3 Anatomy It is a multiaxial ball and socket joint The shoulder has the greatest degree of movement of any joint in the bodyIt is a multiaxial ball and socket joint
4 Anatomy of four muscles that surround the humeral head. The Rotator Cuff is a setof four muscles thatsurround the humeralhead.They function to helpabduct and rotate thearm and also functionas dynamic stabilizersof the joint.
5 Instability, Impingement & DJD Think of all soft tissue shoulder disorders tofall in three broad categories:InstabilityImpingementDJDThe Age of the patient generally places themin each of these categories
6 Shoulder InstabilityMostly cccurs in younger patients <30 years of ageThe extreme form of this is a shoulder dislocationCan cause secondary tendonitis and labrum and cartilage tearsAnterior instability is the most common 95 %Usually occurs when the patient raises their arm overhead in a throwing positionSubluxation vs DislocationDislocation has to be reduced
7 Shoulder InstabilityHistory, the patient is “apprehensive” about putting their arm overheadHistory of previous anterior dislocationsPhysical Exam positive apprehension test improved when posterior pressure is applied over the anterior aspect of the shoulder
10 Shoulder Instability < 20 Years For dislocators < 20 years old there is a 90% chance of redislocation. As one ages the chance of redislocation lessensIn this high risk group, surgical repair and capsular tightening is recommendedArthroscopic techniques have advanced significantly over the past several years
11 Shoulder Instability > 30 Years Anterior Dislocations for first time dislocators over the age of 30, a trial of physical therapy followed by reevaluationAfter a course of PT, On PE if the pt still has a positive apprehension sign this is an indicator that the capsule is stretched and the IGHL complex is not functioning properly
12 Shoulder Instability > 50 Years In patients older than 50 who have a dislocation, concomitant rotator cuff tear at the time of injury needs to be ruled outIf there is a small tear, a trial of therapy can still be initiated to regain motion and strengthen the periscapular musclesIn older patients >65 with a dislocation surgery is usually not necessary and the treatment is physical therapy with rehab12
13 ImpingementOveruse type injuries which occur in the middle aged individualAs the arm is abducted the rotator cuff tendons and biceps tendon abut (impinge) against the acromion causing inflammation in the bursa and wear of the RTC tendonAs this happens thousands of times the rotator cuff starts to fray and tear
15 Rotator Cuff Tendonitis Gradual onset of pain along anterolateral shoulderDifficulty sleeping on the affected sideMay be preceded by an antecedent traumaPatients complain of difficulty with overhead lifting
16 Rotator Cuff Tendonitis Physical exam may include a painful arc from degrees of abductionWeakness on supraspinatus muscle strength testingPositive impingement tests
18 Rotator Cuff Tendonitis Treatment: NSAIDS, subacromial cortisone injections and physical therapyAfter 3-4 months of conservative therapy with no improvement consideration could be given to an arthroscopic subacromial decompression
19 Rotator Cuff Tendonitis Arthroscopic Subacromial Decompression involves removal of any subacromial bone spurs, inflamed subacromial bursa, and direct assessment of the status of the rotator cuff and glenohumeral jointOpen subacromial decompression achieves the same purpose however the deltoid muscle is detached and reattached and a larger incision is involved
20 Rotator Cuff Tear History is similar to RTC tendonitis Physical exam may show increased supraspinatus weakness and atrophy of the supraspinatus fossaMRI is the study of choiceArthrogram is also a good study to just look at whether there is a tear in the rotator cuff
