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Identifying Shoulder
Pathology with Surgical
Repairs and Replacement of
the Shoulder
Dr. Terry Rzepkowski, DPT
Associate Professor
Provider Disclaimer
•Allied Health Education and the presenter of this webinar do not have any financial or other associations with the
manufacturers of any products or suppliers of commercial
services that may be discussed or displayed in this presentation.
•There was no commercial support for this presentation.
•The views expressed in this presentation are the views and opinions of the presenter.
•Participants must use discretion when using the information contained in this presentation.
Shoulder Objectives
Understanding:
• UE anatomy and musculature
• Mechanisms of injury
• Clinical testing
• Operative procedures
• Non-op Interventions
The ShoulderAnatomy
Clarification of Terms
Shoulder Complex =
Shoulder girdle
(scapula and clavicle)
and
Shoulder joint
(scapula and humerus)
Scaption Position
Natural position is scaption: 30
degrees anterior to the Frontal
plane1,2
Clarification of Terms(cont’d)
Shoulder Complex
A. Sternoclavicular joint
B. Acromioclavicular joint
C. Glenohumeral joint
D. Scapulothoracic
articulation
Often imitated, never duplicated
Video
Steering and suspension
Shoulder Girdle
• Term used to discuss activities of the scapula,
clavicle, and sternum
• The sternoclavicular (SC) and
acromioclavicular (AC) joints allow shoulder
girdle motions3-5
– Elevation and depression
– Protraction and retraction
– Upward and downward rotation
– Upward tilt-Reduction of Upward Tilt
Joint Motions Shoulder GirdleA. Elevation-depression
B. Protraction-retraction
C. Upward rotation-downward rotation
D. Upward tilt-Reduction of Upward Tilt
D
Sternoclavicular Joint: Motions
Frontal plane
Elev/Dep
Sagittal plane
Post Rot
Horizontal plane
ProT/ReT
Ant/Post axis
Vertical axis
Acromioclavicular Joint: Osteokinematics
Horizontal plane
adjustments
during scapulothoracic
protraction
Sagittal plane adjustment
during scapulothoracic
elevation
Companion MotionsShoulder Joint and Shoulder Girdle
• Movement of the scapula is accompanied
by movements of the glenohumeral joint
and vice-versa
• Example: Shoulder flexion is accompanied
by upward scapular rotation
• Impairment of one joint will also impair
function at the other
Muscular
Considerations• Poor Posture
– Pec Minor tightness
– Biceps (short head) tightness
• Result
– Scapular protraction
– Decrease posterior tilt of
scapula
– Decreased S-A space height
• Patient education point
– “Slouching active elevation test”
Scapulohumeral rhythm
• Shoulder Joint
– abduction
– Adduction
– flexion
– extension
– internal rotation
– external rotation
– horizontal abduction
– horizontal adduction
• Shoulder Girdle
– upward rotation
– downward rotation
– elevation/upward rot.
– Depression/downward rot.
– Abduction (protraction)
– adduction (retraction)
– adduction (retraction)
– abduction (protraction)
Active ROM Tests*Performed Bilaterally
• Apley’s Stretch Test
– Touch opposite acromion with hand of affected
shoulder (add/IR)
– Reach behind the head and touch opposite
shoulder from behind(abd/ER)
– Reach behind back and touch opposite
scapula(add/IR)
Appley Scratch Test
• Adduction and Internal rotation: Ask the patient to
place their hand behind their back, and instruct them
to reach as high up their spine as possible. (T1)
• Abduction and External rotation: Ask the patient to
place their hand behind their head and instruct them
to reach as far down their spine as possible. (C7)
Appley Scratch Test
Video
Appley Test
The Shoulder Joint
• Also called the glenohumeral joint
– Ball-and-socket diarthrosis between head of humerus and
glenoid cavity of scapula.
