Ryan Wilkins, MD

Uncovering the Cause ofYour Shoulder PainRyan Wilkins, MD07/18/2013

3Bony Anatomy

Four JointsShoulder consists of fourjoints:‣ 1. Glenohumeral joint‣ 2. Acromioclavicularjoint‣ 3. Sternoclavicularjoint‣ 4. Scapulothoracicarticulation4

Sternoclavicular JointVery stable jointRarely the site of pathologyAllows the clavicle to function as a strutGray’s Anatomy5

Acromioclavicular JointRelies on Ligaments for stabilityAC Joint capsule providesanterior-posterior (Front-back)stabilityCoracoclavicular ligaments– Hold the clavicle down“SeperatedShoulder”6

Scapulothoracic “Joint”

Shoulder Elevation120° GH motion + 60° ST motion = 180° of Elevation

Glenohumeral JointNot a true “ball andsocket”

Bony AnatomySpherical humeralhead (Ball)Shallow glenoid fossa(Tee)shouldersurgeon.com10

Mobility vs Stability

Glenohumeral StabilityStatic StabilizersScapula (Glenoid(Glenoid)Humeral HeadGlenoid LabrumGlenohumeral Ligaments(capsule)Dynamic StabilizersRotator CuffPeriscapular muscles

Glenoid LabrumDeepens the glenoid cavityby 50%Biceps tendon attachessuperiorlyServes as an anchor forattachment of the jointcapsule13

Shoulder CapsuleANTERIORPOSTERIORAnterior CapsulePosterior Capsule

Rotator CuffFour Muscles‣ Subscapularis‣ Supraspinatus‣ Infraspinatus‣ Teres Minor

Rotator Cuff Functions‣ Internal and External Rotation‣ Provides Joint Compression‣ Initiates Elevation‣ Allows the larger muscles (i.e., deltoid) tofunction efficiently16

Rotator CuffMuscles on oppositesides of the joint createa net force allowing forjoint compression17www.orthop.washington.edu

DeltoidThree heads– Anterior (Front)– Middle (Middle)– Posterior (Back)Elevates the humerusRelies on a functioningrotator cuff to workefficiently18

Scapular Stabilizers / RotatorsStabilize / position the scapula to allow forefficient glenohumeral motionlivestrong.com19

Why Does My Shoulder Hurt?

Q: Is it my rotator cuff?A: MAYBE‣ Age USUALLY >40‣ Anterior (front) and Lateral (side) Shoulderpain‣ Reaching and Overhead Activities‣ Weakness (pain related?)

Q: Is it my rotator cuff?A:PROBABLY NOT‣ Age < 30 (exceptions)‣ No Anterior or Lateral Arm Pain‣ No Weakness

nottinghamshoulders.comSub-acromialImpingementMost commondiagnosis for patientspresenting withshoulder pain

Sub-acromialImpingementortho-md.com

Acromion Morphology

Sub-acromialImpingementTreatment– At least 4-646 weeks of conservativemanagement initiallyAvoid aggravating activities / positionsPhysical therapyAcetaminophen/NSAIDsas needed

Positive Response?Continue PTTransition to home exercise program

Persistent Pain?Sub-acromialinjection– Diagnostic andtherapeutic benefitConsider MRI toevaluate for rotatorcuff tear

Acromioplasty

Sub-acromialdecompressionnottinghamshoulders.com,drgartsman.com

Rotator Cuff Tears

Partial Thickness TearsHabermeyer et al, JSESKwon et al, JKOA

Partial Thickness TearsDebride vs Repair50% RuleBig Difference in Recovery– Must be prepared for either(3-6 6 months vs 6-12 months)

Full Thickness RC Tearshttp://orthoinfo.aaos.org

Q: Who Needs Surgery?A: NOBODY!

Q: Who Benefits Most FromSurgery?Young Physiologic AgeAcute TearsHigh Demand PatientsSignificantly Compromised Function– Unable to compensatePersistent pain (repair vs debride)

Lo and Burkhart, AJSMNot All RC Tears Are TheSame!Crescent and U shapedL- Shaped

Not All RC Tears Are TheSmall / Acute TearSame!Large (Massive) /ChronicTearnguyensportsmed.comVaishnav et al, JSES

Rotator Cuff RepairTechniques have advanced tremendously!Open Rotator Cuff Repair Mini-openRotator Cuff Repair All ArthroscopicRotator Cuff RepairCaution! Small incisions, big surgery!

