1. ATRAUMATIC SHOULDER CONDITIONS Matthew J. Landfried, MD Orthopaedic Surgeon Genesee Orthopaedics and Sports Medicine

2. NON TRAUMATIC SHOULDER PROBLEMS

3. Shoulder Topics to be covered: Impingement Bursitis Tendonitis Tears: RTC/Biceps Instability Arthritis Frozen shoulder Thoracic outlet Cervical spine

4. WHY DO I NEED TO KNOW THIS? 10-28% of all visits to PCP are musculoskeletal 6-8% of all pediatric visits are MSK related 78% of all MSK injuries are seen by primary care

5. WHY IT CAN BE SO DIFFICULT

6. IT STARTS WITH(A) HISTORY

7. INTRINSIC -EXTRINSIC  Careful history  r/o: 1.cervical 2.splenic 3. cardiac

8. GLENOHUMERAL VS EXTRA-GLENOHUMERAL GLENOHUMERAL  Arthritis  Labral pathology  Intra-articular biceps  Loose body  Instability  Adhesive capsulitis

9. EXTRA-GLENOHUMERAL ROTATOR CUFF -impingement -RTC tears CALCIFIC TENDONITIS AC JOINT ARTHRITIS BURSITIS -sub acromial -scapula-thoracic

10. HISTORY –what to ask  What - are symptoms?  Where- does it hurt?  When- does it hurt?  What -makes it worse?  What- makes it better?  What- treatment have you had?

11. -What are symptoms –Pain, stiffness, radiation, instability -Where does it hurt –Remember surface map -When does it hurt –Nighttime, with activity, after activity -What makes it worse –Similar question and answers -What makes it better –medicine, shots, therapy, rest, heat, cold -What treatment –failed, successful (helps with where to start) DO THE ANSWERS MATTER? YES!

12. IMPINGEMENT SYNDROME (most common diagnosis) -Nighttime pain “wakes me up every night” -Pain with abduction, internal rotation, and overhead activities -Common to hear “it hurts to fasten my bra, put on a belt, shirt or coat, hurts to get my wallet, hurts to fasten seat belt”

13. EXAM ROM active and passive Strength (may or may not see weakness) Provocative maneuvers (Mcbride, Hawkins,Neer, Apley scratch) Pain to palpation Muscle atrophy XRAY

14. DIFFERENTIAL  Impingement  AC joint arthritis  Glenohumeral arthritis  Rotator Cuff strain, tendonitis or tear  CERVICAL -Herniated Disc (radicular)  Nerve entrapment (subscapular)

15. TREATMENT

16.  Rest  NSAIDs  PT  Steroid injections  MRI

17. CALCIFIC TENDINITIS ( calcium hydroxyapatite )  Calcium deposition in tendon  Can be extremely painful  May be acute onset  EXAM SIMILAR TO IMPINGMENT

18. DIAGNOSIS ON XRAY

19. TREATMENT  REST  NSAIDS  INJECTION  THERAPY  SURGERY(rarely)

20. ROTATOR CUFF TEAR  SIMILAR HISTORY AND SYMPTOMS  DIFFERENCES: -may be a history of trauma or single event -may be insidious -c/o weakness -more common over 40  EXAM - weakness -atrophy -drop arm

21. TREATMENT  Rest  NSAIDs  PT  Steroid injections  SURGERY

22. AC JOINT ARTHRITIS  HISTORY AND EXAM - Anterior shoulder pain - Point tenderness -Positive scratch test  TREATMENT - Rest, ice, NSAIDS, injection, surgery

23. GLENOHUMERAL ARTHRITIS  STIFFNESS  PAIN  LIMITED ROM  XRAY DX

25. TREATMENT  NSAIDS  Injection  Therapy  Surgery

26. BICEPS PATHOLOGY  Tendinopathy  Tear  Popeye sign

27. TREATMENT 1.Tendinoapathy -Rest, ice, NSAIDS, PT 2. RUPTURE -rest, ice, NSAIDS, PT -no significant functional loss (brachioradialis and short head biceps =85% of flexor strength)

28. INSTABILITY  BASED ON HISTORY AND EXAM Dead arm apprehension Shoulder sliding out + relocation test Clear dislocation sulcus sign  TREATMENT Rest, anti-inflammatory modalities, PT, surgery

29. LABRAL PATHOLOGY  Instability –bankart (labral tear)  SLAP –biceps symptoms, scapula pain  Diagnosis- MRI ARTHROGRAM  Treatment Rest, NSAIDs, PT, surgery

30. ADHESIVE CAPSULITIS

31. ADHESIVE CAPSULITIS (FROZEN SHOULDER)  STIFF, PAINFUL SHOULDER  MOST COMMON: WOMEN 40-60  IDIOPATHIC –true pathologic condition -DM, Parkinson's, COPD, stroke  REACTIVE -tendinopathy, immobilization, low pain tolerance

32. DIAGNOSIS - painful limited ROM, especially external rotation TREATMENT –rest, NSAIDs, PT, injection, rarely manipulation and/ or surgery Natural history : it will improve with time (2 years)

33. You May feel like this at start of the conference

34. Like this during the conference

35. Like this at the end of the conference

36. And hopefully not like this after wine tasting

37. Thank you!