– Allows more motion than any other joint
– Is the least stable
– Supported by 2 types of stabilizers:
1. Dynamic skeletal muscles and tendons
2. Static stabilizers of ligaments, labrum
The Shoulder Joint• Shoulder Ligaments
– Coraco-acromial- Causes SA compression often removed
– Coracoclavicular- Holds clavicle to scapular complex
– Acromioclavicular- Stabilizes AC joint
– Coracohumeral- Not commonly traumatized, or compromised
surgically
– Glenohumeral- Anterior dislocation and TSA
• Shoulder Separation: Acromioclavicular Joint
– Shoulder Dislocation: Glenohumeral Joint
Ligament Injuries
Shoulder Separation Shoulder Dislocation
Coracoacromial ligament
G. Coracoacromial
ligament
– Connects coracoid
process to acromial
process
– Roof over head of
the humerus,
serves as a
protective arch
Shoulder Joint
Impingement Syndrome
• Very common
– Laborers
– Persons who do repetitive overhead motion
– Athletes
• Cause
– “the tendons of the rotator cuff (and subacromial bursa) are crowded, buttressed, or compressed under the Coraco-acromial arch, resulting in mechanical wear, stress, and friction”
Subacromial Space
Primary Bony Impingement
• Causes for decreased subacromial space
– Degenerative changes
– Osteophyte formation
• On Acromion process
– Shape of acromion process
• Straight (Type 1)
• Slight hook (Type 2)
• Hooked (Type 3)
– Loss of scapular stabilization
Supraspinatus
• Compression, centering of humeral head
• Peak activity = 30-60° elevation
Abduction at Glenohumeral JointInitiates abduction
Active for first 110 degrees of abduction
Active 90-180 degrees of abduction
Superior dislocating component neutralized by infraspinatus, subscapularis, and teres minor
Roll/slide mechanics
Impingement: Roll-Slide Kinematics
“Roll” created by abduction not countered with “Slide” action
• Primary contributor = osseous
adaptation
– Humeral retroversion
– Repetitive torsional stress
(horizontal abduction and external
rotation)
– Professional pitchers
– Average increase = 17° side to side
– Crockett, AJSM ’02
Adaptive Changes
“Glenohumeral Internal Rotation Deficit”(G.I.R.D.)
Rotator Cuff Injuries
• “Internal Impingement”• Impingement of RC on
posterior-superior glenoid rim and labrum
• Extreme shoulder abduction with ER
• Contributing factors
• Excessive anterior translation
• Excessive ER
• Excessive humeral retroversion
• Pain at late cocking phase
Effects of Primary and Secondary
Rotator Cuff Impingement
• Scapular Weakness– Affects humeral head stabilization
– “functional scapular instability”• Affects
– Scapular position during activities that causes
» “relative decrease in subacromial space”• This can cause secondary impingement
– Weak scapular muscles (serratus anterior, traps (3),
rhomboid) with postural imbalance of levator and
pec minor
Impingement
Possible mechanisms
Weak or inflexible rotator cuff
Small anatomical space
GH ABD + ROT
Scapular positioning and weakness
2 types of Impingement
• Primary
• Anatomical cause of rotator cuff injury
– Mechanical compression of r/c tendons
• Primarily which one?
• Secondary
• Kinesiological cause of injury
– Related to GH instability that creates reduced
subacromial space
• Causes of GH instability?
MRI of RTC Impingement
ROTATOR CUFF
TENDON
Impinged Tissues
Tests for RTC Impingement
• Impingement tests:
• Neer (Coracoacromial arch)
• Hawkins Kennedy (Sub-acromial region)
• Cross Over (AC region)
• *Literature indicates that these tests are better for ruling out
a condition if negative than ruling in if positive4
Requirements of All impingement tests
1. Stabilize the scapula
2. Full internal rotation
3. Taken to the end of capsular motion with overpressure
4. Note area of discomfort, is it correlative to the referral area
for pain.