Rotator Cuff Repair - TechniqueAhmad et al,AJSM

Rotator Cuff RepairHealio.com

RC Repair: Post-op op RehabInitial period of relative immobilization– 4-66 weeksRange of Motion– 6 weeks 3 monthsStrengthening– 3 months 6 months

Q: Is it a Frozen Shoulder?Gradual OnsetNo Clear MechanismDiffuse PainWorse at nightProgressive loss of motion

Adhesive Capsulitisa.k.a. “Frozen Shoulder”Idiopathic (sponatneous(– unknown cause)painful, global restriction of shoulder motionRestriction of Both Active and Passive motionMay be secondary to another injury– Use it or Lose it

Frozen Shoulder

Frozen Shoulder: Stage 1Inflammatory Stage: Gradually Increasing Painand Loss of Motion– 0-33 months– Increasing difficulty with simple activities ofdaily livingCombing hairFastening a BraReaching for walletTucking a shirt

Frozen Shoulder: Stage 2Freezing Stage: Stiffness worsens, Painpersists– 3-99 months– Passive motion = Active motion

Frozen Shoulder: Stage 3Frozen Stage: Stiffness persists, Painlessens– 9-15 months– Passive motion = Active motion– PT generally more well-tolerated

Frozen Shoulder: Stage 4Thawing Stage– 15-24 months– Initially minimal pain, but severe restriction inmotion– Effectiveness of PT improves as the capsuleremodels– Gradual, but not complete return of range ofmotion– 15% of patients never regain full range

Who Gets a Frozen Shoulder?Has been described in all age groupsThose at greater risk include:– Women 40-60 years of age– Diabetics (5x)– Thyroid Dysfunction– History of Breast Cancer– Prolonged Immobilzation

AC: Natural HistoryMost Commonly– Self Limited Condition– Lasts 12-24 24 months

Frozen ShoulderNon-Operative Management– Physical Therapy (gentle stretching,mobilizations)– NSAIDs as needed– Glenohumeral and/or sub-acromialinjection

AC: Non-OperativeManagmentManipulationUnder Anesthesia

AC: Surgical ManagementArthroscopicCapsular Release

Frozen Shoulder TreatmentPhysical therapy in any phaseSub-acromialand/or glenohumeral injection(inflammatory and freezing stages)Manipulation +/- arthroscopic release ifsymptoms are intolerable and unresponsivefor at least 3 monthsPT immediately following procedure

Q: Is it arthritis?Final common pathway for manyconditions– Post-traumatictraumatic– Chronic Rotator cuff tears– Multiple “shoulder stabilizing” procedures– General wear and tear– Bad luck

Acromioclavicular Joint Arthritis

AC Joint ArthritisWho?– 50-60 % of asymptomatic people over age 65will have AC joint arthritis on xrays

AC Joint ArthritisWho needs treatment?Pain on top of shoulderTenderness at the AC jointRelief from injection– Typically laborers, weightlifters, recreationalathletes

AC Joint ArthritisNon –Operative TreatmentAvoid aggravating activitiesAnti-inflammatory inflammatory medicationsInjection (Diagnostic and Therapeutic)

AC Arthritis: SurgeryDistal ClavicleExcision:– 5-15 mm of distalclavicle removed– Open or arthoscopicPost-op

Glenohumeral ArthritisRelatively diffuse, “deep” shoulder painPain with activity and following activityFrequent crepitationProgressive loss of fuction

Glenohumeral Arthritis: Xraysshouldersurgery.com

Glenohumeral Arthritis:Non-operative operative TreatmentActivity ModificationGentle PTAnti-inflammatory inflammatory medicationsSteroid Injections‣ Manage the symptoms

Glenohumeral Arthritis:Hemi-resurfacing (PartialReplacement)

GH Arthritis: Total ShoulderReplacementRequires intact rotator cuff for good function

Rotator Cuff Tear ArthopathyChronic rotator cufftearHumeral headmigrates superiorlyArthritis with wear ofthe acromion

Reverse Total ShoulderAllows the deltoidto compensate fora deficient rotatorcuffChanges theresting tension ofthe deltoid andimproves itsmoment armReplacement

Thank You!