shoulder, elbow, wrist, hand paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · shoulder,...
TRANSCRIPT
![Page 1: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/1.jpg)
Shoulder, Elbow, Wrist, Hand Pain:Diagnosis and Managementg g
h GillThomas J. Gill, M.D.Chairman, Department of Orthopedic Surgery
Steward Health Care NetworkProfessor of Orthopedic Surgery
Tufts University School of MedicineDirector, Boston Sports Medicine and Research Institute, p
Boston, MA
![Page 2: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/2.jpg)
The “Shoulder”The Shoulder
• Sternoclavicular joint
• Acromioclavicular joint• Acromioclavicular joint
• Scapulothoracic joint
• Glenohumeral joint
![Page 3: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/3.jpg)
HistoryHistory
• Key points - age chief complaint• Key points - age, chief complaint• Young - instability, A-C, acute injuries• Old - rotator cuff, arthritisOld rotator cuff, arthritis• Mechanism• Chronicityy• Associated sx’s• Referred pain
![Page 4: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/4.jpg)
HistoryHistory
• Instability injury in ABD / ER• Instability - injury in ABD / ER• A-C Joint - direct blow• Rotator cuff pain at night; overhead• Rotator cuff - pain at night; overhead
![Page 5: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/5.jpg)
Ph sical E aminationPhysical Examination
• Must be undressed • PalpationMust be undressed
• Observation lki i
Palpation » based on knowledge of anatomy» S-C, clavicle, A-C, acromion, greater
tuberosity, biceps groove» walking into room» taking off shirt» ROM » asymmetry
• Motion » active / passive FF (150-180), ER (30-
60), ERA (70-90), IR (T4-T8)» asymmetry» atrophy» skin» “popeye”
• Strength » supraspinatus» ER» popeye
» winging» ER, » O’Brien’s
![Page 6: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/6.jpg)
Neurovascular TestingNeurovascular Testing
S R flSensory
• C5 - lateral arm
Reflex• C5 - biceps• C6 brachioradialis• C6 - thumb
• C7 - middle finger
• C6 - brachioradialis• C7 - triceps
• C8 - small finger
• T1 - medial arm
Pulses
• Adson/Wright, Roos tests
![Page 7: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/7.jpg)
Radiographic StudiesRadiographic Studies
• True AP• True AP• Axillary• Trans scapular Y• Trans-scapular Y• CT • U/S• U/S• MRI• Arthrograms• Arthrograms
![Page 8: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/8.jpg)
Case #1Case #1
• 45 y o construction worker• 45 y.o construction worker• fell from scaffold 4 weeks ago• pain over superior/posterior shoulder• pain over superior/posterior shoulder• not getting better despite NSAID’s, P.T.
![Page 9: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/9.jpg)
Rule out Referred PainRule out Referred Pain
• Herniated cervical disc• Herniated cervical disc• Cervical stenosis• “Burners” / “Stingers”Burners / Stingers• Cervical strain
• Remote etiologies - Phrenic nerve irritation» e.g. diaphragmatic abscess, pancoast tumorg p g , p
![Page 10: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/10.jpg)
Cervical ExaminationCervical Examination
• ROM• ROM• Tenderness• L’Hermitte’s sign• Spurling’s Test
![Page 11: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/11.jpg)
Cervical StrainCervical Strain
k h• Hx: “My neck hurts”
• No radicular / arm symptoms
• PE: Tender paraspinal muscles
N ti l i t t• No provocative neurologic tests
![Page 12: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/12.jpg)
Cervical StrainCervical Strain
• X ray: depends on history• X-ray: depends on history• Loss of cervical lordosis• Rx: heat, massage, strengthening, NSAID’s• ? Collar acutely
![Page 13: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/13.jpg)
“Whiplash”Whiplash
• Cervical strain• Cervical strain• Typically MVA• Forced flexion / extensionForced flexion / extension• Must rule out cervical instability• X-ray: lateral flexion / extension !y• Rx: like cervical strain
» often takes months
![Page 14: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/14.jpg)
Disc HerniationDisc Herniation
• Relatively rare in office settingRelatively rare in office setting• Hyperflexion / trauma• Hx: true radicular complaints
» occasionally just pain +/- spasm
• PE: neuro exam, L’Hermitte’s, Spurling’s
• Rx: NSAID’s, “tincture of time” for stable exam» ? decompression» ? decompression
![Page 15: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/15.jpg)
“Burners”“Burners”
• Upper cervical root neurapraxia• Upper cervical root neurapraxia» C5, C6
• “My arm went dead”• My arm went dead• Lateral neck flexion, arm distraction• Return to sports/work when no sx’s• Return to sports/work when no sx s• Rule out cervical disc / stenosis • Prevention neck roll in football• Prevention - neck roll in football
![Page 16: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/16.jpg)
FracturesFractures
• H/o trauma• H/o trauma
• When in doubt, X-ray!
