Shoulder Pain:
Common conditions
Marc Labbé, M.D.
Taylor Brown, M.D.
Presented at The Health Museum
4/19/2012
Shoulder Pain:
Common conditions
Anatomy
Evaluation
Conditions
Impingement
Frozen Shoulder
Calcific Tendinitis
Rotator Cuff Tear
Instability
Arthritis
Fractures
Review/Tips
Anatomy: overview
tendons connect muscles to bones to move
joints that are surrounded by bursae
Anatomy: Bones
– Humerus
– Clavicle
– scapula
Anatomy: Tendon
– Cord that
connects
muscles to
bone
Anatomy: Bursa
• Fluid filled sac
• Cushion
between bones
and overlying
soft tissues
• Reduces
friction
• Allows
increased
motion
Shoulder Physiology
• Muscles
control
position of
shoulder blade
and humerus
• Stability is a
balance of
ligaments and
muscles
Shoulder Pathology
•
Posture
•
Muscular weakness
•
Proper Working Position
Shoulder Evaluation
• History
• Injury
• Duration
• Specific
Limitations
• Area of Pain
Shoulder Evaluation
• Examination
• Motion
• Strength
• stability
Shoulder Evaluation
• X-Rays
Trauma
No Injury
Stiff
Abnormal XRay
Stiff
Normal X-Ray
Weak
Inflamed
Arthritis
Frozen
Shoulder
Impingement
Shot
Medicine
Exercise
Shot
Medicine
Exercise
Shot
Medicine
Exercise
Weak
Loose
Bruised
Abnormal XRay
Rotator Cuff
Tear
Instability
Fracture
Repair < 30 years
Repair
Exercise > 30
years
Sling/Repair
Shoulder Pain:
Common conditions
1.
2.
3.
4.
5.
6.
Impingement
Frozen Shoulder
Rotator Cuff tear
Instability
Arthritis
fracture
• Codman – Supraspinatus and the Subacromial Bursa 1934
Impingement Syndrome
•
•
•
“Tendonitis”
“Bursitis”
“Bone spur”
Impingement Syndrome
• Men = women
• Any age
• Weeks to months
Impingement Syndrome
• Ache
• Activity related
• Night pain
Impingement Syndrome
• Started after Too much…
•
•
•
•
•
•
•
Computer use
Gardening
Heavy lifting
Tennis
Golf
Throwing
fishing
Impingement Syndrome
• “bone spur”
• Acromion rubs on
the rotator cuff
and bursa
• bursitis and
tendonitis early
• rotator cuff tear
over time
Impingement Syndrome
• Impingement signs
• Neer
• Pain with passive
forward flexion
while internally
rotated
• Hawkins
• Pain with passive
internal rotation
while abducted 90
degrees
– AJSM 2003
Impingement Syndrome
Diagnose with history, physical exam,
xrays, and a likely successful result
with conservative treatment
•
•
Codman – Supraspinatus and the Subacromial Bursa 1934
Bigliani – JSES 2008
Impingement Syndrome
• Initial treatment
• Relative rest
• Ice
• Antiinflammatory
medications
• cortisone
injection
• Physical
therapy
Impingement Syndrome
• 90% successful
with non-operative
treatment
• Shot
• Medicine
• Exercises/Posture
Correction
Impingement Syndrome
• Cortisone Injection
• primary indication is
difficulty sleeping
•70% improved with a
single shot
•20% better with a
second shot
•If no better, Check
MRI
•
Consider arthroscopic subacromial
decompression if symptoms persist
Impingement Syndrome
• Arthroscopic
subacromial
decompression
• 30 minute day surgery
• General anesthesia and
a nerve block/pain pump
• Sling 2-4 weeks
• No restrictions
• Begin rehab exercises
immediately
• 2-3 months to feel
better
Impingement Syndrome
• Arthroscopic subacromial decompression
– Cutting block technique
• Caspari 1992
Impingement Syndrome
Frozen Shoulder
Shoulder Pain:
Common conditions
1.
2.
3.
4.
5.
6.
Impingement
Frozen Shoulder
Rotator Cuff tear
Instability
Arthritis
fracture
Frozen Shoulder
Adhesive capsulitis
– Capsule surrounding shoulder ball and
socket scars and “shrink wraps” itself
inhibiting full motion and causing pain
Frozen Shoulder
• Severe pain
•
•
•
•
•
Front of
Shoulder
constant
stiff
Getting worse
May or may not
know why
Frozen Shoulder
• No injury
• Shortly after
minor injury
• following breast
or heart surgery
Frozen Shoulder
• 40 - 60 years
old
• Women > Men
• Thyroid disease
• Diabetes
• Heart disease
• Will Occur on
Opposite Side
30% of Time
Frozen Shoulder
• Three phases
• Inflammatory
• Frozen
Davis mountains
• Thawing
Frozen Shoulder
• Loss of exernal
rotation
• Passive and active
motion loss
• Normal strength
Frozen Shoulder
• Initial treatment
• Time
• 18+ months to
spontaneous resolution
• Pain medicine
• Cortisone injections
• 2-3
• Stretching
• May help or worsen
Frozen Shoulder
• Arthroscopic
capsular release
with manipulation
• If not improved with
initial conservative
measures
• Capsule and ligaments
are partially excised
• Stretched to full motion
while anesthetized
• Cortisone Injection
Frozen Shoulder
• Arthroscopic
capsular release
with manipulation
• Sling 2-4 weeks for
comfort only
• Immediate motion
• Immediate therapy to
maintain motion
• Capsulitis may grow
right back without
stretching
Calcific Tendonitis
• Rare
• Calcium buildup
inside tendon
• Cortisone
injection
• Arthroscopic
removal
Shoulder Pain:
Common conditions
1.
