COMMON SHOULDER INJURIES: What to do, when to refer
Todd C. Battaglia, MD, MS Syracuse Orthopedic Specialists March 2014
Introduction •
Grew up in Marcellus
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Amherst College – lacrosse & rugby
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SUNY-Buffalo School of Medicine
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Residency / MS (Ortho Research) at UVa
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Fellowship at New England Baptist Hospital (Sports Medicine & Arthroscopic Surgery)
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Partner / Director of Sports Medicine at Syracuse Orthopedic Specialists
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Team doc – OCC, ESF, Silver Knights, numerous high schools
Overview •
The Big Three – Rotator Cuff – Fractures & Dislocations – Arthritis *
* for another day
Topic: Rotator Cuff
Interactive Question: 78 y/o female with 6 week history of right shoulder pain. No previous tx. No injury. Full ROM with (+) impingement signs NSAIDs – mild relief Slight weakness on supraspinatus isolation No visible atrophy
A) MRI B) Refer to ortho C) Subacromial injxn D) PT E) Rheum work-up
Interactive Question: 45 y/o male fell from roof 4 days ago No previous shoulder problems Full passive ROM Active elevation 45 degrees Weakness on SS isolation and ER
A) MRI B) Refer to ortho C) Subacromial injxn D) PT E) Rheum work-up
Rotator Cuff: A blanket of four muscles that cover the arm bone (humerus) in the shoulder joint. Supraspinatus Infraspinatus Teres minor Subscapularis
Acromion: Extension of the scapula that forms “roof” over shoulder Supraspinatus: Rotator cuff muscle most commonly injured, lies between the “ball” of the humerus and the acromion
Rotator Cuff Injuries • Rotator cuff tendons can •
become damaged or inflamed (tendinitis) Supraspinatus most commonly injured tendon – Different causes of tendonitis
(often inter-related): l Overuse (“wear-and-tear”) l Impingement l Calcification l Tears l Acute trauma
Tendinitis • Overuse • Impingement • Calcific • Acute / traumatic • Part of a inflammatory constellation with bursitis, synovitis, etc.
Tears and Splitting l
l
l l
Partial or complete tearing of the rotator cuff Can be an end result of any type of tendonitis Can be end result of TRAUMA Symptoms – shoulder pain and weakness
Exam - RTC lLocation
of pain: l lateral shoulder, down lateral arm to elbow lQuality / timing of pain l Can be dull, aching l Can be sharp with specific maneuvers l NIGHT PAIN – RTC tear l Mechanical sx (clicking, catching) lRange
of motion
lStrength
– can test each muscle individually
Exam - Xrays X-Ray: AP, axillary, and outlet (scapular-Y)
Exam - Xrays Special: RTC arthropathy
Exam - Imaging •
MRI – now gold standard – dye increases detail but
not usually necessary
Various patterns of cuff pathology
Treatment: Non-Operative • For patients of all ages with pain due to:
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Subacromial bursitis Impingement Cuff tendonitis AND NO SIGNIFICANT CUFF TEAR
• May also be appropriate for older patients with tears and good muscular compensation (minimal functional deficits)
Non-Operative Management lAnti-inflammatory lSteroid
medications
injection
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decreases pain & inflammation
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long-term efficacy debated
lActivity
modification lPhysical Therapy – key -
cuff strengthening
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builds compensatory muscles
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relieves impingement
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May also include heat / massage
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At least 2-3x per week
Interactive Question: When I feel a patient needs a subacromial injection, I use a: A) anterior approach B) lateral approach C) posterior approach D) refer to ortho E) radiology-guided
ASIDE: Subacromial injection Typically 80 mg depomedrol w/ local anesthetic 22 gauge needle Most common / reliable approaches either lateral or posterior Posterior: mark back corner of acromion; down 2cm, over 1cm (“soft spot”); angle parallel to acromial slope Should meet little resistance Should cause mild pain Should see short-term improvement from local Accuracy ~70%, so if not confident, refer
So who really needs ortho? (Always – any patient you are uncomfortable managing!) 1. Failed conservative measures 2. MRI with high-grade RTC pathology (e.g. “full-thickness” or “high-grade partial” ...don't sweat terms like “rim-rent tear,” “minimal partial thickness,” “high-grade tendinosis”) 3. Reproducible loss of strength, esp. ER at side 4. Significant loss of motion 5. Extended duration of symptoms 6. Lower referral threshold for high-energy trauma?
