Shoulder 101 Lutul D. Farrow, MD University Medical Center Human Motion Institute Assistant Professor, Clinical Orthopaedic Surgery University of Arizona College of Medicine Department of Orthopaedic Surgery
Disclosure I have nothing to disclose
Objectives After this presentation, the participant should be able to: Diagnose common shoulder injuries Understand nonoperative management of these injuries List basic surgical treatment options for these various shoulder injuries
Introduction MSK injuries are common 40% of complaints to PCP Affects ADL’s Lost work/wages
The Shoulder Basics Shoulder problems are simple Three diagnoses Impingement Arthritis Instability
The Shoulder It gets simpler! Less than 25 Over 40 years old Think instability Over 40 years old Impingement Arthritis
IMPINGEMENT
The Shoulder Impingement Multiple pathologies Blanket term Tendinopathy Bursitis Rotator cuff tears Biceps tendinopathy
The Shoulder Pain generators AC joint Bursa Rotator cuff Biceps tendon
The Shoulder Impingement History Pain – variable location PAIN WITH OVERHEAD ACTIVITIES +/- Trauma Subjective weakness Easily fatigued NIGHT PAIN
The Shoulder Exam Palpation Impingement tests Strength tests Cervical spine
The Shoulder Palpation Big 3 AC joint Bursa Bicipital groove
The Shoulder Assess range of motion Painful arc Active Passive Quick and dirty Painful arc
The Shoulder Strength Testing Jobe’s Drop-arm Test Resisted ER “Empty can” Drop-arm Test Resisted ER Shoulder 201
The Shoulder Plain X-ray AP Outlet Axillary
The Shoulder To MRI or not to MRI Gotta earn it!!!! Profound weakness Shoulder dislocation older person Failed conservative management Gotta earn it!!!!
The Shoulder Nonoperative treatment Activity modification NSAID’s Physical therapy Scapular stabilization Strengthening Modalities Injections
The Shoulder Operative treatment Arthroscopy Rotator cuff Decompression Biceps Distal Clavicle Arthroscopy
Instability
The Shoulder Instability 45% of dislocations involve glenohumeral joint 85% anterior Incidence - 1.7% (anterior dislocation) Male (78%) >> Female (22%) Much Higher incidence in persons < 30 y.o.
The Shoulder Mechanism of Injury Pathoanatomy Abducted, externally rotated arm Humeral head driven anterior Common in contact sports and overhead athletes Hi-end athletes Pathoanatomy Torn capsule/ligaments Torn Labrum Variable bony injury BEWARE RTC INJURY!!!!
The Shoulder History Traumatic Episode Direction? Red Herrings Electrocution Seizures
The Shoulder Physical Examination Apprehension test Rotator cuff Axillary nerve Ligamentous Laxity
The Shoulder Imaging
The Shoulder Treatment 1st timers Athletes and repeat offenders Rehab Consider surgery
The Shoulder Bottoni et al AJSM 2002 Nonoperative: 75% recurrence Arthroscopic stabilization: 11% recurrence Kirkley, Miniaci et al Arthroscopy 1999 Nonoperative: 47% Arthroscopic stabilization: 15.9% (p < .03) Porcellini et al Arthroscopy 2002 Acute arthroscopic stabilization: 92% stable at 2 year follow-up
The Shoulder Sachs et al JBJS 2007 Copers and Non-Copers 57% shoulders remained stable 20% requested surgical stabilization Conclusion Need for surgery in the acute period cannot be predicted Copers and Non-Copers 60:40 Rule 80% won’t need surgery!
The Shoulder Surgical Repair
Arthritis
The Shoulder Arthritis Shoulder less commonly affected Typically > 50 yo Typically “post-traumatic” Genetic predisposition
The Shoulder Symptoms Activity pain ↓ ROM Stiffness Grinding/catching Can mimic impingement
The Shoulder Exam Imaging Decreased ROM Crepitance Strength Active = Passive Crepitance Strength Imaging Plain films MRI: little utility
The Shoulder Conservative management Tylenol ASA NSAIDs Therapy Injections?
The Shoulder Arthroscopic debridement Resurfacing Hemiarthroplasty Total arthroplasty Reverse arthroplasty
Conclusion Shoulder problems are very common Age-based approach can be helpful Most will be “impingement” related Be careful about red herrings Systematic approach will lead to high success rates with return of premorbid function
Thank You