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

Overview

• • • Most mobile joint in body Most dislocated joint Stability – Bony articulation – Ligamentous – Muscular

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

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

Labrum

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

Subacromial Space

• Bursa – Subacromial space – Source of pain down arm

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

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

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

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

Physical Exam

• External Rotation – Infraspinatus – Teres Minor

Physical Exam

• Supraspinatus – 45 Degrees from front

Physical Exam

• Impingement – Greater Tuberosity under acromion

Physical Exam

• Cross Arm Test – Specific for AC Joint

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

Etiology of Shoulder Pain

• • • • • Trauma Overuse Chronic Previous Surgery Instability • • • • Neck Pain Infection Dislocation Frozen Shoulder

Trauma

• • Shoulder Dislocation Fracture

Treatment

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

Shoulder Dislocation

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

Shoulder Dislocations

• Mechanism?

– Anterior vs. posterior • Forced abduction, external rotation, extension • Forced adduction, internal rotation

Shoulder Dislocations

• Dislocation vs. Subluxation?

Shoulder Dislocations

• Defects following dislocation?

– Hill-Sachs – SLAP – Bankart – Rotator Cuff Tear – Fractures

Shoulder Dislocations

• Hill-Sachs lesion – Posterior lateral aspect – Compression

Shoulder Dislocation

• Superior Labrum Anteroposterior Lesion (SLAP) – Affects biceps

Shoulder Dislocations

• Bankart Lesion – Arthroscopic vs. open – Anterior labrum

• • Unidirectional Multidirectional

Instability

Shoulder Dislocations

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

• • • Repetitive Motion Microtrauma Deconditioning

Overuse

Chronic Pathology

• • • Impingement Biceps Pathology Arthritis – Trauma or Overuse • • Rotator Cuff Syndrome Frozen Shoulder

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

Previous Surgery

• • Rotator Cuff Re-tear Shoulder Stabilization

RC Tear

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

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

Rotator cuff tears

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

Injection

• 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

Treatment

• • • • • 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

Frozen Shoulder

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

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

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

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

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

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

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

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

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

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

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

Treatment

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

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.

• Ref for Shoulder: Burkhart, Stephen MD et al, Arthroscopic Rotator Cuff Repair, Journal of American Academy of Orthopedic Surgery, Vol 14, No 6, June 2006, 333 346.

Iannotti, JP et al, Partial-thickness tears of the rotator cuff: evaluation and management, Journal of American Academy of Orthopedic Surgery 1999; 7: 32-43 Bedi, Asheesh et al, Massive Tears of the Rotator Cuff, The Journal of Bone and Joint Surgery (American). 2010;92:1894-1908 .

Thank You

Manish A. Patel, MD, FAAOS Office: (757) 562-7301 Pager: (757) 562-8047 Cell: (215) 519-9317 Email: [email protected]