Interactive question: 49 year-old female with 4 month hx of shoulder pain after a slip and fall. PT x 6 weeks did not help. Naprosyn course provided minimal relief. Complains of pain in back of shoulder / scapula, down side of arm to hand. MRI shows mild subacromial bursitis and supraspinatus tendinosis. Next.... A) Refer to Battaglia, shoulder specialist extraordinaire B) Subacromial injection C) More PT D) Acupuncture E) Opana
Differentiate shoulder v. cervical 1. Absence of pain with movement of shoulder 2. Increased pain during periods of inactivity or rest 3. Weakness is greater complaint than pain (painless weakness!) 4. No response to traditional shoulder regimen 5. Increased shoulder pain brought on by neck motion or position 6. Referred pain below level of elbow THESE MAY SUGGEST POSSIBLE CERVICAL ETIOLOGY
Treatment: Surgery •
For patients who have failed non-surgical treatment
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Recommended treatment for most patients with full thickness – or large partial thickness – rotator cuff tears
Operative Management • Techniques: - Arthroscopic – minimal incision, “all-inside” - Mini-open – small incisions, minimize muscle disruption - Open – formal, large incisions (largely historical except certain situations)
• Procedures (often in combination)
- Subacromial decompression (impingement surgery) - AC resection - Bursal debridement - Cuff debridement - Cuff repair
Impingement Surgery • • • • •
Remove “spur” (aka Acromioplasty) (aka Subacromial decompression) Inspect rotator cuff Repair rotator cuff if torn
Impingement Post-op Immediate Sling for comfort Ice, pain meds Move elbow, wrist and hand at least 4 times per day. Begin dangling exercises and pendulum motions as soon as tolerated.
Weeks 1-4 Passive / active shoulder range of motion (wand, pulley) to regain full motion as tolerated. Sub-maximal strengthening
Weeks 4-8 Progress passive and active range of motion as tolerated. Rigorous strengthening program using theraband, weights Emphasis of strengthening on high reps and low weight, with postural awareness. Sport-specific training or work hardening at week 8 if needed.
Rotator Cuff Surgery •
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Partial cuff tears • May only require debridement • Depends on amount / thickness of involved tendon (~50% cutoff) Full thickness tears
• Requires secure repair of tendon to humeral head
THE OLD
Open / mini-open
Arthroscopic RTC Repair • • • • •
Fewer complications Cosmesis Deltoid sparing Patient preference ** Can much better assess tear pattern for tension-free repair
(BUT: more difficult, may take longer)
RTC repair
Arthroscopic Rehab • Still limited by the biology of healing – MUST •
WAIT FOR TENDON TO HEAL TO BONE O BEGIN STRENGTHENING Perhaps a couple weeks faster than open – Sling 4 weeks – Motion at weeks 4 to 8 – Resistance exercises at 8 to 12 weeks, depending on
quality of repair
RTC Post-op: Immediate: Ice, pain meds Elbow, wrist and hand ROM. Sling full time except dangling exercises or pendulum motions are allowed.
Weeks 2-4: Start formal PT for PASSIVE motion only Shoulder blade exercises – posture, shrugging No use of rotator cuff muscles whatsoever
Weeks 5-8: Sling will be discontinued at 4-6 weeks per doctor’s instruction. Begin GENTLE active assisted range of motion, progress to regain full assisted motion by week 7-8.
Weeks 8-12: Begin strengthening program with theraband, advance to pulleys / light weights at week 10. At 10 weeks post-op, begin Core Rotator Cuff exercises
Weeks 12-: Begin conventional weight lifting with machine weights and progress to free weight if desired
Questions?
Topic: Instability
Interactive Question: 22y/o football player, dislocated shoulder in game last week, reduced at ER No previous shoulder problems. Mildly limited ROM Normal strength Normal neurovascular Xrays show no fracture
A) MRI B) Refer to ortho C) Subacromial injxn D) PT E) MRI-arthrogram
Interactive Question: 15 y/o female swimmer with “loose shoulder,” feels like it “slips around in socket” No injury Full ROM Normal strength Normal neurovascular
A) MRI B) Refer to ortho C) Subacromial injxn D) PT E) TigerBalm
Shoulder instability Incidence - most commonly dislocated major joint in the body (45%)
Different types: Acute (new injury) vs. Chronic (many dislocations) Traumatic (football injury, fall, etc) vs. Nontraumatic (“loose joints”) Direction (anterior, posterior, multi-directional?)
Shoulder Instability Many factors contribute to a stable joint - Ball in socket shape - Ligaments - Muscles - Negative pressure in joint - LABRUM ***
LABRAL TEARS
Associated injuries - LABRAL TEARS – esp. young (<30 y/o) - Fractures - Nerve injury – Axillary n palsy (535%) - esp. elderly *** - Arterial injury – esp. elderly - RTC tears (older pts) (15% if over 40 yo, >40% if over 60 yo)
Instability Exam History Initial or recurrent Position of the arm at time of event
Physical Muscle atrophy Location of tenderness Careful neurologic / strength exam Range of motion Laxity – in what direction(s) is shoulder loose General “loose joints?”
