1. The Shoulder

2. Outline Anatomy Rot cuff disorders: Tendinitis
Chronic (painfull and/or impingement )
Calcific
Tear
Frozen shoulder
Instability

3. Introduction
The part of the body where the humerus attaches to the scapula.
The shoulder must be mobile enough for the wide range actions of the arms and hands, but also stable enough to allow actions such as lifting, pushing and pulling.
It is made up of 3 bones.
Clavicle,
Scapula
Humerus.

5. Shoulder Joints
Glenohumeral joint (ball and socket joint, articulation between the glenoid fossa of the scapula (shoulder blade) and the head of the humerus
Acromioclavicular joint (articulation between the acromion process of the scapula and the lateral end of the clavicle )
Sternoclavicular joint (articulation between sternal end of the clavicle, and the manubrium sterni
There are two kinds of cartilage in the joint:
1. Articular cartilage : covers humerus head and glenoid surface. It’s a white cartilage which allows the bones to glide and move on each other. When this type of cartilage starts to wear out (a process called arthritis), the joint becomes painful and stiff.
2. Labrum : its a ring of rigid fibrous cartilage surrounding the glenoid cavity, it stabilizes the ball and socket joint!

8. Shoulder Movements: It is the most mobile joint in the human body.
The muscles and joints of the shoulder allow it to move through a remarkable range of motion:
Arm abduction
Arm adduction
Arm flexion (180°)
Arm extention (45°)
Medial rotation of the arm (55°)
Lateral rotation of the arm(40-45°)
Arm circumduction (this is a combination of the above movement)

10. Rotator Cuff muscles
The group of four muscles and their tendons that act to stabilize the shoulder.
The strength of the joint depend on the tone of these group of muscle which across in front, above & behind the joint.
Supraspinatous – abducts the arm
Infraspinatous – external rotation
Teres Minor – external rotation
Subscapularis – internal rotation
Nerve supply:axillary and suprascapular nerve

12. Rotator Cuff Disorders
Tendinitis
Tear
Frozen Shoulder
Instability

13. Calcific Tendinitis
A disorder characterized by deposits of crytalline calcium phosphate in any tendon of the rotator cuff muscles causing inflammation and pain.
Unknown etiology.
Most people over the age of 40
Supraspinatus tendon is the most common affected.
Pain is aggravated by elevation of the arm above shoulder level or by lying on the shoulder.
Sever Pain may awaken the patient from sleep.
Its one of the most painful conditions in the shoulder.

14. When this condition is symptomatic, it may present in the following 2 ways:
Chronic, relatively mild pain with intermittent flares, similar to shoulder impingement syndrome, is believed to indicate that the condition is in the formative phase.
Mechanical symptoms may arise from a large calcific deposit → build up of pressure in the tendon → intense pain → limitation of movement

15. Diagnosis X-ray Ultrasound (more accurate)
Calcific deposits are visible as
Lumps
Cloudy areas
Mostly found on the greater tuberosity

17. Treatment: NSAID injection
Injections, needling & lavage Breaking up the calcific deposits by repeatedly puncturing them with a needle, aspirating the calcific material, with the help of saline.
Physiotherapy to regain muscle strength
Surgery (rarely required)

18. Impingement Syndrome (chronic tendinitis)
Also called: swimmer's shoulder or thrower's shoulder
It is a clinical syndrome which occurs when the tendons of the rotator cuff muscles become irritated and inflamed as they pass through the subacromial space, the passage beneath the acromion.
Individuals at highest risk are laborers and those working in jobs that require repetitive overhead activity like swimmers and athletes.
Symptoms: pain increase at night, weakness and loss of movement at the shoulder
Increase in shoulder pain with overhead activities

19. Causes
The rotator cuff muscle tendons pass through a narrow space between the acromion process of the scapula and the head of the humerus. anything which causes further narrowing of this space can result in impingement syndrome.
Bony structures such as subacromial spurs (bony projections from the acromion), osteoarthritic spurs on the acromioclavicular joint, and variations in the shape of the acromion.
Thickening or calcification of the coracoacromial ligament can also cause impingement.
Loss of function of the rotator cuff muscles, due to injury or loss of strength, may cause the humerus to move superiorly, resulting in impingement.
Inflammation and subsequent thickening of the subacromial bursa.

20. Treatment: Conservative mostly: Injectable corticosteroid Ice packs
Cessation of painful activity and rest
Physiotherapy
If the patient remains significantly disabled and has no improvement after 3 months of conservative treatment, consider other etiologies or refer for surgical evaluation.

21. Rotator Cuff tears
Tears of one or more of the 4 tendons of the rotator cuff muscles.
Rotator cuff tears are among the most common conditions affecting the shoulder
The most frequent cause of rotator cuff damage is age related degeneration and less frequently by sports injuries or trauma
The supraspinatus muscle is most frequently torn as it passes below the acromion;
The tear usually occurs at its point of insertion onto the humeral head at the greater tuberosity

22. Clincal Features Age: 45-75 year old.
Acute tears: raising arm against resistance, (like in weight lifting,) or falling forcefully, causes Immediate pain that radiates through the arm, and limited range of motion, specifically during abduction motions of the shoulder .
Drop Arm sign (The result is positive if the patient is unable to lower the affected arm slowly and smoothly from a position of 90 degrees of abduction. The arm drops immediately to the side.