• Don’t forget ligamentous injuries
• Immobilize
• Refer
![Page 17: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/17.jpg)
DefinitionsDefinitions
• Sprain - ligament injury• Strain - muscle injury• Tendon - muscle to bone• Ligament - bone to bone• Laxity - joint translation• Subluxation - pathologic laxity• Dislocation - no contact of joint surfaces
![Page 18: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/18.jpg)
Anatomy of Muscles / Nervesato y o usc es / Ne ves
![Page 19: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/19.jpg)
Anatomy of Ligaments / CapsuleAnatomy of Ligaments / Capsule
![Page 20: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/20.jpg)
Common Soft Tissue InjuriesCommon Soft Tissue Injuries
“S t d h ld ”• “Separated shoulder”• Dislocation / subluxation• Overuse injury (tendinitis, impingement)
• Rotator cuff tear• Biceps tendinitis / rupture • SLAP lesion• SLAP lesion
![Page 21: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/21.jpg)
Case #2Case #2
• 31 y o hockey player• 31 y.o. hockey player• Hit into glass • C/o shoulder pain• C/o shoulder pain
![Page 22: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/22.jpg)
“Separated Shoulder”Separated Shoulder
T I VI• Types I-VI
• I, II - non-operative
• III - ?
• IV V VI - surgeryIV, V, VI surgery
![Page 23: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/23.jpg)
A C Sprain: “Separated Shoulder”A-C Sprain: “Separated Shoulder”
Eti l di t bl t h ld• Etiology: direct blow to shoulder; very common
• PE: tender over AC joint; pain with cross-body adduction
• X-ray: A-C joint widening / dislocation
• Ice, compression
• ? Injection acutely (marcaine, steroid)
• P T not needed but maintain ROM• P.T. not needed, but maintain ROM
• Indications for surgery
![Page 24: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/24.jpg)
Case #3Case #3
• 49 y o woman c/o pain• 49 y.o woman c/o pain• night• overhead• overhead• can’t swim, play tennis• weak• weak• trauma?
![Page 25: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/25.jpg)
Impingement SyndromeImpingement Syndrome
• Most common cause of pain• Most common cause of pain• Rotator cuff tendinitis• “Bursitis”• Bursitis• Cuff tears rare in patients
< 35 years of age< 35 years of age
![Page 26: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/26.jpg)
Impingement SyndromeImpingement Syndrome
• Repetitive overhead activity• Repetitive overhead activity» throwers, tennis, swimmers, craftsmen
![Page 27: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/27.jpg)
Diagnosis of ImpingementDiagnosis of Impingement
Hi t• History» pain with overhead activity
» pain at night; +/ weakness» pain at night; +/- weakness
• Examination» Neer and Hawkins impingement signs» Neer and Hawkins impingement signs
» forward flexion; adduction/IR
• Injection test very helpful for diagnosis AND treatment• Injection test - very helpful for diagnosis AND treatment» up to 3 sometimes needed
![Page 28: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/28.jpg)
Treatment of ImpingementTreatment of Impingement
• NSAID’s
R t t ff t th i• Rotator cuff strengthening
• Injections x 3 (if needed)
• Arthroscopic decompression after 6 months of rehab
![Page 29: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/29.jpg)
Rotator Cuff TearsRotator Cuff Tears
• Partial - thickness vs full-thicknessPartial - thickness vs. full-thickness• Can be very debilitating / painful
![Page 30: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/30.jpg)
Diagnosis of RTC TearDiagnosis of RTC Tear
• Hx:Hx: » pain at night
» pain with overhead use
• PE:» impingement signs
» supraspinatus / ER resistance» supraspinatus / ER resistance
» discrepancy between active / passive ROM
• Injection test
![Page 31: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/31.jpg)
Imaging for RTC TearsImaging for RTC Tears
• MRI confirms PE findingsMRI confirms PE findings• Ddx:
» Impingement tendinitis, SLAP lesions, partial vs. full tears
![Page 32: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/32.jpg)
Treatment of RTC TearsTreatment of RTC Tears
• P T role to restore ROM pre op not “avoid surgery”• P.T. role - to restore ROM pre-op, not avoid surgery• Small tears tend to become large tears• Large tears difficult/impossible to repair• Large tears difficult/impossible to repair
» high rate of complications
![Page 33: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/33.jpg)
RTC RepairRTC Repair
• Most full thickness tears should be repaired depending on• Most full-thickness tears should be repaired, depending on patient co-morbidities
