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