COMMON PROBLEMS IN
ORTHOPEDICS:
NON-TRAUMATIC
Kitiphong Kongrukgreatiyos, MD
Thai Veterans General Hospital
PROBLEM BASE APPROACH
¢  Shoulder
—
—
—
—
Pain
Adhesive Capsulitis
Subacromion Impingement Syndrome
Rotator Cuff disease
Glenoid labrum disease
¢  Knee
Pain: OA knee Versus ?
¢
¢  Work
Related Pain
¢  Elbow
¢  Wrist/
Hand
THE SHOULDER: PAIN
—
—
—
—
Adhesive Capsulitis
Subacromion Impingement Syndrome
Rotator Cuff disease
Glenoid labrum disease
ADHESIVE CAPSULITIS
(FROZEN SHOULDER)
CASE 1
¢  A
53 years old woman with chronic shoulder
stiffness for over a year
¢  Conservative treatment: medication, physical
therapy, acupuncture
¢  Limit external rotation
¢  Complains about limit movement > pain
CASE 2
¢  A
49 years old Thai male with chronic shoulder
pain for past year.
¢  Had medication, steroid injection, physical
therapy
¢  Loss of passive and active ROM especially
abduction external rotation and forward flexion+
¢  + Impingment signs ?
¢
patients in similar scenarios
¢  But
they are actually different…
DEFINITION OF FROZEN SHOULDER
—
Common problem but poorly understood
—
Neviaser ‘s “adhesive capsulitis”
—
—
Contracted thickened joint capsule with chronic
synovitis
Uncertain cause characterized by spontaneous
onset of pain with restriction of both active and
passive ROM of shoulder
Iannotti JP, Williams GR. Disorders of the Shoulder. 2nd edition. Lippincott Williams & Wilkins. 2007.
CLASSIFICATION
—
—
Primary (idoiopathic)
Secondary(known disorders)
—
—
—
—
Systemic: DM, hypothyroidism, hyperthyroidism,
hypoadrenalism
Extrinsic: CVA, cervical disc, cardio-pulmonary
disease, humerus fractures, Parkinson’s
Intrinsic: rotator cuff tendinitis, rotator cuff tears,
biceps tendinitis, calcific tendinitis, AC arthritis
Tertiary
—
Postoperative, post fracture
Iannotti JP, Williams GR. Disorders of the Shoulder. 2nd edition. Lippincott Williams & Wilkins. 2007.
NATURAL HISTORY
¢  Phase
—
pain with progressive stiffness
¢  Phase
—
II(lasts 4-12 months):
Stiff, contracted
¢  Phase
—
I (lasts 2-9 months):
III (lasts 12-42 months):
Thawing phase where motion gradually improves
Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol. 1975;4:193-196.
NATURAL HISTORY
—
—
Four stages of adhesive capsulitis
Stage 1 (3 months)
—
—
—
Stage 2 “freezing” (3 - 9 months)
—
—
—
Decrease ROM
Diffuse synovitis
Stage 3 “frozen” (9 – 15 months)
—
—
—
—
—
Pain with near normal ROM
Synovitis at anterosuperior capsule
Minimal pain except at extremes of motion
Loss of motion
Rigid end feel
Thickened, fibrotic capsule with no huypervascularity of
capsule
Stage 4 “thawing” ( 15 – 24 months)
—
Minimal pain with progressive improvement in ROM
Hannafin JA, Chiaia TA. Adhesive capsulitis: a treatment approach. Clin Orthop. 2000. 372: 95 – 109
.
PATHOLOGY “THEORIES”
—
—
—
—
—
—
—
—
—
—
Thickened and noncompliant capsule
Tightened coracohumeral ligament
1896 Duplay scapulohumeral periarthritis from the
obliteration of subdeltoid bursa
Changes in biceps tendon
McLaughlin “Contracture of subscapularis”
Synovitis
Autoimmune (high human leukocyte antigen B27, low
IgA)
Myofascial pain syndrome with active trigger points
in rotator cuffàhypoxiaàfibrous tissue in area
Prolong immobilization
WE DON’T KNOW THE TRUTH.