Neer impingement Test
RTC impingement test Coracoacromial arch
Hawkins Kennedy Test
RTC impingement Test Subacromial
Cross Over Impingement Test
RTC impingement testAcromioclavicular
Video
Impingement tests
MRI of RTC Impingement
ROTATOR CUFF
TENDON
Sub Acromial Decompression (SAD)
• Impingement (anatomical, and bio-mechanical),
RTC Tendonitis, Sub acromial bursitis that is
unresponsive to conservative treatment.
• The operation aims to increase the size of the
subacromial area and reduce the pressure on
the tendon. It involves cutting the ligament and
shaving away the bone spur on the acromion
bone.
Sub Acromial Decompression (SAD)• Also commonly performed preceding arthroscopic
rotator cuff repair
Video
SAD
BREAK!!
Clavicular
Ligaments
E. Acromioclavicular ligament
– Hold the acromion process to
the clavicle and prevents
posterior dislocation of the
clavicle
F. Coracoclavicular ligament
– Not directly located at the
acromioclavicular joint
F1. Conoid portion - medial
F2. Trapezoid portion – lateral
AC SeparationCommonly caused by a fall directly on the "point" of the
shoulder or a direct blow received in a contact sport resulting in a
piano key deformity
The Bucs quarterback injured on 10/15/17 played on 10/22 and
completed 31 of 43 passes for 385 yards, three touchdowns and
one interception against one of the best pass defenses in the NFL—and he did that with no real
passing game, while injured, on the road.
AC separation imaging
X-Ray is the best way to image this, MRI is actually
harder to visually appreciate due to the
narrow field of reference
Glenohumeral Joint Instability and
Dislocation
• Anterior Dislocation
• Occurs with arm abducted, extended, ext rot
(FOOSH)
• Occurs more often in men
• Occurs much more commonly than posterior
Glenohumeral Ligaments (B)
• Reinforces anterior portion
of the capsule
• Not well-defined
– Superior glenohumeral
ligament
– Middle glenohumeral
ligament
– Inferior glenohumeral
ligament
• Actually pleated folds of the
capsule
The Shoulder Joint
• Socket of the Shoulder Joint
– Glenoid labrum
• Deepens socket of glenoid cavity
• Fibrous cartilage lining
• Extends past the bone
• Processes of the Shoulder Joint
– Acromion (clavicle) and coracoid process (scapula)
• Project laterally, superior to the humerus
• Help stabilize the joint
• Patient is in pain
• There is loss of the normal contour of
the shoulder with a square
appearance. Loss of the contour of
the shoulder may appear as a step
• Anterior bulge of head of humerus
may be visible or palpable
• A gap can be palpated above the
dislocated head of the humerus
• Holds the injured limb with other
hand close to the trunk (carry angle)
• The shoulder is abducted and the
elbow is kept flexed
X Ray anterior Dislocation of Shoulder
Anterior Shoulder dislocation
•Hill Sach’s Lesion
•Can cause neurological
symptoms even once reduced
Hill Sach’s imaging
GH Joint Dislocations Cont……….
• Bankart Lesions
• Occurs and classified when force of dislocation
great enough to completely dislocate from the
glenoid thus tearing the labrum
• “an avulsion of the capsule and labrum off the anterior aspect of the glenoid”
• Results from a traumatic ant. dislocation
Bankart lesions
Hill Sach’s and Bankart
• Hill Sachs: Posterolateral humeral head
compression fracture as the humeral head
comes to rest against the anterior inferior part
of the glenoid.
• Bankart: Detachment of the anterior inferior
labrum from the underlying glenoid. It may be
labral only ("soft Bankart"), or involve the bony
glenoid margin (impaction fracture) and this is
called a "bony Bankart".1
Video
Bankart and Hill Sach’s
Subscapularis involvement
Cadaver dissection Relation to GH dislocation
• Anterior dislocation will
weaken if not cause
tearing and disruption
to the subscapularis.
• Positive clinical testing
for the subscapularis
may indicate previous
subluxation/dislocation
of the GH joint
Multi-directional Instability
(MDI)
• Subluxation in multiple directions
• Sports with repetitive abduction and ER
– Swimmers, gymnasts
• Symptoms
– Sensation of dislocation
– “Directional symptoms”• Anterior: HAB, 90-90° position
• Posterior: HAD, pushing movements
• Inferior: discomfort carrying heavy objects
Sulcus sign
• Seen in CVA when there is not enough tone to
resist gravity.
