The Complex Shoulder The Complex Shoulder SimplifiedSimplified

Manish A. Patel, MD, FAAOSManish A. Patel, MD, FAAOS

Assistant Professor – Eastern Virginia Medical Assistant Professor – Eastern Virginia Medical SchoolSchool

Chief of Surgery-Southampton Memorial Chief of Surgery-Southampton Memorial HospitalHospital

(757) 562-7301(757) 562-7301

www.SouthamptonOrtho.comwww.SouthamptonOrtho.com

OverviewOverview

• Most mobile joint in bodyMost mobile joint in body

• Most dislocated jointMost dislocated joint

• StabilityStability– Bony articulationBony articulation– LigamentousLigamentous– MuscularMuscular

Review of shoulder anatomyReview of shoulder anatomy

• BonesBones– ScapulaScapula– ClavicleClavicle– Humeral headHumeral head– Posterior rib cagePosterior rib cage

• JointsJoints– SternoclavicularSternoclavicular– AcromioclavicularAcromioclavicular– GlenohumeralGlenohumeral– ScapulothoracicScapulothoracic

Glenohumeral JointGlenohumeral Joint

• 25% humeral head 25% humeral head surface in contact surface in contact with glenoidwith glenoid

• Joint space Joint space thinning seen with thinning seen with OAOA

• Humeral head Humeral head coverage increased coverage increased to 75% with to 75% with glenoid labrumglenoid labrum

LabrumLabrum

• Glenoid LabrumGlenoid Labrum– Dense, fibrous structureDense, fibrous structure– OvalOval– Deepens glenoid fossaDeepens glenoid fossa– StabilityStability

Subacromial SpaceSubacromial Space

• BursaBursa

– Subacromial spaceSubacromial space– Source of pain down arm Source of pain down arm

Rotator cuff musclesRotator cuff muscles• Supraspinatus, Supraspinatus,

infraspinatus, teres infraspinatus, teres minor, subscapularisminor, subscapularis

• Form cuff around Form cuff around humeral headhumeral head

• Keeps humeral head Keeps humeral head within joint (head within joint (head depresser)depresser)

• Abduction, external Abduction, external rotation, internal rotation, internal rotationrotation

Physical ExamPhysical Exam

• Visualize from front and backVisualize from front and back

• AsymmetryAsymmetry– Pts with rotator cuff tears hold shoulder Pts with rotator cuff tears hold shoulder

higherhigher

• AtrophyAtrophy– Sign of chronic glenohumeral joint pathologySign of chronic glenohumeral joint pathology

• EffusionsEffusions– Shoulder joint can hide a lot of fluidShoulder joint can hide a lot of fluid

Active range of motionActive range of motion

• Forward flexionForward flexion

• Abduction/adductionAbduction/adduction– Painful arc of abduction – sensitive, not Painful arc of abduction – sensitive, not

specific specific

• External rotationExternal rotation

• Internal rotationInternal rotation

Passive range of motionPassive range of motion

• Immobilize the scapula to prevent Immobilize the scapula to prevent rotationrotation– Use one arm to push down on shoulderUse one arm to push down on shoulder– Use other arm to do the PROM exercisesUse other arm to do the PROM exercises

• AbductionAbduction

• Internal and external rotationInternal and external rotation– Have arm at patient’s side and abducted Have arm at patient’s side and abducted

to 90 degreesto 90 degrees

Physical ExamPhysical Exam

• External RotationExternal Rotation– InfraspinatusInfraspinatus– Teres MinorTeres Minor

Physical ExamPhysical Exam

• SupraspinatusSupraspinatus– 45 Degrees from 45 Degrees from

frontfront

Physical ExamPhysical Exam

• Impingement Impingement – Greater Tuberosity Greater Tuberosity

under acromionunder acromion

Physical ExamPhysical Exam

• Cross Arm TestCross Arm Test– Specific for AC Joint Specific for AC Joint

Biceps Strength TestingBiceps Strength Testing

• Arms outstretched with palms up at Arms outstretched with palms up at level of shoulderlevel of shoulder

• Forced supination of hand with elbow Forced supination of hand with elbow flexed at 90 degreesflexed at 90 degrees

• Can be positive for SLAP TestCan be positive for SLAP Test

Etiology of Shoulder PainEtiology of Shoulder Pain

• TraumaTrauma

• Overuse Overuse

• ChronicChronic

• Previous SurgeryPrevious Surgery

• InstabilityInstability

• Neck PainNeck Pain

• InfectionInfection

• DislocationDislocation

• Frozen ShoulderFrozen Shoulder

TraumaTrauma

• Shoulder Shoulder DislocationDislocation

• FractureFracture

TreatmentTreatment

• Fractures – Not all Fractures – Not all require surgeryrequire surgery

• Surgical options includes Surgical options includes (Rods / Plate / Partial vs (Rods / Plate / Partial vs complete replacement)complete replacement)

