1. Shoulder lesions H.Makhmalbaf MD Consultant Orthopedic & Knee surgeon Ghaem Hospital Medical School

2. Painful arc syndrome Pain in mid ROM of abduction Pain in mid ROM of abduction Partial supraspinatus tendon tear Partial supraspinatus tendon tear Tendinitis of Supraspinatus Tendinitis of Supraspinatus Calcium deposite in supraspin. Tendon Calcium deposite in supraspin. Tendon Sub-acromial bursitis Sub-acromial bursitis Greater tuberosity fracture Greater tuberosity fracture

3. Painful arc syndrome Pain in 45° abduction – 160 Pain in 45° abduction – 160 X-ray calcium deposit or # X-ray calcium deposit or # H/o trauma? Or inflamation H/o trauma? Or inflamation Conservative treatment mainly Conservative treatment mainly Or acromioplasty Or acromioplasty

4. Frozen shoulder Painful restriction of ROM Painful restriction of ROM Unknown etiology Unknown etiology Gradually progressive Gradually progressive Chronicity Chronicity Slow spontaneous restoration of ROM Slow spontaneous restoration of ROM

5. Etiology Tendinitis of rotator cuff Tendinitis of rotator cuff Bicipital tenosynovitis Bicipital tenosynovitis Muscle imbalance, inactivity Muscle imbalance, inactivity RSD RSD Association with cardiovascular dis. Association with cardiovascular dis. Trauma; degeneration; granulation tissue; adhesions Trauma; degeneration; granulation tissue; adhesions

6. Frozen shoulder

7. Clinical picture 5 th & 6 th decades particularly women 5 th & 6 th decades particularly women Insidious onset ;injury ? Inactivity Insidious onset ;injury ? Inactivity Pain over anterolateral of shoulder Pain over anterolateral of shoulder Worse at night Worse at night Limitation of active & passive ROM Limitation of active & passive ROM Muscle spasm; internal rotation Muscle spasm; internal rotation Tenderness over bicipital grove Tenderness over bicipital grove

8. Treatment: Bed rest, heat, sedation Bed rest, heat, sedation If RA :injection of steroids & oral If RA :injection of steroids & oral Pendulum exercises Pendulum exercises No forcible movement No forcible movement Only MUA if necessary Only MUA if necessary Rarely need surgical release Rarely need surgical release

9. Lesions of the rotator cuff Aging, degenerative change Aging, degenerative change Rupture of cuff, deltoid takes over Rupture of cuff, deltoid takes over Recurring pain & stiffness, aggravated by activity in the shoulder & arm Recurring pain & stiffness, aggravated by activity in the shoulder & arm Tenderness over tuberosity & bicipital grove Tenderness over tuberosity & bicipital grove H/o fall or lifting, acute pain & snap H/o fall or lifting, acute pain & snap

10. Rotator cuff rupture Unable to abduct arm Unable to abduct arm 45’ abd. by deltoid, 45- 90 is painful 45’ abd. by deltoid, 45- 90 is painful Size of tear is important Size of tear is important Repair acute tear Repair acute tear Conservative neglected & old Conservative neglected & old

11. Calcified deposits in the rotator cuff Ca phosphate & Ca carbonate Ca phosphate & Ca carbonate In the tendon, lig. & capsule In the tendon, lig. & capsule Mainly in the white collar middle age Mainly in the white collar middle age Freq. Bilateral, men 3 rd & 4 th decades Freq. Bilateral, men 3 rd & 4 th decades Gradual or acute, pain, lim. Abduction Gradual or acute, pain, lim. Abduction X-ray Ca deposits X-ray Ca deposits

12. Treatment : Conservative : Conservative : –Ice bag, rest, needle aspiration irrigation –Diathermy, steroids, exercises Surgical : Surgical : –Relieves pain completely –Large deposits, recurrence, –Resistant to conservative, impingement

13. Tennis elbow Chronic disabling pain Chronic disabling pain At radiohumeral articulation At radiohumeral articulation Epicondylitis Epicondylitis Degeneration of origin of ext.c.r.brevis Degeneration of origin of ext.c.r.brevis Frequent rotary motion of forearm Frequent rotary motion of forearm Incomplete healing response to stress of overload & overuse Incomplete healing response to stress of overload & overuse

