2. DR. M.ABBASI RHEUMATOLOGIST QUMS Periarthritis Of Shoulder Joint

3. EPIDEMIOLOGY Shoulder pain  16-26% of all musculoskeletal complaints  Is the third most common MSK pain  I- LBP  II- Knee pain  III- Shoulder pain  %50 of the population will suffer during their life  60% may experience symptoms for a year or more Especially common in diabetic patient  Female>male  Right shoulder>Left shoulder  In iran 14/5%

4. Anatomy of the shoulder

6. Joints The shoulder consists of three joints : 1-Acromioclavicular 2-Sternoclavicular 3-Glenohumeral joint And two gliding planes: 1-Scapulothoracic 2-Suacromial shoulder joint is the most mobile joint of the body

7. Range of motion

8. > 80% Periarticular disorders < 15% Referral pain 5% Arthritis & OA

9. common causes of periarticular disorders of shoulder Rotator cuff (R.C.) tendinitis or impingement syndrome Rotator cuff tear Calcific tendinitis Bicipital tendinitis Frozen shoulder

11. Rotator cuff tendinitis Impingement may be defined as the encroachment of the acromion, coracoid process or AC joint on the rotator cuff as it passes beneath them during glenohumeral motion

12. Rotator cuff It is composed of four muscular units: Supraspinatus Infraspinatus Teres minor Subscapularis ANATOMY AND FUNCTION

13. Movement is created by the 4 RC. Muscles, originate from the scapula & insert at the greater tuberosity Movement is facilitated by a subacromial bursa, lies above supraspinatus muscle RC. plays a significant role in stabilizing the GH J. Initiates AbdSupraspinatus Initiates Ex.RInfraspinatus Initiates In.RSubscapularis Initiates AddTeres minor

14. Rotator cuff tendinopathy Epidemiology of 70% shoulder pain(most common) High prevalence in female workers Athletes Age over 40 years The prevalence increases with age

15. Etiology and pathogenesis * Extrinsic compression *Osteophytic spurring of acromion * Calcific tendinitis * Instability * Trauma *Diminished vascular supply *Intrinsic, degenerative event *Age related degeneration *Overuse

16. Clinical sign and symptoms  Mechanical shoulder pain(especially during overhead activity, Ext.Rot)  Dull  Site of pain:anterolateral aspect  Night pain (Especially when is lateral decubitus)  Weakness & pain(impingement syndrom +RC tear)

17. Physical examination Inspection: Atrophy, asymmetry, deformity swelling(seldom) palpation: Tenderness point in subacromion Ac joint, bicipital groove ROM: Active (Abd,Ext.Rot) Clinical tests: painful arc Neer impingement sign Clancy test

19. impingement sign Sensitivity 95% Specificity 95%

20. Clancy test Sensitivity:95% Specificity : 95%

21. Is predominantly clinical A woman or man with: More than 40 years old Mechanical shoulder pain especially during overhead activities Impingement sign Diagnosis

22. *Rest(cessation of repetitive overhead activity) *NSAIDs *Physical modalities *Steroid Injection: used when the patient has significant pain(3-injection) *Opiate- based drugs used in the acute setting (fall) *Exercise is mainstay of treatment Control of symptoms stretching RC. Improving symptoms return to normal overhead activities (sporting)

24. Rotator cuff tear

26. Rotator cuff tearing SIZE: Small: <1cm Medium: 1-3 cm Large: 3-5 cm Massive:>5 cm ETIOLOGY: RA, SLE, renal osteodystrophy Glucocorticoids Stage III rotator cuff tendinitis

27. Etiology Can be acute or chronic,complete or incomplete Acute: predominantly in young patient (falling on an outstretch- arm) Chronic : predominantly in old patient>50 Y History of trauma (50%) History of chronic impingement (95%) Decreased vascularity &cellularity

28. Clinical sign and symptoms. Acute tearing Pain & weakness of abduction and ext-Rotation Chronic tearing Crepitation, stiffness, atrophy and weakness Supraspinatus tearing Inability to abduction, drop arm test Infraspinatus tearing Inability to Ext. Rotation, can't reach spoon to mouth, inability to combing ext- rotation lag test Subscapularis tearing Internal rotation lag test

30. External rotation lag test(sup.&inf. )

31. Internal rotation lag test (subscapularis)

32. Depend in the degree of tear Partial or full thickness - tears Age, functional status Degree of pain

33. Acute Acute Ruptures in a young or active patient (a athlete with overhead activity) only early Surgery In an older or less active patient Conservative 3 -6 months no acceptable function Surgery (Subacromial decompression, cuff repair)

