1. The Complex Shoulder Simplified Manish A. Patel, MD, FAAOS Assistant Professor – Eastern Virginia Medical School Chief of Surgery-Southampton Memorial Hospital (757) 562-7301 www.SouthamptonOrtho.com

2. Overview • Most mobile joint in body • Most dislocated joint • Stability • Bony articulation • Ligamentous • Muscular

3. Review of shoulder anatomy • Bones • Scapula • Clavicle • Humeral head • Posterior rib cage • Joints • Sternoclavicular • Acromioclavicular • Glenohumeral • Scapulothoracic

4. 25% humeral head surface in contact with glenoid Joint space thinning seen with OA Humeral head coverage increased to 75% with glenoid labrum Glenohumeral Joint

5. Labrum • Glenoid Labrum • Dense, fibrous structure • Oval • Deepens glenoid fossa • Stability

6. Subacromial Space • Bursa • Subacromial space • Source of pain down arm

7. Rotator cuff muscles • Supraspinatus, infraspinatus, teres minor, subscapularis • Form cuff around humeral head • Keeps humeral head within joint (head depresser) • Abduction, external rotation, internal rotation

8. Physical Exam • Visualize from front and back • Asymmetry • Pts with rotator cuff tears hold shoulder higher • Atrophy • Sign of chronic glenohumeral joint pathology • Effusions • Shoulder joint can hide a lot of fluid

9. Active range of motion • Forward flexion • Abduction/adduction • Painful arc of abduction – sensitive, not specific • External rotation • Internal rotation

10. Passive range of motion • Immobilize the scapula to prevent rotation • Use one arm to push down on shoulder • Use other arm to do the PROM exercises • Abduction • Internal and external rotation • Have arm at patient’s side and abducted to 90 degrees

11. External Rotation Infraspinatus Teres Minor Physical Exam

12. Supraspinatus 45 Degrees from front Physical Exam

13. Impingement Greater Tuberosity under acromion Physical Exam

14. Cross Arm Test Specific for AC Joint Physical Exam

15. Biceps Strength Testing • Arms outstretched with palms up at level of shoulder • Forced supination of hand with elbow flexed at 90 degrees • Can be positive for SLAP Test

16. Trauma Overuse Chronic Previous Surgery Instability Neck Pain Infection Dislocation Frozen Shoulder Etiology of Shoulder Pain

17. Shoulder Dislocation Fracture Trauma

18. Fractures – Not all require surgery Surgical options includes (Rods / Plate / Partial vs complete replacement) Treatment

19. Shoulder Dislocation • Fast Facts • 50 % of ALL dislocations • 95 % anterior • 85 % caused by trauma recur • Posterior think seizures or direct trauma

20. Shoulder Dislocations • Mechanism? • Anterior vs. posterior • Forced abduction, external rotation, extension • Forced adduction, internal rotation

21. Shoulder Dislocations • Dislocation vs. Subluxation?

22. Shoulder Dislocations • Defects following dislocation? • Hill-Sachs • SLAP • Bankart • Rotator Cuff Tear • Fractures

23. Shoulder Dislocations • Hill-Sachs lesion • Posterior lateral aspect • Compression

24. Shoulder Dislocation • Superior Labrum Anteroposterior Lesion (SLAP) • Affects biceps

25. Shoulder Dislocations • Bankart Lesion • Arthroscopic vs. open • Anterior labrum

26. Unidirectional Multidirectional Instability

27. Shoulder Dislocations • Chronic Instability – Increasing laxity due to repeat incidents, trauma, genetics, or neuromuscular deficits • Signs and Symptoms • Sport • Clicking • Pain • Weakness

28. Repetitive Motion Microtrauma Deconditioning Overuse

29. Impingement Biceps Pathology Arthritis Trauma or Overuse Rotator Cuff Syndrome Frozen Shoulder Chronic Pathology

30. Impingement syndrome • Compression of rotator cuff tendons and subacromial bursa between greater tuberosity and acromion (type 3) • Repetitive overhead motions • Main cause of rotator cuff tendonitis • Can lead to bursitis, partial or full rotator cuff tears

31. Rotator Cuff Re-tear Shoulder Stabilization Previous Surgery

32. Rotator Cuff Tear (Most Common) – Night Pain Pain Radiating up / down Numbness Weakness Decrease Motion 50+ age group RC Tear

