Anatomy of the Shoulder Rotator Cuff or Rotator Cup: A rational - PowerPoint PPT Presentation

12/12/2015 Anatomy of the Shoulder Rotator Cuff or Rotator Cup: A rational approach to common shoulder problems Brian Feeley, MD Associate Professor Department of Orthopaedic Surgery, University of California, San Francisco ABC Primary Care Sports Medicine 2015 Rotator Cuff (dynamic stabilizers) Long Head Biceps • Supraglenoid / • Suprapinatus superior labral origin • Infraspinatus • • Stabilizer when Teres Minor • Subscapularis shoulder rotating AND • elbow flexing Motion and stability • Originate scapula and terminate as short, flat tendons fusing with capsule • Balance deltoid pull • Active and passive restraint 1

12/12/2015 Glenohumeral joint Long Head Biceps (static stabilizer) • One-third of a sphere • Head-shaft angle 130° • Anatomic neck (capsule) • Surgical neck (fractures) • 3 Tuberosities – Greater – Lesser – Deltoid Glenoid Labrum (static stabilizer) Glenoid Fossa (static stabilizer) • Triangular in cross-section • Small, pear-shaped, bony • Increases humeral contact area depression • Increases glenoid depth 50% • Surface area 33% humeral head • Overall, bony contact minimal • Anchors the capsule • Added stability without compromising motion • Biceps origin 2

12/12/2015 Putting it all together-real time anatomy Approach to shoulder problems Differential Diagnosis – Rotator Cuff Tears (45%) – Shoulder arthritis (15%) – Frozen shoulder (15%) – Biceps problems (15%) – Dislocations (5%) – Fractures (5%) – Bruise (5%) – Cervical spine problems (25%) Approach to shoulder problems Approach to shoulder problems Differential Diagnosis Differential Diagnosis – Rotator Cuff Tears (45%) ROTATOR CUFF TEARS – Rotator Cuff Tears (45%) Pain at night, pain overhead, – Shoulder arthritis (15%) – Shoulder arthritis (15%) WEAKNESS – Frozen shoulder (15%) – Frozen shoulder (15%) – Biceps problems (15%) SHOULDER ARTHRITIS – Biceps problems (15%) Pain all the time, loss of – Dislocations (5%) motion – Dislocations (5%) – Fractures (5%) – Fractures (5%) FROZEN SHOULDER – Bruise (5%) Pain all the time, loss of – Bruise (5%) – Cervical spine problems motion – Cervical spine problems (25%) (25%) 3

12/12/2015 HISTORY Complete Good history + physical exam Key questions to ask = Correct diagnosis in 95% of cases 2 steps 1. Was there an acute injury? • Patient history 2. Are you losing strength? • Physical examination • (Radiographs) 3. Are you losing range of motion? • (Advanced imaging) Physical Examination-3 minute office exam Shoulder examination • Inspection “VPMCB” – Patient in gown • Visual inspection • Palpation • • Palpation ROM • Strength • Motion – Supraspinatus – Infraspinatus & Teres • Cuff-Specific testing minor – Subscapularis – Biceps • Biceps Testing • http://meded.ucsd.edu/clinicalmed/joints2.htm, permission granted by Dr. Charles Other tests Goldberg, UCSD SOM 4

12/12/2015 Visual Inspection Inspection • Remove shirt • Presence of infraspinatus atrophy increases • Systematic likelihood of rotator cuff disease – Deltoid • Positive LR 2.0 – Supraspinatus – Infraspinatus • Negative LR 0.61 – Biceps – AC joint – Skin changes – Scars Litaker D et al, J Am Geriatr Soc, 2000. Shoulder examination Palpation • Inspection What is he pressing on? Press where it hurts • Palpation Location Diagnosis • ROM Clavicle Clavicle fracture • Strength – Supraspinatus AC joint AC joint arthritis – Infraspinatus & Trapezius/Neck Muscle strain Teres minor – Subscapularis Front of shoulder Biceps pathology – Biceps • Other tests Back of shoulder Arthritis http://meded.ucsd.edu/clinicalmed/joints 2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM 5

12/12/2015 Rotator Cuff Testing RANGE OF MOTION --Neer ’ s/Hawkins tests No arthritis No arthritis No problem No problem No cuff tear No cuff tear With AROM With AROM Impingement No frozen shoulder No frozen shoulder Active Range of Motion Muscle Strength “What can you do?” No problem with passive No problem with passive --Teres Minor Think CUFF TEAR Think CUFF TEAR --Infraspinatus Difficulty with active Difficulty with active --Supraspinatus -check passive -check passive Problem with passive Problem with passive --Subscapularis Think Shoulder OA or Think Shoulder OA or Frozen Shoulder Frozen Shoulder What’s the best way for PCPs to Rotator cuff disease exam examine the shoulder for RCD? • Pain provocation tests • Pain and strength tests • Often the pain radiates to lateral shoulder/proximal arm (“deltoid”) We concluded that there is insufficient evidence upon which to base selection of physical tests for shoulder impingement, and potentially related conditions, in primary care. 6

