Our next lectures are going to be on the diagnosis of common shoulder pain as well as imaging of common shoulder pain. And it's going to be kind of a tag team between these next two speakers, Dr. Sherman and Dr. Tu. So Dr. Sherman completed his internship in physical medicine residency at the University of Washington in Seattle, and then went on to complete a fellowship in spine and sports and musculoskeletal rehabilitation at Beth Israel Hospital in New York. And then he began his tenure at the University of Miami Miller School of Medicine, where he is currently a professor and the vice chair of education for the physical medicine and rehabilitation department. So he is very active in the Florida Academy of Physical Medicine and Rehabilitation, where he currently serves as a vice president and the annual assembly program director. He's currently busy with an academic clinical practice specializing in spine, sports, neuromuscular, and musculoskeletal disorders. And he also performs interventional procedures, injections, and electrodiagnostic testing. He is a very well-known local, regional, and national speaker. So we're very honored to welcome him and his colleague, Dr. Tu, who is board certified in sports medicine and physical medicine and rehabilitation. And he is an assistant professor at the University of Miami Miller School of Medicine. He's been a covering physician for various sporting events, including the US National Figure Skating Championships, as well as the New York City, Boston, and Chicago Marathons. So he is focusing on preserving and restoring function to patients of all ages and abilities. So please join me in welcoming Dr. Sherman and Dr. Tu. Thank you. And good, good morning, everybody. And thanks for inviting us to give this talk. I don't think anyone can tolerate me for an hour. So we thought we would split these up into two, really four smaller talks, because then we'll go on and do treatment after diagnosis. There's some overlap to these talks, but not too much. And so I will start out with basic diagnosis and then hand it over to Dr. Tu, whose expertise is in ultrasound imaging and some of the higher, as we say, higher, more technical aspects of PM&R. I'm not sure how many are in the audience live, because I can't see you. You can see me. But for those in the audience, we do have 30, I think 32 on Zoom, which is a great number. And one last thing, thank you for plugging the FSPMR. If those of you who do live in Florida, who may not know about that, we do have a actual Florida Society of PM&R, and we do have an annual meeting in Tampa as well, coming up in August. And so we have a whole set of activities, and you're all encouraged to join us there. And we have a great time for the weekend in, actually, July, end of July, not August. So what we're talking today about, let me see if I can just, there we go, is shoulder, We have many shoulder fellows, spend a whole year talking about the shoulder, and we have just a couple hours. So we'll see what we can get through, and hopefully learn a little bit from that. And this is actually, I can't start our talk without saying that I have nothing to disclose, but now I can't start our talks anymore without at least showing off our new facility, which is the Lynn Rehabilitation Center down in Miami, a very beautiful 80-bed facility, and can be actually 100 if they build the last floor up. But it's really nice to finally work in a modern facility after 20 years, and be able to provide rehab in Miami at a high level. So when we talk about shoulder pain, or shoulder injury, shoulder disorders, how does the patient present to your office? Do they say, well, and we see this with the spine a lot, patient comes in and says, well, I have a herniated disc, and they show you an MRI scan. Well, what does that mean? Considering that, especially in the osteopathic world, you spend four years learning the ins and outs of musculoskeletal diagnosis, and structures, and how they function. And the patient just presents you a scan and says, that's what I have. Well, in the shoulder, the analogy would be, well, I have a MRI that says I have a torn rotator cuff tendon, I have a torn supraspinatus tendon. Well, what does that mean? The patient really presents you with, and they present with pain, weakness, instability, and a lack of range of motion. So they look like that, and here's somebody at the bottom with a lack of range of motion. And from that, you create your differential diagnosis. And oh boy, we're actually, you realize in thinking that there's a lot of stuff here. This is not just shoulder pain, and we always hear this garbage, these, we call them garbage pale terms, because you just throw them all into one pail, and say shoulder pain. But that shoulder pain is medicine, and there is a whole array of different diagnostic possibilities that can occur, depending on your history, physical exam, and imaging studies. There are medical causes. Now that's a real issue. Is it shoulder pain at all? And here we see big red, heart attack, that's a problem. Could this be referred pain from cancer? We've seen upper lobe cancers in the lung refer to the shoulder. Could this just be a rheumatological, a systemic problem? Or is it a traumatic problem? So we see patients with dislocations, or maybe months later after dislocation with instability. We see patients with acute slap tears, which are in the cartilage of the shoulder. And then there's the most common. So when we talk about a practice in musculoskeletal medicine, PM&R, office-based practice, 90% of what we're seeing is, and maybe more, is non-traumatic overuse, osteoarthritis, AC joint, clinic humoral joint, overuse. Are we talking about tendinitis, tendinosis? What's the difference? Frozen shoulder versus instability. Obviously, two opposite ends of the spectrum. And neurogenic, we see a lot of nerve problems. And we just heard about the suprascapular nerve block as helping shoulder pain. But is this actually a nerve problem