CLINICAL EVALUATION
¢  History
—
—
—
Pain with restricted motion
Sharp pain at endpoint of restricted shoulder
Associated medications: protease inhibitors anti-HIV,
barbiturates, antituberculosis
CLINICAL EVAULATION
¢  Physical
ROM
—
—
—
—
—
Examination: PASSIVE = ACTIVE
vs. infection: swelling, erythema
vs. neuropathy (cervical/axillary): muscle atrophy,
loss
of active motion
vs. fracture: palpate bone/crepitation
vs. tumor:
vs. ***Rotator Cuff pathology***
Impingement sign, Hawkins’ sign, Jobe’s test are
unreliable.
¢  Lift-off sign/ abdominal compression: limited by loss of
active internal rotation.
¢
IMAGING STUDIES
¢  Used
mainly to exclude other disorders causing a
stiff shoulder
—
—
Radiographs
MRI
¢  Right
—
diagnosis
Frozen shoulder primary vs. secondary
¢  Right
treatment
TREATMENT
—  Conservative
—  Medication
—  Physical
therapy
—  ------ 90%improve ------—
Operative
—
—
—
—
Capsule fluid distension (Brisement)
Manipulation under anesthesia
Arthroscopic capsular release
Open capsular release
CONSERVATIVE
—
Aim: reduce pain + stretching program
Lee PN, Lee M, Haq AM, et al. Periarthritis of the shoulder: trial of treatments investigated by multivariate analysis. Ann Rheum Dis. 1974;33:116-119.
—
Steroids injection: second most common medical
intervention
better outcome with combine steroid + exercise
compare to just exercise
—
Carette S, Moffet H. Tardif J, et al. Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in
the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial. Arthritis Rheum. 2003;48:829-838.
Concerns with fail delivery of steroids into the glenohumeral
joint
Studies showed failure of 68% administered by “experts”
without radiologic guidance
Eustace JA, Brophy DP, Gibney RP, et al. Comparison of the accuracy of steroid placement with clinical
outcome in patients with shoulder symptoms. Ann Rheum Dis. 1997;56:59-63.
Concerns with other pathologies such as rotator cuff tear, SLAP
lesions.
STRETCHING PROGRAMS
INTRA-ARTICULAR SHOULDER INJECTION
MANIPULATION UNDER ANESTHESIA
(MUA)
—
Contraindication
—
—
—
No improvement or worsening in ROM after previous
MUA
Osteopenia
Rotator cuff tear
FEAR
—
—
—
Results 25% to 90% of patients improving 3 months
after manipulation
70% improving after 6 months
12.8% persistent disability
Dodenhoff RM, Levy D, Wilson A, et al. Manipulation under anesthesia for primary frozen shoulder.
Effects on early recovery and return to activity. J Shoulder Elbow Surg. 2000;9:2-26.
INTRA-ARTICULAR JOINT DISTENTION
(BRISEMENT )
¢  Capsule
disruption by fluid distention
¢  Good short term benefits 1-3 months but no
difference in long-term outcome compared to
other treatment modalities
Harryman DT, Lazarus MD. The Shoulder. Philadelphia: WB Saunders; 2004: 1121-1172.
¢  What
can we do with recalcitrant frozen
shoulder?
¢  Conservative treatment
—
—
—
—
Medication
Physical therapy and rehabilitation
Injection
Nothing?
—  Arthroscopic
capsular release
QUESTIONS TO ANSWER BEFORE DOING
ARTHROSCOPIC SURGICAL CAPSULAR RELEASE
¢  Shoulder
stability
¢  Where to release
¢  Dangerous territory
¢  Tools to use
ROLE OF SURGERY
¢  Capsular
—
—
—
—
—
—
—
—
release but which structures?
Coracohumeral ligament
Rotator interval
Superior glenohumeral ligament
Middle glenohumeral ligament
subscapularis
IGHL: anterior band, posterior band
Axillary pouch
Posterior capsule
INFERIOR GLENOID HUMERAL LIGAMENT
¢  anterior
and posterior bands along with the
intervening axillary pouch
¢  - primary restraint to anterior and anteroinferior
instability;
-limits anterior translation in abduction and
external rotation;
- posterior band limits posterior translation in
abduction and internal rotation
IS EXTENDED RELEASE OF THE INFERIOR
GLENOHUMERAL LIGAMENT NECESSARY FOR
FROZEN SHOULDER?
p529-535.
