Shoulder Impingement. Eden Raleigh Orthopaedic Surgeon Shoulder & Knee Surgery. Ph:
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1 Shoulder Impingement Eden Raleigh Orthopaedic Surgeon Shoulder & Knee Surgery Ph:
2 My Background Specialising in Shoulder and Knee Surgery Main focus on Arthroscopic/Sports Surgery FRACS (2006) Melbourne Fellow Guy s & St. Thomas, London Fellow Paris Cinq (Paris) Fellow PanAm Clinic (Canada)
3 WHERE AM I? 89 Erin St, Richmond (op. Epworth) Bounce Healthcare Epworth Eastern Epworth - Lilydale Consulting Suites Berwick
4 What is impingement? Popularised by Charles Neer 1972 Pathological compression of rotator cuff against the anterior structures of the coracoacromial arch, Anterior third of acromion, CA ligament and AC joint
5 Definitions Shoulder Impingement Compression and mechanical abrasion of cuff as it passes below the arch during arm elevation Rotator Cuff Tendonitis Encompasses impingement and results from acute cuff overload, intrinsic cuff degeneration or chronic overuse
6 Rotator Cuff Syndrome Term used to describe the process whereby impingement and tendonitis are ongoing simultaneously Painful Arc Syndrome Pain during midrange of glenohumeral abduction, with freedom from pain at extremes of range
7 Impingement causes mechanical irritation of the cuff tendons (haemorrhage and swelling) This also causes bursitis
8 Signs and Symptoms Pain, tenderness Pain, weakness with active abduction in midrange Limited Internal rotation Specials tests Tenderness to palpation
9 1. Anatomical Factors
10 spur
11 ACJ Spur
12 Others Poor scapular control Occasionally anterior instability Postural (forward head, rounded posture)
13 Internal Impingement Overuse (baseball) Loose joint Instability Superior Labrum injury associated Muscle imbalance
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15 Signs Impingement tests ie. Neer and Hawkins- Kennedy
16 Signs Strength testing ie. empty can,
17 Treatment 1. Functional Modifications (Most important) Activity stops until can reintroduce pain free
18 2. Medicines Oral Anti-inflam Subacromial injections Combinations with TENS etc.
19 3. Physio General physio Mm TENS LASER, heat Other modalities
20 TENS Machine
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24 4. Injections CSI (cortisone) & Hydro CSI- Into subacromial space - Steroid/LA Hydrodilatation - Into Glenohumeral Joint ml good results What are you treating??
25 When is CSI the best option Impingement pain +- RCT For diagnostic reasons - is this patients pain due to impigment - Exclude ACJ, GHJ OA, Labral etc.
26 When are Hydro s a good idea Capsulitis Frozen Shoulder Stiffness Remember, most patients with Impingement/cuff stiffness have the pathology in the subacomial space, and wont respond to hydro. If you fix the subacromial space, you can get the shoulder going
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28 How Many Injections Can I give? How Often Can I give Injections? PRP? Stem Cells?
29 5. Surgery
30 Case 1 45 year old Man Presents with 2 weeks of impingement type symptoms in dominant shoulder Last few days of increasing pain and weakness
31 XR: mild ACJ OA MRI: Full thickness tear in S.S. - 2cm retraction What is the BEST way to tell if his weakness is related to tendon dysfunction or pain? A. MRI B. XR C. Injection with Local Anaesthetic & Reexamine D. CT Scan
32 Diagnostic Injection What is the BEST way to tell if his weakness is related to tendon dysfunction or pain? A. MRI X B. XR X C. Injection with Local Anaesthetic & Re-examine D. CT Scan X Strength testing after lignocaine injection may help to distinguish RC tendinopathy vs. tear
33 When to Refer? 1. Young < 60 yrs 2. Active/independent in older pop. 3. TRUE WEAKNESS with functional disturbance 4. Failure of non-operative therapy
34 Osteoarthritis Should I order an xray?? Bony metastasis these patients presented with rot cuff tears!!
35 Rotator Cuff Arthropathy When a massive tear is present, the shoulder will sublux superiorly. Secondary arthritis will follow
36 Thank you Questions? Mr. Eden Raleigh Orthopaedic Surgeon Specialising in Shoulder & Knee Surgery Ph:
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