Christina Allen, M.D. Clinical Professor UCSF Sports Medicine 2 - - PowerPoint PPT Presentation

12/9/2016 1

Top Shoulder Problems in Primary Care: raise your hand if you want to know more

Christina Allen, M.D.

Clinical Professor UCSF Sports Medicine Disclosures

• OREF (Orthopaedic Research and

Education Foundation) - Research Grant Recipient

• Major Duke Fan

2

Anatomy of the Shoulder- basic training Deltoid

• Origins 3 areas:

Anterior-clavicle Middle-acromion Posterior-scapular spine

• Deltoid Tuberosity
• Innervation: Axillary
• Shoulder abduction,

flexion, extension based on part activated

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Rotator Cuff

(dynamic stabilizers)

• Suprapinatus
• Infraspinatus
• Teres Minor
• Subscapularis
• Motion and stability
• Originate on scapula and

terminate as short, flat tendons fusing with capsule on humerus

• Balance deltoid pull
• Active and passive restraint

Long Head of Biceps

• Supraglenoid /

superior labrum origin

• Stabilizer when

shoulder rotating AND elbow flexing

Acromioclavicular Joint

• “Shoulder Separation”

joint

• Acromioclavicular

ligaments

• Coracoclavicular ligaments

– Prevent inferior displacement

• f acromion and coracoid from

clavicle

Glenohumeral joint- the true shoulder joint

• One-third of a sphere
• Head-shaft angle 130°

° ° °

• Anatomic neck (capsule)
• Surgical neck (fractures)
• 3 Tuberosities

– Greater – Lesser – Deltoid

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Glenoid Fossa

(static stabilizer)

• Small, pear-shaped,

bony depression

• Surface area 33%

humeral head

• Overall, bony contact

minimal

Glenoid Labrum

(static stabilizer)

• Triangular in cross-

section

• Increases humeral

contact area

• Increases glenoid depth

50%

• Anchors the capsule
• Added stability without

compromising motion

• Biceps origin

Approach to shoulder problems

ROTATOR CUFF TEARS Pain at night, pain

• verhead,

WEAKNESS SHOULDER ARTHRITIS Pain all the time, loss

• f motion, slow onset,

grinding FROZEN SHOULDER Pain all the time, loss

• f motion

Differential Diagnosis

– Rotator Cuff Tears – Shoulder arthritis – Frozen shoulder – Biceps problems – Dislocations – Fractures – Bruise – Cervical spine problems

HISTORY- 90% of the diagnosis

Key questions to ask

• 1. Was there an acute injury?
• 2. Are you losing strength?
• 3. Are you losing range of motion?

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Shoulder Physical Exam (Dr. Feeley to discuss)

• Inspection
• Palpation
• Range of Motion

– Passive and active

• Strength
• Special Tests

Case 1

54 year old woman presents with 4 months of shoulder pain that occurred after taking her jacket off. She now has trouble getting things off high shelves and can’t put her belt on.

Case 1—Key points in the history

– Was there an acute injury? – Are you losing strength? – Are you losing range of motion?

not really No YES, OH YES!

ROTATOR CUFF TEARS Pain at night, pain

• verhead, WEAKNESS

SHOULDER grinding SHOULDER ARTHRITIS Pain all the time, loss of motion, slow onset, grinding FROZEN SHOULDER Pain all the time, loss of motion

Physical Examination

• Visual inspection
• Palpation
• Motion
• Strength
• Specific testing

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Frozen Shoulder=Adhesive Capsulitis

• Key points in the history

and physical

– No ‘real’ trauma – Pain all the time – Limited ROM active AND passive

Frozen Shoulder Mimics All Other Processes!

Causes

• 2nd most common cause of shoulder pain in US

in patients 40-60

• Mostly unknown

– Associated with Diabetes, Thyroid Problems

Natural History

Thickening of capsule with Inflammatory cells and fibrosis

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State of the Art: Frozen Shoulder Tx

• 1976: May be auto-immune
• 2010-2013:

– Everyone will get better over time- but may take over a year! – Injections may quicken improvement

• UTZ injections are more effective
• Glenohumeral Joing
• Use a low dose steroid

– Surgery only for those that fail all

• ther treatment courses

Case 2

• 43 year old male, 6 months of

shoulder pain, hurts at night, pain with overhead activity, no weakness. He says that he can’t lift at the gym as well.

Case 2—Key points in the history

– Was there an acute injury? – Are you losing strength? – Are you losing range of motion?