¢  74
—
—
—
—
Chen et al. Arthroscopy. Vol 26, No 4 (April) 2010
patients into two groups
Release anterior capsular structures
Group 1 anterior band of IGHL
Group 2 additional posterior and inferior of IGHL
release
FU 28 months
¢  Abduct,
flexion, external rotation more rapidly in
group 2 at 3 months
¢  No differences at six months.
AXILLARY NERVE
¢  Nerve
is at risk at 5 to 7 o’clock.
¢  12.4 mm from glenoid rim at 6 o’clock
¢  Abducted
and externally rotated shoulder to
reduce risk of injury to nerve
¢
Jerosch J. et al. Which joint position puts the axillary nerve at the lowest risk when performing an arthroscopic
capsular release (ACR) in patients with adhesive capsulitis of the shoulder? Knee Surg Sports Traumatol Arthrosc
2002;10:126-129.
HOW I DETERMINE WANT TO RELEASE
¢  Anterior
¢  Posterior
¢  Inferior
ANTERIOR CAPSULE:
LIMIT ABDUCTION, EXTERNAL ROTATION
CORACOID IMPINGEMENT
POSTERIOR CAPSULE:
RESTRICTION IN CROSS BODY ADDUCTION AND INTERNAL
ROTATION
INFERIOR CAPSULE
¢  Restricted
forward flexion, abduction
CORACOIDPLASTY, ACROMIOPLASTY
270 DEGREES RELEASE
PITFALL: DID NOT RELEASE IGHL?
CASE
¢  Frozen
shoulder in a dislocated shoulder
¢  Limit forward flexion, abduction and external
rotation
Release CHL, RI, coracoidplasty,
Did not release IGHL, posterior capsule
Post-op
9 months!
IMPINGEMENT SYNDROME
“IMPINGEMENT”
¢  การกระทบ
¢  การปะทะ
¢  การกระแทก
HISTORY
¢  Coracoacromion
arch and tendon
¢  1931 Meyer rotator cuff tendon tears from friction
¢  1949 Armstrong suggested acromionectomy
¢  Mclaughlin suggested lateral acromionectomy
¢  1972 Neer “subacromion impingement syndrome”
SUBACROMION IMPINGEMENT SYNDROME
¢  hypothesized
that the rotator cuff is impinged upon by
the anterior one-third of the acromion, the
coracoacromial ligament, and the acromioclavicular
joint rather than by just the lateral aspect of the
acromion
SUBACROMION IMPINGEMENT SYNDROME
¢  formation
of spurs in the substance of the
coracoacromial ligament leads to chronic wear and to
tears of the rotator cuff
NEER’S ANTERIOR ACROMIOPLASTY
¢  débridement
of the inflamed subacromial bursa
¢  resection of the coracoacromial ligament and any
spurs that are present
¢  resection of the anteroinferior aspect of the acromion
¢  resection of overhanging osteophytes from the
acromioclavicular joint or of the entire joint if there is
preoperative tenderness.
ETIOLOGY
¢  Intrinsic
—
—
—
Muscle weakness causing humeral head migration
Overuse of shoulder
Degenerative tendinopathy
¢  Extrinsic
—
Neer: type I (flat), type II (curve), type III (hook)
NEER IMPINGEMENT STAGES
¢  Stage
I: acute bursitis with subacromial edema
and hemorrhage
¢  Stage II: subacromial bursa loses its ability to
lubricate and protect the underlying rotator cuff
and tendinitis of the cuff develops
¢  Stage III: full-thickness tear of the rotator cuff
SIGNS AND SYMPTOMS
¢  Neer
—
( impingement ) sign
Stand behind patient and passively elevate arm in
scapular plane. Pain usually at 70-120 degrees
HAWKINS TEST
IMPINGEMENT TEST
¢  Inject
10cc 1% xylocaine into subacromial space
¢  Test for impingement sign will no longer be
painful
IMPINGEMENT SIGN
10 CC XYLOCAINE SUBACROMION SPACE
IMPINGEMENT TEST +VE:
PAIN RELIEVED AFTER INJECTION
RADIOLOGY
¢  30
caudal tilt view
SUPRASPINATUS OUTLET VIEW
¢  Position:
Erect with anterior aspect of affected
shoulder against x-ray plate and rotating other
shoulder out 40 deg°.
