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The Painful Shoulderorthosports The Painful ShoulderOrthosports Orthosports Level 1 Meeting Orthposports Orthosports Orthposportswww.orthosports.com.au Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports The Painful Shoulder Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports ANATOMY Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports ANATOMY Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports ANATOMY Glenoid labrum • Deepens Glenoid by 9mm sup‐inf and by 5mm AP Orthosports •Weakest at 4 o’clock Orthosports Function of labrum 1. Increases s.a. for contact with h.h. Orthposports Orthosports 2. Creates a buttress limiting translation 3. Acts asOrthposports attachment for GH ligaments Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports HISTORY History •Age Orthosports • Occupation Orthosports •Hand dominance • SportsOrthposports Orthosports • Injury Orthposports Orthposports Common Conditions Impingement – gradual onsetOrthosports with repetitive activity Cuff tear – heavy lifting, fall, dislocation Orthosports Instability – external rotation/abduction, fall AC jointOrthposports – fall on point of shoulderOrthosports SLAP – ballistic movement Orthposports Adhesive – no trauma capsulitis Orthposports MOST COMMON CONDITIONS •20 yrs to 40 yrs ‐ impingementOrthosports ‐ instability (under diagnosed) ‐ calcific tendonitisOrthosports •30 yrs to 50 yrs ‐ impingement Orthposports Orthosports ‐ adhesive capsulitis (overdiag) •50 yrsOrthposports + ‐ impingement / r.c. tear ‐ arthritis (uncommon) Orthposports History • Pain Profile Orthosports –Location – ant/lat, upper arm –Nature Orthosports – Day/night Orthposports Orthosports –Exacerbating factors (elevation/lifting) – RelievingOrthposports factors • Disability ‐ loss active ROM/ Dead arm Orthposports History (Instability) • Degree of trauma Orthosports • Position of arm at time of dislocation • Frequency of instability episodesOrthosports •“dead arm’ Orthposports Orthosports • Associated symptoms • SubtleOrthposports instability symptoms – throwing athlete • Prior medical treatment – ops & type of physio Orthposports CONFUSION WITH CERVICAL SPINE & OVERUSE SYMPTOMS • Posterior shoulder Orthosports pain • Not related to shoulder Orthosports movement • PainOrthposports radiates to Orthosports forearm and hand • ParaesthesiaOrthposports • Occupational overuse Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Inspection Palpation • Sternoclavicular joint Orthosports • Acromioclavicular joint Orthosports •Acromion •GreaterOrthposports tuberosity Orthosports •Lesser tuberosity Orthposports • Coracoid Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Range of Motion Range of Motion •Active and Passive Orthosports If Active < Passive – rotator cuff ‐ neurologicalOrthosports ‐ pain inhibition Orthposports Orthosports If ActiveOrthposports and Passive both reduced ‐ Adhesive capsulitis, osteoarthritis, lockedOrthposports posterior dislocation Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Range GlenohumeralComponents vs Scapulothoracic of motion of Motion Rotator Cuff Job’s Test – Supraspinatus Orthosports 90 degrees abduction 30 degrees forward thumbs down. Resisted elevationOrthosports Orthposports Orthosports Orthposports Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Resisted External Rotation - Infraspinatus Rotator Cuff Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Lift Off TestRotator - Subscapularis Cuff Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Rotator Impingement CuffTests Impingement Tests Orthosports Neer’s Hawkin’s Orthosports Orthposports Orthosports Orthposports Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Subacromial LA and Corticosteroid and retest Injection Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Cross Body Adduction Acromioclavicular joint – pain Confirm diagnosis with LA injection Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports AP Draw Instability Apprehension/ relocation Tests Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Physical examination • Apprehension signs • Relocation signs • Sulcus sign Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Sulcus - inferior Instability Jerk - Posterior Tests Completion •Neurovascular Orthosports •C Spine Orthosports • Ligamentous Laxity Orthposports Orthosports Orthposports Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports •True AP • Scapula Lateral XRays • Axillary Lateral • Supraspinatus outlet view True AP ‐ Looks through GH joint Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports AP in plane of Thorax Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Scapula Lateral Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports GH instability Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports West Point View Calcified Anterior Glenoid Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Reverse Hill Sachs Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Type III acromion - Impingement AC joint not well visualised Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Zanca view of AC joint Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Tube tipped 10-150 superiorly Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports AC Joint Separation Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports AVN Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Cuff Tear Arthropathy Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Calcific Tendonitis Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Glenoid # best seen on CT Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports OA Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Locked Posterior Dislocation Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Special Radiographs Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Ultrasound - No role in imaging the rotator cuff Imaging 40% Accurate Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Imaging Soft tissueMRI modality – Arthrogram of choice Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Treatment of Rotator Cuff Tears Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Rotator Cuff Tears •Many older people have Orthosports RC tears •Many people with RC Orthosports tears have no pain and full or near full function Orthposports •Non operative Orthosports management gives good outcomeOrthposports in many •Risk of developing arthritis small Orthposports “Functional” Rotator Cuff Tear • Anatomically Orthosports deficient • Biomechanically Orthosports intact Orthposports Orthosports • Patient has a RC tearOrthposports but has no pain and good function Orthposports Tear Is Not The Cause Of Pain !!!! Pain Caused By •TearsOrthosports can get bigger • Impingement with time •Edge of tear instability –(especiallyOrthosports if they are • Synovitis large and there is a • CapsulitisOrthposports high demand on the Orthosportsshoulder) • Biceps / s.l.a.p. Orthposports Orthposports Absolute Surgical Indications •Young patient (less than 50 years) –tear is likely to get bigger Orthosports •Patient involved with heavy or overhead occupation Orthosports –tear likely to get bigger •FollowingOrthposports dislocation in older patientOrthosports – (usually large tears) •AcuteOrthposports & very large tear –NO ER POWER Orthposports Need Surgery Within 1 Month Non Surgical Treatment • Patients over 55 years – small tears and low demand on shoulder and with force couples intact Orthosports • Patients older than 65 years – RC tear and good function even if forceOrthosports couples not intact • LargeOrthposports tears with poor quality RC Orthosports OrthposportsProviding force couples are intact and patient not too young non op treatment is likely to be Orthposportssuccessful Non Operative Treatment 80% to 90% successful over 3 monthsOrthosports • Subacromial cortisone injections •NSAIDs Orthosports • Physiotherapy - capsularOrthposports stretches - strengthening Orthosports Avoid heavyOrthposports lifting & overhead activity Orthposports Operative Technique • Arthroscopic Rotator Orthosports Cuff Repair • Biceps Tenotomy or Orthosports Tenodesis often required Orthposports Orthosports • 6 weeks in a sling • 1 yearOrthposports for full recovery Orthposports Orthosports Orthosports Orthposports Orthosports Orthposports Orthposports Treatment of Arthritis Osteoarthritis •Uncommon Orthosports • Non weight bearing joint • Loss of active
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