The Painful Shoulderorthosports

The Painful ShoulderOrthosports

Orthosports Level 1 Meeting Orthposports Orthosports

Orthposportswww.orthosports.com.au

Orthposports The Painful Shoulder Orthosports

Orthosports

Orthposports Orthosports

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Orthposports ANATOMY

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Orthposports ANATOMY

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Orthposports ANATOMY

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Orthposports 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

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Orthposports HISTORY

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Orthposports 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 Inspection

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Orthposports Palpation

• Sternoclavicular joint Orthosports • Acromioclavicular joint Orthosports •Acromion •GreaterOrthposports tuberosity Orthosports •Lesser tuberosity Orthposports • Coracoid

Orthposports Range of Motion

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Orthposports 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 Range of Motion Components of motion Orthosports Glenohumeral vs Scapulothoracic Orthosports

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Orthposports Rotator Cuff Job’s Test – Supraspinatus Orthosports 90 degrees abduction 30 degrees forward thumbs down. Resisted elevationOrthosports

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Orthposports Rotator Cuff Resisted External Rotation - Infraspinatus Orthosports

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Orthposports Rotator Cuff Lift Off Test - Subscapularis Orthosports

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Orthposports Rotator Cuff Impingement Tests Orthosports

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Orthposports Impingement Tests

Orthosports Neer’s Hawkin’s Orthosports

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Orthposports Subacromial Injection

LA and CorticosteroidOrthosports and retest

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Orthposports Cross Body Adduction

Acromioclavicular joint – pain Orthosports

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Orthposports Confirm diagnosis with LA injection Orthposports Instability Tests

AP Draw Apprehension/ relocation Orthosports

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Orthposports Physical examination

Orthosports • Apprehension signs Orthosports • Relocation signs Orthposports Orthosports

• Sulcus sign Orthposports

Orthposports Instability Tests

Sulcus - inferior Jerk - Posterior Orthosports

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Orthposports Completion

•Neurovascular Orthosports •C Spine Orthosports • Ligamentous Laxity Orthposports Orthosports

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Orthposports XRays •True AP Orthosports • Scapula Lateral • Axillary Lateral Orthosports • Supraspinatus outlet view Orthposports Orthosports

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Orthposports True AP ‐ Looks through GH joint

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Orthposports AP in plane of Thorax

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Orthposports Scapula Lateral

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Orthposports GH instability

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Orthposports West Point View

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Orthposports Calcified Anterior Glenoid Reverse Hill Sachs

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Orthposports Type III acromion - Impingement

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Orthposports AC joint not well visualised

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Orthposports Zanca view of AC joint

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Orthposports Tube tipped 10-150 superiorly AC Joint Separation

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Orthposports AVN

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Orthposports Cuff Tear Arthropathy

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Orthposports Calcific Tendonitis

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Orthposports Glenoid # best seen on CT

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Orthposports OA

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Orthposports Locked Posterior Dislocation

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Orthposports Special Radiographs

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Orthposports Imaging

Ultrasound - No role in imaging the rotator cuff Orthosports 40% Accurate Orthosports

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Orthposports Imaging MRI – Arthrogram Orthosports Soft tissue modality of choice Orthosports

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Orthposports Treatment of Rotator Cuff Tears

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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 Treatment of Arthritis

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Orthposports Osteoarthritis

•Uncommon Orthosports • Non weight bearing joint • Loss of active & passive Orthosports motion • IntraarticularOrthposports cortisone Orthosports •NSAIDs • Total shoulderOrthposports replacement Orthposports Normal Arthritis

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Orthposports Osteoarthritis

• Presents with pain and loss of function Orthosports

• Forceful physio to stretch Orthosports shoulder capsule makes it worse Orthposports Orthosports

• ArthroscopicOrthposports debridement only helps half the time

Orthposports INDICATIONS FOR T.S.R.

•Severe pain unresponsiveOrthosports to NSAIDs and analgesics •Significant functional loss Orthosports •Interference with activities of daily living Orthposports Orthosports •Some patients have severe O.A. on xray but fewOrthposports symptoms –we do not operate on the xray appearance but ratherOrthposports the patient’s symptoms TOTAL SHOULDER REPLACEMENT

• R.C. must be intact Orthosports • Good pain relief • Expect 60% normal Orthosports movement only Orthposports • Physio post op mainly Orthosports to strengthen Deltoid and OrthposportsR.C.