¢  Beam: aimed from posteriorly along scapular
spine but with the beam aimed with 10° caudal
tilt
TREATMENT
¢  Nonoperative
¢  rest
¢  Control
inflammation
¢  Physical therapy:stretching, strengthening programs
OPERATIVE: INDICATION
1) FAILURE CONSERVATIVE TREATMENT
2) ROTATOR CUFF TEAR (STAGE III)
SUPERIOR LABRAL LESIONS
ANTERIOR TO POSTERIOR
HISTORY
¢  Recognition
of glenoid labral pathology and its
association with shoulder instability early as
1906 by Perthes and in 1938 by Bankart
¢  Andrews first to report labral tears superiorly
near the biceps tendon origin in 73 overheadthrowing athletes treated arthroscopically
¢  Snyder coined the term ‘‘SLAP’’ (superior labral
tear, anterior to posterior)
EPIDEMIOLOGY
¢  Snyder
and colleagues reported an incidence of
only 6% in more than 2,000 arthroscopic shoulder
cases
ANATOMY
¢ glenoid
labrum is a rounded
fibrocartilaginous structure which
deepens the glenoid and
contributes to shoulder stability
¢ continuous with the articular
cartilage anteriorly and inferiorly
ANATOMY
Similar to the menisci of the knee,
the blood supply penetrates
peripherally and runs in a radial
and circumferential fashion
minimal vascularity conferred
from the underlying bone
ANATOMY
¢ the
superior and
anterosuperior quadrants of
the labrum demonstrate the
poorest blood supply
CLASSIFICATION
TYPE I
¢  Degenerative
fraying of the free edge of the
superior labrum but an intact peripheral
attachment and a stable biceps anchor
TYPE II
¢  Unstable
lesions in which the superior labrum
and biceps anchor are detached from the superior
glenoid rim
most
common (41%)!
TYPE III
a bucket-handle tear of a meniscoid superior
labrum but with an intact biceps anchor!
TYPE IV
a type III bucket-handle tear with extension into
the biceps tendon root!
¢  Morgan
and colleagues subclassified type II tears
based on their location: anterior, posterior, or
combined anterior and posterior lesions
¢  type IIB lesions develop posterosuperior
instability that can present with ‘‘pseudolaxity’’
and a positive arthroscopic drive-through sign
anteroinferiorly
MAFFET TYPE V
¢  Bankart-type
labral disruption in continuity with
a type II SLAP tear
MAFFET TYPE VI
a combination of a type II tear with an unstable
labral flap!
MAFFET TYPE VII
¢  Type
VII lesions are extensions of type II tears
through the capsule and beneath the middle
glenohumeral ligament, rendering it incompetent
POWELL TYPE VIII
¢  variants
of type II lesions with extension into the
posterior labrum
POWELL TYPE IX
¢  more
extensive injuries, and consist of type II
tears with circumferential labral disruption
POWELL TYPE X
¢  type
II tears combined with posteroinferior labral
disruption
PATHOPHYSIOLOGY AND
MECHANISM OF INJURY
Microtrauma
from overhead
activity
torsional
force on the
postero
superior
labrum
Scar and
contracture of
posterior/ inferior
capsule
BURKART
PEEL BACK
MECHANISM!