• Also seen in the unstable MDI shoulder when
a traction force is applied.
Video
Piano key and sulcus sign
Special Tests - Instability
• Anterior apprehension sign2
Relocation Test
• Following positive apprehension pain is
reduced with posterior humeral head force
Anterior Release/Surprise Test
• Place the pt. in the 90/90 position
• Apply a posterior translator
humeral force
• Release quickly
• Pain on rebound is a positive test
Combination of Anterior GH Instability
tests can all be done in sitting
Video
GH Dislocation tests
Bankart Lesion Repair
GH Joint Dislocation Cont……
• Hill-Sachs Lesion
• Results from an injury to head of the humerus
• Caused by anterior instability
• The actual ‘lesion’ is a compression “impaction” type fracture to the posterolateral aspect of the humeral head
• Results in “instability "and is not the cause
• Instability can occur in a multi-direction pattern: anteriorly,
posteriorly, and inferiorly
Remplissage Procedure. 'Remplissage' is French for 'to fill in'.
Video
Dislocation Repair
Athletic trauma
SLAP Lesions
• Superior Labrum,
Anterior to Posterior
• Traumatic
– Fall on outstretched arm
• Atraumatic
– Overhead sports
SLAP Lesions
• SLAP= Superior Labrum Anterior Posterior
• FOOSH mechanism with arm flexed to 90, in closed chain
occurs in sports, weight lifting, and also MVA with
avoidance pressure on the steering wheel.
Traumatic SLAP Injuries
• Traumatic events, such as falling on an outstretched
arm or bracing oneself during a motor vehicle
accident, may result in a SLAP lesion due to
compression of the superior joint surfaces
superimposed with subluxation of the humeral
head.
MRI Imaging Case example
Case study MRI and arthroscopic findings
Atraumatic SLAP Lesions
Proposed Mechanisms of Injury• Eccentric loading
– Deceleration
• Eccentric contraction of
biceps
• Tension on long head
• Tendon “pulls off” labrum
– E-stim to biceps
• Separation from glenoid
• “Peel back” mechanism– Cocked position
• Torsional stress at biceps
anchor
– Pradham, AJSM ‘01• Increased superior labral strain
during late cocking
– Contribution of compressive
load? (internal impingement)
Andrews, AJSM ‘85 Burkhart, Arthroscopy ‘98
SLAP Lesions
Classification (Snyder, Arthroscopy ‘90)• Type I
• Superior labral fraying
• Type II• Most common
• Biceps anchor detachment from glenoid
• Type III• Bucket handle tear of labrum
• Normal biceps anchor
• Type IV• Bucket handle tear of labrum
that extends into biceps tendon
• Detachment of biceps anchor
SLAP Lesions
• SLAP and Instability
• SLAP tear associated with increased G-H
translation
• SLAP tear = 6mm increase in anterior translation
Pagnani, JBJS ‘95
Special Tests – SLAP Lesions
• O’Briens Test, great sensitivity not secificity
• Standing, GH joint flexed to
• 90/adducted to 15
• Forearm pronated/humerus IR
• Apply downward force and repeat in supination3
A-P Slide test
• Stabilize the scapula with heel of the hand on the spine of the
scapula and the fingers over the coracoid
• Isolate the head of the humerussliding anterior and posterior.
• SLAP will produce pain in the
opposite direction due to labral separation. Bankart will be in the same direction due to instability.
Special Tests – SLAP Lesions
• Compression / rotation test, good specificity, pain is 180
opposite the compression due to labral separation.