![Page 34: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/34.jpg)
Case #4Case #4
• 52 y o female• 52 y.o. female• C/o shoulder pain• Limited ROM• Limited ROM• PMH: Diabetes
![Page 35: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/35.jpg)
Adhesive Capsulitis ( h ld )(“Frozen Shoulder”)
Li it d ti d i ROM• Limited active and passive ROM
• Differentiate 1º vs. 2 º
• Different phases of pathology
• Hx: Pain stiffnessHx: Pain, stiffness
• Diabetes
![Page 36: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/36.jpg)
Adhesive Capsulitis:Treatment
NSAID’• NSAID’s
• Physical Therapy
• Subacromial Injection(s)
• Role of surgeryRole of surgery
![Page 37: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/37.jpg)
Case #5Case #5
• 28 y o man c/o pain• 28 y.o. man c/o pain• night• overhead• overhead• reaching into back seat
![Page 38: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/38.jpg)
Shoulder InstabilityShoulder Instability
• Must differentiate between shoulder “dislocation” and• Must differentiate between shoulder dislocation and “subluxation”
![Page 39: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/39.jpg)
Shoulder Instability:Hi tHistory
• Pathology occurs along a• Pathology occurs along a spectrum of severity
• Complaints or shoulderComplaints or shoulder “pain” more common than “instability”
![Page 40: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/40.jpg)
Shoulder Instability:History
• Does your shoulder feel loose?• Does your shoulder feel loose?
• Have you ever dislocated your shoulder?
• Do you avoid placing your arm in certain positions?
• Do you have difficulty reaching behind you• Do you have difficulty reaching behind you, throwing, or pushing open a heavy door?
I it diffi lt t lift h b ?”• Is it difficult to lift a heavy bag?”
![Page 41: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/41.jpg)
Shoulder Instability:Ph i l EPhysical Exam
Apprehension test Relocation testApprehension test Relocation test
![Page 42: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/42.jpg)
Shoulder Instability:I iImaging
• MUST have axillary view or• MUST have axillary view or trans-scapular Y-view!
• AP alone NOT acceptableAP alone NOT acceptable
• Hill-Sachs, Bankart lesion
![Page 43: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/43.jpg)
Management of InstabilityManagement of Instability
• Acute dislocation» reduction, nv assessment
40 ld• > 40 years old » r/o rotator cuff tear!
Sli• Sling» symptomatic relief only » does not decrease recurrence rate» does not decrease recurrence rate
![Page 44: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/44.jpg)
Management of InstabilityManagement of Instability
• Re-establish early ROM
• Rotator cuff strengthening
• Recurrence rate » > 90% less than 20 years old
» < 25% over 40 years old
![Page 45: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/45.jpg)
Management of InstabilityManagement of Instability
• Role for arthroscopy and early stabilization in young athletic• Role for arthroscopy and early stabilization in young, athletic patients
![Page 46: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/46.jpg)
“SLAP” Lesion“SLAP” Lesion
• Superior Labrum Anterior to Posterior tear• Superior Labrum, Anterior to Posterior tear
![Page 47: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/47.jpg)
SLAP DiagnosisSLAP Diagnosis
• Etiology: eccentric contraction of biceps muscle tears• Etiology: eccentric contraction of biceps muscle tears superior labrum at biceps anchor; deceleration phase of throwing; fall on outstretched armg
![Page 48: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/48.jpg)
SLAP DiagnosisSLAP Diagnosis
• History• History» anterior shoulder pain» “rotator cuff symptoms”» rotator cuff symptoms
• Examination» O’Brien’s sign» O Brien s sign » resistance in humeral adduction/flexion/IR» weakness on rotator cuff testing» weakness on rotator cuff testing
![Page 49: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/49.jpg)
Treatment of SLAP LesionsTreatment of SLAP Lesions
• MRI - can be very helpful in ddxMRI - can be very helpful in ddx• Rx: Arthroscopic repair for persistent pain/weakness
![Page 50: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/50.jpg)
Biceps RuptureBiceps Rupture
• Proximal long head of biceps at biceps groove or glenoid• Proximal - long head of biceps at biceps groove or glenoid attachment
• Distal - biceps tuberosity at elbowDistal biceps tuberosity at elbow
