Shoulder | Basics of Ortho

Impingement Syndrome

Cause/Pathophysiology
- Repetitive use, especially overhead
- Acute or chronic
- Inflammation of the subacromial bursa and rotator cuff tendons
History and symptoms
- Usually a chronic mechanism (painting, raking, trimming limbs, etc.) but can be acute
- Pain when raising arms overhead or sleeping on side
- +/- pain at rest
Exam Findings
- Pain with AROM and PROM overhead
- + Neer, Hawkins tests
- + rotator cuff testing
Imaging
- X-Rays - No acute findings but type 2 or 3 acromion may be present and predispose
Treatment
- First Line
  - Reduce inflammation - RICE, NSAIDs
  - PT
- Second Line
  - Subacromial cortisone injection
- Third Line
  - Surgery
Common ICD-10 codes
- M75.40

Subacromial/Subdeltoid Bursitis

Cause/Pathophysiology
- Repetitive use, particularly overhead
- Acute or chronic
- Inflammation of subacromial bursa
History and symptoms
- Usually an acute or chronic mechanism (painting, raking, trimming limbs, etc.)
- Pain when raising arms overhead or sleeping on side
- +/- pain at rest
Exam Findings
- Pain with ROM overhead
- + Neer, Hawkins tests
- - rotator cuff testing
Imaging
- X-Rays - No acute findings but type 2 or 3 acromion may predispose
Treatment
- First Line
  - Reduce inflammation - RICE, NSAIDs
  - PT
- Second Line
  - Subacromial cortisone injection
- Third Line
  - Surgery

Common ICD-10 codes
- M75.50

Rotator Cuff Tendonitis/Tendonopathy

Cause/Pathophysiology
- Repetitive use, particularly overhead
- Acute or chronic
- Inflammation of the rotator cuff tendons - Tendonitis
- Chronic micro-damage to rotator cuff tendons - Tendonopathy
History and symptoms
- Usually an acute or chronic mechanism (painting, raking, trimming limbs, etc.)
- Pain when raising arms overhead or sleeping on side
- +/- pain at rest
Exam Findings
- Pain with ROM overhead
- - Neer, Hawkins tests
- + rotator cuff testing (resisted ROM, empty can)
Imaging
- X-Rays - No acute findings but type 2 or 3 acromion may predispose
- MRI - if conservative treatment fails, beneficial to make sure there is no tear
Treatment
- First Line
  - Reduce inflammation - RICE, NSAIDs
  - PT
- Second Line
  - Subacromial or Intraarticular cortisone injection
- Third Line
  - Surgery

Common ICD-10 codes
- S46.099

Rotator Cuff Tear

Cause/Pathophysiology
- Acute - traumatic injury
- Chronic - progressive micro-tearing associated with repetitive use
History and symptoms
- Acute - usually associated with a trauma (fall, MVA, etc.)
- Pain when raising arms overhead or sleeping on side
- +/- pain at rest
- Pain with lifting away from body ("I can't lift the milk jug out of the refrigerator")
- Varying degrees of weakness
Exam Findings
- Pain with ROM, particularly with ABD overhead
- AROM may be limited, but PROM should be full
- Weakness with ABD, FF, ER at side (best indicator of significant tear in my opinion)
- + rotator cuff testing (drop arm, empty can)
Imaging
- X-Rays - may be normal or have high-riding humeral head if tear is chronic and longstanding
- MRI or MRI arthrogram (better if suspect a small tear or patient has history of previous repair)
- Ultrasound or CT arthrogram if patient cannot have MRI
Treatment
- First Line
  - Acute
    - work up and surgical repair, especially if patient is younger
  - Chronic
    - Inflammation/pain reduction - NSAIDs or non-opioid analgesics or Subacromial cortisone injection
    - PT
- Second Line
  - Chronic
    - Surgical repair

Common ICD-10 codes
- M75.100

Labral Tear/SLAP (Superior Labrum Anterior to Posterior) tear

Cause/Pathophysiology
- Acute - traumatic injury, can be a sequela of dislocation
- Chronic - progressive micro-tearing associated with repetitive use
History and symptoms
- Acute - usually associated with a trauma/dislocation (fall, MVA, etc.)
- Pain when raising arms overhead or sleeping on side
- +/- pain at rest
- Pain with lifting away from body ("I can't lift the milk jug out of the refrigerator")
- Frequently see in those that were/are throwing athletes or weighthlifters
Exam Finding:
- +/- pain with ROM, particularly FF
- +/- O'Brien's, Crank test
Imaging
- X-Rays - usually normal
- MRI arthrogram
Treatment
- First Line
  - Inflammation/pain reduction - NSAIDs or non-opioid analgesics or Intraarticular cortisone injection
  - PT
- Second Line
  - Surgery - repair or debridement with biceps tenodesis

