Is This Really a Musculoskeletal Problem?
Anthony Luke MD, MPH
Annual Review in Family Medicine 2015
UCSF Orthopedics Primary Care Sports Medicine
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
Case 1
• Who? 15 year old male football player • When? Last season • 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 % NPV = 90 %
MacDonald et al. J Shoulder Elbow Surg, 2000; 9: 299-301.
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
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Case 2
• Who? 48 year old female, looks exhausted
• 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?
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Impingement/Rotator Cuff Tears
Impingement
Partial Cuff Tear
Full Thickness Tear
Calcific tendinosis
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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?
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Case 3
• Who? 40 year old male with R anterior shoulder and scapular pain and “winging”
• What? Pain with overhead activities and 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
Flexion and External rotation
Painful Arc 60 - 120°
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 % Spec = 100 % Naredo et al. Ann Rheum Dis,
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
Case 4
• Who? 38 year old female secretary
• What? Neck pain with radiating pain to the 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 4th and 5th fingers
Case 4 • LOOK 5’ 5”, 130
pounds – Rolled forward
shoulder posture, head forward posture
• FEEL – Tender over cervical
spine near R C7 facet joint
• MOVE – C-spine - ROM 45°
flexion 40° extension painful; right rotation 50° left rotation 70°
– ROM shoulder 180 flexion bilaterally
• SPECIAL TESTS – Rotator cuff strength
5/5 – Neer and Hawkin’s
negative test – Spurling’s test
positive – Roos’ test positive,
Adson’s positive on right
– Elbow flexion test positive
– Tinel’s sign negative – U/E 5/5, Reflexes
normal, sensation intact to light touch
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.
Wright’s Hyperabduction Test
• With patient seated, the clinician hyperabducts and externally rotates the patient’s arm while assessing the ipsilateral radial pulse
• Positive findings: Diminution or elimination of the radial pulse and reproduction of the paresthesias
• No studies have examined validity
Roos Stress Test • Patient holds shoulders in
abduction and external rotation at 90 degrees with elbows flexed at 90 degrees and repeatedly open and close their hands for three minutes.
• Positive findings: Reproduction of their symptoms or a sensation of heaviness and fatigue.
• No studies have examined validity of the Roos stress test as it pertains to thoracic outlet syndrome.
Case 4
• Who? 38 year old female secretary
• What? Neck pain with radiating pain to the 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 4th and 5th fingers
What is “Normal” Flexibility?
• Flexibility is the range of motion available at a joint or series of joints
• Hypermobility vs. Hypomobility
• Spectrum like hypertension
Modified Marshall Test Micheli Score • Look at passive
thumb abduction of the right hand
• Grade 1 = 0° • Grade 2 = 45° • Grade 3 = 90° • Grade 4 = 135° • Grade 5 = thumb
touches forearm • Can use + or – for
in between grades
Common Pictures
Hyperlaxity • OVERUSE &
Postural problems • Associations with
subluxation of the hip, patella, shoulder, and proximal cervical spine, osteoarthritis, chondrocalcinosis,
• Bad sprains
Tight • Patellofemoral
syndrome, hamstring and quad strains
• Tendinopathies • Osgood-Schlatter’s
disease, Sever’s disease and peripelvic apophyseal avulsion fractures
Multidirectional instability
Stability Tests
Sulcus sign (MDI)
No Sens / Spec Data
Subtalar Tilt test
Posture
• Lines: ear lobe-acromion-iliac crest
• Lordosis, kyphosis
• Pelvic inclination - ASIS lower than PSIS
Rehab, rehab, rehab
Strengthening • Core stability • Postural exercises
– Upper Back
• Proprioception exercises • Endurance / conditioning • Ergonomic assessment at
work ? Chronic pain
Take Home Points
• Always think about Posture • Check for flexibility • Consider hypermobility syndrome • Use physical therapy
You may not have seen it, but it has seen you.
• Problem with Look, Feel, Move ?
• Worry especially if problems greater than 6 months
• No relief or worse with physiotherapy
• Internal derangement symptoms
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