Older Shoulders

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Older Shoulders

• Rotator Cuff Disease

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Rotator Cuff Tears

• Anatomy

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Rotator Cuff Tears

• Anatomy

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Rotator Cuff Tears

• DefinitionPathologic changes of therotator
  cuff tendons

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Rotator Cuff Tears

• Progressive thinning and weakening with ? age

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Rotator Cuff Tears

• CauseTraumaDegenerative

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Rotator Cuff Tears

• TypesTendinitisPartial thickness tearFull
  thickness tear

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Rotator Cuff Tears

• Partial Thickness Tear

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How to Recognize

• ComplaintsPain, ? sleep, overhead, weakness,
  stiffness, catching, popping

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How to Recognize

• HistoryAcute (traumatic)vs. Chronic
  (insidious)

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How to Recognize

• ExamAtrophy, ecchymosis, weakness, subacromial
  roughness, pain,positive injection test

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How to Recognize

• Atrophy

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How to Recognize

• Subacromial Roughness

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How to Recognize

• Weakness

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How to Recognize

• Pain

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Differential Diagnosis

• Acromioclavicular arthritis
• Frozen shoulder
• Glenohumeral arthritis
• Herniated cervical disc
• Suprascapular nerve entrapment
• Fracture (Skiers)

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How to Work-Up

• X-raysGreater tuberosity reactive changes,
  acromial sourcil/spur, high-riding humeral head

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How to Work-Up

• Greater tuberosity reactive changes, acromial
  sourcil/spur

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How to Work-Up

• High-riding humeral head

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How to Work-Up

• Other Imaging StudiesArthrogramUltrasoundMRI

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How to Work-Up

• Positive arthrogram with dye leakage

Acromion
Humeral Head
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Ambulatory Treatment

• Conservative - rest, ROM, NSAID,s, injection
  (?), time, avoidance, modifications, education,
  compensatory muscle strengthening, progressive
  resumption of activities (except acute tear in
  young/active?)

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Ambulatory Treatment

• Progressive Range of Motion

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Ambulatory Treatment

• Compensatory Muscle Strengthening

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Outcome

• Most do well with appropriate conservative
  management

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Other Thoughts

• Wheelchair/Crutch AmbulatorsDifficult, rehab,
  rehab, rehab, rarely if ever repair

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Other Thoughts

• After dislocation in 40 y.o.Beware potential
  for RCT,image those doing poorly with rehab EARLY

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Other Thoughts

• Calcific Tendinitis

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Other Thoughts

• Calcific Tendinitis- Insidious onsetPAIN!-
  Try conservative approach- May need to remove or
  decompress if symptoms persist

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Impingement
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Impingement

• Question what it isTriad!- posterior capsular
  tightness- subacromial bursitis- cuff pathology
  (-itis vs. tear)

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When to Refer

• AcuteWeakness, bruising,positive
  study,especially young/active pts.

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When to Refer

• ChronicAfter several months, positive study,
  failure of conservative care, continued/worsening
  pain dysfunction, difficulty sleeping

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How We Treat It

• More Rehab/Avoidance/Modification
• Meds/Injections
• Explanation of risks/benefits
• Surgery - arthroscopic or open subacromial
  smoothing/debridement vs. repair

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How We Treat It

• RCT ? RCR

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How We Treat It
Prognostic indicators for RCR Failure

• ? Age ( 70)
• ? Chronicity
• Atraumatic

? Injections ? tendons Smoking
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How We Treat It

• Open rotator cuff repair

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Outcome

• Most do well extremely well with near complete
  recovery of function and relief of pain

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Outcome
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Rotator Cuff Tears

• Summary- VERY common problem- Can be acute or
  chronic- Many will improve adequately with
  conservative care- Some require surgery

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Rotator Cuff Tears

• Summary- In young/active/traumatic tearsthink
  early referral
• - In elderly/sedentary/insidious tearsthink
  rehab, refer prn

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Older Shoulders

• Stiffness

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Capsular Laxity
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Frozen Shoulder

• Definition - Symptomatic limitation of passive
  motion in a shoulder
• Cause - Stiffening of joint capsule after
  inflammation

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Inflammation
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Adhesions
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Actually

• Four Types (etiologies) of StiffnessIdiopathic
  Frozen ShoulderDiabetic Stiff ShoulderPost-Traum
  atic Stiff ShoulderPost-Surgical Stiff Shoulder

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Capsular Contracture
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How to Recognize

• History - loss of comfort function (inability
  to sleep comfortably )
• Exam - limited range of flexion, external
  rotation, internal rotation and/or cross body
  motion
• X-rays - normal