Common ICD-10 codes
- S43.439

Bicipital Tendonitis/Tendonopathy

Cause/Pathophysiology
- Inflammatory (tendonitis) or micro-trauma/degenerative (tendonopathy) condition of the long head proximal biceps tendon tendon
- Repetitive use
- Can be acute or chronic in nature
- Frequently in conjunction with rotator cuff disease
History and symptoms
- History of repetitive use
- Difficulty lifting
Exam Findings
- Pain with motion, particularly ABD, FF, possibly forearm supination
- + Speed's, Yerguson's
- TTP over long head biceps tendon in bicipital groove
Imaging
- X-Rays negative
- MRI if no improvement with conservative treatment
Treatment
- First Line
  - Reduce inflammation - RICE, NSAIDs
  - PT
- Second Line
  - Cortisone injection
- Third Line
  - Surgery - tenodesis or tenotomy

Common ICD-10 codes
- S46.199

Biceps Tendon (Long head) Tear

Cause/Pathophysiology
- Acute or chronic
- Chronic is a result of longstanding tendonitis/tendonopathy
- Usually occurs when lifting
History and symptoms
- Usually a pop or tearing sensation felt
- Pain with use of arm
- May have noticed a deformity
Exam Findings
- Proximal deformity (muscle balled up distally)
- Ecchymosis if acute
- +/- Speed's, RC, impingement testing
Imaging
- Clinical diagnosis
- Can be confirmed with US or MRI, but not necessary in most cases
Treatment
- First Line
  - Mostly, conservative with RICE, NSAIDs
  - PT
- Second Line
  - Cortisone injection
- Younger, active patients, with an acute injury may benefit from primary tenodesis

Common ICD-10 codes
- S46.109

Acromioclavicular Sprain

Cause/Pathophysiology
- Injury to the acromioclavicular alone or in conjunction with the coracoacromial ligaments
  - Type I - no displacement, AC ligament
  - Type II - ~50% displacement, AC ligament complete, CC partial
  - Type III - 100% displacement, AC and CC complete
- Fall onto point of the shoulder
History and symptoms
- MOI
- Pain, particularly with raising arm above shoulder height, across body, or behind back
Exam Findings
- +/- step-off deformity
- +/- swelling
- +/- ecchymosis
- TTP over AC Joint
- Pain with ABD and FF overhead, IR behind back
- + Scarf test, +/- Piano key sign
Imaging
- X-Ray - +/- AC displacement, depending on severity
  - Bilateral weighted X-Ray may be better for revealing severity
Treatment
- Mostly conservative with RICE, NSAIDs
- Surgery may be beneficial for younger active populations for Type III injuries

Common ICD-10 codes
- S43.50XA

Glenohumeral Osteoarthritis

Cause/Pathophysiology
- Chronic degeneration of the humeral head and/or glenoid articular cartilage
History and symptoms
- Gradually worsening pain over years
- +/- motion limitation
Exam Findings
- +/- TTP anterior/posterior shoulder
- +/- AROM and PROM limitation
- +/- crepitus
- Strength may be normal if rotator cuff is intact
Imaging
- X-Ray - decreased glenohumeral joint space, +/- osteophytosis
Treatment
- First Line
  - NSAIDs
  - PT - limited benefit
- Second Line
  - Cortisone injection
- Third Line
  - Surgery - anatomic total (intact RC) or reverse total (RC not intact) shoulder arthroplasty

Common ICD-10 codes
- M19.019

Acromioclavicular Osteoarthritis

Cause/Pathophysiology
- Chronic degeneration of articular cartilage of AC Joint
History and symptoms
- Pain with overhead activity, reaching across body or behind
- Pain with lying on side
- Can be associated with history of AC Joint sprain
Exam Findings
- +/- hypertrophic AC Joint
- TTP over AC Joint
- Pain with ROM overhead
- + Scarf/Crossarm test
Imaging
- X-Ray - Joint space loss, +/- hypertrophic changes
Treatment
- First Line
  - NSAIDs
  - Ice/heat
  - PT - limited benefit
- Second Line
  - Cortisone injection
- Third Line
  - Surgery - total (intact RC) or reverse total (RC not intact) shoulder arthroplasty

