1 Shoulder Problems

2 Shoulder has most ROM of any joint Shoulder has most ROM of any joint Patient complains of pain or instability Patient complains of pain or instability Think of other conditions Think of other conditions Cervical nerve root impingmentCervical nerve root impingment TumorTumor ?Pancoast tumor?Pancoast tumor

Shoulder Problems Rotator cuff pathology Rotator cuff pathology Instability Instability Acromio-clavicular joint pathology Acromio-clavicular joint pathology Biceps tendinitis Biceps tendinitis Frozen shoulder Frozen shoulder 3

4 Shoulder Problems By age By age <30<30 Dislocation Dislocation Instability Instability Acromio-clavicular joint sprain Acromio-clavicular joint sprain Rotator cuff strain, impingement Rotator cuff strain, impingement Biceps tendinitis Biceps tendinitis >50>50 Rotator cuff tear Rotator cuff tear Frozen shoulder Frozen shoulder

5 Acromio-clavicular joint Acute sprains (AC joint separation or dislocation) Acute sprains (AC joint separation or dislocation) Chronic pain Chronic pain

6 Acute AC joint sprains Often a fall onto the top of the shoulderOften a fall onto the top of the shoulder Biking Biking Hockey Hockey Wrestling Wrestling Football Football Sprained ligamentsSprained ligaments Acromio-clavicular Acromio-clavicular Coraco-clavicular Coraco-clavicular

7 Acute AC joint sprains

8 8

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10 Pain at top of shoulder Pain at top of shoulder Pain with movements of shoulder Pain with movements of shoulder Tender over acromio-clavicular joint Tender over acromio-clavicular joint Deformity? Deformity? X-rays (with weights) may show upriding of distal clavicle X-rays (with weights) may show upriding of distal clavicle

11 Acute AC joint sprains-Rx Grades I and II Grades I and II Non-operativeNon-operative Sling and symptomatic treatmentSling and symptomatic treatment Good prognosis even with deformityGood prognosis even with deformity Grade III Grade III Occasionally need surgeryOccasionally need surgery Grades IV-VI unusual Grades IV-VI unusual

12 Chronic AC joint pain Pain with aDduction Pain with aDduction Tender over top of shoulder Tender over top of shoulder X-rays may show narrowing or spurs at AC joint X-rays may show narrowing or spurs at AC joint

13 Chronic AC joint pain-adduction test

14 Chronic AC joint pain-Rx NSAIDS NSAIDS Steroid injection Steroid injection Surgery to resect distal clavicle if conservative treatment fails Surgery to resect distal clavicle if conservative treatment fails

15 Instability Often follows dislocation or subluxation Often follows dislocation or subluxation Can be an overuse injury Can be an overuse injury Repetitive stress in abduction and external rotationRepetitive stress in abduction and external rotation e.g. pitchers e.g. pitchers

16 Instability Dislocations Dislocations AnteriorAnterior >90% >90% Abduction/external rotation Abduction/external rotation Traumatic--fall on outstretched arm Traumatic--fall on outstretched arm PosteriorPosterior Can follow electric shock or seizure Can follow electric shock or seizure MultidirectionalMultidirectional Non-traumatic Non-traumatic ?Voluntary ?Voluntary ?Generalized ligamentous laxity ?Generalized ligamentous laxity

17 Instability Dislocations Dislocations Young patientsYoung patients Tend to recur Tend to recur Older patientsOlder patients Look for rotator cuff tear as well Look for rotator cuff tear as well

18 Dislocation

19Instability Most instability is anterior Most instability is anterior Shoulder ‘slips out of joint’ Shoulder ‘slips out of joint’ Symptoms increase with abduction and external rotation Symptoms increase with abduction and external rotation

20 Instability-exam Apprehension sign for anterior instability Apprehension sign for anterior instability

21 Instability-radiology X-rays may show Hill-Sachs or Bankhart lesion X-rays may show Hill-Sachs or Bankhart lesion Evidence of previous dislocationEvidence of previous dislocation MRI may show capsular damage MRI may show capsular damage

22Instability-Rx Usually requires surgery Usually requires surgery Open reconstructionOpen reconstruction ArthroscopicArthroscopic

