Orthopedic Shoulder Problems

Sunny Cheung, MD

Disclosures

No financial affiliation with industry or pharmaceuticals

Introduction to Shoulder Pain

#3 most common cause of musculoskeletal disability

Non-Operative Problems

Frozen ShoulderImpingementBiceps RuptureDegenerative LabrumShoulder Dislocation

Frozen ShoulderAka “Adhesive Capsulitis”Affects 2% of general populationCauses

Usually small, incidental trauma

Frozen Shoulder

Risk factorsDiabetesHyperthyroidismHigh triglyceridesAge 40-60Female

Frozen Shoulder3 Phases

Inflammatory (Painful) phaseConstant painWorse with motion2-9 months

Freezing (Adhesive) phaseStiffness, loss of motionLoss of external rotation3-9 months

Thawing (Regressive) phasePain lessensRegain range of motion12-24 months

Frozen ShoulderTreatments

Physical therapy Relieve pain and inflammation

Then restore range of motion

Steroid injectionsTylenol, motrin

Occasionally narcotics

Patience

Rotator Cuff Anatomy

Rotator cuff dynamically stabilizes shoulder

Impingement / Rotator Cuff Tendonitis

Very commonRotator cuff is pinched between humeral head and acromion

Impingement / Rotator Cuff Tendonitis

SymptomsPain with overhead activity

TreatmentMotrin, anti-inflamatoriesPhysical therapy

Relieve pain and inflammationStrengthen rotator cuff

Correct muscular imbalances

Steroid injectionAcromioplasty (shaving the bone)

Biceps Rupture (Long Head)

Occurs in older ageBiceps attaches to a fibrocartilage rim (labrum) in the shoulder socket (glenoid)

Biceps Rupture (Long Head)Degenerative wear over timeSymptoms

Cramping painCosmetic deformity

More noticeable in men

Treatmentre-attach tendon to bone Or - just leave it alone

Labral TearYoung

Repetitive stress injuryRehab or surgery

OlderDegenerative attritional wearUsually not the source of painUnpredictable outcomes with surgery

DETACHED LABRUM AFTER REPAIRNORMAL LABRUM

Shoulder DislocationBall of shoulder dislocated in front of socketNo prolonged immobilizationPhysical therapySurgery for younger athletes if recur

Operative Problems

Rotator Cuff TearFracturesArthritis

Rotator Cuff Tear

EpidemiologyFull thickness tears

411 asymptomatic volunteers13% age 50-5920% age 60-6931% age 70-7951% > age 80

Tempelhof et al JSES 1999

•• Overall cuff tearOverall cuff tearprevalanceprevalance 34% 34% •• 96 96 Asymptomatic Asymptomatic

ptspts•• partial or full tear partial or full tear

54% in age > 6054% in age > 60

Sher Sher JS et al JBJS Am 1995JS et al JBJS Am 1995

Natural history51% of asymptomatic cuff tears become symptomatic at average 2.7 years

Tear progressionPatients with symptomatic full thickness tear on one shoulder have 35% chance of full thickness tear on other shoulder!

But symptomatic side on average 30% larger

Yamaguchi et al JSES 2001

Predictors of nonsurgicaloutcome

Good prognostic factorsPretreatment symptoms < 3 months

82% excellent/good result

Bad prognostic factorsPretreatment symptoms >12 months

42% excellent/good result

Full thickness tear equal or more than 1 cm2

Functional impairment & weakness

Bartolozzi A et al CORR 1994

Steroid injections…. Don’t work?

Review of 9 randomized clinical trialsNo reproducible evidence showing improvements in

Range of motionPainFunction

Koester et al JAAOS 2007

Full Thickness tear

Surgery advocated forAcuteSignificant weaknessFunctional impairmentFailed conservative Rx

Treatment of small rotator cuff tears is usually successful with arthroscopicsurgery

80-94% success in small to medium cuff tears

Small Tears

MRI Coronal ImageTorn tendon edgeTendon

should be here

Repaired tendon with anchor

Arthritis

Cartilage is worn offBone rubbing against bone

Arthritis

TreatmentPain medicationsSteroid injectionsShoulder Replacement

Fractures

Thank you!