2.
3.
4.
5.
6.
Impingement
Frozen Shoulder
Rotator Cuff tear
Instability
Arthritis
fracture
Rotator Cuff Tear
•
•
•
•
Detachment of
the tendon
from the bone
Does not heal
on own
Acute: single
injury greater
than threshold
Chronic: long
term overuse,
wear and tear
Rotator Cuff Tear
• history
• Injury (25%)
• Pain without injury (75%)
• Loss of overhead or behind the back
activity without pain
Rotator Cuff Tear
• Symptoms
• Pain: anterior superior shoulder or
deltoid insertion
•Rest
•Night
•activity related
• Weakness or disability
• instability
Rotator Cuff Tear
• Exam findings
• Weakness/Pain
• Active motion loss/Pain
• Passive motion maintained
Rotator Cuff Tear
• Diagnosed with
•
•
•
•
History
Exam
Xrays
Mri (or ultrasound)
Rotator Cuff Tear
Full thickness
Partial thickness
Rotator Cuff Tear
•
Nonoperative
• cortisone
injection
• physical
therapy
• oral
analgesics
• Temporary
relief
• It will get
worse with time
Rotator Cuff Tear
Arthroscopic rotator Cuff
Repair
Rotator Cuff Tear
Arthroscopic rotator Cuff Repair
Rotator Cuff Tear
Arthroscopic rotator Cuff Repair
• Sling 1 month
• Healing 3
months
• 98% with small
tears
• 50-85% with
large tears
• Maximum
recovery 6 – 12
months
Rotator Cuff Tear
• Arthroscopic Rotator cuff tear
Repair: predictors of success
• Tear size
• Small < 1.5 cm
• Large >3 cm
• Age of Tear
• Muscle and Tendon Atrophy
• Patient age
• <62 years
• Tobacco usage
Rotator Cuff Tear
Arthroscopic Allograft Cuff
Augmentation
Rotator Cuff Tear
Arthroscopic Allograft Cuff
Augmentation
Shoulder Pain:
Common conditions
1.
2.
3.
4.
5.
6.
Impingement
Frozen Shoulder
Rotator Cuff tear
Instability
Arthritis
fracture
• Codman – Supraspinatus and the Subacromial Bursa 1934
instability
• Dislocation
• Ball Slips Out of
Socket
• Subluxation
• Balls Shifts
Abnormally in
Socket
instability
• Traumatic
•
Fall or Pull on
Outstretched
Arm
•
Direct pressure
on Extended Arm
or Elbow
• Non-Traumatic
•
“DoubleJointed”
•
Developmental
(Repeated
stretching over
time)
instability
•
•
•
Can occur
repeatedly after
ligaments and
cartilage are torn
Causes pain and
uneasiness when
arm is elevated
away from body
Can result in
arthritis
instability
• Non-operative
• Physical
therapy
• Activity
avoidance
• Operative
• Arthroscopic
bankart labral
repair
Shoulder Pain:
Common conditions
1.
2.
3.
4.
5.
6.
Impingement
Frozen Shoulder
Rotator Cuff tear
Instability
Arthritis
fracture
arthritis
1.
2.
3.
4.
Osteoarthritis
post-instability
Rheumatoid
Rotator cuff
tear
arthritis
• Non-operative
• Oral analgesics
• Cortisone
injection
• Physical therapy
• Operative
• Partial
replacement
• Total shoulder
replacement
Shoulder Pain:
Common conditions
1. Impingement
2. Frozen
Shoulder
3. Rotator Cuff
tear
4. Instability
5. Arthritis
6. fracture
Fractures
Fractures
• Most treated
successfully
without surgery
• Sling or brace
• Oral analgesics
• Calcium and
vitamin d
• 3 months to heal
• 12 months to
recover
Fractures
• Surgery if widely displaced
• Plates and screws
• Nails
• Partial replacement
Shoulder Pain:
Common conditions
Review
1.
2.
3.
4.
5.
6.
Impingement
Frozen Shoulder
Rotator Cuff tear
Instability
Arthritis
Fracture
- Initial non-surgical care
• Codman – Supraspinatus and the Subacromial Bursa 1934
Shoulder Pain:
Common conditions
Review
1.
2.
3.
4.
5.
Relative rest
Ice
Oral analgesics
Cortisone injection
Gradual return to activity
when pain free
6. Exercise/Therapy
Shoulder Pain:
Common conditions
Review
Seek professional evaluation early if …
• Trauma/specific injury
• Cannot raise arm above shoulder
level
• Pain, weakness, or disability not
improved with initial conservative
treatment
Shoulder Pain:
Common conditions
Review
1.
2.
3.
4.
5.
6.
Impingement
Frozen Shoulder
Rotator Cuff tear
Instability < 30 y.o.
Arthritis
Fracture
- Initial surgical care
• Codman – Supraspinatus and the Subacromial Bursa 1934
Tips - Activities to avoid
• Reaching into the
back seat of the car
• working behind you
• Lifting heavy
objects above
shoulder level
• Overexertion
- KEEP GOOD
POSTURE
Tips - Shoulder Exercises
www.aaos.org
-patient information
Shoulder Pain:
Common conditions
and treatments
Marc Labbé, M.D.
mlabbe@bjc-houston.com
Taylor Brown, M.D.
tbrown@bjc-houston.com
(713) 790-1818