ATRAUMATIC SHOULDER CONDITIONS. Matthew J. Landfried, MD Orthopaedic Surgeon Genesee Orthopaedics and Sports Medicine
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1 ATRAUMATIC SHOULDER CONDITIONS Matthew J. Landfried, MD Orthopaedic Surgeon Genesee Orthopaedics and Sports Medicine
2
3 MATTHEW LANDFRIED MD Board Certified in Orthopedic Surgery and Sports Medicine Received MD from Temple University in 1985 Residency at Shriner's Hospital for Crippled Children and Hamot Medical Center both located in Erie, PA. Member of American Academy of Orthopaedic Surgeons, NYS Medical Society and WNY Orthopaedic Society
4 Disclaimer I have no conflicts of interest related to this presentation.
5 NON TRAUMATIC SHOULDER PROBLEMS
6 Shoulder Topics to be covered: Impingement Bursitis Tendonitis Tears: RTC/Biceps Instability Arthritis Frozen shoulder Thoracic outlet Cervical spine
7 WHY DO I NEED TO KNOW THIS? 10-28% of all visits to PCP are musculoskeletal 6-8% of all pediatric visits are MSK related 78% of all MSK injuries are seen by primary care
8 WHY IT CAN BE SO DIFFICULT
9 IT STARTS WITH(A) HISTORY
10 INTRINSIC -EXTRINSIC Careful history r/o: 1.cervical 2.splenic 3. cardiac
11 GLENOHUMERAL VS EXTRA-GLENOHUMERAL GLENOHUMERAL Arthritis Labral pathology Intra-articular biceps Loose body Instability Adhesive capsulitis
12 EXTRA-GLENOHUMERAL ROTATOR CUFF -impingement -RTC tears CALCIFIC TENDONITIS AC JOINT ARTHRITIS BURSITIS -sub acromial -scapula-thoracic
13 HISTORY what to ask What - are symptoms? Where - does it hurt? When - does it hurt? What - makes it worse? What - makes it better? What - treatment have you had?
14 DO THE ANSWERS MATTER? YES! -What are symptoms pain, stiffness, radiation, instability -Where does it hurt remember surface map -When does it hurt nighttime, with activity, after activity -What makes it worse similar question and answers -What makes it better medicine, shots, therapy, rest, heat, cold -What treatment failed,successful (helps with where to start)
15 IMPINGEMENT SYNDROME (most common diagnosis) -Nighttime pain wakes me up every night -Pain with abduction, internal rotation and overhead activities -Common to hear it hurts to fasten my bra, put on a belt, shirt or coat, hurts to get my wallet, hurts to fasten seat belt
16 EXAM ROM active and passive Strength (may or may not see weakness) Provocative maneuvers(mcbride, Hawkins,Neer,Apley scratch) Pain to palpation Muscle atrophy XRAY
17 - 39 yo w female, c/o of pain when reaching in the cupboard, doing her hair, fasten her bra, putting on a coat - Pain wakes her up at night - Over the counter nsaids help a little - Denies injury - Present for several months
18 Mri/xray ithiosyte Ac joint erosity
19 DIFFERENTIAL Impingement AC joint arthritis Glenohumeral arthritis Rotator Cuff strain, tendonitis or tear CERVICAL -Herniated Disc (radicular ) Nerve entrapment (subscapular)
20 TREATMENT
21 TREATMENT Rest NSAIDs PT Steroid injections MRI
22 IMPINGEMENT
23 scope
24 CALCIFIC TENDINITIS (calcium hydroxyapatite) Calcium deposition in tendon Can be extremely painful May be acute onset EXAM SIMILAR TO IMPINGMENT
25 DIAGNOSIS ON XRAY
26 TREATMENT REST NSAIDS INJECTION THERAPY SURGERY(rarely)
27 CALCIFIC TENDINITIS Mri picture
28 ROTATOR CUFF TEAR SIMILAR HISTORY AND SYMPTOMS DIFFERENCES: -may be a history of trauma or single event --could be insidious though -c/o weakness -more common over 40 EXAM - weakness -atrophy -drop arm
29 Pt hx 46yo w male loading a truck and reached for a package he dropped and felt a tearing, searing pain Now having difficulty using arm and sleeping Alternate history 46 yo male with 8 months of pain at night, working overhead lifting away from his body
30 TREATMENT Rest NSAIDs PT Steroid injections MRI SURGERY
31 MRI RTC TEAR
32 Scope pic
33 AC JOINT ARTHRITIS HISTORY AND EXAM - Anterior shoulder pain - Point tenderness - Positive scratch test TREATMENT - Rest, ice NSAIDS, injection, surgery
34
35
36
37 GLENOHUMERAL ARTHRITIS STIFFNESS PAIN LMITED ROM XRAY DX
38 - 81 yo w male with chronic shoulder pain - He has lost motion with increasing pain - Now like a constant toothache in the shoulder - He avoids activity more and more due to pain
39
40 TREATMENT NSAIDS Injection Therapy Surgery
41 Scope pic
42 RESURFACING(COPELAND CAP)
43 HEMIARTHROPLASTY
44 TOTAL SHOULDER
45 REVERSE TSA
46 BICEPS PATHOLOGY Tendinopathy Tear Symptoms: Pain ant. Shoulder Pain lifting Positive mcbrides and speeds POPEYE Diagnosis: Popeye sign MRI
47 TREATMENT 1.Tendinoapathy - rest, ice, NSAIDS, PT - surgery 2. RUPTURE -rest, ice, NSAIDS, PT -no significant functional loss (brachioradialis and short head biceps =85% of flexor strength)
48 BICEPS
49 BICEPS TENODESIS james pries
50
51
52 INSTABILITY BASED ON HISTORY AND EXAM Dead arm apprehension, Shoulder sliding out + relocation test Clear dislocation sulcus sign TREATMENT Rest, anti-inflammatory modalities, PT, surgery
53 LABRAL PATHOLOGY INSTABILTY bankart (labral tear) SLAP biceps symptoms, scapula pain POSTERIOR RELOCATION TEST DIAGNOSIS - MRI ARTHROGRAM TREATMENT - rest, NSAIDs, PT, surgery
54 MRI INSTABILITY Bankart Slap lesion
55 SLAP LESION
56
57
58 MULTIDIRECTIONAL INSTABILTY & BANKART
59
60
61 LABRUM GLENOID
62
63
64
65 ADHESIVE CAPSULITIS
66 ADHESIVE CAPSULITIS (FROZEN SHOULDER) STIFF, PAINFUL SHOULDER MOST COMMON: WOMEN IDIOPATHIC - true pathologic condition - DM, Parkinson's, COPD, stroke REACTIVE tendinopathy, immobilization, low pain tolerance, can lead to true frozen shoulder
67 DIAGNOSIS - painful limited ROM, especially external rotation TREATMENT rest, NSAIDs, PT, injection, rarely manipulation and/ or surgery Natural history: it will improve with time (2 years)
68 - 55yo female complaining of increasing pain and decreasing motion - Pain is mostly constant - She has tried NSAIDS without much relief- the only thing that helps at Norco pain meds - -Therapy was too painful Exam reveals reluctance to move are/shoulder. Passive motion reveal limited painful motion especially in external rotation, abduction and attempts at ABER positioning. Any abduction past 20 degrees involves scapula.
69
70
71 USUALLY RELIEVES SOME PAIN WITH INCREASE IN MOTION REQUIRES PHYSICAL THERAPY STILL TAKES EXTENDED TIME TO RECOVER
72 I hope I have shed some light on this for you
73 Thank you!
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