Christina Allen, M.D. Clinical Professor UCSF Sports Medicine 2 - PowerPoint PPT Presentation

12/9/2016 Top Shoulder Problems in Primary Care: Disclosures raise your hand if you want to know more • OREF (Orthopaedic Research and Education Foundation) - Research Grant Recipient • Major Duke Fan Christina Allen, M.D. Clinical Professor UCSF Sports Medicine 2 Anatomy of the Shoulder- basic training Deltoid • Origins 3 areas: Anterior-clavicle Middle-acromion Posterior-scapular spine • Deltoid Tuberosity • Innervation: Axillary • Shoulder abduction, flexion, extension based on part activated 1

12/9/2016 Rotator Cuff (dynamic stabilizers) Long Head of Biceps • Supraglenoid / superior labrum origin • Suprapinatus • Infraspinatus • Stabilizer when • Teres Minor shoulder rotating AND • Subscapularis elbow flexing • Motion and stability • Originate on scapula and terminate as short, flat tendons fusing with capsule on humerus • Balance deltoid pull • Active and passive restraint Acromioclavicular Joint Glenohumeral joint- the true shoulder joint • Head-shaft angle 130 ° ° ° ° • “Shoulder Separation” • One-third of a sphere joint • Acromioclavicular ligaments • Anatomic neck (capsule) • Coracoclavicular ligaments • Surgical neck (fractures) – Prevent inferior displacement of acromion and coracoid from • 3 Tuberosities clavicle – Greater – Lesser – Deltoid 2

12/9/2016 Glenoid Labrum (static stabilizer) Glenoid Fossa (static stabilizer) • Triangular in cross- section • Small, pear-shaped, • Increases humeral bony depression contact area • Surface area 33% • Increases glenoid depth 50% humeral head • Overall, bony contact • Anchors the capsule minimal • Added stability without compromising motion • Biceps origin Approach to shoulder problems HISTORY- 90% of the diagnosis ROTATOR CUFF TEARS Key questions to ask Differential Diagnosis Pain at night, pain – Rotator Cuff Tears overhead, 1. Was there an acute injury? – Shoulder arthritis WEAKNESS – Frozen shoulder SHOULDER – Biceps problems 2. Are you losing strength? ARTHRITIS – Dislocations Pain all the time, loss – Fractures 3. Are you losing range of motion? of motion, slow onset, – Bruise grinding – Cervical spine problems FROZEN SHOULDER Pain all the time, loss of motion 3

12/9/2016 Case 1 Shoulder Physical Exam (Dr. Feeley to discuss) 54 year old woman presents with 4 Inspection • months of shoulder pain that occurred Palpation • after taking her jacket off. She now has Range of Motion trouble getting things off high shelves and • can’t put her belt on. – Passive and active Strength • Special Tests • Physical Examination Case 1—Key points in the history ROTATOR CUFF • Visual inspection TEARS – Was there an acute injury? • Palpation not really Pain at night, pain • Motion – Are you losing strength? overhead, WEAKNESS • Strength No SHOULDER SHOULDER • Specific testing – Are you losing range of ARTHRITIS motion? Pain all the time, loss of YES, OH YES! motion, slow onset, grinding grinding FROZEN SHOULDER Pain all the time, loss of motion 4

12/9/2016 Frozen Shoulder=Adhesive Capsulitis Causes Frozen Shoulder Mimics All Other Processes! • 2 nd most common cause of shoulder pain in US • Key points in the history and physical in patients 40-60 – No ‘real’ trauma • Mostly unknown – Pain all the time – Associated with Diabetes, Thyroid Problems – Limited ROM active AND passive Natural History Thickening of capsule with Inflammatory cells and fibrosis 5

12/9/2016 State of the Art: Frozen Shoulder Tx Case 2 • 1976: May be auto-immune • 43 year old male, 6 months of shoulder pain, hurts at night, pain • 2010-2013: with overhead activity, no weakness. – Everyone will get better over time- but He says that he can’t lift at the gym as may take over a year! well. – Injections may quicken improvement • UTZ injections are more effective • Glenohumeral Joing • Use a low dose steroid – Surgery only for those that fail all other treatment courses Impingement of the Shoulder Case 2—Key points in the history ROTATOR CUFF Very common in middle age people TEARS – Was there an acute injury? – “Bursitis” Pain at night, pain Not really – Insidious onset of pain overhead, WEAKNESS – Are you losing strength? – Pain with overhead activities Not really SHOULDER SHOULDER – Are you losing range of – Pain with reaching behind back ARTHRITIS motion? No Pain all the time, loss of – Pain at night (can’t sleep on that side) motion, slow onset, – Difficulty doing some, but not all ADLs grinding grinding – No weakness on exam FROZEN SHOULDER – Positive impingement signs Pain all the time, loss of motion 6

