Common Shoulder Problems

Ted Parks, MD Which structure is least likely affected by subacromial impingement?

1. Subacromial bursa 2. Supraspinatous muscle and tendon 3. Tendon of the long head of the biceps 4. Deltiod muscle and tendon The most common shoulder (glenohumeral) joint dislocation is:

1. Anterior 2. Posterior 3. Inferior 4. Superior

The “reverse total shoulder” procedure gets its name from the fact that:

Anatomy: Layer One Scapula

Anatomy: Layer One Anatomy: Layer Three Anatomy: Layer Three Rotator Cuff (Anterior View)

Rotator Cuff (Posterior View)

Anatomy: Layer Four Anatomy: Layer Five #1: The Glenoid is Small and Shallow

#2: The deltoid force vector is essentially vertical when the Arm is at the side

#3: The deltoid inserts on the lateral humerus

Common Shoulder Problems Impingement • Bursitis • Rotator cuff & Biceps tendonitis • Rotator cuff & Biceps tears • Cuff tear arthtopathy

Glenohumeral AC joint • Instability • Instability • Arthritis • Arthritis Subacromial Space Impingement

Anantomy: Layer Two

Anatomy: Layer Two Rupture of Biceps tendon at shoulder from impingement

Anatomy: Layer Two Shoulder Impingement

Subacromial Impingement

History  pain with overhead activities  night pain  pain that radiates to the upper third of the humerus  pain reaching behind the back

Subacromial Impingement

Physical Exam  Impingement signs  Tender over the greater tuberosity  Pain and/or weakness with rotator cuff strength testing

Subacromial Impingement

Physical Exam  Impingement signs  Tender over the greater tuberosity  Pain and/or weakness with rotator cuff strength testing Resisted Internal Rotation = Subscapularis Resisted External Rotation = Infraspinatus “Jobe’s Test” for Supraspinatus Subacromial Impingement

Studies:  X-rays AP Y view

Y-View X-Ray Y View X-Ray “Y” View X-ray Subacromial Impingement Studies:  MRI

Subacromial Impingement

Treatment:

 Stage 1: NSAIDS Physical Therapy

Subacromial Impingement

Treatment:

 Stage 2: Subacromial Cortisone Injection

Subacromial Injection Technique

1cc Steroid 4cc Lidocaine

 Patient sitting  Arm at side  Lateral approach (posterior works, too) Four scenarios after injection:

 They get better and stay better (winner!)

 They get better for a long time (>4mo), then it comes back (re-inject?)

 They get better for a short time (<4mo), then it comes back (surgery?)

 They get nothing out of the shot (MRI?) SLAP (Superior Labrum, Anterior – Posterior)

Subacromial Impingement

Treatment:

 Stage 3: Surgery: • Subacromial decompression

• +/- Rotator cuff repair

Subacromial Decompression

Arthroscopic Subacromial Decompression

Decompress Repair

Common Shoulder Problems

Impingement

Glenohumeral joint problems

AC joint problems Instability (dislocation)

Glenohumeral Joint Arthritis

History  Age

Physical Exam  Poor rotation with elbow at side X-Rays

X-RAY

Taking a Bad AP Taking a Good AP Incorrect True AP Treatment: Non-Surgical

 Anti-inflammatory Medicines  Supplements (?)  Cortisone Shots  Physical Therapy

Surgical Rx: Shoulder Replacement

Common Shoulder Problems

Impingement

Glenohumeral joint problems

AC joint problems AC Joint Problems

 Instability (separation) Types of AC Separation

Type I

Types of AC Separation

Type II

Types of AC Separation

Type III

AC Joint Arthritis AC Joint Arthritis

History

Physical Exam  Point tender over AC joint X-Rays

Treatment: Non-Surgical

 Anti-inflammatory Medicines  Supplements (?)  Cortisone Shots

Surgical Rx: Distal Clavicle Resection

Which structure is least likely affected by subacromial impingement?

1. Subacromial bursa 2. Supraspinatous muscle and tendon 3. Tendon of the long head of the biceps 4. Deltiod muscle and tendon The most common shoulder (glenohumeral) joint dislocation is:

1. Anterior 2. Posterior 3. Inferior 4. Superior

The “reverse total shoulder” procedure gets its name from the fact that:

1. A posterior (instead of anterior) incision is used 2. The humeral component is implanted upside down 3. The ball is on the scapula and the socket on the humerus 4. The posterior muscles are moved to the anterior side and visa/versa Subacromial Injection Therapeutic Injections in your practice A great choice for:  Your Patients  You  Me Therapeutic Injections

Me (Orthopedists)  Decreases volume of non operative patients

Therapeutic Injections

You (Primary Care Providers)  Satisfaction of rendering effective treatment  $ Corticosteroid Injections

Patients  Safe  Effective  Inexpensive (Cortisone shot=$6.00)

Am J Med. 2005;118:1208-1214. Arthritis Rheum. 2002;46:328-346. Corticosteroid Injections

Syringe and Needle Prep

 Betadine  Alcohol  Gloves  Lidocaine  Cold Spray (ethyl chloride)

Infection rate=1:15,000 Clin Fam Prac,Vol 7,2:2005 General Rules…

 No more than one injection per month

 No more than 3 injections per year

 Don’t inject infected areas

J Bone Joint Surg Am 1975;57:70-6 Curr Opin Rheumatol 1999;11:417-21 ACTA Orthop Scand 1997;132-4 Subacromial Space Injection

Subacromial Injection Technique

1cc Steroid 4cc Lidocaine

 Patient sitting  Arm at side  Lateral approach Thank You! Ted Parks, MD www.western-ortho.com

Thank You! Ted Parks, MD www.western-ortho.com

AC Joint Arthritis

Injection Technique: 1cc steroid 1cc lido  “walk along and drop in” method

Axillary View