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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