21 Rotator Cuff TearTreatment- In a patient who is <50 years of age immediate referral to an orthopedistKey point is that degenerative rotator cuff tears occur in patients greater than 50 yearsA tear in a patient less than 50 years of age is a traumatic tear unless proven otherwise
22 Rotator Cuff TearTraumatic rotator cuff tears require operative fixationDegenerative Rotator Cuff Tears treatment is controversialMay initiate physical therapy, NSAIDs and 1-2 cortisone injectionsIf no improvement consider surgical repair
25 DJD Degenerative Joint Disease of the shoulder (Osteoarthritis) Commonly occurs in older patients >60 years of ageHistory of stiffness and painRadiologic Diagnosis
26 Degenerative Shoulder Disease History Pain and StiffnessMay be preceded by antecedent traumaPhysical ExamMarked loss of motionDiffuse muscle atrophyCrepitus on ROM
27 Degenerative Shoulder Disease Xray: Grashey Xray true AP xray of the shoulder shows loss of joint space and humeral osteophytesTreatmentGentle ROM and StrengtheningNSAIDSIntrarticular cortisone injection
29 Degenerative Shoulder Disease Surgery is indicated when pain is not amenable to conservative managementSurgery include a hemiarthroplasty vs a Total Shoulder ReplacementSurgery can predictably relieve pain. Functional improvement is not as predictable
30 Case Study # 1Pt. is a 57 yr old male seen for consultation in regards to rt. shoulder. Pt. injured rt. shoulder at work climbing in and out of truck using steering wheel to pull himself up & diagnosed w/rt. shoulder impingement syndrome with AC joint arthritis. Initial treatment of PT and NSAIDS, improving slower than expected. MRI conducted, showed moderate supraspinatus and infraspinatus tendinosis with a small-to-moderate sized interstitial tear and detachment of the tendons.Treatment: Pt. underwent shoulder arthroscopy and debridement with distal clavicle resection. Pt. went back to full duty and was made MMI with 0% impairment. Future medical provided to include antiinflammatory medications and cortisone injectsion as needed for flare ups.
31 Case Study # 2Pt. is a 53 yr old male who injured rt shoulder by a compactor smashing rt shoulder. Had severe rt shoulder pain and difficulty with use of arm. Started on ibuprofin 600 mg & Soma. MRI was performed and showed a supraspinatus complete tear with retraction & AC joint arthritis. Conservative treatment of PT and cortisone injection failed.Treatment: Pt. underwent rt shoulder arthroscopy, rotator cuff tendon repair and resection. Patient returned to full duty., made MMI with no permanent restrictions and 0% impairment rating. Future medical to include antiinflammatory medications and cortisone injection as needed for flare ups.
32 Case Study #3Pt. is a 42 yr old female injured lt shoulder while picking up towels. Also undergoing treatment for RMI for hand/wrist/forearm. Pt had difficulty with overhead use, use of her arm and difficulty sleeping at night. MRI was performed and showed anterior superior labrum signal with mild arthrosis of AC joint.Treatment: Pt underwent lt shoulder cortisone injection and improved with ROM. Still has some residual lt shoulder pain. Made MMI with no permanent restrictions, 0 % whole body impairment and future medical to include follow up visits, antiinflammatory medications, and cortisone injections as needed for flare ups.
33 Case Study # 4Pt. is 46 yr old plumber who injured rt shoulder by using too much force while using cordless drill. Complains of pain, reduced strength and ROM. STAT MRI requested which showed rotator cuff tear.Treatment: right shoulder arthroscopy with subacromial decompression, debridement of labrum, and repair of the partial thickness articular surface tear. Pt fell 1 week after surgery, aggravated injury and delayed recovery. WCE completed which showed Pt will benefit from work hardening program. After completion, Pt was able to return to work full duty, range of motion increased significantly, and pain factors decreased to point where medication no longer needed. Pt extremely happy with outcome.
