Chronic Shoulder Disorders Dr. Mustafa Elsingergy Consultant orthopedic surgeon Dallah Hospita Prof. Mamoun Kremli Almaarefa Medical College
Contents
INTRINSIC Shoulder Pain Due to causes in the shoulder region EXTRINSIC Due to referred pain from outside the shoulder
INTRINSIC Shoulder Pain Due to causes in the shoulder region
EXTRINSIC Shoulder Pain Due to referred pain from outside the shoulder
Shoulder Disorders Due to causes related to : 1. Rotator cuff 2. Shoulder capsule 3. Glenohumeral joint 4. Scapular problems 5. Acromioclavicular joint
Rotator Cuff - Anatomy Originate from the scapula Insert in the Greater Lesser tuberosities Pass under coraco-acromial arch Separate from the ligament by bursa
Rotator Cuff Disorders Acute tendinitis Impingement syndrome Rotator cuff tear
R.C.D - Acute Tendinitis Clinical features: Pain / Tenderness / Painful abduction range X-ray: Normal Area of calcification Treatment: Rest NSAID Local injection
R.C.D - Impingement Syndrome Causes Clinical features Pain Shoulder looks normal or wasted Tenderness Disturbed glenohumeral rhythm Painful abduction ( 6o o TO 120 o ) Neer s test (+VE) Hawkin s test (+ve)
R.C.D - Impingement Syndrome X-ray: Calcification Degenerated AC jt. MRI: Bursitis Thickening of the tendon Treatment: Mild: NSAID, local injection Severe: arthroscopy vs acrmoioplasty
R.C.D - Impingement Syndrome Predisposing factors Degeneration: middle age Chronic irritation by osteophyte Underlying disease: eg. Rheumatoid Precipitating factor: trauma Types: Incomplete Complete
R.C.D - Impingement Syndrome Clinical features: Trauma, pain, limited abduction After few weeks: Incomplete tear: improvement of pain and rom Complete tear: improvement of pain and decrease of active range Look: Early; normal appearance Late; wasting of supraspinatus and infraspinatus muscles Feel: Tender greater tuberosity
R.C.D - Rotator Cuff Tear Clinical features: Move: Incomplete tear; painful weak Complete; passive not painful, active drop arm sign X-rays: Early normal Late degenerative changes MRI: image of choice Treatment: Incomplete tear: PT, NSAID Complete tear: surgery
Biceps Tendon Disorders Tendinitis: Pain Tenderness: Bicepital groove Painful forward flexion Treatment: NSAID, local injection Tear of long head of biceps tendon: Pain Deformity of biceps contour (Popeye s arm) No need for treatment
Adhesive Capsulitis (Frozen Shoulder) Unknown pathogenesis leads to pain and limitation of movement Trauma or RCD may be causes Clinical features: Pain Limitation of movement in all directions of GH range Natural history: Pain and limitation of movement gradually increase then gradually decrease, takes 18 months Treatment: Conservative vs arthroscopy
Recurrent Shoulder Instability Types: Recurrent anterior dislocation (RAD) Recurrent posterior subluxation (rare) Multidirectional instability (MDI) Type RAD MDI Cause Traumatic Atraumatic Clinical feature Apprehension test +ve Sulcus sign positive Treatment Surgical PT
Recurrent Shoulder Instability Multidirectional instability: Generalized ligamentous laxity Sulcus sign (+ve)
Recurrent Shoulder Instability Recurrent anterior dislocation (RAD) Most common H/O acute dislocation Apprehension test (+ve) Image: Hill Sach s lesion Bankart s lesion
Recurrent Shoulder Instability Recurrent anterior dislocation (RAD) Multidirectional instability (MDI) Type RAD MDI Cause Traumatic Atraumatic Clinical feature Apprehension test +ve Sulcus sign positive Treatment Surgery PT
Gleno-humeral Joint Disorder Osteoarthritis Rheumatoid TB Milwaukee
Gleno-humeral Osteoarthritis Usually follows other pathology eg. Trauma, rheumatoid artheritis or rc tears Clinical features: Painful movement Wasting the shoulder muscle Tender joint line, Limited ROM X-ray: Loss of joint space Subchondral sclerosis Treatment: Conservative / Replacement
Gleno-humeral Rheumatoid Arthritis Clinical features: Generalized arthritis affecting other joints Pain and limitation of movement Painful passive movement and limited active movement Lab investigation: +ve rheumatoid factor X-ray: Loss of articular space Peri-articular erosion
Acromioclavicular Disorders Instability Arthritis
Sprengel s shoulder: Congenital Scapular Disorders Winging of scapula: Weak serratus ant muscle
Shoulder Summary Shoulder Symptoms: Pain Stiffness Instability Deformity Loss of Function Shoulder Examination Look Feel Move Special Tests Investigations Lab X-ray MRI Treatment Conservative Surgical