Radiographs
MRI
Instability: Non-op Treatment Nonsurgical Immobilize several weeks Allow stretched structures to tighten
Rehab, restricted activities Maximize strength of muscle stabilizers
BUT: Risk of recurrence inversely proportional to patient’s age < 20 yo = >90%??? 20-25 yo = 50-75% >25 yo = < 50% > 40 yo = < 15%
Acute Surgery: Young athlete?? Irreducible dislocation Displaced fx
Operative Treatment Indications Failure of Non-Operative Treatment l Chronic dislocations l Young first-time dislocators? – controversial but evolving l Certain injury patterns – (size of labral tear, certain fractures, etc.) l Arthroscopic vs. open? l
- With few exceptions, arthroscopic is equivalent, if not superior
Surgery 1. Anatomic repair of the torn labrum (and anterior capsule) back to the glenoid rim 2. Tightening of the stretched ligaments
Instability surgery - rehab IINITIAL WEEKS 1-4: · Sling / immobilizer · May perform gentle pendulum exercises for affected shoulder. · Strict limits on shoulder range of motion, esp. on ER WEEKS 4-8: · Discontinue sling. · Further range of motion, no limit after 6 weeks · Begin light strengthening WEEKS 8-12: · Full range of motions. · Focus on rotator cuff core strengthening WEEKS 12-: · Prepare for return to activity – begin light tossing, conventional weight machines, isokinetics with throwing wand, etc. · Goals: Non-contact sports – return at 14-16 weeks Contact sports – return at 20-24 weeks Throwing sports – return at 24 weeks only after throwing program
Multi-Directional Instability - “symptomatic instability in all 3 directions” - anterior, inferior, posterior
- inherent ligamentous instability
- most common: young females - swimmers, gymnasts, softball pitchers, volleyball
MDI - Treatment Non-surgical Non-surgical Non-surgical - activity modification - deltoid / cuff strengthening - 70-90% success
Surgical only if: - failed conservative (6 months PT minimum) - arthroscopic - anterior / posterior / inferior tightening
Interactive Question: 23 y/o skier, fell on shoulder. Tender directly over AC joint. Full ROM. Normal strength and sensation. Pain with cross-body load XRAY:
A) MRI B) Refer to ortho C) Subacromial injxn D) PT E) Chiropractic
Interactive Question: 23 y/o skier, fell on shoulder. Tender directly over AC joint. Full ROM. Normal strength and sensation. Pain with cross-body load XRAY:
A) MRI B) Refer to ortho C) Subacromial injxn D) PT E) Chiropractic
Classification Type I Sprain of AC joint – ligaments intact Delt and trap intact
Type II AC joint disrupted – widening, <25% displaced CC ligaments sprained Delt and Trap intact
Type III AC and CC ligaments disrupted CC interspace 25-100% increased Deltoid and Trapezius muscles detached from distal end
Classification n
Type IV n n n
n
Type V n n n
n
AC & CC ligaments disrupted Clavicle dislocated posteriorly into or through trapezius Delt and Trap muscles detached
AC & CC ligaments disrupted Delt and Trap muscles detached CC interspace 100-300% increased
Type VI n n n
AC & CC disrupted Distal clavicle trapped UNDER acromion or coracoid Delt and Trap muscles detached
Treatment Type I & II – no role for operative treatment Symptoms subside after 7-10 days (I) / 3-6 weeks (II) Refrain from heavy lifting and contact sports until full motion and no pain Operative treatment only for chronic pain or development of AC arthritis: Distal Clavicle Excision (DCE)
Treatment Type II – nonop treatment is gold standard Sling to support arm for 1-2 weeks No heavy lifting/contact sports for 6 weeks Early return to athletic activities through use of protective padding Operative treatment for chronic problems: AC ligament reconstruction with distal clavicle excision
Treatment Type III – controversial non-op management for majority of patients Sling for 1-2 weeks 80% of motion within 4 weeks 3-4 months for return to full activity
All Type IV, V, and VI injuries Acute reduction and fixation Screws, pins, plates, Tightrope Full activity restricted for 4-6 month
Questions?
Topic: Fractures
Interactive Question: 23 y/o skier crashed on slopes yesterday. Otherwise healthy. Mild global limit ROM Motor painful but intact XRAY:
A) MRI B) Refer to ortho C) Subacromial injxn D) Sling / follow-up E) Laser therapy
Clavicle Fractures Classification: - Middle 1/3 - Proximal 1/3 - Distal 1/3 Immediate attention: -Any skin compromise or breach -Any neurovascular issues
Clavicle Fractures - Treatment Middle 1/3rd: Traditionally, ALL treated non-operatively (except open fxs, vascular injury) Newer: Fix fxs with significant displacement or overlap
Proximal 1/3rd: Rare Treatment controversial (neurovasc. risk)
Distal 1/3rd: Depending on pattern, high likelihood of nonunion Often require operative treatment
Proximal humerus fractures • Usually elderly • Low-energy trauma • Osteporotic bone makes treatment difficult • Nerve injury common (axillary) • Main fx line usually right below “ball” • May also have numerous fragments • Often disrupts blood supply to humeral head
Classification
Fracture treatment • Young patients - usually try to reassemble and fix no matter how smashed • Elderly – Sling vs. fix vs replace • Fix can be: Pins, Plate / screws, Rods
“FUBAR”ed (f***d up beyond all recognition) = replacement
Fracture rehab • Rehab depends on type of fracture / type of treatment • Usually involves sling for 4-6 weeks • Very gradual motion • Strengthening delayed at least 2-3 months • High rates of stiffness, loss of strength
QUESTIONS? Can also reach me through website: www.ToddBattagliaMD. Com or direct email:
[email protected]
May I be excused? My brain is full.
Thanks!
