9/7/14. I do not have a financial relationship with any orthopedic manufacturing organization

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1 I do not have a financial relationship with any orthopedic manufacturing organization Timothy M. Geib, MD Oklahoma Sports & Orthopedic Institute September 27, 2014 Despite what you may have heard, I am old enough to be an orthopedic surgeon Understand how the normal shoulder works Understand the common causes of shoulder pain Understand the available treatment options to enable you and/or your patient s to regain pain-free use of shoulder 1

2 In 2003 approximately 13.7 million patients visited a physician regarding a shoulder problem Causes of shoulder pain Trauma Overhand sports: baseball, swimming, tennis, weight-lifting Overuse Complex Ball and Socket Joint Allows the body to orient the arm and hand in space Relatively large ball and small socket ú Increases motion ú Increases susceptibility to injury and instability Rotator cuff is a series of muscles and tendons that allows the shoulder to elevate and rotate the arm Collarbone and shoulder blade protect the ball and socket joint from direct blows Labrum Analogous to rim of golf tee Helps deepen socket to keep shoulder stable 2

3 Main restraints to instability Anterior band of the inferior glenohumeral ligament is the key structure to prevent anterior dislocation Posterior band of the inferior glenohumeral ligament is the key structure to prevent posterior dislocation Bi =Two heads #5 Short Head #9 Long Head ú Originates in the shoulder joint ú Goes through bicipital groove #10 Composed of 4 muscle/tendon units that allow the shoulder to rotate and elevate Tendons include: ú Supraspinatus ú Infraspinatus ú Teres Minor ú Subscapularis Dislocation Traumatic ú Fall on outstretched arm ú Often requires surgery ú Associated with Recurrent dislocation < 40 y/o Rotator cuff tendon tear >40 y/o Generalized Laxity ú Dislocate with minimal trauma or normal activities of daily living ú Best treated with therapy 3

4 Traumatic Unidirectional Bankart Surgery Pathoanatomy 90% of cases develop a tear of the labrum from the antero-inferior glenoid (Bankart) 80% sustain a divot in the posterior humeral head (Hill Sachs lesion) Anterior According to JBJS March 2010 ú Incidence of 23.9 per 100,000 persons per year ú 71.8% occurred in males ú Maximum incidence in patients age y/o ú 58.8% occurred as a result of a fall ú JBJS November 2006 Risk of recurrent dislocation after primary dislocation on average 55.7% at 2 years after initial event Increased to 66.8% by 5 years Young males highest risk of recurrence ú Associated injuries: axillary nerve palsy, greater tuberosity fracture, rotator cuff tear and/or labral tear Posterior According to JBJS Sept ú Prevalence 1.1 per 100,000 population per year ú Peak in males age y/o and elderly > 70 y/o ú 67% secondary to trauma, remainder seizures ú 17.7% developed recurrent instability within 1 yr ú Recurrent dislocation more common if sustained secondary to seizure, large humeral head defect, and pt < 40 y/o Initial management: closed reduction in the ER Rest, ice, anti-inflammatory medications Sling Ito et al. study indicates may be advantageous to place in external rotation Physical therapy Goal is to strengthen dynamic stabilizers of the shoulder: rotator cuff muscles 4

5 If non-operative treatment fails to stabilize shoulder, surgical stabilization necessary Open used to be gold standard Multiple studies confirm arthroscopic stabilization as effective as open Surgery Goal: tighten capsule and secure torn labrum Failure rate between 5-30% Functional outcomes are often dependent on chronicity of instability and degree of anterior/inferior bone loss Most notable deficit is loss of external rotation Usually less than 5 degrees Mild loss of external and internal rotation strength If anterior/inferior bone loss >25%, a coracoid transfer (latarjet) indicated 0-6 weeks Pillow sling Limited ROM ú Abduction/ER for anterior stabilization ú Adduction/IR for posterior stabilization 6-12 week Discontinue sling RTC strengthening 3-6 months Home program to strengthen RTC Return to full duty at 6 months 5

6 Therapy, Therapy, Therapy. If unable to stabilize with PT, consider surgery Goal: tighten up entire shoulder (capsule) Goal: let capsule scar down 0-6 weeks Sling at all times except shower and AROM elbow, wrist, fingers, pendulum shoulder exercises 6-12 weeks AAROM, AROM, RTC strengthening 3-6 months 6 months return to full duty SLAP Superior Labrum Anterior Posterior Prevalence Clinically relevant in 4-5.9% pts Andrews et al First to report superior labral lesions at origin of long head of biceps High level throwing athletes with shoulder dysfunction Cause repetitive tension overloading of rotator cuff and biceps anchor 6

