S

Why Does My

Shoulder Hurt?

Hilary L. Malcarney, MDSpecializing in Sports Medicine and Shoulder Reconstruction

Project ECHO

August 6, 2015

Let’s review some anatomy!

Cervical Spine

S Muscle strain

S Arthritis

S Cervical disc herniation

S Cervical nerve root inflammation

(Radiculopathy)

S Fracture

Shoulder Anatomy

S Bones

Shoulder Anatomy

Right shoulder x-ray

Humeral Head

Glenoid

ClavicleAC jointAcromion

Coracoid

Shoulder Anatomy

S Muscles / Tendons

Shoulder Anatomy

S Ligaments

Why does my shoulder hurt?

S Rotator Cuff Problems

S Bursitis / Tendinitis

S Partial tear

S Complete tear

Rotator Cuff Impingement

S Inflammation of the rotator cuff due to compression of the tendon complex by the overlying acromial arch, causing pain and swelling of the bursa and tendons below. This may lead to a partial or complete rotator cuff tear, allowing bursal and tendon inflammation to worsen.

The result …

Chronic Shoulder Pain!

Rotator Cuff Tears

S Slow, progressive degeneration of the rotator cuff tendon complex.

S Acute traumatic event.

S Chronic repetitive activity.

S Some combination of above.

Rotator Cuff Tears

S Symptoms

S Pain (* Night Pain)

S Weakness

S Normal range of motion, although may be limited by pain

How are rotator cuff problems

evaluated?

S Talk to the patient.

S Physical examination.

S Plain x-rays.

S MRI if rotator cuff tear suspected or if non-operative

treatment not effective, or if unsure of diagnosis.

Rotator cuff tear

How is rotator cuff

impingement treated?

S Inflammation – Bursitis / Tendinitis

S Rest/Activity Modification

S Ice

S NSAIDs (ibuprofen or naproxen)

S Subacromial steroid injection

S Physical Therapy

S Arthroscopic Surgery

Arthroscopic Surgery

S Diagnosis – Rotator cuff impingement syndrome, which

failed non-operative treatment measures.

S Treatment – Subacromial Decompression

How are rotator cuff tears treated?

S Rotator Cuff Tear (Partial versus Complete)

- Rest, NSAIDS, Steroid Injection, Physical Therapy

- Arthroscopic Surgery

Arthroscopic Surgery

S Most complete, full-thickness rotator cuff tears are optimally

treated with arthroscopic tendon repair in symptomatic

patients who are deemed appropriate for surgery.

Arthroscopic rotator cuff repair

S Why?

S Complete, full-thickness rotator cuff tears do not heal well

without surgical repair.

Arthroscopic rotator cuff repair

S When?

S Medically optimized for surgery.

S Patient needs to allow time for rehabilitation.

S Ideally within a few months of diagnosed tear, especially with

progressive pain and weakness.

Arthroscopic rotator cuff repair

S Who?

S Patient, surgeon, anesthesiologist, certified first assistant, scrub

tech, nursing staff.

S Where?

S Surgery center or hospital

Arthroscopic rotator cuff repair

S How?

Arthroscopic rotator cuff repair

S And then… Post-operative recovery and rehabilitation.

S Sling for six weeks. Simple daily table-top activities allowed.

S Remove sling at six weeks and progress strengthening.

S Limit lifting to 5 lbs between 6-12 weeks post-op.

S Limit lifting to 10 lbs between 12-16 weeks post-op.

S Progress strengthening and activities as tolerated after 16

weeks, with full release to heavy work and sports at 6 months.

Why does my shoulder hurt?

S Arthritis

Normal shoulder x-ray Glenohumeral joint arthritis

Glenohumeral joint arthritis

S Causes – Age, Genetics, Trauma, Repetitive Use

Glenohumeral joint arthritis

S Symptoms

S Pain – Sudden or gradual onset, progressive

S Limited range of motion

S Good strength

How is shoulder arthritis

diagnosed?

S Talk to the patient.

S Physical Examination.

S ** Plain x-rays.

S MRI or CT scan.