![Page 51: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/51.jpg)
Treatment of Biceps RupturesTreatment of Biceps Ruptures
• Hx: “I felt a pop/tear in my arm”• Hx: I felt a pop/tear in my arm
• PE: “Popeye” deformity; loss of elbow flexion / supination t th t dstrength; tenderness
• Early surgical repair for distal ruptures
• Proximal repair - controversial; ? rehab alone
If i d d “th li th b tt ”• If surgery is needed, “the earlier, the better”
![Page 52: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/52.jpg)
Shoulder: FracturesShoulder: Fractures
• Clavicle
• Greater tuberosity
• Proximal humerus
• Physeal (children, y ( ,especially throwers)
![Page 53: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/53.jpg)
Case #6Case #6
• 72 y o man• 72 y.o. man• pain• limited ROM• limited ROM• getting worse• can’t sleep• can t sleep
![Page 54: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/54.jpg)
Glenohumeral ArthritisGlenohumeral Arthritis
• Shoulder is typically not a• Shoulder is typically not a “weight-bearing joint”
• Less common than in hip or knee• Dx:
» crepitus on ROM; limited ROM• Need true AP X ray of• Need true AP X-ray of
glenohumeral joint » “Graci view”
![Page 55: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/55.jpg)
Glenohumeral ArthritisGlenohumeral Arthritis
ild SA ’ O• Mild DJD - NSAID’s, preserve ROM
• Mod DJD - ? Indication for arthroscopy
• Severe DJD - total shoulder arthroplasty
» TSA indicated for pain, not necessarily ROMp , y
![Page 56: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/56.jpg)
Elbow PainElbow Pain
Anatomy is essential...
![Page 57: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/57.jpg)
Lateral Epicondylitis:“Tennis Elbow”
• Hx: “My elbow hurts!”Hx: My elbow hurts!
• PE: » Tender over lateral epicondyle» Tender over lateral epicondyle
» pain with resisted wrist extension
• Tendinosis, not tendinitis,
• Chronic degeneration» overuse at ECRB
![Page 58: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/58.jpg)
Tennis Elbow:Treatment
• NSAID’s forearm strap wrist• NSAID s, forearm strap, wrist spint, ice
• Formal P.T. » often aggravates condition» stretching only initially!
• Injections• Injections » often expedite resolution
• Recalcitrant cases» surgical debridement » less than 1% of cases
![Page 59: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/59.jpg)
Medial Epicondylitis:“Golfer’s Elbow”
C fl• Common flexor mass
• Pain with grasp, flexion
• Rx: same as tennis elbow
![Page 60: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/60.jpg)
“Little League Elbow”“Little League Elbow”
• Medial epicondylitis +/- avulsion ofMedial epicondylitis +/ avulsion of apophysis
• Capitellar OCD
• Valgus overload from repetitive microtrauma
• Limit throwing / cross-train» must be pain-free with full ROM
» avoids extensive chondral injury
![Page 61: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/61.jpg)
Wrist PainWrist Pain
• X rays for all trauma• X-rays for all trauma• “Sprain”
» must r/o scaphoid fracture!» must r/o scaphoid fracture!
• If dx unclear …» place in thumb spica splint» place in thumb spica splint» re-image in 10 days
• Refer to ortho
![Page 62: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/62.jpg)
Carpal Tunnel Syndrome:p yHistory
• Numbness• Numbness• Weakness• “Clumsiness”• Clumsiness• Can’t hold cup• Worse in a m• Worse in a.m.• Median nerve distribution
» thumb index long» thumb, index, long
![Page 63: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/63.jpg)
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
• PE:• PE:» Thenar atrophy» hypesthesia thumb, index, long» Tinel’s sign» Phalen’s test
• EMGG• Night splints• Refer - Role of surgery
![Page 64: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/64.jpg)
De Quervain’s TenosynovitisDe Quervain’s Tenosynovitis
• 1st dorsal extensor compartment• 1st dorsal extensor compartment
• APL, EPB
• Finkelstein’s test
• Splintp
• Injection
![Page 65: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/65.jpg)
HandHand
T i fi• Trigger finger• Dupuytren’s contracture• PIP dislocation• PIP dislocation
» “rugger-jersey finger”
• TraumaTrauma » xray» splint » “functional position”
• holding a can
![Page 66: Shoulder, Elbow, Wrist, Hand Paingims19course.com/uploads/1/2/4/0/124037936/6thurs... · Shoulder, Elbow, Wrist, Hand Pain: Diagggnosis and Management Th Gillhomas J. Gill, M.D. Chairman,](https://reader031.vdocuments.us/reader031/viewer/2022040914/5e8a77e2122c2e1a336cf6dc/html5/thumbnails/66.jpg)
Thank You
www.bostonsportsmedicine.com