supraspinatus or infraspinatus

When inspecting someone with an acute shoulder injury, how might someone present if they have Immobilization or lack of use of the joint?

Atrophy of the larger muscles of the shoulder girdle, like the deltoid or pectoralis major

A 55-year-old female with exercise induced asthma, but no other chronic health problems, presents to the office with left shoulder pain. She is a tennis player, left handed and notices pain serving the ball. When you suggest that it might be her rotator cuff your preceptor asks, "what muscles make up the rotator cuff?" • A. Supraspinatus, infraspinatus, teres major, subscapularis • B. Supraspinatus, infraspinatus, teres minor, subscapularis • C. Supraspinatus, infraspinatus, teres minor, deltoid • D. Supraspinatus, infraspinatus, teres major, teres minor • E. Supraspinatus, infraspinatus, teres minor, rhomboid minor

B has been selected by the expert. The correct answer is B. The muscles that make up the rotator cuff are the supraspinatus, infraspinatus, teres minor and subscapularis muscles. The teres major, deltoid and rhomboid minor are not part of the rotator cuff.

A 23-year-old epileptic male presents to the emergency department after a generalized tonic-clonic seizure. You notice that the patient is holding his right shoulder and that his arm is adducted and internally rotated. What is the best imaging modality for this type of injury? • A. MRI • B. X-ray • C. Ultrasound • D. CT scan • E. PET scan

B has been selected by the expert. The correct answer is B. X-ray is the indicated imaging in the setting of acute injury and suspected fracture or dislocation. MRI is used to evaluate possible rotator cuff tears and other soft tissue etiology. Ultrasound can be used to evaluate soft tissue structures. It's desirable due to its low-cost and because it exposes the patient to no radiation. CT can be used in the setting of complicated fracture, suspected tumor, or when MRI is contraindicated. PET scans indicate functional activity of organs such as the brain, heart and lung and are mostly used in the oncologic setting.

A 41 year old male presents to clinic with left shoulder pain after a fall where he caught himself with his left arm. To assess the injury the patient's arms were placed in thirty degrees of horizontal adduction and shoulders were abducted to ninety degrees. The patient attempted to resist downward pressure and was unable. This test assesses the integrity of the: • A. infraspinatus muscle • B. Teres minor muscle • C. Supraspinatus muscle • D. Biceps tendon • E. Deltoid muscle

C has been selected by the expert. The correct answer is C. The Empty Can Test assesses for pathology of the supraspinatus muscle. For the Empty Can Test, the patient's arms are placed in approximately 30-degrees of horizontal adduction with the shoulders abducted to 90-degrees. The patient attempts to resist downward overpressure applied by the person performing the test. If the patient cannot resist the pressure, that is a positive result and can indicate pathology of the supraspinatus muscle.

If Mr. Chen had restricted passive as well as active ROM of the shoulder, what type of problems involving the shoulder might you consider? Select all that apply. A. Rotator cuff tear B. Rotator cuff impingment C. Adhesive capsulitis D. Tendinopathy of the long head of the biceps E. Glenohumeral arthritis Submit

C, E have been selected by the expert.

What are common bacterial causes of septic joints?

Common bacterial pathogens include gram positive organisms, primarily staph (including methicillin-resistant staph aureus-MRSA) and to a lesser extent strep species.

When do you use sling immobilization in acute shoulder injury?

Conditions that will require sling immobilization include shoulder dislocation and proximal humeral fractures. In other conditions, this could lead to weakening/atrophy of the rotator cuff muscles from diminished use and promote stiffness of the shoulder joint due to decreased movement that could lead to adhesive capsulitis.

A 17-year-old male football player presents to the emergency department with acute onset of right shoulder pain. The pain started approximately two hours ago when he was tackled during a game while carrying the football. Shoulder swelling and pain were present after injury. He is holding ice to a swollen shoulder, and on exam you notice severe bruising, pain on palpation over the lateral edge of the shoulder and raised bump over that same area. There is also severe tenderness over the coracoclavicular ligaments. What is most likely diagnosis? • A. Rotator cuff tear • B. Subacromial impingement • C. Subacromial bursitis • D. AC joint sprain • E. Rotator cuff tendonitis

D has been selected by the expert. The correct answer is D. AC joint sprain presents with swelling, bruising and point tenderness of the AC joint after a fall directly on the acromion with arm adducted.AC joint injuries are classified Type I- Type VI depending on the number of ligaments involved. Type I injuries involve injury of AC ligaments with no injury to the coracoclavicular (CC) ligaments. This causes a tender AC joint that often has mild swelling. This type usually heals within a few weeks.Type II injuries involve a complete tear of the AC ligaments and a sprain or partial tear of the coracoclavicular (CC) ligaments. This causes a tender AC joint, often with significant swelling.Type III injuries involve a complete tear of both the AC and CC ligaments. Significant swelling and tenderness of CC ligaments is present along with visible abnormality of the AC joint. Type III injuries can take several weeks to months to heal.Type IV, V, VI injuries are the most severe. Treatment often requires surgery. With rotator cuff tears, there is limited ROM with significant pain. In a complete tear, the patient will not be able to raise their arm above the head. In patients with subacromial impingement or subacromial bursitis, there will be pain with overhead ROM and patients will have positive Neer and Hawkins-Kennedy tests. Patients with Rotator cuff tendonitis, when mild, will have preserved ROM and minimal pain but can have a positive Apley's scratch tests.