Glenohumeral joint arthritis

S Treatment

S Activity Modification

S NSAIDs (ibuprofen, naproxen)

S Glucosamine Chondroitin Sulfate

S Intra-articular steroid injection

S Physical Therapy

S Joint Replacement – Partial or Total Shoulder Arthroplasty

Total Shoulder Arthroplasty

S Primary TSA

S Arthritis with NO Rotator Cuff Tear

S Reverse TSA

S Arthritis + Rotator Cuff Tear

Primary TSA

Reverse TSA

Total Shoulder Arthroplasty

S Who? Patient with painful shoulder arthritis

S What? Open procedure to replace arthritic joint

surfaces with titanium/chrome and polyethylene

S When? Timing of surgery based on PAIN

S Where? Hospital, overnight stay

S Why? To reduce shoulder pain

Total Shoulder Arthroplasty

Total Shoulder Arthroplasty

S Post-op recovery and rehabilitation

S Sling for six weeks post-op

S Remove sling at six weeks post-op and start light strengthening

S Progress activities as tolerated at 4 months post-op

S ** Lifetime 25 lb lifting restriction

S LIFETIME prophylactic antibiotics before dental work.

Shoulder Instability

Shoulder Instability

S What happens when a shoulder dislocates?

S Labral tear – younger patients, <30 years old

S Rotator cuff tear – older patients, > 60 years old

Labral tear

Rotator cuff tear

Shoulder Instability

S Treatment

S Sling for 7-10 days until pain and swelling subside

S Physical therapy to help regain ROM and strengthen shoulder

S Progress activities as tolerated

S * Consider MRI and surgery for patients <30 after 1st dislocation

(Due to probable labral tear and high rate of recurrence.)

S * Consider MRI for patients >60 with pain and continued weakness

(Due to possible rotator cuff tear that will not heal on its own if full thickness.)

Arthroscopic Labral Repair

S Who? Typically, patients <40 years old

S What? Labrum is arthroscopically repaired to glenoid rim

S When? After 1st dislocation in patients <25 years old

S Where? Outpatient surgery center or hospital

S Why? To avoid future dislocation episodes

Arthroscopic Labral Repair

Arthroscopic Labral Repair

S Post-op recovery and rehabilitation

S Sling for 6 weeks post-op

S Remove sling at 6 weeks post-op and start progressive strengthening

S Return to heavy labor and contact sports – 6 months

Frozen Shoulder

S Frozen shoulder = adhesive capsulitis

Definition – change in collagen structure of the

shoulder joint capsule to a stiffer, less elastic membrane

Causes – diabetes, hypothyroidism, trauma,

physiological or emotional stress

How is a frozen shoulder treated?

S Rest, activity modification

S NSAIDs (ibuprofen, naproxen)

S * Glenohumeral joint steroid injection

S Home stretching program

S Physical Therapy (maybe)

S Arthroscopic surgery, with manipulation (unlikely)

Frozen Shoulder

S A frozen shoulder can persist for 24+ months before it thaws out.

S Freezing – Rest pain, progressively decreasing ROM.

S Frozen – No rest pain, but pain at ROM extremes. Extreme stiffness.

S Thawing – Less pain, with progressively improving ROM and function.

My shoulder hurts…

S Talk to the patient.

S Age

S Hand-dominance

S Occupation

S Traumatic event? Repetitive activity? Cause of shoulder pain?

S Symptoms – duration, quality, exacerbated or alleviated by

S Past treatment

S What does the patient think is wrong with the shoulder?

My shoulder hurts…

S Physical examination

S Cervical spine

S Evaluate opposite shoulder

S Painful shoulder – ROM, strength testing, provocative tests

My shoulder hurts…

S Objective Testing

S X-rays – 4 view (AP Grashey, AP AC joint, supraspinatus

outlet, axillary)

S MRI or CT scan

My shoulder hurts…

S Diagnosis – Examples: rotator cuff tendinitis or tear, glenohumeral joint arthritis, adhesive capsulitis

S Plan -

S Activity modification and NSAIDs (OTC or Rx)

S Steroid injection

S Physical Therapy

S Surgery

S Establish return to activity and/or follow-up plan

My shoulder hurts…

S Listen to what the patient is saying.

S Perform a good physical examination.

S Evaluate x-rays and MR images during office visit.

S Diagnose the problem.

S Formulate a treatment plan with potential options, and discuss

with the patient.

S Hilary L. Malcarney, MD

10635 Professional Circle, Suite A

Reno, Nevada 89521

775-852-0505

nvorthopedics.com

Facebook: Hilary L. Malcarney, MD

Twitter @hmalcarneymd