34 Shoulder Injury Prevention Lift items close to the bodyOnly lift items below shoulder levelWhen using a mouse keep in front of you at fingertip level so you do not have to reach with your arm outstretchedTake posture breaks when repetitively using the arm and shoulder
35 Shoulder Injury Prevention If performing a job which requires repetitive lifting, conditioning with rotator cuff strengthening exercises maybe beneficialStretch before performing lifting tasksTake breaks to prevent muscle fatigue
41 Anterior Knee Pain Patellar Chondromalacia Essentially softening and wear of the patellar cartilage due to overuse or maltrackingPatients complain of pain while climbing stairsMRI shows mild thinning of the cartilageTreatment is NSAIDS/ Cortisone injection
42 Anterior Knee Pain Patellofemoral Arthritis Diagnosed by decreased ROM with crepitus on PELateral Xray shows diffuse narrowing of the patellofemoral compartment with osteophytesTreatment - Cortisone Injection/ Viscosupplementation InjectionsNewer Trials of Isolated Patellofemoral Replacement
48 Bucket Handle Meniscus Tear Pt cannot achieve full extensionModerate to large effusion in kneeThere is a block to extension when passively trying to extend kneeUrgent referral
49 Degenerative Joint Disease Weight Bearing x-rays are crucial!They show the functional space in the kneeAlways specify on the prescription to obtain weight bearing x-raysRadiographically joint space narrowing with osteophytes are classicOtherwise known as osteoarthritis
51 Degenerative Joint Disease Patients c/o of catching and locking of the knee due to the friction caused by the rough surfaces rubbing against each otherHistory of stiffnessPE: May have effusion, decreased ROM and crepitus
52 Treatment Depends on amount of cartilage wear If there is joint space narrowing on xray (greater than 1 cm) this correlates with a large amount of osteochondral wearConsideration should be given for intrarticular cortisone injectionAlso viscosupplementation is an option
53 Medial Collateral Ligament Tear History of traumaValgus force to kneeMedial Joint tendernessReproduction of pain with valgus load to kneeTest against opposite knee
56 Medial Collateral Ligament Tear Treat with crutches and bracing for 4-6 weeks depending on severity of tearUsually PT will help regain Post injury muscle strength and ROM
57 ACL Tear Usually occurs with pivoting and twisting Patients describe a “Pop” when injury occursMarked swelling with an effusionPositive Lachman exam
58 Lachman Test (ACL test) With the patient supine and the knee flexed approximately 30 degreesStabilize the proximal thigh and apply an anterior directed force on the tibia
59 ACL TearInitial treatment goal is to regain ROM of knee and decrease swellingKnee is initially swollenPT sessions to teach ROM and strengthening exercises is helpful
60 ACL TreatmentSurgery reserved for active individuals or those with functional instabilityArthroscopic procedureDifferent types of graft options
61 Case Study # 1Pt. is 68 year old male, injured left knee when he slipped and twisted his knee at work. Diagnosed with Arthrofibrosis, maceration of the meniscus, and left knee marked articular cartilage along weight bearing surface of medical compartment. Returned to work full duty, PT prescribed. Improving slower than expected. MRI ordered revealed medial meniscus maceration and tearing. Ortho consult requested. Treatment: Left knee cortisone injection relieved pain. No permanent work restrictions, 0% impairment. Made MMI with future medical (antiinflammatory medications and cortisone injections) for flare ups.
62 Case Study # 2Pt. is 53 yr old male, injured rt. knee when he tripped over some tied wire. Had increased rt. knee pain, swelling, catching & locking. MRI performed which showed full thickness chondral defect along latereral patellar face ad intrasubstance degeneration of anterior and posterior horn of medical meniscus. Pt had continued rt. knee pain, difficulty weightbearing & use of rt. knee. Treatment: Pt. underwent antiinflammatory medications and activity restriction. Reached maximum medical improvement and made MMI with no permanent work restrictions and 0% impairment. Given future medical to include antiinflammatory medication and cortisone injection as needed for future flare ups of knee.
63 Knee Injury Prevention Every pound of weight is 4-6 pounds of force on the kneeAvoid activities in which the employee is bending or squatting for prolonged periods of timeDesign the space so that the employee can work from a seated position instead of a kneeling one
64 Knee Injury Prevention If you have to kneel for prolonged periods wear well designed knee padsWell designed breaks to allow employees to relieve pressure on the knees and stretchImportant to prevent deconditioning with good quadriceps and hamstring strengthening exercises
65 Questions?Thank you! Dr. Samir Sharma Alliance Occupational Medicine 2737 Walsh Ave. Santa Clara, CA. 315 S. Abbott Ave. Milpitas, CA Monterey Rd. Ste 10 San Jose, CA.