1. New Concepts and Advances (Arthroscopic) for the Treatment of Shoulder Pain
William F Bennett MD

2. 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

3. 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

4. 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

5. 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

6. 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

7. Before discussing intrinsic Causes
Lets diverge and discuss the anatomy and function of the shoulder

8. Anatomy 4 joints-two are articulations Glenohumeral joint
Acromioclavicular joint
Scapulothoracic articulation
Sternocalvicular articulation/joint
Discuss Bones-Bone models

9. Ligaments/Capsule Capsule is the “sac” Ligaments- hold bone to bone
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

10. 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

11. Bursae/Cartilage/Meniscus
Subacromial Bursae
Subdeltoid bursae
Subcoracoid bursae
Glenohumeral articular cartilage
Acromioclavicular meniscus

12. Intrinsic Diagnoses Impingement Tendonitis Bursitis
Rotator Cuff tear-complete
Rotator Cuff tear-partial
others

13. Intrinsic Diagnoses Acromioclavicular joint irritation/arthritis
Glenohumeral joint osteoarthritis
Rheumatologic joint
Pigmented Villonodular synovitis
Chondrometaplasia
Tumors-giant cell, synovial sarcoma

14. Intrinsic Diagnoses Instability/Subluxation-repetitive/chronic
Atraumatic/multidirectional
Dislocation
Traumatic unidirectional
Biceps
Inflammation
Instability/subluxation
Tendonitis/avulsion

15. 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

16. Physical Exam Observation Palpation Range of Motion Strength Test
Specific Tests for lesions
Hoppenfeld- Examination of the Extremies

17. 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

18. 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

19. Treatment
Nsaids- short-term
Physical therapy
Injections
Surgery

20. Physical Therapy Treat Inflammation- Iontophoresis Treat Tight Areas
Stretch
Treat Weakness
Strentghen- rotator cuff muscles
scapular stabilizers

21. 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

22. 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-the-impression” that shoulder surgical intervention was not that effective

23. Arthroscopic Intervention utilized in
Impingement-bursitis, tendonitis
Rotator cuff tears
Instability or dislocation
AC joint arthritis
And yes even in Osteoarthritis

24. Arthroscope has allowed for the further identification of subtle shoulder pathology, previously not identified
See articles-
1) Bennett WF. Subscapularis, Medial and Lateral Head Coracohumeral Ligament Insertion Anatomy: Arthroscopic Appearance and Incidence of "Hidden" Rotator Interval Lesions. Arthroscopy Feb. 17(2)
2) Bennett WF. Visualization of the Anatomy of the Rotator Interval. Arthroscopy

25. Arthroscopic Prospective outcomes are now Published
See Articles-
Bennett 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

26. 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

27. 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.