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Peak age 55 years
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Top 3 in middle age
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Top three 45 years
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Asymmetrical range
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Asymmetrical Range
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Pain at the extreme
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Flexion
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External Rotation
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Internal rotation
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Cross body
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Physical Exam
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How to Work Up

• Rule out predisposing factors
• Diabetes
• Cervical spondylosis
• Underlying shoulder pathology - e.g. tumor
• Previous trauma or surgery

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Good quality films
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Exclude

• Fractures/Dislocations
• Tumors
• Bony Abnormalities
• Arthritis

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Posterior Fx/Dislocation
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Tumor
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Avascular Necrosis
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Rheumatoid Arthritis
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Ambulatory Management

• Treat the PAIN!!!NSAIDsInjectionsAcupuncture
• (ANYTHING But Narcotics)

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Ambulatory Management

• Avoid Overuse and Bothersome Activities!!!Rest
  and Time!No Strengthening!!!

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Ambulatory Management

• Recognize that gentle stretching 5X/day for 6
  weeks will improve most cases
• Demonstrate stretching exercises
• Return visit to check on exercises
• Monitor range of motion, symptoms

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Flexion
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Forward Flexion
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Forward lean
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Cross-body
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Cross Body
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External rotation
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External Rotation
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External rotation
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Internal rotation
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Internal Rotation
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Document progress
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When to Refer to Ortho

• No improvement in range of motion or symptoms
  after 6 - 12 weeks of exercises
• Concern about other diagnoses (e.g. questionable
  X-ray)

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How We Treat It

• Home stretching exercises
• Regular monitoring/feedback
• Possibly exam/manipulation under anesthesia if no
  previous injury/surgery and bone strong
• Possibly surgical release

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How We Treat It
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Capsular Release
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Continuous Motion
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Outcome

• Frozen Shoulders Thaw!Most do well well with
  near complete recovery of function and relief of
  pain, one way or another

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Older Shoulders

• Arthritis

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Shoulder Arthritis

• DefinitionLoss of the cartilaginous surfaces in
  the glenohumeral joint

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Shoulder Arthritis

• CauseGenerally idiopathic,but multiple others
  possible

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Shoulder Arthritis
Potential Causes
Cuff Tear Arthropathy Post-surgical Previous
Infection Tumor Spondyloarthropathy

• Osteoarthritis
• Rheumatoid Arthritis
• Post-traumatic
• Avascular Necrosis

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Shoulder Arthritis

• Post-traumatic Arthritis

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Shoulder Arthritis
Cuff Tear Arthropathy
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How to Recognize

• ComplaintsNight/rest pain, stiffness, weakness,
  roughness,functional limitation

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How to Recognize

• HistoryInsidious, progressive worsening,
  possible distant injuryand/or surgery

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Shoulder Arthritis
Post-surgical
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How to Work-Up

• ExamAtrophy, weakness, stiffness, crepitation,
  tenderness,rarely swelling

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How to Work-Up

• Stiffness

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How to Work-Up

• X-rayAPAxillary Lateral

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How to Work-Up

• Osteoarthritis

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How to Work-Up

• Other StudiesOccasional CT or MRILabs as
  neededto R/O certain dxs

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Shoulder Arthritis

• Avascular Necrosis

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Differential Diagnosis

• Infection
• Charcot Joint
• Fracture of the proximal humerus
• Herniated cervical disc
• Rotator cuff tear
• Tumor

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Ambulatory Treatment

• ConservativeNSAIDs, avoidance, modification,
  passive stretching, ice/heat, support, possible
  cortisone injection (?)

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Ambulatory Treatment

• Passive Stretching

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When to Refer

• Failure of conservative treatment and time (at
  least 3 mos?)
• Severe pain, difficulty sleeping, functional
  limitations disabling

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How We Treat It

• Further conservative management
• Explanation of risks/benefits
• Surgery - Arthroscopic or open smoothing/debrideme
  nt vs. hemi- or total shoulder arthroplasty/fusion

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How We Treat It

• Total Shoulder Arthroplasty

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How We Treat It

• Shoulder Arthrodesis

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Outcome

• Most do well extremely wellwith relief of
  painand improvement of function

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Shoulder Arthritis

• Summary- A challenging problem- Can have many
  etiologies and be very debilitating- If
  conservative care fails, surgery can be very
  rewarding

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Thanks

• To the late Doug Harryman for the videos
• To Steve Lippitt for the illustrations

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More

• For more information, please see the UW Shoulder
  Source
• http//www.orthop.washington.edu/shoulder_elbow
• E-Maildrsmith_at_u.washington.edu