Dr. Mustafa ElsingergyConsultant orthopedic surgeon Dallah Hospita

Prof. Mamoun KremliAlmaarefa Medical College

Chronic Shoulder Disorders

Contents

Shoulder Pain• INTRINSIC

• Due to causes in the shoulder region

• EXTRINSIC

• Due to referred pain from outside the shoulder

Shoulder Pain• INTRINSIC

• Due to causes in the shoulder region

Shoulder Pain• EXTRINSIC

• Due to referred pain from outside the shoulder

Shoulder Disorders• Due to causes related to :

1. Rotator cuff2. Shoulder capsule3. Glenohumeral joint4. Scapular problems 5. Acromioclavicular joint

Rotator Cuff - Anatomy• Originate from the scapula

• Insert in the Greater Lesser tuberosities

• Pass under coraco-acromial arch

• Separate from the ligament by bursa

Rotator Cuff Disorders• Acute tendinitis

• Impingement syndrome

• Rotator cuff tear

R.C.D - Acute TendinitisClinical features:• Pain / Tenderness / Painful abduction range

X-ray:• Normal

• Area of calcification

Treatment:• Rest

• NSAID

• Local injection

R.C.D - Impingement SyndromeCausesClinical features• Pain

• Shoulder looks normal or wasted

• Tenderness

• Disturbed glenohumeral rhythm

• Painful abduction ( 6oo TO 120o )

• Neer’s test (+VE)

• Hawkin’s test (+ve)

R.C.D - Impingement SyndromeX-ray:• Calcification

• Degenerated AC jt.

MRI:• Bursitis

• Thickening of the tendon

Treatment:• Mild: NSAID, local injection

• Severe: arthroscopy vs acrmoioplasty

R.C.D - Impingement SyndromePredisposing factors

• Degeneration: middle age

• Chronic irritation by osteophyte

• Underlying disease:• eg. Rheumatoid

• Precipitating factor: trauma

Types:

• Incomplete

• Complete

R.C.D - Impingement SyndromeClinical features:

• Trauma, pain, limited abduction

• After few weeks:• Incomplete tear: improvement of pain and rom• Complete tear: improvement of pain and decrease of active range

Look:

• Early; normal appearance

• Late; wasting of supraspinatus and infraspinatus muscles

Feel:

• Tender greater tuberosity

R.C.D - Rotator Cuff TearClinical features:

• Move:• Incomplete tear; painful weak• Complete; passive not painful, active

drop arm sign

X-rays:

• Early normal

• Late degenerative changes

MRI: image of choice

Treatment:

• Incomplete tear: PT, NSAID

• Complete tear: surgery

Biceps Tendon DisordersTendinitis:• Pain

• Tenderness: Bicepital groove

• Painful forward flexion

• Treatment: NSAID, local injection

• Tear of long head of biceps tendon:• Pain

• Deformity of biceps contour (Popeye’s arm)

• No need for treatment

Adhesive Capsulitis (Frozen Shoulder)• Unknown pathogenesis leads to pain and limitation of

movement

• Trauma or RCD may be causes

Clinical features:

• Pain

• Limitation of movement in all directions of GH range

Natural history:

• Pain and limitation of movement gradually increase then gradually decrease, takes 18 months

Treatment:

• Conservative vs arthroscopy

Recurrent Shoulder InstabilityTypes:

• Recurrent anterior dislocation (RAD)

• Recurrent posterior subluxation (rare)

• Multidirectional instability (MDI)

Type RAD MDI

Cause Traumatic Atraumatic

Clinical feature Apprehension test +ve Sulcus sign positive

Treatment Surgical PT

Recurrent Shoulder InstabilityMultidirectional instability:

• Generalized ligamentous laxity

• Sulcus sign (+ve)

Recurrent Shoulder InstabilityRecurrent anterior dislocation (RAD)

• Most common

• H/O acute dislocation

• Apprehension test (+ve)

Image:

• Hill Sach’s lesion

• Bankart’s lesion

Recurrent Shoulder Instability• Recurrent anterior dislocation (RAD)

• Multidirectional instability (MDI)

Type RAD MDICause Traumatic AtraumaticClinical feature Apprehension test +ve Sulcus sign positiveTreatment Surgery PT

Gleno-humeral Joint Disorder• Osteoarthritis

• Rheumatoid

• TB

• Milwaukee

Gleno-humeral Osteoarthritis• Usually follows other pathology

• eg. Trauma, rheumatoid artheritis or rc tears

Clinical features:

• Painful movement

• Wasting the shoulder muscle

• Tender joint line, Limited ROM

X-ray:

• Loss of joint space

• Subchondral sclerosis

Treatment: Conservative / Replacement

Gleno-humeral Rheumatoid ArthritisClinical features:

• Generalized arthritis affecting other joints

• Pain and limitation of movement

• Painful passive movement and limited active movement

Lab investigation:

• +ve rheumatoid factor

X-ray:

• Loss of articular space

• Peri-articular erosion

Acromioclavicular Disorders• Instability

• Arthritis

Scapular DisordersSprengel’s shoulder:

• Congenital

Winging of scapula:

• Weak serratus ant muscle

Shoulder Summary• Shoulder Symptoms:

• Pain• Stiffness• Instability• Deformity• Loss of Function

• Shoulder Examination• Look• Feel• Move• Special Tests

• Investigations• Lab• X-ray• MRI

• Treatment• Conservative• Surgical