new concepts and advances (arthroscopic) for the treatment of shoulder pain william f bennett md
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New Concepts and Advances (Arthroscopic) for the Treatment of Shoulder Pain
William F Bennett MD
The Simple Shoulder
While a complex joint with complex function, general approaches to determining the non-descript, cause….is easy!
I.e., intrinsic versus extrinsic
Intrinsic versus Extrinsic
Intrinsic- later and more descript…means pain coming from the shoulder joint itself
Extrinsic- pain that may cause shoulder pain but comes from sources outside the shoulder
Extrinsic
Most common- cervical spine Pancoast tumors of the lung Thoracic spine Peritoneal/Splenic irritation can cause pain at
Erb’s point Angina/MI Metabolic/Oncologic problems, ie., bone marrow
involvement like lymphoma/leukemia, parathyroid
Extrinsic-Cervical Spine
General rule--trapezial pain-cervical
-deltoid pain- intrinsic or from the shoulder
Can have both shoulder and cervical spine affected which makes it more difficult
Cervical spine may have radicular involvement
Intrinsic
Once extrinsic has been ruled out then one can focus on the intrinsic causes.
If a certain shoulder motion whether it be flexion, abduction, external rotation or internal rotation causes pain in the deltoid area and not in the trapezial area, one is probably dealing with an intrinsic problem
Before discussing intrinsic Causes
Lets diverge and discuss the anatomy and function of the shoulder
Anatomy
4 joints-two are articulations– Glenohumeral joint– Acromioclavicular joint– Scapulothoracic articulation– Sternocalvicular articulation/joint
– Discuss Bones-Bone models
Ligaments/Capsule
Capsule is the “sac”– Normal sac allows motion in various planes– Abnormal sac restricts motion in various planes
Ligaments- hold bone to bone– Glenohumeral ligaments– Coracohumeral ligaments– Coracoacromial ligaments– Coracoclavicular ligaments
Muscles/Tendons Rotator Cuff are a confluence of 4 tendons from the
following respective muscle bellies– Supraspinatus– Subscapularis– Infraspinatus– Teres minor
– Biceps– Deltoid
Bone models
Bursae/Cartilage/Meniscus Subacromial Bursae Subdeltoid bursae Subcoracoid bursae Glenohumeral articular
cartilage Acromioclavicular meniscus
Intrinsic Diagnoses
Impingement– Tendonitis– Bursitis– Rotator Cuff tear-complete– Rotator Cuff tear-partial– others
Intrinsic Diagnoses
Acromioclavicular joint irritation/arthritis Glenohumeral joint osteoarthritis Rheumatologic joint Pigmented Villonodular synovitis Chondrometaplasia Tumors-giant cell, synovial sarcoma
Intrinsic Diagnoses
Instability/Subluxation-repetitive/chronicAtraumatic/multidirectional
Dislocation– Traumatic unidirectional
Biceps– Inflammation– Instability/subluxation– Tendonitis/avulsion
Intrinsic Diagnoses History compatible Physical exam compatible Radiologic exam compatible MRI/MRA compatible Less so- blood work, others
– Each is a piece of the puzzle
Physical Exam
Observation Palpation Range of Motion Strength Test Specific Tests for lesions Hoppenfeld- Examination of the Extremies
Treatment “ITIS”- inflammation- tendonitis, bursitis
– Rest, avoidance, NSAIDS, injections, therapy Osteoarthritis- above plus possible total shoulder
replacement, ac joint Rotator Cuff Tears-above +/- repair Instability/Dislocation-+/- repair Frozen Shoulder Biceps Inflammation
– The arthroscope has become an important tool for diagnosis and treatment in virtually all afflictions of the shoulder
Arthroscope Fiber optic device Triangulate-the surgeon never sees the
actual inside of the joint- it is projected upon a monitor and as such, the working tools, “triangulate’ to the point of focus
Minimally invasive Less pain Less rehabilitation
Treatment
Nsaids- short-term Physical therapy Injections Surgery
Physical Therapy
Treat Inflammation-
Iontophoresis
Treat Tight Areas
Stretch
Treat Weakness
Strentghen- rotator cuff muscles
scapular stabilizers
Injections
Must have correct diagnosis Patient may have more than one pain
location Lidocaine Injection test Areas-
– Subacromial space– Glenohumeral joint– Ac joint– Bicipital sheath
Shoulder Pain-traditionally was treated with long delays in surgical intervention-Why?
Shoulder pathology not well understood Open repair required extensive incisions Rehabilitation was long
– Most importantly, in times past, the primary care givers was, in general, “under-the-impression” that shoulder surgical intervention was not that effective
Arthroscopic Interventionutilized in Impingement-bursitis, tendonitis Rotator cuff tears Instability or dislocation AC joint arthritis
And yes even in Osteoarthritis
Arthroscope has allowed for the further identification of subtle shoulder pathology, previously not identified See articles-
1) Bennett WF. Subscapularis, Medial and Lateral Head Coracohumeral Ligament Insertion Anatomy: Arthroscopic Appearance and Incidence of "Hidden" Rotator Interval Lesions. Arthroscopy. 2001 Feb. 17(2) 173-180
2) Bennett WF. Visualization of the Anatomy of the Rotator Interval. Arthroscopy. 2001 17 107-111
Arthroscopic Prospective outcomes are now Published See Articles-
Bennett WF: Arthroscopic Repair of Bennett WF: Arthroscopic Repair of Complete Anterosuperior Rotator Cuff Tears. 2 Year Follow-up. Arthroscopy, January 2003
Bennett WF: Arthroscopic Repair of Complete Subscapularis Tears. 2 Year Follow-up.
Arthroscopy, February 2003
Bennett WF: Arthroscopic Repair of Complete Supraspinatus Tears. 2 Year Follow-up.
Arthroscopy, March 2003 Bennett WF: Arthroscopic Repair of Massive Rotator Cuff Tears. 2-Year Follow-up
Arthroscopy, April 2003
Natural History of Rotator Cuff Tears Recurrence of pain Tears get bigger with time Results of surgical intervention deteriorates
with time Muscle turns to fat Tendon becomes inelastic
At this Point
Most recently anatomy surrounding the rotator cuff and its interrelationship with the bicipital sheath has been identified, clarified, classified, arthroscopic reapir techniques developed and outcome studies published.
At this point I will move to the details of clinical research that I have been performing for the last 12 years.