Chronic Shoulder Disorders

Dr Mustafa Elsingergy

Consultant Orthopedic Surgeon

OBJECTIVES

TO KNOW COMMON CAUSES OF SHOULDER PAIN

HOW TO REACH THE DIAGOSIS OF DIFFERENT DISORDERS CLINCALLY

DIFFERENT IMAGING MODALITIES AND THEIR VALUES

MANAGEMENT OF EACH DISORDER

Shoulder Pain

INTRINSIC

DUE TO CAUSES IN THE SHOULDER REGION EXTRINSIC

DUE TO REFERRED PAIN FROM OUTSIDE THE SHOULDER

Shoulder Pain INTRINSIC

DUE TO CAUSES IN THE SHOULDER REGION EXTRINSIC

DUE TO REFERRED PAIN FROM OUTSIDE THE SHOULDER

Shoulder Pain

INTRINSIC

DUE TO CAUSES IN THE SHOULDER REGION EXTRINSIC

DUE TO REFERRED PAIN FROM OUTSIDE THE SHOULDER

SHOULDER DISORDERS

DUE TO CAUSES RELATED TO :

1. ROTATOR CUFF (RC)

2. SHOULDER CAPSULE

3. GLENOHUMERAL JOINT (GLJ)

4. SCAPULAR PROBLEMS

5. ACROMIOCLAVICULAR JOINT (ACJ)

ROTATOR CUFF

ANATOMY :

ORGINATE FROM THE SCAPULA

INSERT IN THE GT AND LT

PASS UNDER CORACOACROMIAL ARCH

SEPARATE FROM THE LIGAMENT BY BURSA

ROTATOR CUFF DISORDERS

(R.C.D) ACUTE TENDENITIS

IMPINGEMENT SYNDROME

ROTATOR CUFF TEAR

R.C.DACUTE TENDINITIS

CLINICAL FEATURES

PAIN

TENDERNESS

PAINFUL ABDUCTION RANGE

X-RAY

NORMAL

AREA OF CALCIFICATION

TREATMENT

REST

NSAID

LOCAL INJECTION

R.C.DIMPINGEMENT

SYNDROME CAUSES CLINICAL FEATURES

• PAIN

• SHOULDER LOOKS NORMAL OR WASTED

• TENDERNESS

• DISTURBED GLENOHUMERAL RHYTHM

• PAINFUL ABDUCTION ( 6O TO 120 )

• NEER’S TEST (+VE)

• HAWKIN’S TEST (+VE)

R.C.DIMPINGEMENT

SYNDROME XRAY

• CALCIFICATION

• DEGENERATED ACJ MRI

• BURSITIS

• THICKENING OF THE TENDON TREATMENT

• MILD: NSAID, LOCAL INJECTION

• SEVERE: ARTHROSCOPY VS ACRMOIOPLASTY

R.C.DROTATOR CUFF TEAR

CAUSES• PREDISPOSING FACTOR• DEGENERATION: MIDDLE AGE• CHRONIC IRRITATION BY OSTEOPHYTE• UNDERLYING DISEASE ex. RHEUMATOID • PRECEPATATING FACTOR TRAUMA TYPES: INCOMPLETE

COMPLETE

R.C.DROTATOR CUFF TEAR

CLINICAL FEATURES

• TRAUMA, PAIN, LIMITED ABDUCTIOIN

• AFTER FEW WEEKS:

INCOMPLETE TEAR: IMPROVEMENT OF PAIN AND ROM

COMPLETE TEAR: PARTIAL IMPROVEMENT OF PAIN AND DECREASE OF ACTIVE RANGEo LOOK:

