Management of the Persistently Painful Shoulder and Elbow

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1 Management of the Persistently Painful Shoulder and Elbow Mr Nashat Siddiqui Consultant Upper Limb Surgeon Cannizaro House 2 nd March 2016

2 How to approach a painful shoulder/elbow History: acute/chronic/trauma/overuse/disuse Co-morbidities: inflammatory arthropathy; diabetes; steroid use; bone density abnormalities; hypermobility Previous treatment: rest/nsaids/physio/splints/injections/surgery Examination: functional movements; trick movements; ROM compared to normal side; neck; special tests

3 Anatomy of the shoulder

4 Shoulder pathology by age <16 Voluntary instability Traumatic instability ACJ pain in gym enthusiasts Cuff impingement 45+ Cuff disease/ tear 60 + Impingement 65 + OA

5 Shoulder movements Forward elevation Impingement ACJ LHB Abduction (palms up) Impingement Frozen shoulder External rotation Frozen shoulder OA Impingement Subscap rupture (excessive ER) Internal rotation Frozen shoulder Impingement

6 Shoulder - special tests Impingement - over 30, little trauma Empty can, Yocum, Hawkins-Kennedy Cuff tear +/- impingement over 50, occasional trauma (commonest SSp) resisted elevation after empty can or Yocum ER active/resisted (ISp) Belly press/bear hug (SSc)

7 Shoulder - special tests AC joint - usually with impingement; in isolation in weightlifters Cross-body adduction + palpation Instability - under 30, dislocation, repetitive sports Anterior/posterior apprehension, core stability Beighton score over 7/9 Frozen shoulder reduced external rotation (may be OA)

8 Shoulder - investigations X-ray AP / Y-view / axillary MRI if suspicious of cuff tear Weakness/Pain on stressing cuff MR Arthrogram if instability US of limited use Operator dependent Size/retraction of tear/ muscle quality/tendinopathy

9 Preferred tests Impingement: Yocum test Empty can ACJ: cross-body adduction LHB: Speed s test

10 Preferred cuff tests Infraspinatus: Supraspinatus: Yocum Empty can Drop sign ER in adduction Lag sign Subscap: Modified belly press De Beer test (Teres minor: ER in 90 abduction)

11 Healthy bursa

12 Healthy LHB/ cuff

13 Unhealthy cuff

14 Subacromial impingement/ bursitis Shoulder snot

15 Cuff pathology

16 ASAD

17 Cuff treatment Patient dependent Age Co-morbidity Function Time dependent Acute tear Chronic changes in muscle Aetiology dependent Trauma Degenerate Size of tear not so important Age not so important Muscle quality important Patient quality important

18 Structural instability Soft tissue lesions Bankart (found in 85% of recurrent dislocators) SLAP (Superior Labrum - Anterior to Posterior) Capsular laxity (found in 28% of recurrent dislocators) Bone Lesions Bony Bankart glenoid Hill-Sachs humeral head

19 Bankart + Hill Sachs

20 Hill Sachs lesion

21 Reverse Hill Sachs lesion

22 Instability treatment Surgery if structural defect: Labrum (Bankart) - repair SLAP repair/ debride Bony Bankart repair/ Latarjet Hill Sachs / Reverse McLoughlin/ partial resurface/ replace

23 Non-structural Physiotherapy Proprioceptive/ Bio-feedback Scapula positioning Core stability In-patient multi-disciplinary including psychiatric No role for capsular tightening No role for surgery in young + female + hypermobile patient

24 Shoulder - treatment Mild impingement, no functional loss - exercise sheet Moderate /chronic pain /early frozen shoulder /generalised muscular pain physiotherapy course /NSAIDs +/- Steroid subacromial injection - if impingement cuff tear unlikely may reduce success of future cuff repair Instability - refer Significant trauma, weakness or acute functional loss (e.g. brachial neuritis) - refer

25 Anatomy of the elbow Common extensor origin Common flexor origin

26 Aims of elbow treatment Pain relief Range of movement Stiffness Return to work/ sports Other symptoms: locking, instability, etc Most symptoms can be treated without surgery

27 Elbow ROM Check shoulders Flexion Extension Pronation Supination

28 Elbow special tests Tennis elbow (lateral) resisted middle finger extension Golfer s elbow (medial) resisted wrist flexion Elbow flexed vs extended Loose bodies / degeneration Locking / crepitus

29 Elbow - investigations X-rays - exclude calcific deposits/ OA/ loose bodies U/S - tendon thinning/tears if exhausted simple treatment MRI specific indications: occult ligament injuries/ osteochondral defects

30 Tennis Elbow Tennis elbow poorly understood Range of treatments with poor evidence for all Common extensor origin pathology - ECRB Severity scoring (Wixom) Mild/ moderate/ severe Pain on resisted middle finger extension with elbow flexed vs extended Pain at rest/ reduced ROM/ tenderness