causing shoulder pain? So how do we investigate the diagnosis? For all the younger people in the room, there was a guy once called Sherlock Holmes. And us older people know who that is. He was a detective. That's a picture. So what do we start with? Well, we start with the history. And the first thing that we really emphasize is ruling out red flags, making sure we don't miss anything. And anything ominous like cancer or infection or anything neurological that might suggest a C5 palsy or axillary nerve problem. So really, we want to get all the information related to that. And this nice slide shows you that. Betsy will get these slides, and we'll make them available to you. So then your general physical exam, inspection, range of motion, palpation, neurological exam, and special tests. And then that's how you systemically go through doing your exam so you don't miss anything. And this is what I emphasize to my residents, is if you hit all these five things, you should not miss anything and then be able to make a nice stab at a diagnosis. And this is a patient with an atrophied shoulder that you see on inspection and atrophied infraspinatus. So again, on inspection, for some of the benign conditions, we see uneven shoulder. Sometimes we see this most commonly. So this I can certainly write a book on. This is maybe the great problem seen in sedentary workers in this country. And compressed anterior chest wall, shoulders rounded, and muscles between the scapula become lengthened. And what does this all do? Causes the scapula inferior tip and medial border of the scapula to pop up away from the rib cage. So what does this have to do? This isn't a neck pain lecture. This is a shoulder pain lecture. What does kyphosis have to do with shoulder pain? Well, the evidence suggests that, always go back to the evidence, that individuals with shoulder impingement syndrome had a greater thoracic or cervical thoracic kyphosis and less extension range of motion than age and gender matched healthy controls. And so that is, and there's more evidence. For all these evidence slides, I'm just picking one representative study. So then we look at range of motion. So there's direct glenohumeral range of motion. So we could pick up adhesive capsulitis causing shoulder pain. Or on the other hand, we could have instability, which can cause shoulder pain. Oh, and then there's that scapula again, scapular thoracic range of motion. We learned that from Dr. Sink, how important that is. Three studies identified significant increases in scapular upward rotation on the affected side of subjects with adhesive capsulitis as compared to the non-affective side. And what about glenohumeral instability? You mean instability can come from the scapula too? Sure, four studies identified significantly less scapular upward rotation or significantly greater scapulohumeral rhythm ratio indicative of a lesser scapular upward rotation component in the subjects with glenohumeral instability. And then we go to palpation, local tenderness versus referred pain. So if the patient says it hurts here, does it hurt there? Or is it referred pain? Gallbladder, irritating the phrenic nerve, sending pain to the shoulder, just one option that could be referred pain. And then neurological. Well, C5 radiculopathy, pain goes right to the shoulder. Even C6, the pain goes right to the shoulder. C7, we start to really see, even in C6, this pain to the scapula and the shoulder. So wait, they're all causing pain to the shoulder. Yes. Axillary neuropathy, so impingement of the axillary nerve causing either atrophy or pain from many different areas, the most common being a old dislocation. Or suprascapular nerve impingement. And here we can do electrodiagnostic testing. So if you talk to your shoulder surgeons, they're wondering, why didn't my patient get better after I did this wonderful, beautiful shoulder repair? And maybe there's a suprascapular nerve problem. And so often we're asked to do, before they do surgery, we're often asked to do the suprascapular nerve study to make sure there isn't an impingement functionally in the patient before they undergo surgery. And the suprascapular neuropathy has been reported to cause 1% to 2% of all shoulder pains, therefore overlooked. However, the prevalence is higher risk. And this is where we talk about our sports population in certain athletic players, such as volleyball, where it can be as high as 33%. I mean, that was pretty shocking, actually. So if you take care of volleyball players, you have to look out for this. And then finally, neurological thoracic outlet syndrome. Scolanus medius, crunching all of the structures can cause shoulder pain as well. And brachial plexopathy, this is a neurogram showing inflammation, this white where the arrow is of the brachial plexus causing pain, weakness, atrophy in the shoulder. Well, then we get to the best part of what we do, the fun part, I guess. We've ruled all that stuff out. Now we want to make a specific diagnosis of what is causing the pain. Which ligament, which tendon, which, is it the joint? Is it instability? So we've created these special tests. And these tests are, we got a ton of names and a ton of tests, I can't go over all of them. I can say that often these tests are years ago, and I want a special shout out to Rob Gotland, who asked me to do this study, who may or may not be in Tampa with you all. Hello, Rob, if you're there. But years ago, when I was his fellow, 25 years ago, yes, I did a fellowship under an osteopathic physician and learned a lot, and it was 24 years ago. And we presented a talk back then to the AAP Menar on special shoulder tests, where we debunked all of them to some degree, as being based on small case series where the tests were named after the surgeon who did it. I did this test, I did two cases, the case had this, and I call it my test, okay. And it was a fun talk and very educational as well, but still we use the tests. And there are a little more studies