Upper Extremity: Shoulder
Adhesive Capsulitis:
Pathology: a proliferation of myofibroblast cells which thicken the capsule of the shoulder causing pain and marked decreased Range of Motion. It has a higher prevalence in people with Diabetes Mellitus and Thyroid Disorders.
Clinical Stages:
- Painful: gradual onset of diffuse pain (6 weeks to 9 months)
- Stiff: decreased Range of Motion affecting activities of daily living (4-9 months)
- Thawing: gradual return of motion (5-24 months)
Presentation:
- Symptoms: pain and stiffness
- Physical exam: painful arc of motion (forward flexion, abduction, external rotation, and internal rotation) practically speaking difficulty with shaving under your arms or putting your wallet in your back pocket.
Treatment:
- Non-Operative: The mainstay of treatment revolves around Physical Therapy. This will be a program of gentle Range of Motion, stretching and moist heat. Occasionally, intraarticular steroid injection and NSAIDs can be considered.
- Operative: Manipulation Under Anesthesia can be performed if a patient plateaus with PT and is not at a point where they are happy with Range of Motion. Occasionally, a diagnostic arthroscopy with lysis of adhesions and capsular release can be performed.
Acromio-Clavicular Joint Separation:
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Anatomy: injury to one or more of the AC joint ligaments
Incidence: relatively common injury making up 9% of shoulder girdle injuries.
Mechanism: direct blow to the point of the shoulder (ie bicycle rider over the handlebars)
Presentation: Pain over the AC joint with palpation. Possible abnormal shoulder contour secondary to an elevation of the distal clavicle in relation to the Acromion.
Treatment:
- NonOperative: rest, ice, possible sling. Early ROM is advisable. Goal is to regain functional motion by 6 weeks and return to normal activities by 12 weeks.
- Operative: In some types of AC separations, a surgical procedure can repair the damaged ligaments and speed return to normal activities of daily living.
AC joint arthritis:
Epidemiology: Occurs in individuals who load their AC joints such as weight lifters and overhead throwing athletes. It is more common in individuals who have had a prior AC separation.
Presentation: Patients will have activity related pain with reaching across their body or overhead activities. On examination, patients will have pain with direct palpation of the AC joint.
Diagnosis: Physical examination, X-rays, and rarely MRI will be used to verify the diagnosis.
Treatment:
- NonOperative: activity modification, NSAIDs, and possible steroid injection into the AC joint
- Operative: Arthroscopic -vs- Mini-Open Distal Clavicle Excision can be used to resect 8mm of distal clavicle. This is an out patient surgery with a relatively quick recovery.
Arthritis of the Glenohumeral Joint:
Epidemiology: more common with increasing age (generally 50 yr old and above) but can be associated with younger throwing athletes
Pathoanatomy: Osteoarthritis is the loss of articular cartilage in the “ball and socket” joint of the shoulder. This can be secondary to the wear and tear of daily living or from previous trauma.
Presentation: Patients complain of a dull pain at night and pain with activities involving shoulder motion. Patients feel “crunchy sounds” with motion of the shoulder. Physical examination will demonstrate overall decreased range of motion and pain at the extremes of motion. Occasionally, the examiner with feel crepitation (snap, crackle, and pop) with range of motion.
Treatment:
- NonOperative: Patients first line of treatment will be NSAIDs, PT, and steroid injections.
- Operative: There are multiple varieties of shoulder replacements ranging from hemiarthroplasty and Total Shoulder Arthroplasty to Reverse Total Shoulder Arthroplasty. A less common procedure could be a fusion of the shoulder joint. This might be an option for a young laborer.
Calcific Tendonitis:
Epidemiology: generally affects patients in the age groups of 30s-60s and is more common in women
Pathophysiology: generally affects the supraspinatus tendon. There are 3 stages of calcium formation. Formative Phase characterized by cell-mediated calcific deposits. Resting Phase lacks inflammation or vascular infiltration. Resorptive Phase is characterized by a phagocytic resorption and vascular infiltration. Clinically this is the most painful phase.
Presentation: Similar in presentation to subacromial impingement. Symptoms are significant for atraumatic pain, catching, crepitus, and occasional mechanical block. Physical Examination can show muscle atrophy in the supraspinatus fossa. Overall decreased range of motion, scapular dyskinesia and possible decrease in rotator cuff strength.
Diagnosis: Plain x-rays are very often diagnostic as you can see calcium deposits within the supraspinatus tendon. Occasionally, a MRI will be ordered to confirm the exact 3-dimensional location of the deposit and to evaluate the remainder of the shoulder for things such as rotator cuff tear and/or labrum tear.
Treatment:
- NonOperative: steroid injection into the glenohumeral joint and subacromial space in conjunction with formal physical therapy, home exercise program and NSAIDs. Ultrasound guided needle lavage is a consideration.
- Operative: Arthroscopic -vs- mini-open surgical decompression of the calcium deposit and possible repair of the rotator cuff tendon.
Dislocation of the Glenohumeral Joint and Labrum Tear:
Epidemiology: One of the most common shoulder injuries that occurs in 1.7% of the general population annually. Of the patients that sustain a traumatic shoulder dislocation, approximately 80% are teenagers.
Mechanism: The shoulder is in an “at risk” position when there is an anteriorly directed force applied to a shoulder that is abducted and externally rotated.
Associated Injuries: Bankart Lesion, Humeral avulsion of the glenohumeral ligament (HAGL), Glenoid labral articular defect (GLAD), Anterior labral periosteal sleeve avulsion (ALPSA), and a Hill Sachs Lesion.
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Presentation: Patients will spontaneously relocate or reduce the glenohumeral dislocation, or they will present to the ER or Urgent Care Center for reduction by a physician. They will have subsequent complaints of pain and instability. Patients will not like to have their arms abducted 90 degrees and externally rotated 90 degrees.