the biceps tendon
assumes a more vertical
and posterior angle in
the cocking position
Deficit
glenohumeral
internal
rotation
Posterior and
inferior Shift
humeral head
during cocking
phase increased shear
forces at the
posterosuperior
labrum
WEED PULLING
FALL WITH OUTSTRETCH HAND
HISTORY
¢  Most
common complaint: anterior shoulder pain
¢  Intermittent clicking and mechanical symptoms
¢  Instability
¢  Rotator cuff weakness
PHYSICAL EXAMINATION
O’BRIEN’S ACTIVE–COMPRESSION TEST
O’BRIEN’S ACTIVE–COMPRESSION TEST
¢  O’Brien’s
active–compression test
KIBLER’S ANTERIOR SLIDE TEST
BEST IMAGING STUDY
GOLD STANDARD: ARTHROSCOPIC EXAM
TREATMENT
¢  Type
I: debridement and smoothen labrum
¢  Type II: repair
¢  Type III: resection unstable bucket handle
¢  Type IV:repair labrum
¢  >1/3 involvement of biceps tissue à tenodesis or
tenotomy
POST-OPERATIVE REHAB
¢  Phase
—
—
Arm sling
No overhead activity, external rotation
¢  Phase
—
II
ROM exercise but No active biceps activity
¢  Phase
—
I
III
Biceps strengthening
TYPE II SLAP REPAIR USING THE SINGLE
ANCHOR DOUBLE SUTURE (SADS)
TECHNIQUE
Sports Med Arthrosc Rev 2007;15:222–229
Superior Labral Repair
Ronald V. Gregush, MD and Stephen J. Snyder, MD!
MANAGEMENT OF ROTATOR CUFF
INJURY
Kitiphong Kongrukgreatiyos!
HISTORY
—
Two groups of patients
Elderly: insidious onset of shoulder pain and weakness
¢  Young (< 60 years): acute traumatic tear with sudden pain
and weakness after specific injury
¢
—
Night pain
PHYSICAL EXAMINATION
¢  Full
passive range of motion
¢  Decrease active range of motion
—
Infraspinatus
¢
—
Supraspinatus
¢
—
External rotation weakness
Forward elevation (drop arm test)
Subscapularis
Lift off test
¢  Belly press test
¢
INSPECTION
¢  Remove
clothes
(difficulty in removing clothes over head)
¢  Atrophy of muscles
PALPATION
¢  Object
—
—
—
—
—
—
to find any painful points
greater tuberosity
Tip of the acromion
Coracoid process
Coracoacromial ligament
Acromioclavicular joint
Bicipital groove
PASSIVE MOBILITY
SPECIFIC ACTIVE TESTING FOR EACH
ROTATOR CUFF
¢  Subscapularis:
internal rotation
Positive Gerber lift-off test
(Gerber and Krushell, 1991)
Sensitivity and specificity
100% for full tears
PRESS-BELLY (NAPOLEON) TEST
PRESS ON STOMACH WHILE KEEPING HAND, WRIST AND
FOREARM STRAIGHT
+VE IF PATIENT FAILS TO KEEP POSITION
SPECIFIC ACTIVE TESTING FOR EACH
ROTATOR CUFF
¢  Infraspinatus
¢  Test
and teres minor: external rotators
strength of external rotators
SPECIFIC ACTIVE TESTING FOR EACH
ROTATOR CUFF
¢  Supraspinatus:
forward flexion
EMPTY CAN TEST
CAN NOT ACTIVELY RAISE ARM
DROP ARM TEST
Painful drop arm test!
SHOULDER AP:
ELEVATION OF HUMERAL HEAD
MRI
CLASSIFICATION OF ROTATOR CUFF TEAR
¢  Small
(less than 1 cm)
¢  Medium (1 – 3 cm)
¢  Large ( 3 – 5 cm)
¢  Massive ( more than 5 cm)
MANAGEMENT
¢  Nonsurgical
*advise about risk of further tearing*
¢  Surgical
—
—
—
—
—
Arthroscopic debridement
Subacromial decompression with primary repair
Tendon transfer for irreparable tears
Glenohumeral arthrodesis (salvage procedure in
young patients)
Primary glenohumeral arthroplasty with reverse
prosthesis
TEAR PATTERN RECOGNITION
¢  Crescent
¢  L
shape
¢  U shape
shape
INTERESTING CASE:
CHRONIC MYOFASCIAL PAIN AT SCAPULA AREA
WEAK EXTERNAL ROTATORS
+VE OBRIEN TEST
GLENOID CYST WITH SUPRASCAPULAR
NERVE COMPRESSION