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Shoulder Pain: Common conditions

Shoulder Pain: Common conditions. Marc Labbé, M.D. Taylor Brown, M.D. Presented at The Health Museum 4/19/2012. Shoulder Pain: Common conditions. Anatomy Evaluation Conditions Impingement Frozen Shoulder Calcific Tendinitis Rotator Cuff Tear Instability Arthritis Fractures

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Shoulder Pain: Common conditions

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  1. Shoulder Pain:Common conditions Marc Labbé, M.D. Taylor Brown, M.D. Presented at The Health Museum 4/19/2012

  2. Shoulder Pain:Common conditions Anatomy Evaluation Conditions Impingement Frozen Shoulder Calcific Tendinitis Rotator Cuff Tear Instability Arthritis Fractures Review/Tips

  3. Anatomy: overview • tendons connect muscles to bones to move joints that are surrounded by bursae

  4. Anatomy: Bones • Humerus • Clavicle • scapula

  5. Anatomy: Tendon • Cord that connects muscles to bone

  6. Anatomy: Bursa • Fluid filled sac • Cushion between bones and overlying soft tissues • Reduces friction • Allows increased motion

  7. Shoulder Physiology • Muscles control position of shoulder blade and humerus • Stability is a balance of ligaments and muscles

  8. Shoulder Pathology • Posture • Muscular weakness • Proper Working Position

  9. Shoulder Evaluation • History • Injury • Duration • Specific Limitations • Area of Pain

  10. Shoulder Evaluation • Examination • Motion • Strength • stability

  11. Shoulder Evaluation • X-Rays

  12. Shoulder Pain:Common conditions • Impingement • Frozen Shoulder • Rotator Cuff tear • Instability • Arthritis • fracture • Codman –Supraspinatus and the Subacromial Bursa 1934

  13. Impingement Syndrome • “Tendonitis” • “Bursitis” • “Bone spur”

  14. Impingement Syndrome • Men = women • Any age • Weeks to months

  15. Impingement Syndrome • Ache • Activity related • Night pain

  16. Impingement Syndrome • Started after Too much… • Computer use • Gardening • Heavy lifting • Tennis • Golf • Throwing • fishing

  17. Impingement Syndrome • “bone spur” • Acromion rubs on the rotator cuff and bursa • bursitis and tendonitis early • rotator cuff tear over time

  18. Impingement Syndrome • Impingement signs • Neer • Pain with passive forward flexion while internally rotated • Hawkins • Pain with passive internal rotation while abducted 90 degrees • AJSM 2003

  19. Impingement Syndrome Diagnose with history, physical exam, xrays, and a likely successful result with conservative treatment • Codman –Supraspinatus and the Subacromial Bursa 1934 • Bigliani – JSES 2008

  20. Impingement Syndrome • Initial treatment • Relative rest • Ice • Anti-inflammatory medications • cortisone injection • Physical therapy

  21. Impingement Syndrome • 90% successful with non-operative treatment • Shot • Medicine • Exercises/Posture Correction

  22. Impingement Syndrome • Cortisone Injection • primary indication is difficulty sleeping • 70% improved with a single shot • 20% better with a second shot • If no better, Check MRI • Consider arthroscopic subacromial decompression if symptoms persist

  23. Impingement Syndrome • Arthroscopic subacromial decompression • 30 minute day surgery • General anesthesia and a nerve block/pain pump • Sling 2-4 weeks • No restrictions • Begin rehab exercises immediately • 2-3 months to feel better

  24. Impingement Syndrome • Arthroscopic subacromial decompression • Cutting block technique • Caspari 1992

  25. Impingement Syndrome Frozen Shoulder

  26. Shoulder Pain:Common conditions • Impingement • Frozen Shoulder • Rotator Cuff tear • Instability • Arthritis • fracture

  27. Frozen Shoulder Adhesive capsulitis • Capsule surrounding shoulder ball and socket scars and “shrink wraps” itself inhibiting full motion and causing pain

  28. Frozen Shoulder • Severe pain • Front of Shoulder • constant • stiff • Getting worse • May or may not know why

  29. Frozen Shoulder • No injury • Shortly after minor injury • following breast or heart surgery

  30. Frozen Shoulder • 40 - 60 years old • Women > Men • Thyroid disease • Diabetes • Heart disease • Will Occur on Opposite Side 30% of Time

  31. Frozen Shoulder • Three phases • Inflammatory • Frozen • Thawing Davis mountains

  32. Frozen Shoulder • Loss of exernal rotation • Passive and active motion loss • Normal strength

  33. Frozen Shoulder • Initial treatment • Time • 18+ months to spontaneous resolution • Pain medicine • Cortisone injections • 2-3 • Stretching • May help or worsen

  34. Frozen Shoulder • Arthroscopic capsular release with manipulation • If not improved with initial conservative measures • Capsule and ligaments are partially excised • Stretched to full motion while anesthetized • Cortisone Injection

  35. Frozen Shoulder • Arthroscopic capsular release with manipulation • Sling 2-4 weeks for comfort only • Immediate motion • Immediate therapy to maintain motion • Capsulitis may grow right back without stretching

  36. Calcific Tendonitis • Rare • Calcium buildup inside tendon • Cortisone injection • Arthroscopic removal

  37. Shoulder Pain:Common conditions • Impingement • Frozen Shoulder • Rotator Cuff tear • Instability • Arthritis • fracture

  38. Rotator Cuff Tear • Detachment of the tendon from the bone • Does not heal on own • Acute: single injury greater than threshold • Chronic: long term overuse, wear and tear

  39. Rotator Cuff Tear • history • Injury (25%) • Pain without injury (75%) • Loss of overhead or behind the back activity without pain

  40. Rotator Cuff Tear • Symptoms • Pain: anterior superior shoulder or deltoid insertion • Rest • Night • activity related • Weakness or disability • instability

  41. Rotator Cuff Tear • Exam findings • Weakness/Pain • Active motion loss/Pain • Passive motion maintained

  42. Rotator Cuff Tear • Diagnosed with • History • Exam • Xrays • Mri (or ultrasound)

  43. Rotator Cuff Tear Full thickness Partial thickness

  44. Rotator Cuff Tear • Nonoperative • cortisone injection • physical therapy • oral analgesics • Temporary relief • It will get worse with time

  45. Rotator Cuff Tear Arthroscopic rotator Cuff Repair

  46. Rotator Cuff TearArthroscopic rotator Cuff Repair

  47. Rotator Cuff TearArthroscopic rotator Cuff Repair • Sling 1 month • Healing 3 months • 98% with small tears • 50-85% with large tears • Maximum recovery 6 – 12 months

  48. Rotator Cuff Tear • Arthroscopic Rotator cuff tear Repair: predictors of success • Tear size • Small < 1.5 cm • Large >3 cm • Age of Tear • Muscle and Tendon Atrophy • Patient age • <62 years • Tobacco usage

  49. Rotator Cuff TearArthroscopic Allograft Cuff Augmentation

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