Not really Not really No

ROTATOR CUFF TEARS Pain at night, pain

• verhead, WEAKNESS

SHOULDER grinding SHOULDER ARTHRITIS Pain all the time, loss of motion, slow onset, grinding FROZEN SHOULDER Pain all the time, loss of motion

Impingement of the Shoulder

Very common in middle age people – “Bursitis” – Insidious onset of pain – Pain with overhead activities – Pain with reaching behind back – Pain at night (can’t sleep on that side) – Difficulty doing some, but not all ADLs – No weakness on exam – Positive impingement signs

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Impingement Syndrome Mechanism

• Impingement under

acromion with flexion and internal rotation

• f the shoulder
• Rotator cuff,

subacromial bursa and biceps tendon Lateral view of shoulder

MRI

• MRI not needed for

conservative treatment

• Use it to rule out

significant pathology if patient weak, fails PT – Better for surgical planning, not for diagnosis

Impingement Syndrome Treatment

• Strengthening of rotator cuff muscles
• Scapula stabilization-poor posture often a

component

• Control inflammation

– Anti-inflammatories – Ice

• ? Steroid injection
• ? Surgery- Arthroscopic subacromial

decompression- Bursectomy and +/- acromial spur resection

Treatment algorithm for impingement

Impingement Mild pain with activity Night pain Physical Therapy NSAIDS Better Home Exercise Program Not Better MRI to evaluate for cuff tear Consider injection Surgery if not better Moderate pain with activity Wakes pt. up PT NSAIDS Consider injection Better Home Exercise Program

12/9/2016 8

Case 3

• 56 year old male, 3

months of shoulder pain and weakness after an awkward fall while doing crossfit. Hasn’t been able to return to the gym. He has pain at night and lifting things is difficult.

Case 3—Key points in the history

– Was there an acute injury? – Are you losing strength? – Are you losing range of motion?

Yes Yes No

ROTATOR CUFF TEARS Pain at night, pain

• verhead,

WEAKNESS SHOULDER grinding SHOULDER ARTHRITIS Pain all the time, loss

• f motion, slow onset,

grinding FROZEN SHOULDER Pain all the time, loss

• f motion

Rotator Cuff Tears- NEXT TALK

Impingement Partial Cuff Tear Full Thickness Tear

Case 4

• 76 year old male with 4 years of

worsening pain and weakness with

• golf. He has some pain at night and

describes pain as a toothache in his

• shoulder. He notes he has lost some

range of motion.

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Case 4—Key points in the history

– Was there an acute injury? – Are you losing strength? – Are you losing range of motion?

No No Yes

ROTATOR CUFF TEARS Pain at night, pain

• verhead,

WEAKNESS SHOULDER grinding SHOULDER ARTHRITIS Pain all the time, loss

• f motion, slow onset,

grinding FROZEN SHOULDER Pain all the time, loss

• f motion

Shoulder OA Radiographs

severe Moderate

Loss of Motion Treatment

Loss of motion Loss of passive range of motion

Xrays: OA Xrays: no OA =Frozen Shoulder Considerable pain, limited ADL Surgery vs. PT/Injection Mild limitations in daily activities PT/Injection Surgery only if fail non-op Less than 3 months: PT for ROM More than 3 months: Injection 6 months PT/ROM program 6 months PT/ROM program Surgery only if fail non op

Non operative treatment for shoulder OA

• NSAIDS-No good data in last 8 years
• Physical Therapy-mild to moderate

relief (Cochrane)

• Glenohumeral Joint Injections-

– Merolla et al 2011 – steroid 1-2 month improvement, viscosupplementation: 6 month improvement

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Surgical Treatment for OA

• Shoulder replacement

– 2-3 night stay – Sling 6 weeks – 80-90% recovery

• Excellent pain relief
• Good motion

– Complications

• Infection, dislocation,

loosening

Case 5

• 37 year old

computer engineer has 4 months of anterior shoulder

• pain. He cannot

complete his

• workouts. He is

markedly tender along his anterior

• shoulder. He has an

MRI arthrogram that shows a superior labral tear.

Case 5—Key points in the history

– Was there an acute injury? – Are you losing strength? – Are you losing range of motion?

No- more overuse No No

ROTATOR CUFF TEARS Pain at night, pain

• verhead,

WEAKNESS SHOULDER grinding SHOULDER ARTHRITIS Pain all the time, loss

• f motion, slow onset,

grinding FROZEN SHOULDER Pain all the time, loss

• f motion

The biceps shoulder complex

Differential for Anterior Shoulder Pain Biceps tendonitis Subscapularis Tear SLAP tear (usually posterior) AC joint arthritis

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Biceps vs. SLAP tear?

