1. Rotator Cuff & Shoulder Syndromes Edward Via Virginia College of Osteopathic Medicine 19 November 2014 Roger Depra, MD Chief Medical Officer Spartanburg VA Outpatient Clinic

2. Anatomy Differential Diagnosis Impingement Syndrome  Bursitis  Rotator Cuff Tendinopathy Adhesive Capsulitis Glenohumeral Joint Arthritis Acromioclavicular Arthritis Little Leaguer’s Shoulder Thoracic Outlet Syndrome Overview

3. Rotator cuff muscles rotate the arm and stabilize the humeral head against the glenoid. Rotator cuff weakness predisposes to superior subluxation of the humeral head in the subacromial space Narrowing of the subacromial space normally greater than 7 mm suggests a long standing rotator cuff tear.

4. Abduction = supraspinatus (along w/ deltoid) Int rotation = Subscapularis Ext rotation = Infraspinatus Adduction = Subscapularis, Infraspinatus, Teres minor (along w/ pec major and lat dorsi)

5. A prominent suprascapular ridge indicates atrophy of the supraspinatus/ infraspinatus muscles and may indicate a rotator cuff tear.

6. Differential Diagnosis Traumatic vs Non-traumatic Intrinsic vs Extrinsic Extrinsic Causes  Cervical Radiculopathy  Referred pain from abdomen  Cardiovascular Glenohumeral vs Extra-glenohumeral Extrinsic causes usually present w/ vague pain plus other symptoms. Cervical radiculopathy usually presents in dermatomal pattern with numbness and tingling. Referred pain from the abdomen is caused by diaphragmatic irritation manifesting pain in the shoulder eg acute cholecystitis. Similarly pain from an MI may radiate to the left shoulder.

7. Case 1 A 63 year old male presents with several months of right shoulder pain located anterior and lateral. It hurts all the time, especially worse after activity. It recently flared again painting his fence last week. When he lays down at night, it throbs and wakes him from sleep. He recalls no trauma and is otherwise healthy. He has pain on attempting to initiate abduction of the shoulder.

8. Impingement Syndrome AKA Rotator cuff tendinitis/tendinopathy, Bursitis Presentation  Pain localized to anterior and lateral shoulder with active motion  Gradual onset but may be exacerbated acutely  Overhead activity  Night pain and difficulty sleeping on affected side  Muscular atrophy Physical Exam  Inspection  Palpation  Range of motion  Special tests Management X-rays – Why? NSAIDs and rest Physical therapy Injection Referral

9. Impingement Syndrome Hawkin’s Sign: Examiner exerts internal rotation of humerus with 90º of forward flexion and 90º of elbow flexion; a positive test is reproduction of pain

10. From Impingement to RC Tear… From Impingement to RC Tear… a continuum Grade I - Edema and hemorrhage Grade III - Full thickness tendon tears, bony changes, and tendon rupture Grade II - Cuff fibrosis, thickening, and partial cuff tearing Normal (Months) Frank RC Tear

11. Case 2 A 48 year old female diabetic complains of progressive pain with lifting her arm over her head for the past 4 months. She is now really having trouble even brushing her hair. Pain is over her whole shoulder, achy 4/10, and associated with limited ROM.

12. Adhesive Capsulitis AKA “Frozen Shoulder”, “Stiff Shoulder” Idiopathic loss of passive and active ROM Presentation  Middle Age 40-60  Most common cause rotator cuff tendinopathy  Risk factors include DM, hypothyroidism, Parkinson Disease, Stroke  Symptoms progress from “freezing” phase of pain to loss of motion to “thawing” phase of decreasing discomfort and improved ROM  6 months to 2 years to resolve Physical Exam  Significantly Decreased Active and Passive ROM  Painful motion at extremes  Pain and tenderness common at deltoid insertion or diffuse tenderness

13. Management  X-rays indicated to ensure integrity of joint and r/o other pathology eg osteophytes, loose bodies, tumor, etc  NSAIDs, moist heat, and gentle stretching  Consider Injection  Full motion and resolution of pain 1-2 years Adhesive Capsulitis

14. Case 3 A 70 year old male presents with several months of progressive loss of motion of his right shoulder. It is stiff in the morning for about an hour, painful at the extremes of motion, and he notices he can not move it as well as he used to. Pain is deep and achy. It hurts all the time; especially worse after activity and when bad weather is coming on. He has a h/o remote fracture of the humeral head.

15. Glenohumeral arthritis Destruction of joint cartilage with loss of joint space Presentation  Age > 50 years  Possible h/o trauma or RC tear  Localizes to posterior shoulder or “deep” in shoulder  Pain worse w/ activity progressing to rest pain and night pain  Decreased ROM affecting ADLs Physical Exam  Inspection  Palpation  Range of motion Spine of scapula

16. Management  X-rays indicated  NSAIDs  Heat/ice  Stretching exercises to preserve motion  Glucosamine/chondroitin  Injection not as effective  Referral for intolerable shoulder pain or progressive loss of motion Glenohumeral arthritis

17. Case 4 A 60 year old male is c/o right shoulder pain worse when he reaches over to his left side. He has a h/o right clavicle fracture practicing jujitsu. It feels like his shoulder “grinds” when he reaches across his chest.

18. Acromioclavicular joint arthritis Presentation  Anterior shoulder pain  Grinding or popping sensation when reaching overhead or across the chest  Remote h/o trauma Physical Exam  Adduction across chest will reproduce pain at the AC joint Management  NSAIDs  Injection

19. Case 5 13 year old with pain at the supero-lateral aspect of shoulder. Started after a hard throw from the outfield a few days ago. Achy, worse at night, can’t throw, weak 6- 8/10. Arm just “feels dead.”

20. Little Leaguer’s Shoulder Etiology: Overuse due to repetitive throwing Widening of proximal humeral growth plate  RC muscles attach on greater tuberosity  Traction with slowing… Adolescents 11-14 with open epiphyseal joint  Time of rapid bone growth  Learning and over-practicing new pitches »Technical errors »Pitch count Pain in lateral shoulder, deep aching & throbbing with throwing

21. Physical Exam Pain on palpation  Lateral proximal humeral head Mild pain with external rotation Pain with infraspinatus testing Pain with supraspinatus testing (empty can) Confirm diagnosis with radiographs Management: Sling for 6 weeks or until symptoms subside Physical Therapy as tolerated Pain control

22. Definition – compression of the brachial plexus and/or subclavian vessels between the superior shoulder girdle and the first rib Clinical presentation  Paresthesias  Intermittent swelling and discoloration of the arm Physical Exam – neurovascular provocation DDx – CTS, cervical disc herniation, impingement, pancoast tumor, ulnar nerve entrapment Treatment - nonoperative Thoracic Outlet Syndrome

23. Question A 60 yo female presents to your office complaining of right shoulder pain. She spent the long weekend painting her fence. She is having difficulty raising her arm above her shoulder. She localizes pain to the anterior and lateral shoulder. She is having difficulty sleeping due to pain and avoids lying on her right side. Physical exam reveals normal range of motion, tenderness to palpation of the anterior shoulder, preserved rotator cuff strength but pain with testing, and normal neck exam. History and physical exam is most consistent with a. Rotator cuff tear b. Adhesive capsulitis c. Cervical radiculopathy d. Rotator cuff tendinopathy/tendinitis e. Acromioclavicular arthritis