Which of the following conditions may present with shoulder pain? Choose the single best answer. A. Myocardial infarction B. Cancer of the lung C. Cholecystitis D. Ruptured ectopic pregnancy E. All of the above

E has been selected by the expert.

What are the definitive treatments for septic joints?

Entails surgical drainage and tailored antibiotic therapy. Hospitalization is warranted if this diagnosis is confirmed.

When evaluating acute shoulder injury for range of motion, how would you go about testing that?

First: Active range of motion of the shoulder; Next: Functional range of motion of the shoulder - Apley scratch test; Last: Passive range of motion of the shoulder

When inspecting someone with an acute shoulder injury, how might someone present if they have Anterior dislocation?

Fullness of the anterior shoulder with a large dimple in the posterior shoulder

What are the basic steps to evaluating acute shoulder injury?

Inspection, Palpation, Range of motion, Strength testing, and Special maneuvers

When inspecting someone with an acute shoulder injury, how might someone present if they have Impingement syndrome?

Poor posture with scapulae protracted

What does the infraspinatous do?

Rotator cuff muscle. Assists with external rotation of the shoulder

What does the subscapularis do?

Rotator cuff muscle. Assists with internal rotation of the shoulder

What does the supraspinatous do?

Rotator cuff muscle. Assists with raising of the arm (abduction)

What is "Speed's test"?

Special maneuver to test for biceps tendinopathy. Flex the patient's elbow 20-30 degrees with the forearm in supination and the arm in about 60 degrees of flexion. Resist forward flexion of the arm while palpating the patient's biceps tendon over the anterior aspect of the shoulder.

What is "yergason's test"?

Special maneuver to test for biceps tendinopathy. Flex the patient's elbow to 90 degrees with the thumb up. Grasp the wrist and resist attempts by the patient to actively supinate the arm and flex the elbow.

What is "clunk test"?

Special maneuver to test for labral injuries. With the patient supine, the examiner rotates the patient's arm and loads (force applied) from extension through to forward flexion. The examiner is checking for a "clunk" sound or clicking sensation arising from the glenoid labrum that can indicate a labral tear even without instability.

What is tendinitis and how is it differentiated from tendinopathy?

Tendinitis implies an inflammatory etiology that occurs only in the first days after an acute tendon injury; not appropriate unless injury is very acute. Tendinopathy is a more general term that may imply a degenerative pathology. It is a chronic condition that is characterized by a fibroblastic response, lack of acute phase reactants, and collagenous degeneration.

What is more common: the anterior or the posterior shoulder dislocation?

The most common form of shoulder dislocation is an anterior dislocation. Posterior shoulder locations are much less common and have been documented in the setting of generalized seizures.

What is the apprehension test in the evaluation of acute shoulder pain?

This position reproduces the mechanism for anterior dislocation, and could create some anxiety in a patient with anterior instability. Providing anterior pressure on the humeral shaft may increase sensitivity of the maneuver if the test is not yet positive. Make sure to stop prior to applying anterior pressure if a patient has already expressed apprehension - we don't want to sublux or dislocate any shoulders here in the office.

What are key vascular causes of shoulder pain?

Vascular causes of shoulder pain, although rare, should be readily considered when approaching the patient with shoulder pain. 1. Coronary artery disease leading to myocardial ischemia or frank infarction may cause pain to be referred to the shoulder. 2. Much less common but more local causes of circulatory abnormality that can present with shoulder pain include axillary artery aneurysm and axillary vein thrombosis. 3. Finally, in thoracic outlet syndrome, compression of the axillary artery may cause shoulder pain.

When is an orthopedic surgical consultation warranted?

Warranted in an active athlete with a suspected complete tear of the rotator cuff though it would not need to be urgent. Not warranted for incomplete tear. Urgent orthopedic consultation is warranted in the setting of suspected septic glenohumeral arthritis or subacromial bursitis or complicated fracture and/or dislocation.

What are three key components of strength testing in acute shoulder injury?

• 1. Test strength of the muscles surrounding the shoulder ("Empty can" or Jobes Test. ) • 2. Isolate each of the rotator cuff muscles (Resist internal rotation with patient's elbows at his sides to test the subscapularis muscle • Resist external rotation with patient's elbows at his side to test infraspinatous and teres minor muscles) 3. Standing Push up Against the Wall

• How is labral tear most commonly caused and diagnosed?

• Labral tears may occur through repetitive damage from glenohumeral joint instability or secondary to frank dislocations or other sudden trauma. • Clunk and O'Brien's tests are the best clinical special tests for labral pathology. • Remember, however, that labral pathology is often picked up as a diagnosis of exclusion.

What does the standing push up against the wall test indicate when evaluating acute shoulder pain?

• Unilateral winging may be indicative of damage to the long thoracic nerve, as might happen during a mastectomy. • Asymmetric movement of one scapula usually indicates weakness or dyskinesis in the scapular stabilizers.