33. Radiology for rotator cuff tears • Interpret carefully • 34% asymptomatic pts (all ages) and 54% pts >60 yo have partial rotator cuff tears • Abnormal rotator cuff signal after trauma may represent strain rather than tear • X-rays • Look for high riding humeral head • Ultrasound • Highly operator dependent • MRI

34. Rotator cuff tears

35. Tx of rotator cuff tears • Ice, NSAIDs, restrict aggravating motions • Weighted pendulum • No arm slings • Steroid injection • Surgery – refer if young pts, full/large tears, dominant arm • Best if done within 6 weeks • Acromioplasty and debridement

36. Subacromial Space 22 Gauge needle 1.5” 10 cc total vol. 40 mg kenelog Post placement Aim for Coracoid GH Joint Spinal needle 3” 10 cc total vol. 40 mg Kenelog Straight Aim Posterior placement Beware of Diabetics Injection

37. Rotator Cuff / Biceps – Good clinical Exam to Start Conservative Options – PT / Injections / Meds Xray and MRI helpful Surgery (Arthroscopic only way to these days in my opinion) Rehab Course Better Treatment

38. Frozen Shoulder – Diabetics Decrease range of motion in all planes Pain with any motion 40-50 age group Frozen Shoulder

39. Radiology for adhesive capsulitis • X-rays have limited use • Might see calcifications or degenerative changes that would lead to frozen shoulder • MRI • Enhancement of joint capsule and synovial membrane • 4 mm thickening is 70% sensitive and 95% specific

40. Tx of adhesive capsulitis • Watchful waiting • Up to 2 years for resolution • Incomplete recovery more likely in pts with DM, or pts with >50% loss of external rotation/abduction • Steroid injection (2 locations) • Manipulation under anesthesia • Aggressive therapy • Pain medication

41. Biceps tendonitis • Inflammation of long head of biceps • Passes through bicepital groove of anterior humerus • Usually due to repetitive lifting or reaching • Inflammation, microtearing, degenerative changes • Up to 10% pts will have spontaneous rupture • Popeye deformity

42. Sx of biceps tendonitis • Anterior shoulder pain • Worse with lifting or overhead reaching • Often pts point to bicepital groove • Usually no weakness in elbow flexion

43. Exam for biceps tendonitis • Bicipital groove tenderness • Look for subacromial impingement • Tendon rupture • Test biceps strength • Yergason test • Elbows flexed with forearms in front • Pt actively resisting external rotation • Tendon may pop out of bicipital groove when downward pressure applied to forearm

44. Ruptured biceps tendon • Usually rotator cuff tear also present • Get the “popeye” sign • Rarely get significant weakness • Brachioradialis and short head of biceps provide 80-85% elbow flexor strength • Tx is supportive

45. Tx of biceps tendonitis • Reduce inflammation • Strengthen biceps muscle and tendon • Prevent rupture • Ice, NSAIDs, avoid aggravating motions • 5-10% risk of rupture with noncompliance • Weighted pendulum • Elbow flexion toning exercises • Steroid injection • Surgical referral if sx persist >3 months

46. Glenohumeral Osteoarthritis • Same risk factors as with OA in other areas • Trauma, obesity, age • Less common than OA in weight bearing joints or spine • Pain, stiffness over months to years • Anterior shoulder is most painful area • Worse with activity • Distinguish from RA, adhesive capsulitis

47. Exam for Glenohumeral OA • GH joint line tenderness and swelling • Just below coracoid process • Use outward and upward pressure • Effusion may be very hard to see • Decreased ROM • External rotation, abduction • Endpoint stiffness • Crepitus

48. Joint space narrowing (loss of articular cartilage) Osteophytes Humeral head sclerosis and flattening Club-like deformity Goat’s Beard on X-ray Imaging for glenohumeral OA

49. Arthritis – From trauma or genetic Conservative – PT (sometimes) / Injections / Meds / Lifestyle modification Surgery – Partial vs Total (Reverse Shoulder) Rehab Treatment

50. Glenohumeral Joint Infection • Very rare • Increased incidence in diabetics, immuno-compromised patients. • Shoulder looks normal, just bigger. • SEVERE pain. Any motion hurts. • Often a fever. Get labs (CBC, blood cultures, ESR, CRP), XR, then: • Get a consult.