Special Tests – SLAP Lesions
Compression Rotation Test
Photos courtesy of MikeReinold.com
Biceps Load II
The patient is in the supine position with the shoulder in 120 degrees of elevation and full external rotation, while the elbow
is in 90 degrees of flexion, and the forearm in supination. The patient is then asked to flex the elbow as the clinician
provides resistance.Diagnostic PropertiesSensitivity: 0.897
Specificity: 0.966
SLAP and Biceps LH
• Superior labral tears and detachment of the
Biceps LH
• Labral repair surgery involves re-anchoring or
trimming the torn piece of cartilage.
Video
Slap repair
BREAK!!
The Muscles of the RTC
93
Rotator cuff = S.I.T.S.SupraspinatusInfraspinatusTeres MinorSubscapularis
Function of Rotator Cuff
• Large external muscles
(e.g., lats, delts) create
shear forces
• Rotator cuff provides
– Joint compression
– Tangential restraint
(Ant, Post, Sup)
Deltoid produces superior shear force at GH joint.
Subscapularis
• Resists superior shear
• Produces simultaneous
internal rotation
Infraspinatus & Teres Minor
• Resists superior shear
• Neutralizes SUBSCAP
internal rotation
Summary of Active
Arthrokinematics Resisting Shear
Destabilizing Action of Latissimus
Dorsi
• LD pulls humerus INF
• SSP resists INF force
• INF & SUBSCAP create
compressive force
Overhead Sport Skills
Overhead Mechanics
Complexities of Pitching &
Overhead Serving• Highly skilled
• High angular velocities
• High rotational torques
• High generated forces
• Tremendous flexibility/ROM
• Muscular strength
• Muscular coordination
• Synchronicity of motion
• Force transmission
• Neuromuscular control
• Dynamic stabilization
• Repetitive loading
Extraordinary demands on
soft tissue, joints and
growth plates
HIGH INJURY
RISK
Goals of Kinetic
Chain• Proximal segments
– Large relative muscle mass
– Primary force / kinetic energy producer
– Accelerate the chain
– Sequentially transfer energy to next distal segment
– Decelerate forces after release
• End result
– Transfer maximum force through distal segment to ball
– Dissipation of forces after release by continuing the
chain movement
Functional Importance of Kinetic
Chain
• Seamless transfer of energy
• Maximize use of momentum
• Minimize stress to:
– Ligaments
– Dynamic stabilizers (fatigue
concerns)
– Joint
Injury-free, unrestricted
participation in sport
Not the Goal of
the Kinetic Chain
Rotator Cuff Injuries
• Primary tensile cuff disease
– Undersurface RC injury tear
– Tensile overload due to
deceleration
– Pain after ball release
MRI of RTC Tear
ROTATOR CUFF
TENDON
Preferred ERLS Position
“The ERLS is highly specific and
acceptably sensitive for diagnosis of full-
thickness tears, even in the case of an
isolated lesion of the supraspinatus
tendon.”5
External rotation lag sign (ERLS)Infraspinatus / teres minor
Damage test. Drop arm 1 + 2
For the supraspinatus: 1 is against
gravity, 2 is with light distal tapping
to account for upper trap
compensation.
Video
Drop Arm
Damage test. Empty can
External rotator test
For the External rotators: a resistive test look, for
compensation
Make sure the elbows are bent with shoulders internally
rotated. This is not a deltoid C5 myotome test
Supraspinatus isolation
• If dissymmetry suspected with empty can test,
perform supine isolation for external rotators
with scapular stabilization, compare
bilaterally.
Damage test, Gerber Lift Off
subscapularis test
For the subscapularis: likely present with GH dislocation test, but
can be seen without, may be present in overuse (swimmers)
Internal Rotation LAG sign IRLS
For the subscapularis: performed only if Gerber is positive
Video
RTC tests
RTC repair• For tears and/or detachment of the any of the
RTC tendons, open and arthroscopically
• repair surgery involves trimming damaged ends
and re-anchoring the torn section of tendon.
Video
Arthroscopic RTC repair
Video
Open RTC repair
What is Regenerative Medicine?
Regenerative medicine (Ortho Biologics) seeks to
decrease pain and improve function by using your
body’s own natural cellular mechanisms to accelerate healing, reduce pain and inflammation, and potentially
regenerate tissue.
