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The Complex Shoulder Simplified

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Presentation on theme: "The Complex Shoulder Simplified"— Presentation transcript:

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

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 Sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic joints. Thin capsule. Subacromial bursa. Rotator cuff tendons attach to humeral tuberosities.

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

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 Supraspinatus – abduction (also with deltoid). Infraspinatus and teres – external rotation. Subscapularis – internal rotation.

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

9 Active range of motion Forward flexion Abduction/adduction
Painful arc of abduction – sensitive, not specific External rotation Internal rotation Flexion – arms outstretched, up in front. Abduction – to the side. External rotation – either the penguin, or putting hands behind back (like relaxing). Internal rotation – have pt use thumb to touch the highest point on the spine. Apley scratch test does both abduction and external rotation – reach behind head and touch the superior angle of the opposite scapula. Can touch the inferior angle of the opposite scapula for testing of internal rotation and adduction.

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 Preventing scapula from moving isolates the GH joint. When abducted – internal rotation is pointing down, external rotation is pointing up.

11 Physical Exam External Rotation Infraspinatus Teres Minor

12 Physical Exam Supraspinatus 45 Degrees from front

13 Physical Exam Impingement Greater Tuberosity under acromion

14 Physical Exam Cross Arm Test Specific for AC Joint

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 Bicipital tendonitis – pain at long head of the biceps.s

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

17 Trauma Shoulder Dislocation Fracture

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

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 Instability Unidirectional Multidirectional

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

28 Overuse Repetitive Motion Microtrauma Deconditioning

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

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 Previous Surgery Rotator Cuff Re-tear Shoulder Stabilization

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

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 U/S limitations include with fat patients or small tears.

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 No overhead positioning, reaching, lifting. Steroid injection could possibly weaken tendon, but Up to Date says there is no influence on tendon healing. Rotator cuff is NOT necessary for most normal activities of a sedentary life.

36 Injection Subacromial Space GH Joint 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

37 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

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

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 X-rays: could see evidence of calcific tendonitis or degenerative changes that would suggest problems that could eventually lead to frozen shoulder.

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 Exercise – (1) weighted pendulum exercises, (2) passive stretching. Up to 50% will respond to exercise therapy.

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 Biceps – elbow flexion and supination.

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 Bicipital groove is about 1” below the anterolateral tip of the acromion. Pts can seem weak because of pain.

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 Usually proximal end of the long head ruptures.

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 Surgery rarely necessary since flexion strength only minimally decreased and it usually ends up being a cosmetic issue. Can get slight improvement in elbow flexion and supination.

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 RA – morning stiffness, better with activity. Shoulder sx in RA is common, especially in late stages of dse.

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 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

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

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.

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

52 Thank You Manish A. Patel, MD, FAAOS Office: (757) 562-7301
Pager: (757) Cell: (215)

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