Transcript Slide 1
Managing Shoulder
Pain
Jesse Affonso, MD
©2011 Cape Cod Healthcare Inc.
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Objectives
• Review relevant
anatomy
• Discuss common
causes of pain
• Treatment
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Anatomy – Bony Architecture
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Anatomy – Soft Tissues – Rotator Cuff
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Introduction
• Shoulder pain is an extremely common
complaint (2nd most)
• Difficult joint to examine
• Multidirectional range of motion
• It is important to make an accurate
diagnosis of the cause of your
symptoms so that appropriate treatment
can be directed at the cause
©2011 Cape Cod Healthcare Inc.
Where is the pain coming from?
• Pain arising from the shoulder
• Rotator cuff disorders: rotator
cuff tendinopathy, impingement,
subacromial bursitis, rotator cuff
tears
• Glenohumeral disorders:
capsulitis ("frozen shoulder"),
arthritis, infection (rare)
• Acromioclavicular disease
• Traumatic dislocation
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Where is the pain coming from?
• Pain arising from elsewhere
• Referred pain: neck pain,
myocardial ischemia, referred
diaphragmatic pain
• Polymyalgia rheumatica /
fibromyalgia
• Malignancy: apical lung
cancers, metastases
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Shoulder Examination
• Look
• Feel
• Move
• Active + Passive
• Resisted
Symptoms:
Pain overhead
Pain and weakness
Pain with anything
Duration of symptoms
• Special Tests
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Shoulder Pain - Diagnoses
• Impingement / Bursitis
• Rotator Cuff Tendinitis / Tendinopathy
• Rotator Cuff Tear – Partial vs. Full
thickness
• Adhesive Capsulitis
• Arthritis
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Impingement / Bursitis
Repetitive overhead
activities
Subacromial bursa and/or
rotator cuff impinged
between acromion &
humerus
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Impingement
Impingement
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Impingement - Treatment
• Activity modification: no activity with
elbow away from side, in the gym, or
at the computer.
• Once a day stretch fully overhead.
• NSAID and Ice
• Injection in 3-6 weeks
• Physical Therapy: After pain
subsides:
• Regain ROM / Strengthen
• Surgery
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Rotator Cuff Disease
• Rotator cuff disease
is a large spectrum
from tendinitis to full
thickness tears
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Rotator Cuff Tears – How to tell?
• Pain and Weakness
• Does this mean a Rotator
Cuff Tear?
• Cannot assess rotator cuff
when there is pain
• Treat pain first: NSAID, PT,
ice, rest-4 weeks
• Cortisone shot (once) if
above doesn’t work
• Test cuff when pain
subsides.
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Rotator Cuff Tendinitis - Treatment
• Physical Therapy / Activity
Modification
• Anti-inflammatories
• Ice / Heat
• Tylenol
• Steroid Injections
• Repeat
• Surgery
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Rotator Cuff Tear
Acute vs. Gradual
Repetitive overhead activity or
by wear and degeneration of the
tendon.
Over time the pain may become
noticeable at rest or with no
activity at all
There may be pain when you lie
on the affected side and at night
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Rotator Cuff Tear
• Atrophy or thinning of the muscles about the
shoulder
• Pain when someone lift the arm
• Pain when someone lower the arm from a fully
raised position
• Weakness when someone lift or rotate the arm
• Crackling sensation when someone move his
shoulder in certain positions
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Rotator Cuff Tear
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MRI?
Based on:
duration of symptoms
location
patient age
severity
physical exam
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Rotator Cuff Tear
• Pain relief
• Improve the function of shoulder.
• It may take several weeks or months to restore the strength and
mobility to ones shoulder.
•
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Rest and limited overhead activity
Anti-inflammatory medication
Steroid injection
Strengthening exercise and physical therapy
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Adhesive Capsulitis
Frozen shoulder (adhesive
capsulitis) is a disorder
characterized by pain and
loss of motion or stiffness in
the shoulder.
It affects about two percent
of the general population.
It is more common in
women between the ages of
40 years to 70 years old.
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• The causes of frozen
shoulder are not fully
understood.
• The process involves
thickening and contracture
of the capsule surrounding
the shoulder joint.
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Adhesive Capsulitis
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• Frozen shoulder occurs much more commonly in
individuals with diabetes, affecting 10 percent to 20 percent
of these individuals.
• Other medical problems associated with increased risk of
frozen shoulder include: hypothyroidism, hyperthyroidism,
Parkinson's disease, and cardiac disease or surgery.
• Frozen shoulder can develop after a shoulder is injured or
immobilized for a period of time.
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Adhesive Capsulitis
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• Pain due to frozen shoulder is usually dull or aching.
• It can be worsened with attempted motion.
• The pain is usually located over the outer shoulder area and
sometimes the upper arm.
• The hallmark of the disorder is restricted motion or stiffness in
the shoulder.
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Adhesive Capsulitis
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• The first goal is pain control.
• To restore motion, physical
therapy is usually started.
This may be under the
direct supervision of a
therapist or via a home
program.
• Therapy includes stretching
or range-of-motion
exercises for the shoulder.
Sometimes heat is used to
help decrease pain.
©2011 Cape Cod Healthcare Inc.
Adhesive Capsulitis
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• Nerve blocks: Suprascapular nerve block
• Surgical: manipulation under anesthesia and shoulder
arthroscopy
• Often, manipulation and arthroscopy are used together in
combination to obtain maximum results
• After surgery, physical therapy is important to maintain the
motion that was achieved with surgery
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Shoulder Arthritis
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• Age: > 65
• Male > Female
• Monoarticular
• Account for 60% of Total Shoulder
Replacements
• 5% with Rotator Cuff tears
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Shoulder Arthritis
• Patient Age
• Severity of Symptoms
• Radiographs
• Medical Co morbidities
• Patient Characteristics
Viscosupplementation (HA)
• Hyaluronic Acid
• Variable injection schedule
• Theoretical benefit is to improve lubrication in the joint
• FDA approved for the knee, and has some scientific
support
Wang et al: JBJS 2004
Metaanalysis, confirmed efficacy and safety of treatment
• Minimal literature on usage in the shoulder
Shibata et al (JSES 2001) found it to be equal to corticosteroids
in those with rotator cuff tears
Silverstein et al AJSM 2007
• 30 patients w/ idiopathic glenohumeral OA
• Statistically significant improvements in VAS, UCLA
score, and Simple Shoulder Test Score at 6 months
• ~50% had less than 2 point improvement in VAS
• No complications
• Conclusion: HA may have a beneficial effect on some
patients with glenohumeral OA
• Reasonable option in patients that are not surgical
candidates
Arthroplasty Options
Hemiarthroplasty
Reverse Total
Shoulder
Total
Shoulder
Summary
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• Shoulder pain is a common
complaint and can be multifactorial
• Proper diagnosis is key to
treatment
• Nonsurgical treatment is the first
line
• Surgery only after nonsurgical
treatments fail
©2011 Cape Cod Healthcare Inc.
Contact Information
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• Jesse Affonso
• [email protected]
• Cape Cod Orthopaedics & Sports
Medicine
• 130 North Street
• Hyannis, MA 02601
• 508-775-8282
©2011 Cape Cod Healthcare Inc.