Managing Shoulder Pain Jesse Affonso, MD ©2011 Cape Cod Healthcare Inc.

Objectives Review relevant anatomy Discuss common causes of pain Treatment ©2011 Cape Cod Healthcare Inc.

Anatomy – Bony Architecture ©2011 Cape Cod Healthcare Inc.

Anatomy – Soft Tissues – Rotator Cuff ©2011 Cape Cod Healthcare Inc.

Introduction Shoulder pain is an extremely common complaint (2nd most) Difficult joint to examine Multidirectional range of motion It is important to make an accurate diagnosis of the cause of your symptoms so that appropriate treatment can be directed at the cause ©2011 Cape Cod Healthcare Inc.

Where is the pain coming from? Pain arising from the shoulder Rotator cuff disorders: rotator cuff tendinopathy, impingement, subacromial bursitis, rotator cuff tears Glenohumeral disorders: capsulitis ("frozen shoulder"), arthritis, infection (rare) Acromioclavicular disease Traumatic dislocation ©2011 Cape Cod Healthcare Inc.

Where is the pain coming from? Pain arising from elsewhere Referred pain: neck pain, myocardial ischemia, referred diaphragmatic pain Polymyalgia rheumatica / fibromyalgia Malignancy: apical lung cancers, metastases ©2011 Cape Cod Healthcare Inc.

Shoulder Examination Look Feel Symptoms: Pain overhead Move Active + Passive Resisted Special Tests Symptoms: Pain overhead Pain and weakness Pain with anything Duration of symptoms ©2011 Cape Cod Healthcare Inc.

Shoulder Pain - Diagnoses Impingement / Bursitis Rotator Cuff Tendinitis / Tendinopathy Rotator Cuff Tear – Partial vs. Full thickness Adhesive Capsulitis Arthritis ©2011 Cape Cod Healthcare Inc.

Impingement / Bursitis Repetitive overhead activities Subacromial bursa and/or rotator cuff impinged between acromion & humerus ©2011 Cape Cod Healthcare Inc.

Impingement 11

Impingement ©2011 Cape Cod Healthcare Inc.

Impingement - Treatment Activity modification: no activity with elbow away from side, in the gym, or at the computer. Once a day stretch fully overhead. NSAID and Ice Injection in 3-6 weeks Physical Therapy: After pain subsides: Regain ROM / Strengthen Surgery ©2011 Cape Cod Healthcare Inc.

Rotator Cuff Disease Rotator cuff disease is a large spectrum from tendinitis to full thickness tears ©2011 Cape Cod Healthcare Inc.

Rotator Cuff Tears – How to tell? Pain and Weakness Does this mean a Rotator Cuff Tear? Cannot assess rotator cuff when there is pain Treat pain first: NSAID, PT, ice, rest-4 weeks Cortisone shot (once) if above doesn’t work Test cuff when pain subsides. ©2011 Cape Cod Healthcare Inc.

Rotator Cuff Tendinitis - Treatment Physical Therapy / Activity Modification Anti-inflammatories Ice / Heat Tylenol Steroid Injections Repeat Surgery ©2011 Cape Cod Healthcare Inc.

Rotator Cuff Tear Acute vs. Gradual Repetitive overhead activity or by wear and degeneration of the tendon. Over time the pain may become noticeable at rest or with no activity at all There may be pain when you lie on the affected side and at night ©2011 Cape Cod Healthcare Inc.

Rotator Cuff Tear Atrophy or thinning of the muscles about the shoulder Pain when someone lift the arm Pain when someone lower the arm from a fully raised position Weakness when someone lift or rotate the arm Crackling sensation when someone move his shoulder in certain positions

Rotator Cuff Tear MRI? Based on: duration of symptoms location patient age severity physical exam ©2011 Cape Cod Healthcare Inc.

Rotator Cuff Tear Pain relief Improve the function of shoulder. It may take several weeks or months to restore the strength and mobility to ones shoulder. Rest and limited overhead activity Anti-inflammatory medication Steroid injection Strengthening exercise and physical therapy

Adhesive Capsulitis Frozen shoulder (adhesive capsulitis) is a disorder characterized by pain and loss of motion or stiffness in the shoulder. It affects about two percent of the general population. It is more common in women between the ages of 40 years to 70 years old. The causes of frozen shoulder are not fully understood. The process involves thickening and contracture of the capsule surrounding the shoulder joint. ©2011 Cape Cod Healthcare Inc.

Adhesive Capsulitis Frozen shoulder occurs much more commonly in individuals with diabetes, affecting 10 percent to 20 percent of these individuals. Other medical problems associated with increased risk of frozen shoulder include: hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease or surgery. Frozen shoulder can develop after a shoulder is injured or immobilized for a period of time. ©2011 Cape Cod Healthcare Inc.

Adhesive Capsulitis Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. The pain is usually located over the outer shoulder area and sometimes the upper arm. The hallmark of the disorder is restricted motion or stiffness in the shoulder. ©2011 Cape Cod Healthcare Inc.

Adhesive Capsulitis The first goal is pain control. To restore motion, physical therapy is usually started. This may be under the direct supervision of a therapist or via a home program. Therapy includes stretching or range-of-motion exercises for the shoulder. Sometimes heat is used to help decrease pain. ©2011 Cape Cod Healthcare Inc.

Adhesive Capsulitis Nerve blocks: Suprascapular nerve block Surgical: manipulation under anesthesia and shoulder arthroscopy Often, manipulation and arthroscopy are used together in combination to obtain maximum results After surgery, physical therapy is important to maintain the motion that was achieved with surgery ©2011 Cape Cod Healthcare Inc.

Shoulder Arthritis Age: > 65 Male > Female Monoarticular Account for 60% of Total Shoulder Replacements 5% with Rotator Cuff tears ©2011 Cape Cod Healthcare Inc.

Shoulder Arthritis Patient Age Severity of Symptoms Radiographs Medical Co morbidities Patient Characteristics

Viscosupplementation (HA) Hyaluronic Acid Variable injection schedule Theoretical benefit is to improve lubrication in the joint FDA approved for the knee, and has some scientific support Wang et al: JBJS 2004 Metaanalysis, confirmed efficacy and safety of treatment Minimal literature on usage in the shoulder Shibata et al (JSES 2001) found it to be equal to corticosteroids in those with rotator cuff tears Silverstein et al AJSM 2007

30 patients w/ idiopathic glenohumeral OA Statistically significant improvements in VAS, UCLA score, and Simple Shoulder Test Score at 6 months ~50% had less than 2 point improvement in VAS No complications Conclusion: HA may have a beneficial effect on some patients with glenohumeral OA Reasonable option in patients that are not surgical candidates

Arthroplasty Options Hemiarthroplasty Reverse Total Shoulder

Summary Shoulder pain is a common complaint and can be multifactorial Proper diagnosis is key to treatment Nonsurgical treatment is the first line Surgery only after nonsurgical treatments fail ©2011 Cape Cod Healthcare Inc.

Contact Information Jesse Affonso JAffonso@CapeCodOrtho.com Cape Cod Orthopaedics & Sports Medicine 130 North Street Hyannis, MA 02601 508-775-8282 ©2011 Cape Cod Healthcare Inc.