7 Synder et al Coined the term SLAP lesion General population Found on 23/700 shoulder scopes on retrospective review Felt to occur with compression injury ú FOOSH with shoulder in abduction/forward flex Fewer injured with traction ú Sudden pull on arm ú Throwing or overhead sports Synder Classification Type I (11%) ú Degenerative fraying at free margin Type II (41%) ú Superior labrum detached from glenoid leaving glenoid bone exposed medially >3-5mm Synder Classification Type III (33%) ú Bucket handle tear of superior labrum Non-athlete Fall on outstretched hand Sudden forced abduction/external rotation MVA ú Driver with hands on wheel rear-ended ú Shoulder with seat belt on Type IV (15%) ú Bucket handle tear with extension into biceps tendon Overhead Athlete Symptoms may occur suddenly or gradually Pain with overhead activity Inability to throw with pre-injury velocity 7

8 9/7/14 Patients complain of Pain with overhead activities Deep shoulder pain Occasionally feel catching or locking Inspection: Palpation: Range of motion Speed s Test O Brien Test Sensitivity range % Rotator cuff pain/impingement Increased external rotation & decreased IR in throwers Jobe Relocation Test Scapular protraction Shoulder forward Sensitivity: 44-76% Kibler Test Sensitivity 78.4% 8

9 Plain films Generally normal MR arthrogram Coronal oblique Spinoglenoid cyst MRI CT arthrogram Pandya et al J. Arthroscopy 2008 MRI ú Sensitivity for SLAP 67% when interpreted by surgeon 53% when interpreted by radiologist MRA ú Sensitivity for SLAP 72% surgeon 50% radiologist Initial Decrease inflammation ú NSAID s/prednisone/ice ú Injection Correct scapular posture ú Bracing/taping ú Integrated rehab Strengthen RTC Stretching to attain full ROM Functional Rehab Work with tape S3 brace Monitor work specific activities ú Stop with protraction or fatigue Maintenance Exercises 9

10 Failure of non-operative treatment ~ 3 months Continued Pain Functional impairment Chondromalacia of glenoid Fraying on undersurface of labrum Fraying/roughness of glenoid neck 10

11 Labral Repair 0-4 weeks: Protect in pillow sling Partial articular sided rotator cuff repair 4-8 weeks: Baseline exercises 8-12 weeks: Progressive rehab >12 weeks: Functional rehab SLAP tears clinically significant when instability occurs Clinical diagnosis Arthroscopic repair successful Savoie 39/40 pts satisfied at 4 years UCLA score: 35/35 Bankart score: 97 Curtis, A et al. J. Arthroscopy 2007 Possible contraindications ú Age >40y/o ú Non overhead throwing athlete ú Pain, Decrased ROM, ER 34 0, FF 30 0, IR

12 Fractures Clavicle/Collarbone ú Usually heal without surgery ú Occasionally require plate and screw fixation -Indications: 100% displacement 1.5 cm overlap Distal 1/3 fracture Post-op: Sling for 6 weeks, No heavy lifting until fracture heals (usually 6-8 weeks) Fractures Proximal Humerus ú Ball of ball and socket joint ú Usually heal non-op ú Occasionally require Plate and screw fixation Indications: Varus alignment 3 part fractures RTC avulsions Hemiarthroplasty 4 part proximal humerus fx AC Separation Shoulder Separation Affects A/C joint Treatment depends on severity of injury Type I and II treat non-op Type III, differing opinions on operative vs non-op Type IV, V, and VI require surgical treatment 12

13 9/7/14 Baseball Prone to biceps and rotator cuff tendon disorders Tennis Biceps & labral disorders Impingement Definition: ú Repeated overhead movement Prone to instability Swimming Prone to instability Treatment Non-operative ú Cortisone injection ú Rotator cuff strengthening exercises squeezes and inflames RTC and bursa Volleyball Symptoms Include: ú Pain with overhead activities ú No significant loss of motion ú No weakness ú Commonly occurs with overhead use of arm Operative ú Shoulder Arthroscopy ú Remove bone spur from shoulder blade Example: Painting ceilings 13

14 9/7/14 A/C Arthritis Treatment: Sx: Pain reaching across your body Common in young weight lifters Pain mainly located Injections Surgery ú Arthroscopic distal clavicle excision on top of shoulder Generally patients have normal range of motion and strength 2 main causes 1. Frozen Shoulder/Adhesive Capsulitis - Significant decrease in range of motion - Pain at extremes of motion - May occur with or without injury - Often associated with Diabetes - Usually will improve with therapy but can take up to 1 yr 2 main causes 2. Arthritis: - Osteoarthritis - Wear and tear - Rheumatoid Arthritis - Autoimmune disease - Symptoms: - Painful/decreased Range of Motion - Popping/crepitus - Normal strength - Treatment - Anti-inflammatory medication - Injections/Physical Therapy - Shoulder Replacement Surgery 14

15 Generally occur in patients over age 40 y/o May result from chronic wear and tear or trauma associated with fall Symptoms include: Pain with overhead activities +/- weakness Pain worse at night Initial Treatment Steroid Injection Physical Therapy Treatment Surgery ú Arthroscopic Rotator Cuff Tendon Repair 15

16 Shoulder is a complex joint that allows one to orient their arm and hand in space Disorders of the shoulder can be characterized by certain symptoms - Pain - Range of Motion - Weakness - Provocative testing Most shoulder issues are initially addressed with conservative measures and if refractory respond nicely to operative intervention Questions 16