31 Wixom SM, LaStayo P J Hand Ther 2012 Tennis Elbow Classification Signs and Symptoms Severe Symptoms Moderate Symptoms Mild Symptoms Pain ROM Resisted test Grip test Palpation Pain at rest significantly limits participation in all activities >5 Motion loss at wrist/elbow Pain with minimally resisted wrist extension (elbow flexed) Pain/ >50% GSD with elbow flexed or extended Pain with palpation at lateral epicondyle; no blanching of finger(s) (minimal pressure) Pain with sports and work activities. Mild pain with activities of daily living. Pain limits performance in sports/work Motion loss may or may not be present Pain with resisted wrist extension (elbow flexed or extended) Pain/ >50% GSD with elbow extended. Pain/<50% GSD with elbow flexed Pain with palpation at lateral epicondyle with mild blanching of examiner's finger(s) (moderate pressure) Mild pain after activity which resolves within 72 h after cessation of activity pain does not limit participation in activities No motion loss Pain with resisted wrist extension (elbow extended) Mild pain with grip strength test with elbow extended and minimal to no pain with elbow flexed may not have significant GSD Pain with palpation at lateral epicondyle only with full blanching examiner's finger(s) (firm pressure)

32 Degenerate ECRB

33 Treatment options Rest/ Ice/ NSAIDs/ Strapping/clasps Physio - eccentric strengthening/stretching Steroid injections - repeat once but only if successful (preferably not Depo-Medrone) Autologous blood better than steroid at 4 and 8 weeks (PRP may be superior but poor evidence) Surgery open/ arthroscopic

34 Common Extensor Origin

35 Surgery last resort Nirschl ECRB debridement Decortication/drilling Synovectomy Reattachment/ repair of common extensor origin (ECRL and EDC) +/- PIN decompression Open surgery most commonly performed Arthroscopic surgery increasing in popularity 15 years Percutaneous release

36 Lateral synovitis

37 Surgery - results Siddiqui et al BOA 2013 Grip strength improved to 85% contralateral side at 18 weeks, 54/55 patients returned to normal work/recreation Cochrane review 2011 Not enough evidence to support or refute surgery of any description: PIN release, percutaneous tenotomy, radiofrequency needling, etc

38 Common flexor/pronator origin

39 Golfer s Elbow Golfer s elbow even less well understood Common flexor origin; Flexor/pronator mass Range of treatments with poor evidence for all Shockwave therapy (risk of ulnar nerve damage) Pubmed Medial epicondylitis 145 articles vs 1865 for lateral epicondylitis

40 MCL

41 The degenerate elbow Traumatic Overuse Rheumatoid Neurological/ Charcot

42 Charcot

43 Treating the degenerate elbow Selective use of physiotherapy young Steroid injections soft spot/ posterior Arthroscopy Articular surface Debride synovium, Osteophytes Capsular release Remove loose bodies

44 Bursitis/ Tendinopathy Olecranon- common Leave alone unless recurrent infected Aspirate recurs Surgery Seroma, wound healing problems Biceps rare Rest US guided steroid injection Surgery debride/ reconstruct

45 Postero-Lateral Rotatory Instability (PLRI) Lateral collateral (LUCL) ligament deficiency Pain stressing radio-capitellar joint Clicking, swelling, reduced grip Not always traumatic Painful push off from armchair Surgery several types

46 Posteromedial Instability Pitcher s/ Thrower s Elbow Ulno-humeral joint stresses in valgus MCL strain/ injury Osteophytes Treatment: Rest/ NSAIDs etc Debride osteophytes MCL reconstruction

47 Previous trauma

48 Ulnar Neuropathy Second commonest peripheral nerve compression Variable symptoms paraesthesia, weakness, wasting Three causes: 1. Compression 2. Traction 3. Friction - subluxing EMG unreliable Neuropathic conditions (diabetes etc)

49 Ulnar Neuropathy - Treatment Rest/ Splints/ NSAIDs/ gel pads on armrests/ nerve gliding exercises Steroid injections caution! Surgery: Release areas of compression +/- Medial epicondylectomy +/- Formal transposition

50 Nerve decompression/ transposition

51 PIN/ Radial Tunnel Syndrome Posterior Interosseous Nerve entrapment at several sites Diffuse pain antero-laterally and forearm, especially on supination Weakness variable EMG not always useful Local anaesthetic injection diagnostic Usually resolves with rest/ stretching/ NSAIDs Surgery variable success

52 PIN/ Radial Tunnel Syndrome

53 PIN

54 Elbow Arthroscopy Many indications but associated risks: Transient neuropraxia 10% Permanent nerve injury 1% Useful for: Pain control esp synovitis Debridement of synovial plica Good for improving ROM in mild to moderate arthropathy Locking symptoms, loose bodies

55 Elbow Arthroscopy

56 Arthroscopic surgery Zonno et al Arthroscopy 2010 Cadaveric study Ulnar nerve 20.8mm away MCL 8.3 mm away Deemed safe

57 Lots of pathology at elbow Olecranon bursitis Triceps enthesopathy Bicipital enthesopathy/partial tear/ bursitis Isolated compartment OA Osteochondral lesions Tumours Synovial chondromatosis Anterior Interosseous Nerve entrapment

58 QUESTIONS?

Management of Chronic Elbow Pain

Mr. Nashat Siddiqui Consultant Upper Limb Orthopaedic Surgeon Management of Chronic Elbow Pain Patients presenting with elbow pain can pose a diagnostic challenge, especially if there is no obvious recent