Common ICD-10 codes
- M19.019

Glenohumeral Dislocation

Cause/Pathophysiology
- Dissociation of the humeral head on the glenoid, due to a failure of the stabilizing mechanisms (RC, labrum, GH ligaments)
- Usually anterior
- Frequently due to an injury with the shoulder abducted and externally rotated
History and symptoms
- MOI
- Pain
- Inability to move, particularly ABD, ER
Exam Findings
- Deformity
- TTP
- Decreased ROM
- +/- decreased deltoid sensation due to axillary nerve injury
Imaging
- X-Ray - AP, Axillary, Scapular Y views - Humeral head usually anterior and inferior to glenoid
- MRI arthrogram if chronic instability
Treatment
- Reduction using one of several techniques - my personal preferences are the Stimson External Rotation Maneuvers
- Sling
- PT

Common ICD-10 codes
- S43.006A
- M24.419 - recurrent dislocation
- M25.319 - shoulder instability

Adhesive Capsulitis (Frozen Shoulder)

Cause/Pathophysiology
- Gradual contraction/fibrosing of the soft tissue around the glenohumeral joint
- Generally, idiopathic
History and symptoms
- Progressive shoulder pain and stiffness
Exam Findings
- Decreased PROM and AROM
- Pain with end range motion
- Generally strength and rotator cuff are unaffected
Imaging
- X-Ray - AP, SOV, axillary
  - Clinical diagnosis, but X-Ray can be helpful in ruling out significant glenohumeral osteoarthritis
Treatment
- Conservative options - Vast majority of cases resolve in time but can take a year or more
  - NSAIDs
  - PT
  - Intra-articular cortisone injection
  - Brisement procedure

Common ICD-10 codes
- M75.00

FRACTURES

Clavicle Fracture

Cause/Pathophysiology
- Trauma - frequently a fall onto the shoulder
- Mid-shaft - most common
History and symptoms
- MOI
- Pain
- +/- deformity
- Difficulty using arm
Exam Findings
- +/- deformity
- Swelling
- +/- ecchymosis
- TTP
- +/- creptitus
- MAKE SURE NO SKIN BLANCHING AND SKIN IS MOBILE AT FRACTURE SITE, IF ANGULATED SPIKE
Imaging
- X-Ray
Treatment
- Historically, conservative treatment with sling
- Recent push to consider ORIF for significant displacement and/or young active population

Common ICD-10 codes
- S42.009A

Proximal Humerus Fracture

Cause/Pathophysiology
- Trauma - fall, usually FOOSH or onto elbow
- Most common locations are surgical neck, greater tuberosity
History and symptoms
- MOI
- Pain at rest, worsened with movement
Exam Findings
- +/- deformity
- +/- ecchymosis
- swelling
- decreased mobility with pain
- TTP
- +/- crepitus
Imaging
- X-Ray - usually all that is necessary for diagnosis and monitoring
- CT - evaluate for more complex fracture patterns involving humeral head, amount of displacement
Treatment
- Sling/immobilizer for most non or minimally displaced fractures x 6 weeks
- Surgery - significantly displaced, intra-articular (if step-off), younger and active

Common ICD-10 codes
- S46.209A

Humerus Shaft Fracture

Cause/Pathophysiology
- Trauma - fall, MVA, etc.
History and symptoms
- MOI
- Pain
Exam Findings
- +/- deformity
- +/- ecchymosis
- TTP
- +/- creptius
- Guarding
- MAKE SURE RADIAL NERVE MOTOR AND SENSORY FUNCTION IS INTACT (wrist and finger extension and sensation on dorsal radial hand
Imaging
- X-Rays
Treatment
- Most can be treated conservatively with bracing if radial nerve function is intact
- Surgery if significant displacement, radial nerve injury

Common ICD-10 codes
- S42.399A

Impingement Syndrome

Subacromial Bursitis

Rotator Cuff Tendonitis

Rotator Cuff Tear

Labral Tear

Bicipital Tendonitis

Proximal Biceps Tendon Tear