Transcript New Concepts and Advances (Arthroscopic) for the Treatment

New Concepts and
Advances (Arthroscopic)
for the Treatment of
Shoulder Pain
William F Bennett MD
The Simple Shoulder
 While a complex joint with complex
function, general approaches to determining
the non-descript, cause….is easy!
 I.e., intrinsic versus extrinsic
Intrinsic versus Extrinsic
 Intrinsic- later and more descript…means
pain coming from the shoulder joint itself
 Extrinsic- pain that may cause shoulder pain
but comes from sources outside the
shoulder
Extrinsic
 Most common- cervical spine
 Pancoast tumors of the lung
 Thoracic spine
 Peritoneal/Splenic irritation can cause pain at
Erb’s point
 Angina/MI
 Metabolic/Oncologic problems, ie., bone marrow
involvement like lymphoma/leukemia, parathyroid
Extrinsic-Cervical Spine
 General rule-
-trapezial pain-cervical
-deltoid pain- intrinsic or from the shoulder
Can have both shoulder and cervical spine
affected which makes it more difficult
Cervical spine may have radicular
involvement
Intrinsic
 Once extrinsic has been ruled out then one
can focus on the intrinsic causes.
 If a certain shoulder motion whether it be
flexion, abduction, external rotation or
internal rotation causes pain in the deltoid
area and not in the trapezial area, one is
probably dealing with an intrinsic problem
Before discussing intrinsic
Causes
Lets diverge and discuss the anatomy
and function of the shoulder
Anatomy
 4 joints-two are articulations
– Glenohumeral joint
– Acromioclavicular joint
– Scapulothoracic articulation
– Sternocalvicular articulation/joint
– Discuss Bones-Bone models
Ligaments/Capsule
 Capsule is the “sac”
– Normal sac allows motion in various planes
– Abnormal sac restricts motion in various planes
 Ligaments- hold bone to bone
– Glenohumeral ligaments
– Coracohumeral ligaments
– Coracoacromial ligaments
– Coracoclavicular ligaments
Muscles/Tendons
 Rotator Cuff are a confluence of 4 tendons from
the following respective muscle bellies
–
–
–
–
Supraspinatus
Subscapularis
Infraspinatus
Teres minor
– Biceps
– Deltoid
Bone models
Bursae/Cartilage/Meniscus
 Subacromial Bursae
 Subdeltoid bursae
 Subcoracoid bursae
 Glenohumeral articular
cartilage
 Acromioclavicular meniscus
Intrinsic Diagnoses
 Impingement
– Tendonitis
– Bursitis
– Rotator Cuff tear-complete
– Rotator Cuff tear-partial
– others
Intrinsic Diagnoses
 Acromioclavicular joint irritation/arthritis
 Glenohumeral joint osteoarthritis
 Rheumatologic joint
 Pigmented Villonodular synovitis
 Chondrometaplasia
 Tumors-giant cell, synovial sarcoma
Intrinsic Diagnoses
 Instability/Subluxation-repetitive/chronic
Atraumatic/multidirectional
 Dislocation
– Traumatic unidirectional
 Biceps
– Inflammation
– Instability/subluxation
– Tendonitis/avulsion
Intrinsic Diagnoses
 History compatible
 Physical exam compatible
 Radiologic exam compatible
 MRI/MRA compatible
 Less so- blood work, others
– Each is a piece of the puzzle
Physical Exam
 Observation
 Palpation
 Range of Motion
 Strength Test
 Specific Tests for lesions
 Hoppenfeld- Examination of the Extremies
Treatment
 “ITIS”- inflammation- tendonitis, bursitis
– Rest, avoidance, NSAIDS, injections, therapy
 Osteoarthritis- above plus possible total shoulder
replacement, ac joint
 Rotator Cuff Tears-above +/- repair
 Instability/Dislocation-+/- repair
 Frozen Shoulder
 Biceps Inflammation
– The arthroscope has become an important tool for
diagnosis and treatment in virtually all afflictions of the
shoulder
Arthroscope
 Fiber optic device
 Triangulate-the surgeon never sees the
actual inside of the joint- it is projected
upon a monitor and as such, the working
tools, “triangulate’ to the point of focus
 Minimally invasive
 Less pain
 Less rehabilitation
Treatment
 Nsaids- short-term
 Physical therapy
 Injections
 Surgery
Physical Therapy
Treat InflammationIontophoresis
Treat Tight Areas
Stretch
Treat Weakness
Strentghen- rotator cuff muscles
scapular stabilizers
Injections
 Must have correct diagnosis
 Patient may have more than one pain
location
 Lidocaine Injection test
 Areas–
–
–
–
Subacromial space
Glenohumeral joint
Ac joint
Bicipital sheath
Shoulder Pain-traditionally was
treated with long delays in
surgical intervention-Why?
 Shoulder pathology not well understood
 Open repair required extensive incisions
 Rehabilitation was long
– Most importantly, in times past, the primary
care givers was, in general, “under-theimpression” that shoulder surgical intervention
was not that effective
Arthroscopic Intervention
utilized in
 Impingement-bursitis, tendonitis
 Rotator cuff tears
 Instability or dislocation
 AC joint arthritis
 And yes even in Osteoarthritis
Arthroscope has allowed for the
further identification of subtle
shoulder pathology, previously
not identified
 See articles1) Bennett WF. Subscapularis, Medial
and Lateral Head Coracohumeral
Ligament
Insertion
Anatomy:
Arthroscopic
Appearance
and
Incidence of "Hidden" Rotator
Interval Lesions. Arthroscopy. 2001
Feb. 17(2) 173-180
2) Bennett WF. Visualization of the
Anatomy of the Rotator Interval.
Arthroscopy. 2001 17 107-111
Arthroscopic Prospective
outcomes are now Published
 See ArticlesBennett WF: Arthroscopic Repair of Bennett WF: Arthroscopic Repair of
Complete Anterosuperior
Rotator Cuff Tears. 2 Year Follow-up.
Arthroscopy, January 2003
Bennett WF: Arthroscopic Repair of Complete Subscapularis Tears. 2 Year
Follow-up.
Arthroscopy, February 2003
Bennett WF: Arthroscopic Repair of Complete Supraspinatus Tears. 2 Year
Follow-up.
Arthroscopy, March 2003
Bennett WF: Arthroscopic Repair of Massive Rotator Cuff Tears. 2-Year
Follow-up
Arthroscopy, April 2003
Natural History of Rotator Cuff
Tears
 Recurrence of pain
 Tears get bigger with time
 Results of surgical intervention deteriorates
with time
 Muscle turns to fat
 Tendon becomes inelastic
At this Point
 Most recently anatomy surrounding the
rotator cuff and its interrelationship with the
bicipital sheath has been identified,
clarified, classified, arthroscopic reapir
techniques developed and outcome studies
published.
 At this point I will move to the details of
clinical research that I have been
performing for the last 12 years.