ATRAUMATIC SHOULDER CONDITIONS Matthew J. Landfried, MD Orthopaedic Surgeon Genesee Orthopaedics and Sports Medicine
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
Disclaimer I have no conflicts of interest related to this presentation.
NON TRAUMATIC SHOULDER PROBLEMS
Shoulder Topics to be covered: Impingement Bursitis Tendonitis Tears: RTC/Biceps Instability Arthritis Frozen shoulder Thoracic outlet Cervical spine
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
WHY IT CAN BE SO DIFFICULT
IT STARTS WITH(A) HISTORY
INTRINSIC -EXTRINSIC Careful history r/o: 1.cervical 2.splenic 3. cardiac
GLENOHUMERAL VS EXTRA-GLENOHUMERAL GLENOHUMERAL Arthritis Labral pathology Intra-articular biceps Loose body Instability Adhesive capsulitis
EXTRA-GLENOHUMERAL ROTATOR CUFF -impingement -RTC tears CALCIFIC TENDONITIS AC JOINT ARTHRITIS BURSITIS -sub acromial -scapula-thoracic
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?
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)
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
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
- 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
Mri/xray ithiosyte Ac joint erosity
DIFFERENTIAL Impingement AC joint arthritis Glenohumeral arthritis Rotator Cuff strain, tendonitis or tear CERVICAL -Herniated Disc (radicular ) Nerve entrapment (subscapular)
TREATMENT
TREATMENT Rest NSAIDs PT Steroid injections MRI
IMPINGEMENT
scope
CALCIFIC TENDINITIS (calcium hydroxyapatite) Calcium deposition in tendon Can be extremely painful May be acute onset EXAM SIMILAR TO IMPINGMENT
DIAGNOSIS ON XRAY
TREATMENT REST NSAIDS INJECTION THERAPY SURGERY(rarely)
CALCIFIC TENDINITIS Mri picture
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
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
TREATMENT Rest NSAIDs PT Steroid injections MRI SURGERY
MRI RTC TEAR
Scope pic
AC JOINT ARTHRITIS HISTORY AND EXAM - Anterior shoulder pain - Point tenderness - Positive scratch test TREATMENT - Rest, ice NSAIDS, injection, surgery
GLENOHUMERAL ARTHRITIS STIFFNESS PAIN LMITED ROM XRAY DX
- 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
TREATMENT NSAIDS Injection Therapy Surgery
Scope pic
RESURFACING(COPELAND CAP)
HEMIARTHROPLASTY
TOTAL SHOULDER
REVERSE TSA
BICEPS PATHOLOGY Tendinopathy Tear Symptoms: Pain ant. Shoulder Pain lifting Positive mcbrides and speeds POPEYE Diagnosis: Popeye sign MRI
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)
BICEPS
BICEPS TENODESIS james pries
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
LABRAL PATHOLOGY INSTABILTY bankart (labral tear) SLAP biceps symptoms, scapula pain POSTERIOR RELOCATION TEST DIAGNOSIS - MRI ARTHROGRAM TREATMENT - rest, NSAIDs, PT, surgery
MRI INSTABILITY Bankart Slap lesion
SLAP LESION
MULTIDIRECTIONAL INSTABILTY & BANKART
LABRUM GLENOID
ADHESIVE CAPSULITIS
ADHESIVE CAPSULITIS (FROZEN SHOULDER) STIFF, PAINFUL SHOULDER MOST COMMON: WOMEN 40-60 IDIOPATHIC - true pathologic condition - DM, Parkinson's, COPD, stroke REACTIVE tendinopathy, immobilization, low pain tolerance, can lead to true frozen shoulder
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)
- 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.
USUALLY RELIEVES SOME PAIN WITH INCREASE IN MOTION REQUIRES PHYSICAL THERAPY STILL TAKES EXTENDED TIME TO RECOVER
I hope I have shed some light on this for you
Thank you!