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Orthposports Arthritis with a rotator cuff tear

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Orthposports Cuff Tear Arthropathy

• Massive R.C. tear Orthosports associated with arthritis • Difficult problem Orthosports • “Reverse” shoulder replacementOrthposports is a good Orthosports solution Orthposports

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Orthposports Instability

•The younger you are theOrthosports more likely you are to redislocate •More than one dislocation Orthosportsleads to arthritis of the shoulder Orthposports Orthosports •Surgery now being offered to all first time dislocatorsOrthposports

Orthposports Instability

•Dislocation in an older patientOrthosports usually tears the rotator cuff •Cuff repair urgent Orthosports •They usually don’t have ongoing instability Orthposports Orthosports

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Orthposports Case One

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Orthposports HISTORY

•40 year old housewife •4Orthosports weeks ago, long •R hand dominant singles match followed by service practice •No previous shoulder Orthosports problem session • Developed R lateral • PlaysOrthposports social tennis (doubles) once a week shoulderOrthosports pain for 1 hour •Worse with above Orthposports shoulder activities (hanging clothes on the line, personal care) Orthposports EXAMINATION

•Painful arc of abduction •PowerOrthosports and pain (45° to 120°) returned to normal •Full passive range of followingOrthosports an injection elevation of subacromial local anaesthetic •IR Orthposportslimited (thumb to L4) Orthosports • Positive impingement sign Orthposports • Positive “empty can test” Orthposports INVESTIGATIONS

•XOrthosports‐rays of the shoulder are normal •No Orthosportsother investigations Orthposports warrantedOrthosports • Impingement is a Orthposports clinical diagnosis (not US) Orthposports Diagnosis

• SUBACROMIAL IMPINGEMENTOrthosports

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Orthposports Orthosports

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Orthposports TREATMENT ‐ Impingement

•The patient may requireOrthosports a further 2‐3 injections of subacromial cortisone at 6 weeks intervals to allow herOrthosports to perform her physiotherapy exercises more effectively. Orthposports Orthosports •NSAIDS do work in some patients •Ice Orthposportspacks (NOT heat) •Avoid massage to the area Orthposports Treatment ‐ Impingement

• Physiotherapy is the mainstayOrthosports of treatment and without the exercises the problem always returns: Orthosports –A) Restore range of motion (active and passive) Orthposports–B) Strengthen rotator cuff muscles Orthosports –C) Stabilise the scapula –ImproveOrthposports postural and movement habits • 90% of patients are cured with non surgical treatmentOrthposports but 10% do go on to an arthroscopic subacromial decompression. Case Two

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Orthposports Orthosports

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Orthposports HISTORY

•53 Year old woman •Orthosports Progressive pain • Gardening at home increase and movement •R hand dominant restriction •Recalls a ‘minor strain’ •NightOrthosports pain worsening several weeks prior •Sharp, stabbing pain Orthposports radiating down upper •Initial pain with active limb withOrthosports sudden movement movements (esp lateral) •WasOrthposports told ‘tendinitis’ •Strength is maintained •No better with physio – • Subacromial cortisone possibly worse did not assist Orthposports Examination Signs Depends on the stage Orthosports

 Wasting Orthosports  Tender  ReducedOrthposports ROM, rotation reduces later Orthosportsespecially ER then IR  Normal cuff power  ImpingementOrthposports sign may be positive  Positive passive external rotation overpressure test (EROP)  Normal neurologyOrthposports Investigations

• Normal Xray Orthosports

Orthosports •MRI not needed but must be arthrogram to show loss of capsular volume and scarring Orthposports Orthosports of the rotator interval Orthposports

Orthposports Diagnosis

• Adhesive Capsulitis Orthosports

Orthosports •Can be difficult to differentiate from impingement in the early stages Orthposports Orthosports

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Orthposports Treatment Options in the ‘inflammatory’ phase

 Medications –anti‐inflammatories, analgesia, sedatives  ROM exercise within limits Orthosports  Strengthening to maintain scapular retractors Orthosports  Lifestyle change  Oral cortisone –? not recommended Orthposports Orthosports  Manipulation (MUA)  Education,Orthposports empathy and follow ‐ up  Injection options  Intra‐articularOrthposports cortisone  Hydrodilatation Traditional phases of adhesive capsulitis

Severity Intervention here Orthosports? hydrodilatation

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Orthposports ‘thawing out’

Orthposports 0 4 8 (6-7) 12 (8-9) >24 (9-12) Duration of condition (months) Diagnosis