Diagnosis: Generally speaking by the time the patient reaches an orthopaedic surgeon’s office, the glenohumeral joint dislocation has been reduced. X-rays will be taken to verify that the patient’s shoulder is reduced. A MRI might be ordered to identify any of the aforementioned variations of labral injury.
Treatment:
- NonOperative Management includes a sling for initial comfort and immobilization in external rotation (this is accomplished by a specialized sling from the orthopaedist office). This is followed by a regimen of supervised Physical Therapy and gentle range of motion Home Exercise Program.
- Operative: Arthroscopic -vs- Open repair of the labral tear and tightening of the glenohumeral ligaments.
Fracture of the Clavicle:
Epidemiology: usually occurs in young, active patients and makes up 5-10% of all fractures
Mechanism: typically occurs when there is a direct blow to the lateral aspect of the shoulder or a fall onto an outstretched arm
Diagnosis: plain x-rays
Treatment: Non-operative management with a sling and gentle range of motion as tolerated. Operative management can be used for comminuted fractures or fractures which has greater than 1 cm of shortening. Operative management consists of using plates and screws.
Fracture of the Proximal Humerus:
Epidemiology: 4-6 % of all fractures. It is the 3rd most common fracture seen in elderly patients. Females are twice as likely as males to sustain this fracture.
Mechanism: Low energy falls from standing in the elderly. High energy trauma such as car accident or falls from height.
Diagnosis: Plain x-rays or CAT scan
Treatment: NonOperative Management includes sling and gently progressive Range of Motion. Operative Management options include closed reduction and percutaneous pinning, open reduction and internal fixation, intramedullary rodding, hemiarthroplasty, Total Shoulder Arthroplasty, and Reverse Total Shoulder Arthroplasty.
Gleno-Humeral Internal Rotation Deficit:
Epidemiology: Most commonly seen in baseball pitchers but can occur in any overhead athlete.
Mechanism: Caused by repetitive throwing motion during the late cocking and early acceleration phase.
Presentation: Patients present with vague shoulder pain exacerbated with the throwing motion. Their throwing performance may decrease with loss of velocity and accuracy.
Diagnosis: X-rays and MRI tend to be normal, but the MRI can show some posterior superior labral pathology. Physical examination is significant for loss of greater than 25 degrees of internal rotation in the Sleeper Stretch position when compared to the contralateral side. Physical Examination is more helpful in the diagnosis than imaging studies.
Treatment: NonOperative management consists of rest and performing sleeper stretches. The sleeper stretch will stretch the posterior capsule. Formal Physical Therapy can be useful in stretching the pectoralis minor and working on periscapular and rotator cuff strengthening. Operative management consists of posterior capsular release or anterior stabilization. The need for operative management is extremely uncommon.
Rotator Cuff Tears (Acute):
Epidemiology: These tears tend to occur in younger patients. They can be seen from falls or from dislocations. Full thickness tears need to be repaired in throwing athletes.
Pathoanatomy: Subscapularis tears are typically seen in younger patients following a fall, whereas tears of the Supraspinatus and Infraspinatus are seen in younger patients after a shoulder dislocation.
Presentation: Pain and weakness with overhead activities.
Diagnosis: X-rays will tend to be normal. MRI arthrogram is the test of choice for evaluation of the soft tissues of the shoulder.
Treatment: Partial tears may be treated non-operatively with rest, NSAIDs, injections, and Physical Therapy. Complete tears should be addressed with surgical repair.
Rotator Cuff Tears (Chronic):
Epidemiology: These tears tend to occur in older patients. This type of tear generally involves the supraspinatus, infraspinatus, and subscapularis tendons.
Presentation: Patients complain of a dull, tooth-achy pain that wakes them from sleep. With supraspinatus tears they report weakness with overhead activities.
Diagnosis: X-rays can show Acromio Clavicular arthritis but tend to be normal. MRI arthrogram is the test of choice for evaluation of the soft tissues of the shoulder.
Treatment: Partial tears may be treated non-operatively with rest, NSAIDs, injections, and Physical Therapy. Tears treated non-operatively have the risk of the muscle belly undergoing Fatty Atrophy and the tendon may retract. Both of these situations can make an operative repair difficult. In some cases, the tear may become irreparable. Patients with complete tears should strongly consider their surgical options. Irreparable tears become candidates for Reverse Total Shoulder Arthroplasty.
Subacromial Impingement:
Epidemiology: This entity affects millions of individuals in the ages ranging from their 20s to 80s.
Pathoanatomy: The Bigliani classification of acromion process morphology includes Type 1 è flat, Type 2 è curved, and Type 3 è hooked. Patients with type 2 and type 3 acromion processes are more predisposed to having impingement. Impingement in the subacromial space can cause inflammation of the subacromial bursae resulting in subacromial bursitis.
Presentation: Patients complain of pain with overhead activities and pain at night.
Diagnosis: Physical examination is the mainstay. There are multiple tests which can lead to the diagnosis. They include: Neer Impingement test, Hawkins test, Jobe test, and Internal Impingement test. Imaging studies can be helpful. Plain x-rays including AP, Scapular Y, and Axillary Lateral are standard views of the shoulder. The Scapular Y examination gives a good picture of the morphology of the undersurface of the Acromion. MRI has a place in evaluating the rotator cuff for possible fraying from the impingement.
Treatment: Non-operative management consists of activity modification, Physical Therapy, NSAIDs, and steroid injections. If non-operative management fails, then an arthroscopic subacromial decompression to remove the spurring of the acromion will provide relief. This will effectively convert a Type 2 or Type 3 Acromion to a flat Type 1 acromion.