12/9/2016 Impingement Syndrome MRI Mechanism • MRI not needed for • Impingement under conservative treatment acromion with flexion • Use it to rule out and internal rotation significant pathology of the shoulder if patient weak, fails • Rotator cuff, PT subacromial bursa and – Better for surgical biceps tendon planning, not for diagnosis Lateral view of shoulder Treatment algorithm for impingement Impingement Syndrome Treatment Better Home • Strengthening of rotator cuff muscles Exercise Mild pain • Scapula stabilization-poor posture often a Program with Physical component activity Therapy Night NSAIDS • Control inflammation pain – Anti-inflammatories MRI to – Ice evaluate for cuff Surgery if Impingement Not Better • ? Steroid injection tear not better Consider • ? Surgery- Arthroscopic subacromial injection decompression- Bursectomy and +/- acromial Moderate PT pain with spur resection NSAIDS activity Consider Wakes pt. Home injection up Exercise Better Program 7

12/9/2016 Case 3 Case 3—Key points in the history ROTATOR CUFF TEARS • 56 year old male, 3 months of shoulder Pain at night, pain – Was there an acute injury? pain and weakness overhead, Yes after an awkward fall WEAKNESS – Are you losing strength? while doing crossfit. SHOULDER SHOULDER Yes Hasn’t been able to ARTHRITIS – Are you losing range of motion? return to the gym. He Pain all the time, loss No has pain at night and of motion, slow onset, lifting things is difficult. grinding grinding FROZEN SHOULDER Pain all the time, loss of motion Rotator Cuff Tears- NEXT TALK Case 4 • 76 year old male with 4 years of worsening pain and weakness with golf. He has some pain at night and describes pain as a toothache in his shoulder. He notes he has lost some Full range of motion. Thickness Tear Partial Cuff Tear Impingement 8

12/9/2016 Case 4—Key points in the history Shoulder OA Radiographs ROTATOR CUFF TEARS – Was there an acute injury? Pain at night, pain No overhead, – Are you losing strength? WEAKNESS No SHOULDER SHOULDER – Are you losing range of motion? ARTHRITIS Yes Pain all the time, loss of motion, slow onset, grinding grinding FROZEN SHOULDER severe Moderate Pain all the time, loss of motion Loss of Motion Treatment Non operative treatment for shoulder Considerable Surgery vs. pain, limited OA PT/Injection ADL • NSAIDS-No good data in last 8 years Xrays: OA • Physical Therapy-mild to moderate Mild PT/Injection Loss of Loss of limitations in relief (Cochrane) Surgery only daily if fail non-op passive activities range of • Glenohumeral Joint Injections- motion motion Less than 3 6 months months: PT/ROM – Merolla et al 2011 Xrays: no PT for ROM program OA – steroid 1-2 month improvement, =Frozen Surgery only Shoulder viscosupplementation: 6 month if fail non op improvement More than 3 6 months months: PT/ROM Injection program 9

12/9/2016 Surgical Treatment for OA Case 5 • 37 year old • Shoulder replacement computer engineer – 2-3 night stay has 4 months of – Sling 6 weeks anterior shoulder – 80-90% recovery pain. He cannot • Excellent pain relief complete his • Good motion workouts. He is markedly tender – Complications along his anterior • Infection, dislocation, shoulder. He has an loosening MRI arthrogram that shows a superior labral tear. Case 5—Key points in the history The biceps shoulder complex ROTATOR CUFF TEARS Differential for Pain at night, pain Anterior Shoulder – Was there an acute injury? overhead, No- more overuse Pain WEAKNESS – Are you losing strength? SHOULDER SHOULDER No Biceps tendonitis ARTHRITIS – Are you losing range of motion? Subscapularis Tear Pain all the time, loss SLAP tear (usually No of motion, slow onset, posterior) grinding grinding AC joint arthritis FROZEN SHOULDER Pain all the time, loss of motion 10