34. Treatment Chronic Treatment is conservative Surgery: 1. young patients with massive tearing and weakness 2.Old patients with sever pain that don’t control 3.RC tearing +biceps tendon tearing Response to conservative treatment (90% )

36. Flexion and supination of the forearm Forward elevation of the shoulder Biceps tendon

37. Anatomy of the shoulder

38. Epidemiology of Bicipital tendinitis Men (halter) Women (gymnastic, repetitive carrying of small children)

39. Clinical sign and symptom *Pain over ant- aspect of the shoulder radiates to bicipital groove *Pain is exacerbated with overhead activities, shoulder extention & elbow flexion

40. Diagnostic maneuvers The most common finding Point tenderness by palpation of the bicipital groove Yergason's test Speed's test

41. Speed's Test

42. Yergason's Test a a Elbow flexed 90° with forearm pronated Patient supinates the forearm and flex the elbow against resistance. Pain in the biciptal groove indicates long head of biceps tendon pathology

44. *Acute rupture result from overuse in young patient(weight-lifting) Sudden pain (most common) *In older patient thinning & eventual rupture occur spontaneously Bicipital rupture

45. popeye Clinical feature

46. Paraclinic  Plain radiography Degenerative changes in superior border of glenoid or bicipital groove

47. Imaging  Ultrasonography (US) For detection of:  Subluxation  Diagnosis of tears & tendinitis

48. Provides an excellent visualization for: Superior labral complex Biceps tendon Bicipital groove Bony osteophytes Biceps tendon tears dislocation

49. Treatment Treatment of tearing Conservative Young patients(sports) : surgery Treatment of tendinitis Rest, physiotherapy, NSAIDS laser, injection in tendon sheet Surgery Refractory bicipital tendinitis Recurrent symptom of subluxation

51. Calcific tendinitis *Deposition of calcium hydroxyapatite *Symptoms develop in 35% to 45% *Age 40 to 60 y *More frequent in female ( 57% to 77%) *Usual presentation: chronic painful condition Around the RC.(chronic impingement syndrome) *Acute presentation(7%)

52. pathophysiology Precalcific: formative phase Relatively painless Calcific: calcium crystals are deposited in matrix(quiescent) Postcalcific: resorptive phase Tends to be painful Resorption of calcium crystals

53. Acute subacromial & subdeltoid bursitis Migration of hydroxyapatite microcrystals to bursa: induce acute inflammation Age: 50-60 y, female

54. Clinical history Acute severe pain limiting active & passive movement Occasionally erythema Sometimes swelling No history of injury or overuse

55. Imaging Int & Ext Rotational view

56. management Chronic symptoms conservative treatment Subacromial arthroscopy(stable phase) Acute stage Resting, the arm in sling NSAIDs Steroid injection (subacromial) Prednisolone: 15-20mg/day - Rapidly taper Recovery in few days or weeks

58. FROZEN SHOULDER (RETRACTILE CAPSULITIS)

59. EPIDEMIOLOGY Etiology Prevalence:2-3% Women 40-50 years Primary or idiopathic Secondary: Diabetes, parkinsonism, TB, thyroid disorder, MI, lung tumor, Cervical radiculopathy Major skeletal trauma and soft tissue injury Change from simple or acute tendinitis to capsulitis(mixed shoulder)

60. pathophysiology Stage I Diffuse inflammatory synovitis Stage II Adherence of the capsule Stage III Loss of ROMof normal joint thickening and narrowing of joint capsule

61. Initiation :3-8mo Acute or insidious onset, pain at the extreme of motion, background ache in the suprascapular and deltoid regions Adhesive phase :4-12mo Pain gradually decrease Severe limitation of active & passive ROM Resolution phase : ROM gradually will be better, duration without treatment lasts 1-3 y Signs and symptoms

62. Paraclinic  X ray : at first is normal  Later :Decalcification of humerus head, joint surface are intact  Arthrography : the capacity of joint capsule from 28-35 cc changes to 0.5 -3 cc  Radioisotope scan

63. Arthrography

65. Treatment Exercise is the main treatment Gentle stretching Stage I  NSAID  Steroid injection  Oral steroid  Ice packs, ultrasound  Trans cutaneous electro neuron stimulation(TENS) Refractory conditions Close manipulation Hydraulic distention Surgery Arthroscopic capsulotomy

66. Thanks