A solid history and physical exam, several quick tests to localize pain, and a management plan that incorporates physical therapy can produce good outcomes without resorting to surgery.
During the session “A Lot Riding on My Shoulders,” presented at the 2013 Pri-Med East Conference and Exhibition, Frank Domino, MD, presented slides titled: “Shoulder Pain: Evidence-Based Evaluation and Management.” Domino is attending physician at the Umass Memorial Medical Center, and Professor and Clerkship Director in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester, MA.
Domino used PowerPoint slides, some plastic models, and a black marker to draw on “Mike”—a muscular body builder for his demonstrations. This along with his mandate not to take notes but to watch and participate provided an excellent adult-learning environment for the hundreds of health care providers packed into the ballroom.
Domino said that because there was no good curriculum for shoulder diagnosis 10 years ago, he and two colleagues from the sports medicine program developed this course material. He emphasized that it came from sports medicine research, not his own research. Domino said he takes a conservative approach to treatment of shoulder injuries, noting, “If the patient gets better without surgery, then it is a homerun.” Only after the patient fails conservative treatment does he recommend surgery.
The majority of the injuries that Domino typically sees are impingement syndrome (former name: rotator cuff tendonitis) (>70%), adhesive capsulitis or “frozen shoulder” (12%), and bicipital tendonitis (4%). His first recommendation for diagnosis was to forget about the “sensitivity and specificity” in the literature, but instead to take a quick solid history and do a physical exam (observe, palpate, range of motion)—that will provide the correct answer 90% of the time. He described and demonstrated diagnostic tests with Mike: empty can, Neer, Hawkins, apprehension (stop when the patient becomes anxious or fearful), and Speeds. These quick tests can localize the pain very quickly. His second recommendation was to use the “line of age.” If the patient is over 25 years, it is probably impingement; if the patient is under 25 years it is probably instability or dislocation (the head of the humerus destabilizes).
Proclaiming “Let me teach you so you never forget!”, Domino reviewed the tendons, ligaments and musculature, using plastic models, live model Mike (using a black marker and drawing on his skin), and had the audience follow along and probe deep into their own shoulders. He also reviewed motion and position—supination (‘soup’ bowl!), pronation, flexion, and extension—using his own body, Mike’s body, and the models (again with the audience imitating). Then a review of the acronym SITS for the four muscles of the rotator cuff (because it is on every board exam)—supraspinatus, infraspinatus, teres minor, subscapularis—using Mike and the black marker.
Domino recommended taking a conservative treatment approach first, outlining the steps to take: (1) eliminate the cause (his reminder was Henny Youngman’s “don’t do that”), (2) control the pain (NSAIDS, acetaminophen, corticosteroids), (3) stretch, and (4) rehabilitation.
Domino said he believes strongly in physical therapy, and told the audience, “Good physical therapy can save you from surgery.” The patient can attend physical therapy sessions if insurance allows or be taught to perform the exercise themselves. For example, only a doorknob, a towel, and an exercise band are needed to start rehabilitation of a shoulder injury.
Domino emphasized how easy it was to learn to give a glenohumeral joint injection. Most use the lateral approach; however, as arthritis can block the space needed to inject the steroid, he advised using a posterior lateral approach to avoid bone and move through soft tissue only. He said with this approach, ultrasound wasn’t needed for guidance—that it was easy to do blindly as one can actually feel the aimed-for space and easily “hit the spot.” Mike was used again—black marker lines were drawn on his skin to show the relevant anatomy, which Domino compared to the plastic anatomy models held side-by-side. Then he showed a demonstration video from the “5 Minute Clinical Consult” series with himself as the subject of the injection (Domino is currently the Editor in Chief).
Regarding treatment and recovery, Domino emphasized several times, “If it takes a long time to get bad, it will take a long time to get better.”