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Shoulder Pain and Injuries
Mark Wood, MD
March 16, 2016
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Overview
• Anatomy • Overuse vs Acute injuries • Bursitis/impingement/rotator cuff tendinitis • Arthritis • Shoulder separations and dislocations • Labral Tears • Rotator cuff tears • Fractures
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• A Medical doctor • Extensive training in treating problems
involving bones, joints, ligaments, muscles, tendons, and cartilage
What is an Orthopaedic Surgeon?
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Educating an Orthopaedic Surgeon
• College • Medical School • Internship • Orthopaedic Resident • Fellowship/Board Cert.
Total
4 4 1 4 2-3
15 -16 years
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Orthopaedic Surgeon’s DesireGet You Back Into The Game
Accomplish Your Goals
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Anatomy
Bone and Joints
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AnatomySoft-tissue AC joint Biceps tendon Joint capsule, labrum Rotator cuff
Labrum
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Overuse vs. Acute Injuries
• Overuse - series of excessive and repeated small injuries that results in damage to the tissues.
• Acute - sudden trauma ◼ tears (rotator cuff, biceps tendon, labrum)
◼ strains and sprains (muscle, ligaments, partial tears) ◼ fractures (clavicle)
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Overuse Injuries
Shoulder Bursitis, tendinitis, impingement syndrome
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Rotator Cuff Tendinitis/Bursitis, Impingement Syndrome
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Rotator Cuff Tendinitis & Bursitis• Shoulder pain with overhead activity • Difficulty sleeping • Primarily an inflammatory process
• Treatment ◼REST! -modify, pain-free activities ◼NSAIDs (Aleve, ibuprofen, mobic) ◼Physical Therapy ◼Cortisone injections into bursa ◼ Surgery rarely needed
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SHOULDER ARTHRITIS (GLENOHUMERAL JOINT)
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Arthritis (Osteoarthritis or DJD)
Arthritis “arthr” = joint (cartilage) “itis” = inflammation
Arthritis = degenerating joint cartilage which leads to joint inflammation
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Healthy Joint
Cartilage
Joints – a simple arthritis model
Arthritic Joint
Bone
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Pain
Avoidance Of
Motion
Increased Muscle
Tightness
Stiffness
Cartilage loss leads to Inflammation and Pain
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Diagnosis - X-Rays
Healthy Shoulder Arthritic Shoulder
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Goals of Treatment
1. Relieve pain
2. Increase function
Treatment
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• Medications • Vitamins and supplements • Alternative medicine • Joint protection, rest • Physical Therapy and Exercise • Injections with cortisone • Surgery
Treatment Options
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Treatment Options – Conservative (non-surgical)
Alternative Medicine
Injections
Supplements
Medications
Exercise & Physical Therapy
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Exercise
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Exercise
1. Range of motion (stretching) Prevent stiffness, “frozen shoulder”
2. Strengthening muscles Rotator cuff and shoulder peri-scapular
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Exercise
• Strengthening Correctly ◼Correct positioning
critical ◼Correct exercises
◼Avoid injury
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Failure of Conservative Treatments
Medications
Exercise
Supplements
Physical TherapyNutrition & Weight
SURGERY
FAILEDFAILED
FAILED
FAILED
FAILED
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Surgery for arthritis
• Arthroscopy ◼Debridement (cleanup)
◼Address the biceps ◼Remove inflamed tissue ◼Remove loose cartilage
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Surgery- Joint Replacement
Reverse TSR
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Acute Shoulder Injuries
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AC Separations• Disruption of the acromioclavicular joint after fall
- ligament tears, pain and possible deformity
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CoracoClavicular ligaments torn
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AC Separation - Treatment• Non-op: <100% displaced (Types I, II, III) ◼ Sling, NSAIDS, ice, PT, return to activities when able
• Operative: >100% displaced ◼Goal: restore the anatomy
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CC ligaments
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Arthroscopic Repair
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Arthroscopic RepairSlipped on ice
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Wolf, J Arthroscopy 2010Arthrosopic view
of coracoid
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• Outcome: ◼ Small, cosmetic incisions ◼ 90% Good/Excellent results
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Arthroscopic Repair
Wolf, J Arthroscopy 2010
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SLAP Tears
• SLAPSuperior Labral Anterior to Posterior tear
• Mechanism Fall, traction injury, overhead athlete
• Symptoms Vague pain, mechanical popping, catching
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SLAP (Labral Tear) - Treatment• Surgery is reserved for symptomatic patient
after failing conservative measures
O’Brien, J Arthro 2002, multiple studies
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SLAP Technique
LabrumBiceps
Glenoid Probe
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Acute Shoulder Dislocations• Traumatic, Usually requires reduction in ED
with sedation • Imaging ◼X-ray: confirm reduction, r/o bone fractures ◼MRI: evaluate soft-tissue injury (SLAP, Bankart, RC)
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Shoulder Dislocation - Imaging
Normal Dislocated
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Bankart Lesion
Labrum
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Traditional TreatmentNonoperative
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Traditional TreatmentNonoperative
Acute dislocations • Reduced quickly • Immobilization • Rehabilitation
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RehabilitationNO SIGNIFICANT
DIFFERENCE IN REHAB PROTOCOLS
Hovelius, JBJS 1996 ◼10 yr prospective study ◼Younger (<30) = recurrence ◼Older (>50) = rotator cuff tears
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Rotator Cuff Tears• RC tendon holds ball into the
socket while lifting arm • Tears may occur with or without
significant injury • Shoulder and upper arm pain • Difficulty sleeping • Arthroscopic repair generally
recommended for active people • RC does not heal therefore tears
become larger and retract
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Rotator Cuff Torn = Treatment
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Clavicle Fractures• The most common shoulder fracture • Vast majority do well with non-op care • Consider operative treatment only if significantly
displaced
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Mckee, JBJS 2009
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Distal Clavicle Fractures
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ConclusionsIf you are experiencing shoulder joint pain that alters your
daily activities or sleep, consider conservative options (rest, nsaids, ice, etc)
For more advanced treatment options or when conservative treatment fails, consider visiting an orthopaedic physician or physical therapist
Remember, an Orthopaedic Surgeons desire is to help you get back into the game and accomplish your goals by eliminating pain and maximizing function
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What are your questions and concerns?
Thank you for this opportunity
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Additional Educational Resources
Http://orthodoc.aaos.org/MarkWoodMD/
www.orthoinfo.org
www.WakeOrtho.com
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Rotator Cuff Advancements
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