EARLY; NORMAL APPEARENCE

LATE; WASTING OF SUPRASPINATUS AND INFRASPINATUS MUSCLESo FEEL

TENDER GREATER TUBEROSITY

R.C.DROTATOR CUFF TEAR

CLINICAL FEATURE:o MOVE: INCOMPLETE TEAR; PAINFUL WEAK

COMPLETE; PASSIVE NOT PAINFUL, ACTIVE DROP ARM SIGN

IMAGING: XRAYS: EARLY NORMAL

LATE DEGENERATIVE CHANGES MRI IMAGE OF CHOICE TREAMENT: INCOMPLETE TEAR: PT, NSA ID

COMPLETE TEAR: SURGICAL REPAIR

BICEPS TENDON DISORDERS

TENDENITES PAIN TENDERNECE: BICEPITAL GROOVE PIANFUL FORWAD FLEXTION TREAMENT: NSAID, LOCAL INJECTION TEAR OF LONG HEAD OF BICEPS TENDON PAIN DEFORMITY OF BICEPS CONTOUR ( POPEYE’S ARM) NO NEED FOR TREAMENT

ADHESIVE CAPSULITIS(FROZEN SHOULDER)

UNKNOWN PATHOGENESIS LEADS TO PAIN AND LIMITATION OF MOVEMENT

TRAUMA OR RCD MAY BE CAUSES

CLINICAL FEATURE

PAIN

LIMITATION OF MOVEMENT IN ALL DIRECTIONS OF G-H RANGE

NATURAL HISTORY

PAIN AND LIMITATION OF MOVEMENT GRADUALLY INCREASE THEN GRADUALLY DECREASE, TAKES 18 MONTHS

TREATMENT

CONSERVATIVE VS ARHTROSCOPY

RECURRENT SHOULDER INSTABILITY

TYPES RECURRENT ANTERIOR DISLOCATION (RAD)

RECURENT POSTERIOR SUBLUXATION(rare)

MULTIDIRECTIONAL INSTABILITY (MDI)

RECURRENT SHOULDER INSTABILITY

RECURRENT ANTERIOR DISLOCATION (RAD):

MOST COMMON

H/O ACUTE DISLOCATION

APPREHENSION TEST (+VE)

IMAGE:

HILL SACHUS LESION

BANKART LESION

RECURRENT SHOULDER INSTABILITY

MULTIDIRECTIONAL INSTABILITY :

GENERALISED LIGAMENTOUS LAXITY

SALUCUS SIGN (+VE)

RECURRENT SHOULDER INSTABILITY

RECURRENT ANTERIOR DISLOCATION (RAD)

MULTIDIRECTIONAL INSTABILITY (MDI)

RAD MDI

TRAUMATIC ATRAUMATIC

APREHENSIVE TEST SULCUS SIGN POSITIVE

SURGICAL TREAMENT PT

GLENOHUMERAL JOINT DISORDER

TB

RHEUMATOID

OSTEOARHTERITIS

MIL WAUKEE

GLENOHUMERAL RHEUMATOID ARTHERITIS CLINICAL FEATURE

GENERALIZED ARTHERITIS AFFECTING OTHER JOINTS

PIAN AND LIMITATION OF MOVEMENT PAINFUL PASSIVE MOVEMENT AND LIMITED ACTIVE

MOVEMENT LAB INVESTIGATION: +VE RHEUMATOID FACTOR XRAY: LOSS OF ARTICULAR SPACE PREARTICULAR EROSION

GLENOHUMERAL OSTEOARTHERITIS

USUALLY FOLLOW OTHER PATHOLOGY eg. TRAUMA, RHEUMATOID ARTHERITIS OR RC TEARS

CLINICAL FEATURE

PAINFUL MOVEMENT

WASTING THE SHOULDER MUSCLE

TENDER JOINT LINE

LIMITED ROM

XRAY

LOSS OF JOINT SPACE

SUBCONDIRAL SCHLEROSIS

TREAMENT

ACROMIOCLAVICULAR DISORDERS

INSTABBILITY

ARTHERITIS

SCAPULAR DISORDERS SPRENGEL SHOULDER:

CONGGENITAL

WINGING OF SCAPULA:

WEAK SERRATU ANT MUSCLE

Shoulder SUMMARY Shoulder Symptoms

Pain

Stiffness

Instability

Deformity

Loss of Function

Shoulder EXAMINATIONS

Look

Feel

Move

Special Tests

Investigation

Lab

Images

Treatment

Conservative

surgical

THANK YOU