• Adhesive Capsulitis Orthosports

Orthosports •Treatment usually expectant Orthposports Orthosports

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Orthposports Case Three

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Orthposports History

•20 year old Orthosports •Labourer •RHD Orthosports •He dislocated his Right shoulder in a tackle playingOrthposports league 3 months ago. It Orthosportswas reduced in the emergency department and he wore a slingOrthposports for 2 weeks. The shoulder settled and he returned to work and sport after about 6 weeks.Orthposports History

•He unfortunately redislocatedOrthosports his shoulder when he returned to football 2 weeks ago and again had it reduced inOrthosports A & E. The arm was abducted and externally Orthposports rotated at the time of the dislocation.Orthosports

•He Orthposportshas only mild discomfort with an almost normal range of motion now. •He wantsOrthposports to return to football ASAP Examination

Orthosports • Mild deltoid wasting Orthosports •Sensation intact on lateral deltoid (sargeant badge area) – indicating that he has not injured his axillary nerve Orthposports Orthosports •Some loss of external rotation in adduction • RotatorOrthposports cuff power is normal •no ligamentous laxity Orthposports • Positive apprehension and relocation tests Radiology

Orthosports • Plain Xray shows a Hills Sachs lesion –Confirms the diagnosis of instabilityOrthosports –Try to obtain the Emergency department Orthposportsimages if possible to document Orthosports the direction of the dislocation (usually anterior inferior) •AfterOrthposports plain xrays the imaging of choice is a MRI arthrogram. Orthposports Radiology

•To assess intra‐articular pathologyOrthosports –Labral tears (Bankart lesion, SLAP tear or a partial thickness rotator cuff tear) Orthosports – Glenoid Fractures (known as a boney Bankart Lesion), OrthposportsHill Sachs lesions and Ligament avulsions (HAGL, reverse HAGL) Orthosports – Ultrasound not useful –IfOrthposports can’t have a MRI then a CT arthrogram is the next best test Orthposports Treatment

• Recurrence rate after oneOrthosports dislocation is between 70 –90% •After two dislocations, closeOrthosports to 100% –Even without a return to contact sport Orthposports Orthosports

•TheOrthposports treatment required is a surgical stabilization (either arthroscopic or open) Orthposports Treatment

•After 1 dislocation 20% ofOrthosports patients will develop OA in later life –This increases with each subsequentOrthosports dislocation

Orthposports Orthosports •Multiple dislocations cause bone loss may requiringOrthposports salvage surgery –Laterjet procedure Orthposports Case Four

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Orthposports Orthosports

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Orthposports History •75 year old female, right handed • Longstanding right shoulder painOrthosports with usage of the arm • Minimal rest pain Orthosports •Worse at night and often wakes her •NoOrthposports recent injury but progressive deteriorationOrthosports in function and ability to use the arm at or above shoulderOrthposports height • Currently complains a recent increase in pain and inability to lift the arm overhead Orthposports Clinical Examination

• Deltoid wasting, marked atrophy of theOrthosports Rotator cuff Muscles, particularly supraspinatus Orthosports • Significant loss of Active forward elevation – 40 degrees • NormalOrthposports Passive motion – 160 degrees Orthosports • Significant weakness of rotator cuff, especially external rotationOrthposports • Impingement signs positive, no glenohumeral crepitus Orthposports Imaging

Orthosports • Always start with a plain xray to rule out arthritis or a rotator cuff tear arthropathy Orthosports

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Orthposports Investigations Plain x-rays to rule out arthritis MRI can show tears size, quality of or proximal migration cuff,Orthosports and muscle atrophy

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Orthposports Treatment

• Physiotherapy –strengthenOrthosports deltoid and retrain remaining rotator cuff muscles –takes over function of torn musclesOrthosports • Subacromial Cortisone Injections Orthposports Orthosports –relieve pain to make the exercises easier •3‐4Orthposports injections, 4‐6 weeks apart often needed

Orthposports Treatment

OrthosportsArthroscopic view of a •In the rare massive rotator cuff circumstance where tear the patient has has a Orthosports sudden deterioration of their chronic Orthposports Orthosports condition it may be possible to partially Repair sutures to Orthposports “cover the hole” repair their rotator cuff repair Orthposports Treatment – Pain and loss of motion

•The pseudoparalytic Orthosports Shoulder ‐ Reverse Shoulder Replacement Orthosports • Provides excellent painOrthposports relief and some motion but external Orthosports rotation strength is not Orthposportsrestored. •The deltoid muscle muscleOrthposports be working Orthosports Massive Rotator Cuff Tear Orthosports

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Orthposports Summary

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Orthposports MOST COMMON CONDITIONS

Orthosports Level 1 Meeting Orthposports Orthosports

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Orthposports