14. Tennis elbow Gradual onset Gradual onset Pain over lat. aspect of elbow Pain over lat. aspect of elbow Intensified by grasping or twisting Intensified by grasping or twisting Localized tenderness Localized tenderness Clinical test Clinical test D.D.,OCD of capitulum, OA,radial tunnel syn D.D.,OCD of capitulum, OA,radial tunnel syn

15. Treatment : Non-operative in 90% Non-operative in 90% Avoid overuse, brace, steroid injection Avoid overuse, brace, steroid injection Forceful manipulation under LA. Forceful manipulation under LA. Operative if needed, MUA Operative if needed, MUA Release of tendon, excision of bursa Release of tendon, excision of bursa Rehabilitation Rehabilitation

16. Osteochondritis Dissecan Localized disorder of convex joint surf. Localized disorder of convex joint surf. Segment of subchondral bone becomes avascular & separates Segment of subchondral bone becomes avascular & separates Knee & Elbow commonest Knee & Elbow commonest Rarely hip & ankle Rarely hip & ankle

17. OCD : cause ; Unknown ;impairment of blood supply Unknown ;impairment of blood supply Thrombosis of an end artery? Thrombosis of an end artery? The significance of an injury uncertain The significance of an injury uncertain An inborn susceptibility to the disease An inborn susceptibility to the disease Several joints of a patients Several joints of a patients Several members of the family Several members of the family

18. OCD : pathology Segment of articular surface avascular Segment of articular surface avascular A line of demarcation forms A line of demarcation forms Various sizes:1-3 cm in the knee Various sizes:1-3 cm in the knee Always in the convex surface Always in the convex surface Small segments reattach spontaneous Small segments reattach spontaneous Or separates and form lose body Or separates and form lose body Cavity; irregularity; OA Cavity; irregularity; OA

19. OCD : clinical features Adolescent or young adult Adolescent or young adult Aching ; mechanical irritation Aching ; mechanical irritation Recurrent effusion Recurrent effusion After separation:locking, pain, effusion After separation:locking, pain, effusion O/E : effusion, wasted quads, ROM ok O/E : effusion, wasted quads, ROM ok

20. OCD : radiographic features A clear cut defect of the bone A clear cut defect of the bone Of the articular surface Of the articular surface Med. Femoral condyle of the knee Med. Femoral condyle of the knee Cavity with or without fragment Cavity with or without fragment Lose body in place or elsewhere Lose body in place or elsewhere Tunnel view: P/A knee semiflexed Tunnel view: P/A knee semiflexed

23. Osteochondritis Dissecan

25. OCD : knee arthroscopy Clearly evident, for staging Clearly evident, for staging Articular surface sometimes normal Articular surface sometimes normal Softening, partial separation Softening, partial separation Or total separation in place or out Or total separation in place or out Lose body Lose body

26. OCD : treatment In developing stage; knee support In developing stage; knee support Avoid strenuous activity Avoid strenuous activity Heals spontaneously or Heals spontaneously or Removal of lose body or fixation of Removal of lose body or fixation of A large fragment A large fragment

27. Congenital dislocation of patella Familial & bilateral Familial & bilateral Occasionally with Arthrogryposis M.C Occasionally with Arthrogryposis M.C And Dawn syn. And Dawn syn. Persistent & irreducible, +or- genovalgum & ext. rot. Of tibia Persistent & irreducible, +or- genovalgum & ext. rot. Of tibia Quads contracture Quads contracture

28. Cong. Dislocation of patella Late diagnosis, patella ossifies at 3-4y Late diagnosis, patella ossifies at 3-4y Early operation Early operation Lateral release Lateral release Medial plication of capsule Medial plication of capsule Tibial tubercle transfer Tibial tubercle transfer

29. Osgood-Schelatter’s dis. Apophysitis of tibial tubercle in childhood Apophysitis of tibial tubercle in childhood T.T. becomes enlarged and painful T.T. becomes enlarged and painful Is strain of developing tibial tubercle Is strain of developing tibial tubercle From the pull of patella tendon From the pull of patella tendon

30. O.S: clinical picture Child of 10-14y, usually a boy Child of 10-14y, usually a boy Pain in front of the knee Pain in front of the knee Worse on strenuous activity Worse on strenuous activity T.T. prominent & painful T.T. prominent & painful Tender on palpation Tender on palpation Knee extension against resistant Knee extension against resistant