23 Rotator cuff A group of 4 muscles that cover humeral head A group of 4 muscles that cover humeral head Holds humeral head in glenoid fossa Holds humeral head in glenoid fossa Resists deltoid to produce rotation instead of upward translation of humeral headResists deltoid to produce rotation instead of upward translation of humeral head Helps internal and external rotationHelps internal and external rotation

24 Rotator Cuff

25 Rotator Cuff 25

26 Rotator cuff-pathology Acute tear Acute tear Younger patients with hx of traumaYounger patients with hx of trauma Chronic sxs Chronic sxs Strain-tendinitis-bursitisStrain-tendinitis-bursitis TearTear ImpingementImpingement

27 Rotator cuff tear

28 Rotator cuff Attrition Attrition Tendon becomes damaged over timeTendon becomes damaged over time Decreased blood supply Decreased blood supply Impingement under acromion Impingement under acromion Repetitive stress Repetitive stress

29 Radiographs Rotator cuff arthropathy Rotator cuff arthropathy

30 Rotator cuff-Sxs Pain with abduction or working overhead Pain with abduction or working overhead Pain at night and when lying on shoulder Pain at night and when lying on shoulder Pain is anterior but can be referred to mid-humerus Pain is anterior but can be referred to mid-humerus Popping or grinding Popping or grinding

31 Rotator cuff-exam Painful arc of motion Painful arc of motion ‘drop out’‘drop out’ Occasional crepitus Occasional crepitus Impingement sign Impingement sign ?Inject local anesthetic for diagnosis ?Inject local anesthetic for diagnosis

32 Impingement sign Passive internal rotation and flexion Passive internal rotation and flexion

33 Rotator cuff-Rx Relative rest Relative rest Physical therapy Physical therapy NSAIDs NSAIDs Steroid injection Steroid injection Surgery Surgery ?Repair full-thickness tears?Repair full-thickness tears ?Remove impingment?Remove impingment

34 Asymptomatic rotator cuff tears

35 Frozen shoulder (adhesive capsulitis, arthrofibrosis) Can follow any of these shoulder problems, trauma or surgery Can follow any of these shoulder problems, trauma or surgery Soft tissues around the shoulder become fibrotic and stiff Soft tissues around the shoulder become fibrotic and stiff Fibrous adhesions grow across the joint surfaces Fibrous adhesions grow across the joint surfaces Result is decreased ROM Result is decreased ROM First lose external rotation, then abductionFirst lose external rotation, then abduction

36 Frozen shoulder Diabetes (especially type I) Diabetes (especially type I) A risk factorA risk factor More difficult to treatMore difficult to treat Rx Rx PTPT NSAIDsNSAIDs ?Manipulation?Manipulation ?Wait?Wait

37 What to remember: Most common shoulder problem? Most common shoulder problem? Rotator cuff pathologyRotator cuff pathology

38 What to remember: What ligaments are injured in AC sprains? What ligaments are injured in AC sprains? Acromio-clavicular and coraco-clavicularAcromio-clavicular and coraco-clavicular

39 What to remember: Which AC sprains are treated without surgery? Which AC sprains are treated without surgery? Grades I and IIGrades I and II How do you test for AC joint pathology? How do you test for AC joint pathology? Adduct shoulder (reach across body)Adduct shoulder (reach across body) Which direction do shoulders usually dislocate, sublux and become unstable? Which direction do shoulders usually dislocate, sublux and become unstable? AnteriorlyAnteriorly

40 What to remember: What’s a risk for young patients who dislocate shoulders? What’s a risk for young patients who dislocate shoulders? RedislocationRedislocation Older patients? Older patients? Rotator cuff tearRotator cuff tear How do you test for anterior instability? How do you test for anterior instability? Apprehension testApprehension test

41 What to remember: What does rotator cuff do? What does rotator cuff do? Stabilizes shoulder while deltoid abducts, and performs internal and external rotationStabilizes shoulder while deltoid abducts, and performs internal and external rotation What is the impingement sign? What is the impingement sign? Passively internally rotate and flex shoulderPassively internally rotate and flex shoulder

42 What to remember: Can rotator cuff tears be asymptomatic? Can rotator cuff tears be asymptomatic? Yes-pie chartYes-pie chart What’s a risk factor for frozen shoulder? What’s a risk factor for frozen shoulder? DiabetesDiabetes

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