X-Ray

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​

  • 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​

  • 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​

  • 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

    • 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