23. Types Partial tear: Recover gradually With supraspinatus tendonitis
Complete tear:
Sudden shoulder strainor a complication of tendonitis
Pain soon subside
Gross weakness of abductor muscles

24. Treatment Conservative NSAID injections Rest Physiotherapy Operative
Young active individuals with complete tears.
Contraindicated in elderly

26. MRI for rotator cuff tears

27. Adhesive Capsulitis (Frozen Shoulder)

28. Definition
A disorder in which the shoulder capsule becomes inflamed and stiff, greatly restricting motion and causing pain.
The etiology is unknown (injury or trauma, autoimmune).
Characterized by progressive pain and stiffness which usually resolves spontaneously after 18 months.
Movement of the shoulder is severely restricted, pain is worse at night.

29. Clinical Features Age 40-60, more in females
Slight wasting, some tenderness.
Pain (gradual onset)
Stiffness or decrease in motion.
External rotation (most severely inhibited)
Internal rotation.
Abduction.

30. Radiology X-ray: Arthrography:
Osteoporosis of the proximal humerus (decreased bone density)
Arthrography:
Shows a contracted joint
Dramatic decrease in the injected contrast material.
Loss of normally loose dependent folds of the capsule.

31. Differential Diagnosis
Post-traumatic stiffness (maximal at the start, gradually lessens)
Disuse stiffness
Regional pain syndrome (associated with MI, stroke)

32. Treatment
self-limiting: it usually resolves over time without surgery. Movement is regained gradually but may not return to normal
Conservative:
Analgesics
Heat therapy and exercise (physiotherapy)
Corticosteroid injection.
Manipulation under anesthesia hastens recovery.
Operative Treatment
Arthroscopic division of the interval between supraspinatous and infraspinatous (improve the range of movement).

33. Shoulder Instability

34. Occurs when the humerus separates from the scapula at the glenohumeral joint. The glenoid socket is very shallow and the joint is held secure by the fibrocartilaginous glenoid (labrum) and the surrounding ligaments and muscles.
Types
Anterior instability.
Posterior instability.
Multidirectional instability.

35. Anterior Instability Shoulder drawer sign Apprehension test
Hill-Sachs lesion
Bankart lesion

36. Most common type (~95%).
50% <25 yrs, 50% develop recurrency (the labrum and capsule are detached from the anterior rim of the glenoid)
Occurs as a sequel to acute anterior dislocation of the shoulder, with detachment or stretching of the glenoid labrum and capsule.
Mechanism:
abduction, external rotation, and extension.
falling on outstretched hand, forcing the arm into abduction and external rotation
It can result in damage to the axillary artery.

37. Limitation of movement
Approach
Hx:
Severe pain
Limitation of movement
Overhead arm motions
External rotation
Physical or athletic activities.
Anterior bulging
Hx of trauma.

38. Examination shoulder drawer sign
the examiner manually assesses translation of the humeral head in the glenoid fossa. The humeral head is grasped in one hand, and the clavicle and scapula are stabilized in the other as the examiner pushes anteriorly and posteriorly.
Compared with the unaffected shoulder, the affected shoulder often demonstrates increased laxity.
Apprehension test
The arm is placed in abduction, extension, and external rotation while stressing it in anterior translation. If the patient becomes apprehensive and reports pain, this is considered a positive finding.

39. X-ray findings Humeral head anteriorly.
Axial view is diagnostic. (even for sublaxation).It shows the humeral head riding on the anterior lip of the glenoid.
AP view with the upper arm internally rotated may show Hill-Sachs lesion if recurrent.
Rule out associated humeral neck fracture.
Hill-Sachs lesion :
Depression in the posteriolateral part of the humeral head.
Caused by recurrent forcing of the head of humerus against the anterior glenoid rim (damage to the bone)

40. MRI :
The Bankart lesion (detached glenoid labrum)
Deformity of the humeral head
MRI of anterior inferior labral tear

41. Humeral head anteriorly

42. Hill-Sachs Lesion
Depression in the posteriolateral part of the humeral head

43. Treatment
Reduction
Most techniques are facilitated by the following 2 maneuvers:
Flexion of the elbow 90° to relax the biceps tendon
External rotation of the humerus, which releases the superior glenohumeral ligament and presents the favorable side of the humeral head to the glenoid fossa
Signs of a successful reduction include the following:
Palpable or audible clunk
Return of rounded shoulder contour
Relief of pain
Increase in range of motion
Stimson Maneuver, Scapular Manipulation, External rotation method, Traction and counter traction

44. Surgery Indications: Types of operation:
Frequent dislocations, esp if painful
A fear of recurrent dislocation sufficient to prevent participation in everyday activities.
Types of operation:
Re-attachment of the glenoid labrum (Bankart)
Shoretening and tightening of the anterior capsule and muscles (Putti-Plat)
Reinforcement of the antero-inferior capsule using adjacent muscles (Bristow)

45. Posterior Instability

46. Rare (5%)
Due to violent jerk in an unusual position
If recurrent, it is almost always a sublaxation, with the humeral head riding back on the posterior lip of the glenoid.
Mechanism:
Abduction, flexion, and internal rotation.
Etiology:
Direct trauma.
Epileptic seizure, Electric shock.
Pathology is the same as the anterior one but the capsule is torn posteriorly.
Approach same as anterior dislocation.

47. Diagnosis:
X-rays
CT scans
Treatment:
Reduction
(Apply gentle, prolonged axial traction on the humerus. Then add gentle anterior pressure while coaxing the humeral head over the glenoid rim. Slow external rotation may be needed
Conservative
muscle strengthening exercises and voluntary control of the joint
Surgery
indicated only if disability is marked and there is no gross joint laxity.

49. Multidirectional Instability

50. Associated with capsular and ligamentous laxity, and sometimes with weakness of the shoulder muscles.
The patient complains of the shoulder going out of the shoulder with remarkable ease.
Alternating episodes of anterior and posterior sublaxation or dislocation.
Muscle strengthening exercises and training in joint control are helpful.