Ortho BiologicsOrtho
Biologics
(addresses the
root cause)
Prolotherapy
PRP
Growth factors
BMAC
Stem cell
Not All Procedures are uniform• Differences can include:
• Where the stem cells are harvested from (fat cells more
cosmetic uses, Bone marrow more applicable to joints)
• How stem cells, or platelets in PRP are separated from the rest
of the harvested tissue
• How PRP or stem cells are delivered to the arthritic joint
• These differences are further complicated by more unknowns.
For example, how many stem cells are needed for a particular
treatment? And how do we determine if a patient’s own stem cells are competent enough to aid in healing?
Injection Procedures
Video
Type 1 PRP
Video
Type II PRP
RTC repair vs ortho biologic
Basic Ex progression
Surgical
• Immobilize for 4-6 wks.
• Sling off for bathing and
dressing only
• Ice and meds for pain
• Wks 4-6: Gradual return to
AAROM
• Wks. 6-12: Gradual return
to strengthening
• After wk. 12: Focus on
return to sport/activity
Ortho biologic injection
• Gentle PROM-AROM as tolerated
• No lifting. No sudden lifting, no
pushing, no overhead reaching
• Heat prior to ROM, meds for pain
• Day 4-Week 2: Begin scapular
exercises
• Wks 3-9: Gradual return to
strengthening
• Wk 7: return to sport/activity no
restrictions
Regenerative Non Surgical Coverage• What does Insurance pay for?
• Evaluation, diagnostic imaging and reading of findings (ALL)
• Ortho biologic treatments: Worker’s comp and other self-insured
companies that are self-funded.
• Major Insurance companies as of yet do not cover treatments, but
will pay for any therapy and bracing following treatment.
• Cost Examples vary by condition this is an approximation, actual
costs vary depending on pathology
• Ortho biologic injection of labrum and adjacent tendinopathies
• PRP alone $1200
• Amnio fix growth factor alone $800
• Combination PRP and Growth factor $1800
• 3 phase stem cell injection $6950
Xray and MRI for Arthritic shoulder
Total Shoulder Arthroplasty (TSR/TSA)
• Indications
– Degenerative changes in articular surfaces
– Late-stage OA, RA, Traumatic Arthritis
– Cuff-Tear Arthropathy (CTA)
– Osteonecrosis (avascular necrosis) of the head of the humerus
– Goal is to:
• Relieve pain
• Improve shoulder mobility and stability
• Improve functional use for ADL’s
TSA Implant design, materials, fixation
• Implant Design- high-density
polyethylene glenoid component
(usually all plastic) with a humeral
component made of a metal which
resembles biomechanical features of
human bone
• Fixation- press-fit, bio-ingrowth, cement
• Depends upon surgeon’s preference of design as well as strength and integrity
of patient’s bone----?????bone cement
TSA Prosthetic Designs
• Unconstrained-stemmed humeral component, used
with intact/strong RC
• Semi-constrained-erosion of the glenoid fossa but still
can have rotator cuff repair
• Reversed ball and socket -appropriate for patients with
very damaged and irreparable RC
TSA/RSA Surgical Approach
• Anterior Approach-Deltopectoral Incision
• Tenotomy –Release the subscap tendon from its
attachment on lesser tuberosity
• Osteotomy of humeral head
• ‘Rebalancing of soft tissues intraoperative lengthening or tightening, particularly the rotator cuff
• Repair/Reattachment of the subscapularis
• Dislocation Precautions: “Reaching hand into back
pocket” movement to retrieve wallet (men) and fastening bra from behind (women
TSA and Rev TSA• TSA: involves anatomically replacing the humeral
head and glenoid surfaces
• Rev TSA: involves anatomically reversing the
humeral head and glenoid surfaces
Video
TSA
Reversed anatomy and convex-concave rule, Dislocations tend to occur more posterior-inferior
Reverse Implant
Video
Reverse TSA
Questions