07. Musculoskeletal Medicine Dr. Chris Smith Vietnam Sept. 2012
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Harvard
Medical
School
Musculoskeletal Care for the General
Doctor: Shoulder and Knee Pain
C. Christopher Smith, MD, FACP
Associate Professor of Medicine,
Harvard Medical School
Beth Israel Deaconess Medical Center
Harvard
Medical
School
Disclosure of Financial Relationships
C. Christopher Smith, MD
Have no relationships with any entity producing,
marketing, reselling or distributing health care goods
or services consumed by, or used on patients.
Harvard
Medical
School
The Painful Shoulder and Knee
Recognize, diagnose and treat the most common
causes of shoulder and knee pain in the primary
care setting
Know how to differentiate among other common
causes of shoulder and knee pain
Harvard
Medical
School
The Painful Shoulder and Knee
Anatomy
History
Differential based on patient’s age, location of
pain and other historical elements
Physical exam maneuvers
Initial treatment
Harvard
Medical
School
Shoulder Pain
Harvard
Medical
School
A 65-year-old woman with a history of type II DM
presents for evaluation of new left shoulder pain. The
pain is in her anterior and lateral shoulder and has
gradually worsened over the last three weeks. It is
dull and constant and keeps her up at night. She also
notices marked discomfort when she combs her hair
and cannot get clothes from a high shelf due to pain
and weakness. She denies any trauma or prior
injuries. She works as a shop keeper.
Harvard
Medical
School
Anatomy of the Shoulder
UpToDate, 2006
Harvard
Medical
School
Harvard
Medical
School
The Rotator Cuff Muscles
UpToDate, 2006
Harvard
Medical
School
Causes of Shoulder Pain
Acromioclavicular
Osteoarthritis
Adhesive Capsulitis
Biceps Tendonitis
Brachial Plexus Neuritis
Cervical Radiculopathy
Glenohumeral Arthritis
Instability
Impingement Syndrome
Systemic Inflammatory
Disorders
Referred Pain -
Diaphragmatic,
Subdiaphragmatic and
Intrathoracic Causes
Harvard
Medical
School
In the primary care setting, what is
the most common cause of
nontraumatic shoulder pain?
A. Bicipital Tendonitis
B. Impingement Syndrome
C. Adhesive Capsulitis (Frozen Shoulder)
D. Osteoarthritis of the Glenohumeral Joint
E. Acromioclavicular Joint Osteoarthritis
Harvard
Medical
School
In the primary care setting, what is
the most common cause of
nontraumatic shoulder pain?
A. Bicipital Tendonitis
B. Impingement Syndrome
C. Adhesive Capsulitis (Frozen Shoulder)
D. Osteoarthritis of the Glenohumeral Joint
E. Acromioclavicular Joint Osteoarthritis
Harvard
Medical
School
Causes of Shoulder Pain in the Primary
Care Setting:
Impingement Syndrome > 70%
Adhesive Capsulitis 12%
Bicipital Tendonitis 4%
A/C Joint OA 7%
Other 7%
Smith, J Gen Intern Med, 1992
Harvard
Medical
School
So what is impingement syndrome?
Harvard
Medical
School
Impingement Syndrome
UpToDate, 2006
Harvard
Medical
School
Typical History of Impingement
Syndrome
Any age, but risk increases with age
Anterior or lateral shoulder pain
Pain exacerbated by abduction and forward
flexion
Night pain common
Harvard
Medical
School
Age and Shoulder Pain
Young (< 30 y.o.)
• Dislocations/Instability of Glenohumeral Joint
• Separation of AC joint
• Overuse injury
Less Young (30-60 y.o.)
• Impingement Syndrome
• Adhesive Capsulitis (especially in diabetics)
• Separation/Overuse as above
Older (> 60 y.o.)
• Impingement Syndrome (non-traumatic tears)
• Adhesive Capsulitis
• Systemic Conditions (if bilateral, PMR, RA)
Harvard
Medical
School
Physical Exam
Inspection
Palpation
ROM
• Difference between passive and active
Pain active > passive ROM likely soft tissue disorder
Pain equal with active and passive ROM likely intra-
articular process
Strength and Sensation
Specific Maneuvers to Confirm Diagnosis
Harvard
Medical
School
Maneuvers to Verify Impingement Syndrome
Empty Can Test
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Medical
School
Maneuvers to Verify Impingement Syndrome
Neer’s Test
Neer, Clin Orthop 1983
Harvard
Medical
School
Treatment
Reduce offending activities
Physical Therapy
• Aimed at improving mechanical dysfunction and
shoulder motion
NSAIDs or Subacromial injection
• Each is better than placebo
• Little long term difference
• No benefit in combination treatment
White, J Rheumatol 1986
Petri Arthritis Rheum 1987
Harvard
Medical
School
Supraspinatus Tendon Tear
• Positive “Drop-Arm” Test
• Supraspinatus weakness
• External Rotation weakness
• Impingement Signs
• Greater than 60 years old
Murrell, Lancet 2001
Harvard
Medical
School
Diagnosing Rotator Cuff Tear
# Positive signs* Age Probability of
rotator cuff tear
All 3 Any 98%
Any 2 > 60 98%
Any 2 < 60 64%
Any 1 > 70 76%
Any 1 < 40 12%
None Any 5%
* supraspinatus weakness, weakness in external rotation,
positive impingement signs
Murrell, Lancet 2001
Harvard
Medical
School
A 55-year-old male with IDDM, HTN and GERD
presents with three months of worsening left
lateral shoulder pain, which is worse at night.
He reports pain with most any movement.
Range of motion testing reveals pain and
restricted movement in most directions.
Symptoms are present with both passive and
active movement.
Harvard
Medical
School
Adhesive Capsulitis or Frozen Shoulder
• Thickening and contraction of the capsule
surrounding the glenohumeral joint
• Insidious onset of pain
• Night pain
• Pain in deltoid, but no tenderness to palpation
• Pain and limited active and passive ROM
• Need AP X-ray of glenohumeral joint to rule
out glenohumeral arthritis
• Treatment: Physical Therapy