31. O.S. Enlargement or fragmentation on X-R Enlargement or fragmentation on X-R Self-limiting, normal function when tubercle fused Self-limiting, normal function when tubercle fused Rest in plaster for two month if Rest in plaster for two month if

32. Osgood Schelatter

33. Osteoarthritis :OA Is a degenerative wear & tear in joints Is a degenerative wear & tear in joints That are impaired by congenital defect vascular insufficiency, or previous disease or injury That are impaired by congenital defect vascular insufficiency, or previous disease or injury Is the commonest variety of arthritis Is the commonest variety of arthritis Caused by wear & tear Caused by wear & tear

34. OA No stress no OA No stress no OA Less OA in the joints of the upper limb Less OA in the joints of the upper limb A predisposing factor accelerates w&t A predisposing factor accelerates w&t Any abnormality may be responsible Any abnormality may be responsible Congenital ill-development Congenital ill-development Previous fracture Previous fracture

35. OA : predisposing factors Internal derangement: lose body Internal derangement: lose body Previous disease: RA, hemophilia Previous disease: RA, hemophilia Mal-alignment of a joint, bow leg Mal-alignment of a joint, bow leg Obesity & overweigth Obesity & overweigth Age alone is not a cause of OA Age alone is not a cause of OA Impaired capacity for repair after injury Impaired capacity for repair after injury

36. Overview of the process

37. OA: pathology Any joint may be affected Any joint may be affected Articular cartilage is worn away Articular cartilage is worn away Subchondral bone exposed Subchondral bone exposed Osteophytes form at the margin Osteophytes form at the margin No primary change in capsule or synov No primary change in capsule or synov Often thickening & fibrosis later Often thickening & fibrosis later

38. Cartilage destruction

39. OA: clinical features Most patients are past middle age Most patients are past middle age If younger; a clear cause is If younger; a clear cause is Gradual onset, pain Gradual onset, pain Restriction of ROM; deformity Restriction of ROM; deformity O/E : bony thickening, osteophytes O/E : bony thickening, osteophytes Not warm, limitation of ROM, fixed def Not warm, limitation of ROM, fixed def

40. OA: X-ray Diminution of cartilage space Diminution of cartilage space Subchondral sclerosis Subchondral sclerosis Spurring or lipping of the joint margins Spurring or lipping of the joint margins Cyst formation Cyst formation

41. Severe OA

42. OA: diagnosis History History Clinical findings Clinical findings X-ray features X-ray features OA is not confused with inflammatory OA is not confused with inflammatory No synovial thickening, no local warm. No synovial thickening, no local warm. No muscle spasm no rarefaction on X- No muscle spasm no rarefaction on X- ESR is not increased ESR is not increased

43. OA: treatment No treatment No treatment Conservative Conservative Operative treatment Operative treatment Reassurance and advice Reassurance and advice Conservative : physio, heat, exercises Conservative : physio, heat, exercises Analgesics, support, stick Analgesics, support, stick

44. OA: surgical treatment Osteotomy for realignment Osteotomy for realignment Arthroplasty and replacement Arthroplasty and replacement Arthrodesis Arthrodesis

45. OA of the knee Knee is the commonest Knee is the commonest Particularly in elderly & fat woman Particularly in elderly & fat woman Previous damage: torn menisci Previous damage: torn menisci OCD, torn ligaments OCD, torn ligaments Malalignment of tibia on the femur Malalignment of tibia on the femur Usually both knees Usually both knees

46. OA of the knee: O/E Osteophytes Osteophytes Effusion unusual Effusion unusual Limitation of ROM, crepitation Limitation of ROM, crepitation Wasted quadriceps Wasted quadriceps Varus deformity> valgus Varus deformity> valgus Limitation of extension Limitation of extension

47. Knee deformity & OA

48. OA of the knee; treatment Conservative : heat, phyisio Conservative : heat, phyisio Steroid injection Steroid injection surgery surgery In the worst cases In the worst cases Sever persistent pain Sever persistent pain Especially with deformity Especially with deformity

49. Operative treatment: Arthroscopy & removal of lose bodies Arthroscopy & removal of lose bodies UTO UTO Excision of patella (or elevation) Excision of patella (or elevation) Arthroplasty Arthroplasty Arthrodesis Arthrodesis

58. Thank you Thank you