Is This Really a Musculoskeletal Problem? Anthony Luke MD, MPH UCSF Orthopedics Primary Care Sports Medicine Annual Review in Family Medicine 2015
Disclosures • Founder, RunSafe™ • Founder & CEO, SportZPeak Inc. • Sanofi, Investigator initiated grant • Intel, Industry grant
Outline • How do you use symptoms? • LOOK - FEEL - MOVE - SPECIAL TESTS • Discussion = Differential Diagnosis & Approach • Neck • Nerve • Scapular dyskinesis • Vascular -TOS • Mobility
Differential Diagnosis • Rotator cuff tendinopathy • Rotator cuff tears • SLAP Lesion • Calcific tendinopathy • “ Frozen ” shoulder (adhesive capsulitis) • Acromioclavicular joint problems • Scapular weakness • Cervical radiculopathy
Red Flag Symptoms • Severe disability • Numbness and tingling • Night pain • Constitutional symptoms (fever, wt loss) • Swelling with no injury • Systemic illness • Multiple joint injury
• Who? 15 year old male football player • When? Last season Case 1 • What? Had a right arm “stinger” last year after getting hit; sometimes gets some neck pain with contact but not everytime
Impingement Signs Neer • Passive full flexion • Positive is reproduction of shoulder pain Sens = 83 % Spec = 51 % PPV = 40 % NPV = 89 % MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301.
Impingement Signs Hawkin’s test • Flex shoulder to 90º • Flex elbow to 90º • Internally rotate • Positive - reproduce shoulder pain Sens = 88 % Spec = 43 % PPV = 38 % MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301. NPV = 90 %
Spurling’s test - Cervical radiculopathy Sens = 64% Spec = 95% PPV = 58% NPV = 96%
Burners / Stingers • Axial loading, hyperflexion, hyperextension or sudden rotation can cause injury to cervical spine and surrounding soft tissues
C e r v i c a l S p i n e • Atlantoaxial instability • Multiple level fusion • Significant cervical stenosis • Consider risk of spinal cord injury during sports participation • Select low risk sport • Discuss with specialist Torg Ratio = y/z = 0.8
Posture • Lines: ear lobe- acromion-iliac crest • Lordosis, kyphosis • Pelvic inclination - ASIS lower than PSIS
LOOK “SEADS” • Swelling • Erythema • Atrophy • Deformity • Surgical Scars
Suprascapular Nerve
Ulnar nerve – Cubital tunnel syndrome • Elbow Flexion test • Tinel sign • Ulnar nerve subluxation
TIPS Peripheral Neuropathy • Look for occult onset of pain, weakness, numbness • Might follow acute trauma • Think compression or traction • Look for specific muscle atrophy • Check for dermatomal numbness or focal weakness 28
• Who? 48 year old female, looks exhausted Case 2 • What? Has had severe 12/10 pain • When? 2 nights • Where? Diffuse shoulder pain, will NOT let you move it • How? No trauma, woke with the pain
WHAT DO YOU DO? 30
Impingement/Rotator Cuff Tears Full Thickness Tear Partial Cuff Tear Impingement
Calcific tendinosis 32
Calcific Tendinosis • Severe acute pain in shoulder • Patient unwilling to move shoulder • X-ray may show calcium deposits • Ultrasound more sensitive than MRI • Can consider subacromial steroid injection
Tendon Pain • May be present at the start of an activity then “warm-up” • Sore when the muscle is used • May occur in “compensation” for other structural problems near by • Check for underlying spondyloarthropathy: Psoriasis, GI symptoms, STD
3 Basic P/E findings for tendinopathy 1. Tenderness on direct palpation 2. Reproduction of pain with resisted contraction (eccentric loading) 3. Reproduction of pain with passive stretch
Elbow Tendinopathies Lateral epicondylosis • Tender lateral epicondyle • Resisted third digit extension • Resisted wrist extension Medial epicondylosis • Resisted pronation/wrist flexion Distal biceps • Resisted supination
Bone Pain • Constant • Sharp • Greater load = greater pain (i.e. weightbearing) • May have pressure features
Greater tuberosity fractures • Indications for Greater tuberosity fractures > 2 mm • Isolated axillary nerve injury • Subacromial impingement (common)- due to displacement of fragment or even scar tissue formation, especially extension and external rotation Green A, Norris TR. Skeletal Trauma: Basic science, management, and reconstruction (3rd edition). Elsevier Science, 2003, p. 1558.
