1. The Aging Shoulder Jesse A. McCarron, MD
March 11th 2017
The Aging Shoulder
Jesse A. McCarron, MD
Shoulder & Elbow Reconstruction
Rebound Orthopaedics & Neurosurgery
Assistant Professor
Dept of Orthopaedic Surgery & Rehabilitation
Oregon Health & Science University

2. Disclosures Co-founder: Langley / McCarron Technologies, LLC
Consultant: Acumed, LLC
Royalties: Musculoskeletal Transplant Foundation
Patents:
(1) Stitch re-enforced Fascia
(2) R-Coil

3. Basics of shoulder anatomy Basics of Shoulder biomechanics
Objectives
Basics of shoulder anatomy
Basics of Shoulder biomechanics
Common shoulder pathology
Rotator cuff & arthritis
Clinical presentation
Work-up
Treatment options

4. Shoulder Anatomy

5. Shoulder Anatomy Bone

6. Shoulder Anatomy Glenoid & Labrum
Pictures courtesy of

7. anterior
lateral
posterior

8. anterior
lateral
posterior
Subscapularis
Supraspinatus
Infraspinatus
Teres Minor

9. anterior
lateral
posterior

10. Shoulder Biomechanics
Large Ball & Small Socket
6 degrees of freedom
Largest ROM of any joint
Bone architecture: inherently unstable
Trailer hitch picture
6* freedom pic/vid
XYZ planes

11. Shoulder Biomechanics
Superficial muscles
(deltoid, pectoralis, latissimus dorsi, teres major)
- Provide active motion of the arm
Rotator cuff
(subscapularis, supraspinatus, infraspinatus, teres minor)
- Provide dynamic centering during motion
Concavity Compression
Humeral head depression
fixed fulcrum

12. anterior
posterior

13. Common (Degenerative) Shoulder Pathology
Rotator cuff
Arthritis
Arthritis & Cuff Tear

14. Rotator Cuff Pathology Incidence & Demographics
Prevalence:
40-60% over 60 yoa
Annual Surgeries: 600,000
Young population
(traumatic)
Aging population
(degenerative/atraumatic)

15. Rotator Cuff Pathology Etiology
Intrinsic factors
Vascular
Genetic
Metabolic?
Extrinsic factors
Subacromial impingement
Internal impingement
Trauma
Multi-factorial

16. Rotator Cuff Injury Patient Presentation
Pain
Lateral deltoid
Periscapular muscles
* Pain at night
Tenderness to Palpation
Along acromial edge
Weakness / Limited active ROM
Elevation
External rotation

17. Rotator Cuff Pathology Initial Management
Pain only
No / minimal trauma
No functional deficit
Non-operative management
X-Rays
Rest
Avoidance of provocative activities
Physical Therapy
+/- NSAIDs or subacromial steroid injection

18. Rotator Cuff Management Physical Therapy
Stretching
Tight shoulders prevent normal motion
Tight shoulders cause pain
Strengthening
Weak shoulders can’t stabilize the humeral head
3-6 months optimal physical therapy*
* should be improving by 6 weeks

19. Rotator Cuff Pathology Initial Management
Pain and
Significant trauma
Functional deficit
Further Imaging
MRI
Arthrogram (CT/XR)
Ultrasound

20. Dx: Rotator Cuff Tear Treatment Options Repairable tears
Open or Arthroscopic
Irreparable tears
Debridement
Shoulder arthroplasty
Muscle transfer

21. Indications for Surgery
“Younger” patient
Any obvious rotator cuff tear by MRI
“Older” patient
Tear by MRI and failed conservative measures
Rotator cuff tears do not heal spontaneously

22. Surgical Repair Open Arthroscopic Equivalent Single incision
Deltoid detachment
Arthroscopic
Multiple “stab” incisions
Technically more difficult?
Equivalent
Healing time
3-6 months!
Functional outcome

23. Arthroscopic Repair

24. Glenohumeral Arthritis Incidence & Demographics
Prevalence:
30% over 60yoa
Degenerative process
“wear & tear”
Weight lifters
Manual laborers
Genetic component
Aging population
Increasing demand

25. Glenohumeral Arthritis Clinical Presentation
Pain
- Anterior & posterior (along joint line)
Stiffness
Preserved strength & function
- Within ROM limits

26. Glenohumeral Arthritis Initial Work-up
Imaging
X-Rays establish diagnosis
Pre-operative planning
CT scan to evaluate bone loss
MRI to eval rotator cuff

27. Shoulder Normal Arthritic

28. Glenohumeral Arthritis Initial Management
Non-operative management
- Education
- Maintain function and motion
NSAIDS
+/- Steroid Injection
- Visco-supplimentation?

29. Glenohumeral Arthritis Indications for Surgery
Loss of Glenohumeral joint space
Pain
Decreasing motions or function
Stiffness or Pain
50+ yoa
 “Anatomic” Shoulder Arthroplasty

30. “Anatomic” Shoulder Arthroplasty

31. Rotator Cuff Tear Arthropathy
Shoulder arthritis
30% population 60+yoa
Rotator cuff Tears
40-60% population 60+yoa
Almost exclusively pts 50+ yoa
Increasing incidence with increase in aging population

32. Rotator Cuff Tear Arthropathy Etiology
Non-repairable rotator cuff tear
Changes to joint architecture & mechanics
Loss of Rotator cuff function
Decreased strength
Increased pain

33. Repairable vs. Irreparable Tears

34. Changes to Joint Architecture Normal Arthritic Cuff Arthropathy

35. Rotator Cuff Tear Arthropathy Patient Presentation
Loss of strength with overhead motion
Starts as weakness
May progress to complete loss of active motion
Passive motion often preserved
Variable pain
May be minimal even with severe dysfunction

36. Rotator Cuff Tear Arthropathy Initial Management
Non-operative management
Education
Consider activity modification
NSAIDS
+/- Steroid Injection
Maintain PASSIVE motion

37. Rotator Cuff Tear Arthropathy Indications for Surgery
Non-repairable rotator cuff tear
Pain and/or weakness
60+ yoa
 “Reverse” Shoulder Arthroplasty

38. “Reverse” Shoulder Arthroplasty
Anatomic Shoulder
Reverse Shoulder

39. Implications for Shoulder Arthroplasty
Functional cuff
Dysfunctional cuff
Fixed center of rotation
Anatomic TSA
No fixed center of rotation
Reverse TSA

40. Joint Replacement Surgery (Arthroplasty)
Hip & Knee replacement:
- ~900,000 annually in US
Shoulder replacement:
- ~100,000 annually 2014

41. Trends in Shoulder Arthroplasty
1992:
~12,000 cases
2002:
~25,000 cases
2008:
~47,000 cases
2014:
~100,000 cases
Sunny H. Kim et al. J Bone Joint Surg Am 2011;93:

42. Summary Common degenerative shoulder problems
Rotator cuff
Arthritis
Cuff tear arthropathy (rotator cuff & arthritis)
Surgical options available for each
Even for patients well into 6th, 7th and 8th decades of life