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Hey, Steve. My Shoulder Hurts

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Hey, Steve. My Shoulder Hurts 1/26/2017 WHERE ARE WE? East Amherst East Aurora Hamburg x2 West Seneca Williamsville Boulevard “HEY, STEVE. MY SHOULDER HURTS. WHY?” • Rotator Cuff • Frozen Shoulder • Thoracic Outlet Syndrome • Osteoarthritis • Bursitis • Tendinitis • Impingement Syndrome • Fibromyalgia • Heart Attack • Labral Tear • Cervical Radiculopathy 1 1/26/2017 SHOULDER BASICS • Scapulohumeral Rhythm • 2:1 Ratio for Motion • Upward Rotation • Protraction • Posterior Tilt • 9:1 Ratio with altered position • Pressure Through Range (90) • Blood Flow • Zone of Hypovascularity = common site for degeneration Palmerud G, Forsman M, Sporrong H. Intramuscular pressure of the infra- and supraspintus in relation to hand load and arm position. Eur J Appl Physiol. 2000;83:223-230. SUBACROMIAL SPACE • Subacromial Space • 7-14mm • Static vs. Dynamic Narrowing • Narrowing with Motion • Measure of muscle function • MRI studies reveal decreased space during elevation with RC tendinopathy PUBLIC ENEMY #1 • Thoracic Spine • 40 hours a week • 160 hours a month • 1920 hours a year • What doesn’t this include? • Leisure Sitting • Meals • Driving • Scapular Posterior Tilt • Risk for Slouched Exercise Kebaetse M, McClure E Pratt NE. Thoracic position effect on shoulder range of motion, strength, and three-dimensional scapular kinematics. Arch Phys Med Rehabil 1999;80:945-50. Gumina S, Di Giorgio G, Postacchini F. Subacromial Space in adult patients with thoracic hyperkyphosis and in healthy volunteers. La Chirurgia degli Organi di Movimento. Feb 2008;91(2):93-96. 2 1/26/2017 SHOULDER PAIN IS OFTEN A DOWNSTREAM ISSUE NECK / MID BACK SHOULDER G G G G G PUBLIC ENEMY #2: SELECTIVE TIGHTNESS • Pec Minor • Posterior Tilt • Inferior Capsule • Limits downward movement • Posterior Capsule • Excessive Superior- Anaterior translation • Testing for Tightness 3 1/26/2017 PUBLIC ENEMY #3: WEAKNESS • Scapular Stability • Dec. Serratus Anterior & Lower Trap • Decreased force output, latency, imbalance found in RC tendinopathy • Rotator Cuff Strength • Fiber orientation • Counter Acts Deltoids TAKE HOME MESSAGE • A shoulder program is multifactorial • A shoulder program needs to work the supporting cast • Free Weights vs. Machines • What’s right for me? SOME EXERCISES TO CONSIDER 4 1/26/2017 SOME EXERCISES TO CONSIDER Wall Push Up Table / Bench Push Up Push Up on Knees Standard Push Up DO THIS, NOT THAT Machines < Free Weights < Kettlebells DO THIS, NOT THAT 5 1/26/2017 DO THIS, NOT THAT DO THIS, NOT THAT ONE MORE EXERCISE TO CONSIDER Start on Knees Progress to Toes 6 1/26/2017 TO SUM IT UP…. Shoulder pain is not likely your shoulders fault… 1. STRONG FOCUS ON MOBILITY AT YOUR SPINE 2. THERE’S MORE RISK WITH OVERHEAD ACTIVITIES 3. WORK WITH FREE WEIGHTS AND CABLES, NOT MACHINES THANK YOU! THANK YOU! 7 Buffalo Rehab Group Physical Therapy, P.C. Sidelying Upper Trunk Rotation 2012 Buffalo Rehab Group 2012 Buffalo Rehab Group Lie on your R/L side as shown in left picture. Keep the top knee TOUCHING THE TABLE as you rotate through your trunk. Take deep breaths and rotate further as you exhale. Repeat 10x Repeat on other side 1/26/2017 Northtowns Orthopedics Buffalo Rehab Group 1/25/17 Peter L. Gambacorta, DO Northtowns Orthopedics Medical Director, Department of Sports Medicine Women and Children’s Hospital of Buffalo Peter L. Gambacorta, DO Northtowns Orthopedics – Orthopedic Surgeon – Fellowship Trained Sports Medicine Specialist Arthroscopic Surgery Minimally invasive surgery Knee, Shoulder, Hip, Elbow, Ankle Northtowns Orthopedics Office Locations East Amherst 8750 Transit Road Suite 105 East Amherst, New York 14051 Williamsville 36 North Union Road Williamsville, NY 14221 Holiday Valley 6133 U.S. Route 219 Suite 1001 Ellicottville, New York 14731 1 1/26/2017 After-Hours Orthopedic Service No appointment is necessary! 8750 Transit Road Suite 105 East Amherst, New York 14051 After-Hours Urgent Orthopedics Available: Monday through Friday, 4 pm to 8 pm Saturday, 12 pm to 4 pm Sunday, 12 pm to 4 pm Most major insurance carriers are accepted. (716) 839-2230 Agenda • Introduction • Anatomy • Shoulder • Sports Injury Prevention Anatomy 101 • Bone- – Skeleton – Supports the body – Protects organs – Allows movement – Stores minerals – Makes blood cells 2 1/26/2017 Anatomy 101 • Muscle – “Engine” – Produce motion – Provide stabilization – Generate heat Anatomy 101 • Tendon – Connects Muscle to Bone • Ligament – Connects Bone to Bone Flexibility versus Laxity • Flexibility – Stretch of muscle and tendon • Laxity – Looseness of ligaments 3 1/26/2017 Agenda • Introduction • Anatomy • Shoulder • Sports Injury Prevention Shoulder Anatomy Bones Adult versus Pediatric Shoulder 4 1/26/2017 Shoudler Anatomy • Cartilage Shoulder Anatomy Muscles Shoulder Anatomy Nerves and blood vessels 5 1/26/2017 Why Does My Shoulder Hurt? • Tendonitis • Impingement Syndrome • Capsulitis • Rotator Cuff Tears • Labral Tears • Arthritis Tendonitis • Inflammation of a tendon – Rotator cuff muscles – Biceps • How does it happen – Overuse – Acute injury 6 1/26/2017 Tendonitis • What does it feel like? – Pain with activity – Better with rest – Rotator cuff pain • Lateral arm – Biceps pain • Anterior arm Tendonitis • Treatment – Rest – NSAIDS – Ice – Physical Therapy – Injections Impingement syndrome 7 1/26/2017 Impingement Syndrome Impingement syndrome Impingement syndrome 8 1/26/2017 Impingement syndrome • Do you have Impingement syndrome? – Pain anterior and lateral arm – Pain with over head and cross body motion – Sometime clicking, grinding or catch – Positional weakness Impingement syndrome • Treatment – Rest – NSAID’s – Ice – Physical Therapy – Injections – Surgery Adhesive Capsulitis • Frozen Shoulder syndrome • Inflammation of the shoulder capsule 9 1/26/2017 Adhesive Capsulitis Do I have a frozen shoulder? – Women> Men – Usually 40-60 years old – Pain with motion • You can move it and neither can I – Associated with injury, thyroid, diabetes, immobilization Adhesive Capsulitis • Three phases of disease • Freezing – In the"freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months. • Frozen – Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult. • Thawing – Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years. Adhesive Capsulitis • Treatment • More than 90% of patients improve without surgery – NSAID’s – Steroid injections – Physical therapy Patience is necessary 10 1/26/2017 Adhesive Capsulitis • Surgery – Manipulation – Arthroscopic Lysis of Adhesions Rotator Cuff Tears • Rotator cuff – Group of tendons (4) that form a cuff of tendon around the Glenohumeral joint (Ball and Socket) • Supraspinatus • Infraspinatus • Subscapularis • Teres minor Rotator Cuff Tears • Types of tears – Partial thickness – Complete • Causes – Acute Injury • MVA, Fall, lifting something heavy with a jerking motion – Degenerative • Repetition- exercise or work • Blood supply lessens with age • Bone spurs- impingement 11 1/26/2017 Rotator Cuff Tears • Do I have a Rotator Cuff Tear? – Age>40 years – Repetitive lifting or exercise – Acute fall or injury – Pain at rest and at night – Pain with lifting motions – Weakness – Cracking and popping noises – Pain with activities of daily living Rotator Cuff Tear • Treatment – 50% of patients can improve pain and function with conservative treatment – Rest – Activities – NSAID’s – Physical Therapy – Injections *Shoulder strength usually does not improve with non surgical treatment Rotator Cuff Tear • Surgical treatment – Continued pain is the main indication for surgery – Your symptoms have lasted 6 to 12 months – You have a large tear (more than 3 cm) – You have significant weakness and loss of function in your shoulder – Your tear was caused by a recent, acute injury 12 1/26/2017 Arthritis • Breakdown of articular cartilage in a joint – Osteoarthritis • “Wear and tear” – Rheumatoid Arthritis • Chronic disease attacking multiple joints in the body • Synovium swelling – Post traumatic arthritis – Rotator cuff arthropathy – Avascular necrosis Arthritis • Symptoms – Pain • With activity and gets progressively worse • Decreased motion • Grinding, popping and clicking • Night pain Arthritis Treatment: • Rest or change in activities to avoid provoking pain. • Physical therapy exercises • Nonsteroidal anti-inflammatory medications (NSAIDs) • Corticosteroid injections in the shoulder can dramatically reduce the inflammation and pain. However, the effect is often temporary. • Moist heat • Ice your shoulder for 20 to 30 minutes two or three times a day to reduce inflammation and ease pain. • If you have rheumatoid arthritis, your doctor may prescribe a disease-modifying drug, such as methotrexate. • Dietary supplements, such as glucosamine and chondroitin sulfate may help relieve pain 13 1/26/2017 Arthritis • Surgical Treatment Shoulder Instability • “Ball popped out of socket” • Dislocation or Subluxation • Anterior >>> Posterior • Injury – <40 y/o Labral injury – >40 y/o Rotator cuff injury Labral Tear • Glenoid labrum – Cartilage ring in shoulder around Glenoid (cup) – Suction seal – Stability 14 1/26/2017 Shoulder Dislocations • Skeletally immature- – 12-17 yrs old – Labral tear (Bankart) less frequent • Skeletally mature- – Labral tear (Bankart) -97% – Hill sachs -91% Postachinni
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