Other problems in the area • Acromioclavicular joint osteoarthritis • Sternoclavicular joint injuries • Osteolysis of the distal clavicle
Acromioclavicular Joint • Swelling, tenderness +/- step deformity over AC joint • Cross over sign Sens = 64% Spec = 95% PPV = 58% NPV = 96%
Take Home Points - Symptoms • Ask More About Function (as well as Pain) • How does this problem affect your day to day function? • What can’t you do that makes this a problem? • If you could take this problem away immediately (magic), how would your life be? 41
• Who? 40 year old male with R anterior shoulder and scapular pain and “winging” • What? Pain with overhead activities and Case 3 sleeping • When? He has had pain progressively worsening over 6 months • How? Had an injury skiing around 6 months ago but only vague history; Works as auto mechanic • Where? Shoulder radiating to lateral arm
Winging • Long Thoracic Nerve – Serratus Anterior • Less common – Spinal Accessory Nerve (trapezius) – Dorsal Scapular Nerve (rhomboids) • Scapular Dyskinesis – MOST COMMON – Pain may alter mechanics or vice versa
Scapular – Dynamic Stabilizers • Levator scapulae • Trapezius muscle • Serratus anterior • Rhomboids • Latissimus dorsi • Pectoralis minor
Scapulohumeral Rhythm • Ratio of Scapular to Humeral movement • Occurs via coupled movement of the scapular muscles • Through elevation, scapula upwardly rotates, posteriorly tilts and externally rotates
Observation • Rest • Range of Motion • Function!! • Asymmetry • Four point palpation
MOVE Painful Arc 60 - 120° Flexion and External rotation
MOVE External rotation Internal rotation
Diagnosis?
Rotator Cuff strength testing Supraspinatus • Empty can • Thumbs down abducted to 30º • Horizontally adduct to 30º For tendonitis Sens = 77 % Spec = 38 % For tears, Sens = 19 % Naredo et al. Ann Rheum Dis, Spec = 100 % 2002; 61: 132-136.
Rotator Cuff strength testing Infraspinatus/teres minor - External rotation • Keep elbows at 90º • Patte’s test at 90º shoulder abduction For tendonitis, Sens = 57 % Spec = 71 % For tears, Sens = 36 % Spec = 95 % Naredo et al. Ann Rheum Dis, 2002; 61: 132-136.
Rotator Cuff Tear vs Impingement? • Difficulty lifting – Pain vs weakness ? • Drop arm sign • Fail conservative Tx • Tears uncommon < 40 y.o. Sens = 10 % PPV = 100 % Bryant et al. J Shoulder Elbow Surg, 2002; 11: 219-224.
Take Home Points • Scapular dyskinesis is common as a pattern of dysfunction, more than neurogenic winging • Use impingement signs to rule in shoulder problems • Rotator cuff strength tests help diagnose shoulder issues
• Who? 38 year old female secretary • What? Neck pain with radiating pain to the Case 4 right elbow and right arm numbness and some ulnar nerve symptoms • When? She has had worsening pain over 3 months • How? Talking on her phone is painful, sleeping is sore • Where? Numbness to 4 th and 5 th fingers
Case 4 • LOOK 5’ 5”, 130 • SPECIAL TESTS pounds – Rotator cuff strength 5/5 – Rolled forward shoulder posture, head – Neer and Hawkin’s forward posture negative test • FEEL – Spurling’s test positive – Tender over cervical spine near R C7 facet – Roos’ test positive, joint Adson’s positive on right • MOVE – Elbow flexion test – C-spine - ROM 45° positive flexion 40° extension – Tinel’s sign negative painful; right rotation 50° left rotation 70° – U/E 5/5, Reflexes normal, sensation – ROM shoulder 180 intact to light touch flexion bilaterally
Sudden Death Round Thoracic Outlet syndrome • Repetitive upper extremity use – shoulder, elbow, hand • assembly line • computer with mouse and phone • Poor posture • Reaching • Stress • Apical breathing
Thoracic Outlet Syndrome tests • Possible compression of the subclavian artery between the scalenes and any cervical rib • Compression of neurovascular symptoms in the upper extremity by the pectoralis minor
Adson’s Test • Seated patient extends and turns head toward the tested shoulder • Shoulder is abducted and extended. • Subject inhales while the examiner palpates the ipsilateral radial pulse. • Positive findings: Diminution or elimination of the pulse and reproduction of the paresthesias • Studies show poor to good specificity and good sensitivity.
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