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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

• A Medical doctor • Extensive training in treating problems

involving bones, joints, ligaments, muscles, tendons, and cartilage

What is an Orthopaedic Surgeon?

Educating an Orthopaedic Surgeon

• College • Medical School • Internship • Orthopaedic Resident • Fellowship/Board Cert.

Total

4 4 1 4 2-3

15 -16 years

Orthopaedic Surgeon’s DesireGet You Back Into The Game

Accomplish Your Goals

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)

Overuse Injuries

Shoulder Bursitis, tendinitis, impingement syndrome

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Rotator Cuff Tendinitis/Bursitis, Impingement Syndrome

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)

Arthritis (Osteoarthritis or DJD)

Arthritis “arthr” = joint (cartilage) “itis” = inflammation

Arthritis = degenerating joint cartilage which leads to joint inflammation

Healthy Joint

Cartilage

Joints – a simple arthritis model

Arthritic Joint

Bone

Pain

Avoidance Of

Motion

Increased Muscle

Tightness

Stiffness

Cartilage loss leads to Inflammation and Pain

Diagnosis - X-Rays

Healthy Shoulder Arthritic Shoulder

Goals of Treatment

1. Relieve pain

2. Increase function

Treatment

• Medications • Vitamins and supplements • Alternative medicine • Joint protection, rest • Physical Therapy and Exercise • Injections with cortisone • Surgery

Treatment Options

Treatment Options – Conservative (non-surgical)

Alternative Medicine

Injections

Supplements

Medications

Exercise & Physical Therapy

Exercise

Exercise

1. Range of motion (stretching) Prevent stiffness, “frozen shoulder”

2. Strengthening muscles Rotator cuff and shoulder peri-scapular

Exercise

• Strengthening Correctly ◼Correct positioning

critical ◼Correct exercises

◼Avoid injury

Failure of Conservative Treatments

Medications

Exercise

Supplements

Physical TherapyNutrition & Weight

SURGERY

FAILEDFAILED

FAILED

FAILED

FAILED

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

AC Separations• Disruption of the acromioclavicular joint after fall

- ligament tears, pain and possible deformity

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CoracoClavicular ligaments torn

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

Arthroscopic RepairSlipped on ice

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Wolf, J Arthroscopy 2010Arthrosopic view

of coracoid

• Outcome: ◼ Small, cosmetic incisions ◼ 90% Good/Excellent results

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Arthroscopic Repair

Wolf, J Arthroscopy 2010

SLAP Tears

• SLAPSuperior Labral Anterior to Posterior tear

• Mechanism Fall, traction injury, overhead athlete

• Symptoms Vague pain, mechanical popping, catching

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

Bankart Lesion

Labrum

Traditional TreatmentNonoperative

Traditional TreatmentNonoperative

Acute dislocations • Reduced quickly • Immobilization • Rehabilitation

RehabilitationNO SIGNIFICANT

DIFFERENCE IN REHAB PROTOCOLS

Hovelius, JBJS 1996 ◼10 yr prospective study ◼Younger (<30) = recurrence ◼Older (>50) = rotator cuff tears

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

Rotator Cuff Torn = Treatment

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

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

What are your questions and concerns?

Thank you for this opportunity

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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