Chronic Scapulothoracic Painor

Chronic Shoulder Pain

Steve Moll, DOSenior Medical OfficerUSS SAIPAN (LHA-2)

Chronic Scapulothoracic Pain

At the conclusion of this activity, you should:

Appreciate the degree to which myofascial painsyndromes from the scapulothoracic region can cause shoulder pain.

Understand the importance of treating predisposing factors in myofascial pain syndromes.

Know that successful treatment requires a multi-factorial approach.

The Shoulder...

The shoulder consists of four joints:

1.Glenohumeral

2.Acromioclavicular

3.Sternoclavicular

4.Scapulothoracic

It’s not just a “Joint,” but a “Complex.”

Differential Diagnosis

Shoulder pain arising from problems:• Intrinsic to the A-C / glenohumeral joints, or

• Extrinsic “ “ “ “(“referred pain” patterns)– Somatic– Visceral

Differential Diagnosisacromioclavicular arthritisacromioclavicular separationadhesive capsulitisadhesive capsulitisapical lung tumorsavascular necrosisaxillary vein thrombosisbicipital tendonitisbiliary tract diseasebrachial neuritisbrachial plexopathycalcific tendonitiscephalobrachialgiacervical root compression (esp.C5)

cervicodorsal sympathalgiacoronary artery disease & anginacostoclavicular syndromedislocationfibromyalgiaforward head syndromefractures: clavicle, scapula, humerusglenohumeral arthritis - crystal-induced - osteoarthritis - post-traumatic - rheumatoid - septic

Differential Diagnosisglenohumeral instability

- AMBRI- TUBS

impingement syndromelabral tears (SLAP tear)levator scapulae syndromelumbar facet syndromemyofascial pain syndromeParsonage-Turner syndromepneumoniapolymyalgia rheumaticareflex sympathetic dystrophy

rotator cuff tearscapulocostal syndromeshoulder instabilitysnapping shoulder syndromespinal cord lesionssplenic lesionssubacromial bursitissupraspinatus nerve compressionsupraspinatus tendonitisswimmer’s shoulderthoracic outlet syndrometumor

History & Physical Exam

History

What’s new or different in the 6 months prior to the onset of pain?

History

What’s new or different in the 6 months prior to the onset of pain?- New job? Longer hours in front of the computer? - New car? Longer commute? - New duty station (shipboard)? Running shoes? - Raked leaves? - More stress? Less/poorer sleep? - Marital conflict? - Different pillow? - Pregnancy?

History

What occupies the majority of your day?

How much time do you spend- sitting?- talking on the phone?

- driving?, or- being ‘driven nuts’?

History

• Is there a time of the day when your is pain better? Worse?

• How well do you sleep?

Physical Exam

- ROM (active & passive)

- Strength

- Special tests (lift off; Neer; Hawkins; cross-body adduction; “empty can”)

Physical Exam

- ROM (active & passive)

- Strength

- Special tests (e.g. lift off; Neer; Hawkins; cross-body adduction; “empty can”)

- Palpate

- Posture

Travell Trigger Points (TrPs) & Myofascial Pain Syndrome

• TrP: "a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is tender when pressed and can give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena.

• Palpation is a reliable diagnostic criterion for locating TrPs.

Travell Trigger Points (TrPs) & Myofascial Pain Syndrome

Etiology of TrPs:1. Local myofascial tissues

- Motor end plate dysfunction cascade5

- from genetic defects, or- acquired defects (nicotine, caffeine,

psychological & physiological stress2. CNS factors (central sensitization)4,5

3. Biomechanical factors

Referred pain patterns

Treatment

Direct Tx of TPs

- pressure

- injection

- dry needling

- massage

Treatment of Perpetuating Factors

Treatment of Perpetuating Factors

Postural stresses

• Psychological stress

• Mechanical factors

• Constriction of muscles

• Social habits

Treatment of Perpetuating Factors

Postural stresses- poor posture - misfitting furniture- immobility - frequent repetitive movements

Treatment of Perpetuating Factors

Psychological stress

- hopelessness

- depression

- anxiety & tension

Treatment of Perpetuating Factors

Mechanical factors

- SI dysfunctions

- hemipelvic disparities

- limb length discrepancy

- Morton's foot (long second metatarsal)

Treatment of Perpetuating Factors

Social habits

- nicotine

- caffeine

- alcohol abuse

Conclusion

The Family Practice Physician

is eminently qualified to successfully manage

the multifactorial problems which plague the chronic pain patient.

Common Concomitants

Forward Head SyndromeForward Head SyndromeMyofascial Pain (Scapulothoracic) SyndromeMyofascial Pain (Scapulothoracic) SyndromeRotator Cuff SyndromeRotator Cuff SyndromeThoracic facet syndrome (somatic dysfunction)Thoracic facet syndrome (somatic dysfunction)

Treatment (cont’d)

• Fix the SLEEP problem!No sleep. No relief. No hope.

• Raise SEROTONIN levels.

• Treat the depression &/or anxiety.

Treating Insomnia• R/O Obstructive Sleep Apnea

• Trazodone (Desyrel)– Allow self-titration– Explicit verbal & written instructions– Treatment failures?…

Bipolar until proven otherwise.• TCAs (nortriptylene; amitriptyline)• Gabapentin (Neurontin)

• Zolpidem (Ambien)

• SSRIs

Boosting Serotonin Levels

• SSRIs– Start early– Escalate doses, as tolerated

• “Yes… this is an ‘anti-depressant’.” “No… I don’t think you’re depressed.”“I am giving this to you as an adjunct…”