Shoulder DislocationShoulder Dislocation

• Fast FactsFast Facts– 50 % of ALL dislocations50 % of ALL dislocations– 95 % anterior95 % anterior– 85 % caused by trauma recur85 % caused by trauma recur– Posterior think seizures or direct traumaPosterior think seizures or direct trauma

Shoulder DislocationsShoulder Dislocations

• Mechanism?Mechanism?– Anterior vs. posteriorAnterior vs. posterior

• Forced abduction, external rotation, extensionForced abduction, external rotation, extension

• Forced adduction, internal rotationForced adduction, internal rotation

Shoulder DislocationsShoulder Dislocations

• Dislocation vs. Subluxation?Dislocation vs. Subluxation?

Shoulder DislocationsShoulder Dislocations

• Defects following dislocation?Defects following dislocation?

– Hill-SachsHill-Sachs– SLAPSLAP– BankartBankart– Rotator Cuff TearRotator Cuff Tear– FracturesFractures

Shoulder DislocationsShoulder Dislocations

• Hill-Sachs lesionHill-Sachs lesion– Posterior lateral aspectPosterior lateral aspect– CompressionCompression

Shoulder DislocationShoulder Dislocation

• Superior Labrum Anteroposterior Superior Labrum Anteroposterior Lesion (SLAP)Lesion (SLAP)– Affects bicepsAffects biceps

Shoulder DislocationsShoulder Dislocations

• Bankart LesionBankart Lesion– Arthroscopic vs. openArthroscopic vs. open– Anterior labrumAnterior labrum

InstabilityInstability

• UnidirectionalUnidirectional

• MultidirectionalMultidirectional

Shoulder DislocationsShoulder Dislocations

• Chronic Instability – Chronic Instability – Increasing laxity due to Increasing laxity due to repeat incidents, trauma, genetics, or neuromuscular repeat incidents, trauma, genetics, or neuromuscular

deficitsdeficits

– Signs and SymptomsSigns and Symptoms•SportSport

•ClickingClicking

•PainPain

•WeaknessWeakness

OveruseOveruse

• Repetitive MotionRepetitive Motion

• MicrotraumaMicrotrauma

• DeconditioningDeconditioning

Chronic PathologyChronic Pathology

• ImpingementImpingement

• Biceps PathologyBiceps Pathology

• Arthritis Arthritis – Trauma or OveruseTrauma or Overuse

• Rotator Cuff Rotator Cuff SyndromeSyndrome

• Frozen ShoulderFrozen Shoulder

Impingement syndromeImpingement syndrome

• Compression of rotator cuff tendons Compression of rotator cuff tendons and subacromial bursa between and subacromial bursa between greater tuberosity and acromion (type greater tuberosity and acromion (type 3)3)

• Repetitive overhead motionsRepetitive overhead motions

• Main cause of rotator cuff tendonitisMain cause of rotator cuff tendonitis

• Can lead to bursitis, partial or full Can lead to bursitis, partial or full rotator cuff tearsrotator cuff tears

Previous SurgeryPrevious Surgery

• Rotator Cuff Re-Rotator Cuff Re-teartear

• Shoulder Shoulder StabilizationStabilization

RC TearRC Tear

• Rotator Cuff Tear (Most Common) Rotator Cuff Tear (Most Common) – Night Pain – Night Pain

• Pain Radiating up / downPain Radiating up / down

• NumbnessNumbness

• WeaknessWeakness

• Decrease MotionDecrease Motion

• 50+ age group50+ age group

Radiology for rotator cuff Radiology for rotator cuff tearstears• Interpret carefullyInterpret carefully

– 34% asymptomatic pts (all ages) and 54% 34% asymptomatic pts (all ages) and 54% pts >60 yo have partial rotator cuff tearspts >60 yo have partial rotator cuff tears

– Abnormal rotator cuff signal after trauma Abnormal rotator cuff signal after trauma may represent strain rather than tearmay represent strain rather than tear

• X-raysX-rays– Look for high riding humeral headLook for high riding humeral head

• UltrasoundUltrasound– Highly operator dependentHighly operator dependent

• MRIMRI

Rotator cuff tearsRotator cuff tears

Tx of rotator cuff tearsTx of rotator cuff tears

• Ice, NSAIDs, restrict aggravating motionsIce, NSAIDs, restrict aggravating motions

