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

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

3. Anatomy – Bony Architecture
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4. Anatomy – Soft Tissues – Rotator Cuff
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5. 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.

6. 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.

7. 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
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8. 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
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9. Shoulder Pain - Diagnoses
Impingement / Bursitis
Rotator Cuff Tendinitis / Tendinopathy
Rotator Cuff Tear – Partial vs. Full thickness
Adhesive Capsulitis
Arthritis
©2011 Cape Cod Healthcare Inc.

10. Impingement / Bursitis
Repetitive overhead activities
Subacromial bursa and/or rotator cuff impinged between acromion & humerus
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11. Impingement 11

12. Impingement
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13. 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
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14. Rotator Cuff Disease
Rotator cuff disease is a large spectrum from tendinitis to full thickness tears
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15. 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.
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16. Rotator Cuff Tendinitis - Treatment
Physical Therapy / Activity Modification
Anti-inflammatories
Ice / Heat
Tylenol
Steroid Injections
Repeat
Surgery
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17. 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.

18. 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

19. Rotator Cuff Tear
MRI? Based on: duration of symptoms location patient age severity physical exam
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20. 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

21. 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.

22. 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.

23. 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.

24. 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.

25. 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
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26. Shoulder Arthritis Age: > 65 Male > Female Monoarticular
Account for 60% of Total Shoulder Replacements
5% with Rotator Cuff tears
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27. Shoulder Arthritis Patient Age Severity of Symptoms Radiographs
Medical Co morbidities
Patient Characteristics

28. 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

29. 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

30. Arthroplasty Options Hemiarthroplasty Reverse Total Shoulder

31. 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
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32. Contact Information
Jesse Affonso
Cape Cod Orthopaedics & Sports Medicine
130 North Street
Hyannis, MA 02601
©2011 Cape Cod Healthcare Inc.