SLAP TEAR

• Throwing/Acute injury
• Younger patient
• Pain with O’Brien’s test

– Pain is often deep and posterior

• No Pain in biceps

groove

– No improvement with Biceps injection

BICEPS

• Overuse/activity related

(change in activity)

• Pain with O’Brien’s test

– Pain is often anterior

• TTP in biceps groove

– Improvement with injection

Operative SLAP Lesions

• Repetitive overhead stress
• Traction injury
• Fall on outstretched hand
• Positive O’

’ ’ ’Brien’ ’ ’ ’s Test

• Younger Patient

Treatment for SLAP tears

• If younger than 35, PT, then consider surgery

for repair in non-operative management fails

• If patient OLDER than 35—OFTEN SLAP TEAR

IS A “NORMAL” (INCIDENTAL) FINDING ON MRI

– NON OP TREATMENT (PT/NSAIDS) – higher rate of failure with SLAP repair (3x higher failure rate). Biceps tenodesis generally better surgical option

SLAP/BICEPS TREATMENT

SLAP/BI CEPS

SLAP ONLY BICEPS TENDONITIS <35, acute injury PT, Surgery for SLAP repair if PT fails >35, no acute injury PT/Injection Surgery only if fail non-op Less than 3 months: PT for ROM More than 3 months: PT vs Injection 70% improve and return to sports 90% improve and return to sports Biceps tenodesis Biceps tenodesis

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SLAP Lesions Case 5

• 25 year old rugby player is attempting to

make a tackle when his arm is forced into an abducted and externally rotated

• position. He falls to the ground in pain

and is unable to continue. Exam on the sideline reveals significant shoulder pain and an inability to actively or passively internally rotate the arm

Case 5—Key points in the history

– Was there an acute injury? – Are you losing strength? – Are you losing range of motion?

Yes Yes- Arm painful Yes

ROTATOR CUFF TEARS Pain at night, pain

• verhead,

WEAKNESS SHOULDER ARTHRITIS Pain all the time, loss of motion, slow

• nset, grinding

FROZEN SHOULDER Pain all the time, loss of motion

Glenohumeral Dislocation

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Glenohumeral Dislocation

• 90% of dislocations are out the front (anterior)
• Rarely dislocation out the back (posterior)

Dislocation/Instability

• Most dislocations can be

managed without an operation after reduction in ED

• Watch for Cuff tears with

dislocations in older patients

• Short period of immobilization
• Methods of immobilization
• Exceptions

– Recurrent dislocation – Bone loss – Cuff tear

Operative repair

• Indications based on

– Frequency of dislocations – Age of patient – Bone loss – NOT MDI or VOLUNTARY DISLOCATORS!!!

• < 25 years

– Bankart lesion

• MRI
• Arthroscopy

– Operative repair

• > 45 years

– Rotator cuff tear highly likely

• MRI

– Repair cuff

Bankart Repair

12/9/2016 14

Case 6

• 24 year old football player gets tackled

and his right shoulder is driven into the ground when he lands on his side. He has immediate pain over the top of the shoulder and a palpable deformity on the top of the shoulder.

Case 6—Key points in the history

– Was there an acute injury? – Are you losing strength? – Are you losing range of motion?

Yes Yes- Arm painful Yes

ROTATOR CUFF TEARS Pain at night, pain

• verhead,

WEAKNESS SHOULDER ARTHRITIS Pain all the time, loss of motion, slow

• nset, grinding

FROZEN SHOULDER Pain all the time, loss of motion

Acromioclavicular joint Injury

• Fall on the lateral aspect of shoulder
• “

“ “ “Separated Shoulder” ” ” ” injury to AC and CC ligmaments

• Prominence over AC joint
• Tenderness
• Weakness due to muscle shutdown, pain

AC Joint – “ “ “ “separated shoulder” ” ” ”

• Prominence over the top part
• f the shoulder
• Majority heal without

needing intervention

• A few need reconstruction or

repair

Right Left

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• Pain with palpation over

AC joint

• ACHY pain on top of

shoulder “The great masquerader”

• Pain with cross chest

adduction tests

• Relief with AC joint

cortisone injection

• Can often be treated with

distal clavicle excision

AC Joint arthritis

Rare (but not so rare) Shoulder Zebras

Calcific Tendonitis

• Acute Onset of Severe

Atraumatic Shoulder pain

– May bring reasonable patient to ED to demand narcotics – Acute Inflammatory process due to breakdown of calcific deposits in bursa or Rotator Cuff – May lead to frozen shoulder – Often can see Calcium deposits on Xray in Subacromial Space – Treatment: NSAIDS, PT – Subacromial Cortisone Injection +/- Barbitage of calcium deposit can give patient tremendous relief

Calcific Tendonitis

68

12/9/2016 16

Parsonage Turner Syndrome

• Seems like a severe cuff tear with no history of

acute injury

– Pain and radicular symptoms 1st (1-2 weeks) – Significant weakness follows, even marked muscle atrophy – Axonal injury: Dx is with MRI (negative) and diagnostic EMG – Treatment: NSAIDS, narcotics, PT, PATIENCE – Prognosis-85% recovery (but at 3 years)

Feinberg, HSS J

Summary

• Common shoulder problems:

– Cuff, Frozen Shoulder, Biceps, OA

• Use a rational guided approach to

shoulder history and exam

• Treatment based on patient goals and

level of incapacity

– (Nothing, NSAIDS, PT, INJECTIONS, SURGERY)

– When all else fails, think Zebras

Thank You

Christina R. Allen, MD Clinical Professor of Orthopaedics UCSF Sports Medicine 415.885.3832 allenc@orthosurg.ucsf.edu