• Weighted pendulumWeighted pendulum

• No arm slingsNo arm slings

• Steroid injection Steroid injection

• Surgery – refer if young pts, full/large Surgery – refer if young pts, full/large tears, dominant armtears, dominant arm– Best if done within 6 weeksBest if done within 6 weeks

• Acromioplasty and debridementAcromioplasty and debridement

Injection Injection

• Subacromial SpaceSubacromial Space– 22 Gauge needle 22 Gauge needle

1.5”1.5”– 10 cc total vol.10 cc total vol.– 40 mg kenelog40 mg kenelog– Post placementPost placement– Aim for CoracoidAim for Coracoid

• GH JointGH Joint– Spinal needle 3”Spinal needle 3”– 10 cc total vol.10 cc total vol.– 40 mg Kenelog40 mg Kenelog– Straight AimStraight Aim– Posterior placementPosterior placement

Beware of DiabeticsBeware of Diabetics

TreatmentTreatment

• Rotator Cuff / Biceps – Good Rotator Cuff / Biceps – Good clinical Exam to Startclinical Exam to Start

• Conservative Options – PT / Conservative Options – PT / Injections / MedsInjections / Meds

• Xray and MRI helpfulXray and MRI helpful

• Surgery (Arthroscopic only way Surgery (Arthroscopic only way to these days in my opinion)to these days in my opinion)

• Rehab Course BetterRehab Course Better

Frozen ShoulderFrozen Shoulder

• Frozen Shoulder – Frozen Shoulder – DiabeticsDiabetics

• Decrease range of Decrease range of motion in all planesmotion in all planes

• Pain with any Pain with any motionmotion

• 40-50 age group40-50 age group

Radiology for adhesive Radiology for adhesive capsulitiscapsulitis• X-rays have limited useX-rays have limited use

– Might see calcifications or degenerative Might see calcifications or degenerative changes that would lead to frozen changes that would lead to frozen shouldershoulder

• MRIMRI– Enhancement of joint capsule and Enhancement of joint capsule and

synovial membranesynovial membrane– 4 mm thickening is 70% sensitive and 4 mm thickening is 70% sensitive and

95% specific95% specific

Tx of adhesive capsulitisTx of adhesive capsulitis

• Watchful waitingWatchful waiting– Up to 2 years for resolutionUp to 2 years for resolution– Incomplete recovery more likely in pts with Incomplete recovery more likely in pts with

DM, or pts with >50% loss of external DM, or pts with >50% loss of external rotation/abductionrotation/abduction

• Steroid injection (2 locations)Steroid injection (2 locations)• Manipulation under anesthesiaManipulation under anesthesia• Aggressive therapyAggressive therapy• Pain medicationPain medication

Biceps tendonitisBiceps tendonitis

• Inflammation of long head of bicepsInflammation of long head of biceps– Passes through bicepital groove of anterior Passes through bicepital groove of anterior

humerus humerus

• Usually due to repetitive lifting or reachingUsually due to repetitive lifting or reaching

• Inflammation, microtearing, degenerative Inflammation, microtearing, degenerative changeschanges

• Up to 10% pts will have spontaneous Up to 10% pts will have spontaneous rupturerupture

• Popeye deformityPopeye deformity

Sx of biceps tendonitisSx of biceps tendonitis

• Anterior shoulder painAnterior shoulder pain

• Worse with lifting or overhead Worse with lifting or overhead reachingreaching

• Often pts point to bicepital grooveOften pts point to bicepital groove

• Usually no weakness in elbow flexionUsually no weakness in elbow flexion

Exam for biceps tendonitisExam for biceps tendonitis

• Bicipital groove tendernessBicipital groove tenderness• Look for subacromial impingementLook for subacromial impingement• Tendon ruptureTendon rupture• Test biceps strengthTest biceps strength• Yergason testYergason test

– Elbows flexed with forearms in frontElbows flexed with forearms in front– Pt actively resisting external rotationPt actively resisting external rotation– Tendon may pop out of bicipital groove Tendon may pop out of bicipital groove

when downward pressure applied to forearmwhen downward pressure applied to forearm

Ruptured biceps tendonRuptured biceps tendon

• Usually rotator cuff Usually rotator cuff tear also presenttear also present

• Get the “popeye” signGet the “popeye” sign

• Rarely get significant Rarely get significant weaknessweakness– Brachioradialis and Brachioradialis and

short head of biceps short head of biceps provide 80-85% elbow provide 80-85% elbow flexor strengthflexor strength