12/12/2015 Pain test: Impingement signs Pain test: Painful arc If painful, positive LR 3.7 for RCD. If not painful, negative LR 0.36 for RCD. Hawkin’s JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. Neer’s Photos from Dr. Christina Allen • Hawkins ’ ’ Test ’ ’ • Jobe ’ ’ s test Rotator Cuff Impingement ’ ’ Supraspinatus 30° – 75% sensitive – 90º abduction • Neer ’ ’ ’ ’ s Test – 30º anterior flexion – 49% specific – Internal rotation (palms down) – Pain/weakness – 85% sensitive – 44% specific – 53% sensitive/82% spec. – (Park, et al. JBJS 12) Park, et al. JBJS 2012 7

12/12/2015 Infraspinatus Pain/strength test: Drop arm test • External rotation strength • 0º abduction & 45º ER Positive LR 3.3, negative LR 0.82 for rotator cuff disease. Infraspinatus My favorite test for rotator cuff, pre and post op JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. Pain & Strength test: Subscapularis Subscapularis = internal rotation lag test aka ‘lift off’ Positive LR 5.6, negative LR 0.04 for full thickness rotator cuff tear. Lift off test Bear Hug test About 70% reliable About 70% reliable (JAMA 2013) (JAMA 2013) JAMA. Rational clinical exam: Does this patient have rotator cuff disease? Aug 2013. 8

12/12/2015 Case 1 Biceps • Bicipital Tendonitis 54 year old woman presents with 4 months of – TTP at biceps groove shoulder pain that occurred after taking her • Compare to other jacket off. She now has trouble getting things off side high shelves and can’t put her belt on. Physical Examination Case 1—Key points in the history • Visual inspection – Was there an acute injury? • Palpation Yes, but not really – Are you losing strength? • Motion No • Specific testing – Are you losing range of motion? YES, OH YES! 9

12/12/2015 Frozen Shoulder=Adhesive Capsulitis Causes • Key points in the history and physical • 2 nd most common cause of shoulder pain in – No ‘real’ trauma US in patients 40-60 – Pain all the time • Mostly unknown – Limited ROM – Associated with Diabetes, Thyroid Problems Frozen Shoulder Mimics All Other Processes! Natural History Thickening of capsule with Inflammatory cells and fibrosis 10

12/12/2015 JSES 2012 Treatment Options • 100 patients, 5 year follow up (no treatment) – Average duration of symptoms-1.6 years – 91% return to full/near full function Do Nothing Treatment • Injections done blindly vs. injections done under ultrasound – Patients with less pain at the time of injection – More likely to get better after UTZ injection 11

12/12/2015 Am J Sports Med 2012 Surgery for Adhesive Capsulitis • Only for people who fail non-operative – 6 months PT, injections • 53 patients randomized to steroid (low or high dose) vs placebo • Both steroid injection groups got better faster than placebo group • No side effects Loss of motion Considerable State of the Art: Frozen Shoulder Surgery vs. pain, limited PT/Injection ADL • 1976: May be auto-immune Xrays: OA • 2010-2013: Mild PT/Injection – Everyone will get better limitations in Surgery only if daily activities fail non-op Loss of passive – Injections may quicken improvement range of motion • UTZ injections are more effective Less than 3 6 months months: PT/ROM • Use a low dose steroid Xrays: no OA PT for ROM program =Frozen Surgery only if – Surgery only for those that fail all other treatment Shoulder fail non op More than 3 6 months months: PT/ROM Injection program 12

12/12/2015 Case 2 Case 2—Key points in the history • 43 year old male, 6 months of shoulder pain, – Was there an acute injury? hurts at night, pain with overhead activity, no Not really weakness. He says that he can’t lift at the – Are you losing strength? gym as well. Not really – Are you losing range of motion? No Impingement of the Shoulder Impingement Syndrome Mechanism Very common in middle age people • Impingement under – Insidious onset of pain acromion with flexion and – Pain with overhead activities internal rotation of the shoulder – Pain at night (can’t sleep on that side) • Rotator cuff, subacromial – Difficulty doing some, but not all ADLs bursa and biceps tendon – No weakness Lateral view of shoulder – Positive impingement 13