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1 Burwood Road, Concord 160 Belmore Road, Randwick
2 Conservative management of subacromial pathology Mel Cusi MBBS, Cert Sp Med, FACSP, FFSEM (UK)
3 Presenting symptoms Shoulder pain Stiffness Loss of function
4 Clinical examination Look, move, feel Range of motion Elevation Abduction Internal rotation External rotation Active and passive Power Internal rotation (lift off) External rotation Abduction (empty can) Impingement Hawkins Neer Biceps
5 SUBACROMIAL IMPINGEMENT IS A CLINICAL DIAGNOSIS Not an Ultrasound report
6 The subacromial space Dr Dr Mel Mel Cusi Cusi Sport & Sport Exercise & Exercise Medicine Physician
7 What pathologies Subacromial impingement Tendinitis (acute), tendinosis (chronic) Bursitis (acute or chronic)
8 What pathologies Subacromial impingement Tendinitis (acute), tendinosis (chronic) Bursitis (acute or chronic) Partial thickness tears of the rotator cuff
9 Subacromial impingement Tendinitis (acute), tendinosis (chronic) What pathologies Bursitis (acute or chronic) Partial thickness tears of the rotator cuff Full thickness tears with good function
10 What goals Restore muscle balance about the shoulder by: Improving efficiency of humeral head depressors (without Deltoid activation) Decompressing the sub-acromial space Preventing impingement
11 Rehabilitation stages 1) Restore range of motion A stiff shoulder is a painful shoulder 2) Strengthening programme Including scapular stability and postural work 3) Functional activities ADL Sporting activities
12 The first steps Relative rest (minimum 2 weeks) Avoid aggravating activities Do NOT immobilise (risk of developing shoulder capsulitis) Assist with NSAIDS, cortisone injections Anti-inflammatory modalities Passive ROM gentle exercises (pendulum) Stretching RC and capsule (not anteriorly)
13 Following up 1) Strengthening programme Humeral head depressors (Infraspinatus, Teres minor, Subscapularis) Scapular elevators (Trapezius, Levator scapula, Serratus anterior) 2) Postural training Sitting and standing Ergonomic arrangements at work and home
14 Strengthening program Holmgren et al, BMJ 2012;344:e787 Eccentric Rotator Cuff strengthening Supraspinatus, Infraspinatus, Teres minor Concentric/Eccentric Scapular stabilisers Middle and Lower Trapezius, Rhomboids, Serratus Anterior Posterior shoulder stretch
15 Strengthening program Randomised, double blinded controlled study 12 weeks Both groups: information, ergonomics, posture Results Holmgren et al, BMJ 2012;344:e787 Greater improvement in Constant scores (24 v 9) Successful outcome (69% v 24%) (Recovered or large improvement ) Fewer patients had subsequent surgery (20% v 63%)
16 Predictive Factors 118 patients, 123 shoulders Full thickness tears on MRI 62 patients (65 shoulders) improved 56 ( 58 ) required surgery Predictor Surgery Conservative Rx Integrity of SS tendon 24% 58% SS atrophy (occupancy ratio) 69% 78% Impingement sign 80% 30% ER range Tanaka et al, 2010
17
18 Our approach Surgical management initially in limited cases Conservative management Monthly injections (usually 3) NSAIDS Physiotherapy as described If not sufficient improvement, consider surgical options
19 Cortisone or PRP injections Different purposes Cortisone, anti inflammatory PRP encourages tissue healing PRP meant to increase the concentration of growth factors (in cuff tears) Accelerates the healing process So far insufficient evidence that it works Evidence of increased growth factors after arthroscopic acromioplasty
20 THANK YOU
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