• Tx is supportiveTx is supportive

Tx of biceps tendonitisTx of biceps tendonitis• Reduce inflammationReduce inflammation• Strengthen biceps muscle and tendonStrengthen biceps muscle and tendon• Prevent rupturePrevent rupture

• Ice, NSAIDs, avoid aggravating motionsIce, NSAIDs, avoid aggravating motions– 5-10% risk of rupture with noncompliance5-10% risk of rupture with noncompliance

• Weighted pendulum Weighted pendulum • Elbow flexion toning exercisesElbow flexion toning exercises• Steroid injectionSteroid injection• Surgical referral if sx persist >3 monthsSurgical referral if sx persist >3 months

Glenohumeral OsteoarthritisGlenohumeral Osteoarthritis

• Same risk factors as with OA in other Same risk factors as with OA in other areas areas – Trauma, obesity, ageTrauma, obesity, age

• Less common than OA in weight bearing Less common than OA in weight bearing joints or spinejoints or spine

• Pain, stiffness over months to yearsPain, stiffness over months to years– Anterior shoulder is most painful areaAnterior shoulder is most painful area

• Worse with activityWorse with activity• Distinguish from RA, adhesive capsulitisDistinguish from RA, adhesive capsulitis

Exam for Glenohumeral OAExam for Glenohumeral OA

• GH joint line tenderness and swellingGH joint line tenderness and swelling– Just below coracoid processJust below coracoid process– Use outward and upward pressureUse outward and upward pressure– Effusion may be very hard to seeEffusion may be very hard to see

• Decreased ROMDecreased ROM– External rotation, abductionExternal rotation, abduction– Endpoint stiffnessEndpoint stiffness

• CrepitusCrepitus

Imaging for glenohumeral Imaging for glenohumeral OAOA

• Joint space narrowing Joint space narrowing (loss of articular (loss of articular cartilage)cartilage)

• OsteophytesOsteophytes

• Humeral head Humeral head sclerosis and sclerosis and flatteningflattening

• Club-like deformityClub-like deformity

• Goat’s Beard on X-rayGoat’s Beard on X-ray

TreatmentTreatment

• Arthritis – From trauma or geneticArthritis – From trauma or genetic

• Conservative – PT (sometimes) / Conservative – PT (sometimes) / Injections / Meds / Lifestyle Injections / Meds / Lifestyle modificationmodification

• Surgery – Partial vs Total (Reverse Surgery – Partial vs Total (Reverse Shoulder)Shoulder)

• RehabRehab

Glenohumeral Joint InfectionGlenohumeral Joint Infection

• Very rareVery rare• Increased incidence in diabetics, Increased incidence in diabetics,

immuno-compromised patients.immuno-compromised patients.• Shoulder looks normal, just bigger. Shoulder looks normal, just bigger. • SEVERE pain. Any motion hurts.SEVERE pain. Any motion hurts.• Often a fever. Get labs (CBC, blood Often a fever. Get labs (CBC, blood

cultures, ESR, CRP), XR, then:cultures, ESR, CRP), XR, then:• Get a consult.Get a consult.

• Ref for Shoulder:Ref for Shoulder:  

Burkhart, Stephen MD et al, Arthroscopic Rotator Cuff Repair, Burkhart, Stephen MD et al, Arthroscopic Rotator Cuff Repair, Journal of American Academy of Orthopedic Surgery, Vol 14, No Journal of American Academy of Orthopedic Surgery, Vol 14, No

6, June 2006, 333-346.6, June 2006, 333-346.  

Iannotti, JP et al, Partial-thickness tears of the rotator cuff: Iannotti, JP et al, Partial-thickness tears of the rotator cuff: evaluation and management, Journal of American Academy of evaluation and management, Journal of American Academy of

Orthopedic Surgery 1999; 7: 32-43Orthopedic Surgery 1999; 7: 32-43Bedi, Asheesh et al, Massive Tears of the Rotator Cuff, The Journal Bedi, Asheesh et al, Massive Tears of the Rotator Cuff, The Journal

of Bone and Joint Surgery (American). 2010;92:1894-1908of Bone and Joint Surgery (American). 2010;92:1894-1908..

Thank YouThank You

Manish A. Patel, MD, Manish A. Patel, MD, FAAOSFAAOS

Office: (757) 562-7301Office: (757) 562-7301

Pager: (757) 562-8047Pager: (757) 562-8047

Cell: (215) 519-9317Cell: (215) 519-9317

Email: Email: mdy2k@yahoo.commdy2k@yahoo.com