that have been done in the last 20 years about just what these tests do. And what we find is that they have actually high sensitivity for abnormalities, pain, instability, numbing, as you recreate the numbness, but what really limits these tests is the low specificity. And most often it's due to overlapping syndrome. People have many pain causes. How many patients have you seen come back with an MRI scan where it says, okay, there's eight different things. I think the radiologist may get paid for each of the things, and it's a slap tear and arthritis and rotator cuff arthropathy and tendinopathy of three different tendons and the biceps tendon. So, due to these overlapping syndromes, it reduces the specificity of any single test. That's why it's helpful to do multiple tests and ultimately where imaging is so important that you'll hear from Dr. Tu. So what are some of these tests just to have a little fun? And so you have some ammunition to go back with you if you're not so knowledgeable about these. So first test is for, we call it shoulder impingement. Near's test, Hawkins-Kennedy test for impingement to assess the impingement of soft tissue structures. Notice it's not being specific about a particular tendon. Could be infraspinatus, could be supraspinatus. Either way, a positive test is painful. And these are the two different motions, Near and Hawkins-Kennedy, two famous surgeons, of course. And here's another show of a Hawkins-Kennedy impingement test pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament and coracoid process, pain being that. And here, this shows that the sensitivity of each was 79%, but the specificity in this particular study was only 59 or 60%. Here's Job's test, another surgeon. Empty can test. We hear this a lot. First described in 1983 and sets out to preferentially test the supraspinatus, although isolated from the deltoid is difficult and most commonly affected tendon, usually. Again, sensitivity of 94% and a specificity of, I'm not sure how you can get 44%. That's like less than 50-50, but I don't know. That's what this study published. And then this one's very common for people who have this history of dislocated shoulder, anterior, you push forward and if they get apprehension in the externally rotated position, then that's suggestive of instability. Posterior, now remember with instability, we have anterior instability, but there's also posterior instability. And so this test up here is showing what's called the jerk test or jump test, and they're pushing backward to see if there's instability posteriorly with 90 degree flexion. This is one of the more controversial tests to say that it's actually not so specific and very sensitive to shoulder pathology in general. So O'Brien's test. So here you're flexing the glenohumeral joint and you're abducting, and then here's your thumb down and here's your thumb even. And if the pain is with internal rotation and decreases with external rotation and there is clicking, that's a slap lesion and pain in the AC joint indicates AC pathology. Biceps tendinopathy, sometimes overlook that anterior pain. And there's two tests that we know of, Speed's test and Jaegersen's test. And here you're just applying a downward force on the speeds and they're performing a opposite pronation, supination force on the Jaegersen. And here's the sensitivity, 80% and specificity, 43%. Oops. Range of motion testing. I mean, these tests are great when the patient has range of motion. If there's no range of motion, they're not able to do this test. And so we all know about the internal rotation where we first take one hand, see how high you can go up and then the other hand, see how high you can go up. And if one is less than the other, then it's abnormal. And one thing to know again, sports medicine, tennis players will always, just normally from playing tennis for over a dozen years, will have an abnormal test, Apley's scratch test and have reduced internal rotation. It's not really clear why that's the case. It may be because of the severe pronation at the level of the shoulder and the elbow with the top spin shot for years and years and years and years and years, causes a reduction of internal rotation. And then finally, the lateral scapular slide test. And we're gonna be really focusing on this area a lot in our next talk when we talk about rehabilitation treatments. But this is a test to see designed by Kibler in 1998, who is a surgeon, but really has works with a number of physical therapists and physiatrists who've really focused on the scapula and scapular pathology as a source of shoulder pain. And multiple studies suggest that the lateral scapular spine test has good interrelator validity and reliability, but actually doesn't really correlate with shoulder pathology. And so often we're seeing if one scapula is moving while the other scapula is stable or vice versa as a indicator of shoulder pathology. So in summary, diagnosis with history and physical balances sensitivity with a lack of specificity. And where does that leave us? Well, we do detect red flags for more serious condition. And if we are able to do that, then we can move on to what we call the fun stuff of using our toolkit to improve pain and dysfunction. And the HMP, even as being less specific, you combine a bunch of the tests together, you begin to narrow down differential diagnosis so that you can be smart about directing the imaging and expensive studies. So maybe you don't waste studies or you can direct your ultrasonography test to the most likely area of pathology that makes sense for your patient. And with that, I'm going to pass it over to Dr. Tu for our discussion on the imaging. And one question was, do you find the combination of multiple tests increases specificity? And the answer is that makes intuitive sense. However, we don't have any studies that have been published to confirm that.

shoulder pain diagnosis

imaging techniques

physical exams

ultrasound

Dr. Sherman

Dr. Tu