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 (gleno- humeral) 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 Anatomy 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 Glenohumeral Joint Arthritis 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 (gleno- humeral) 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 .