COMMON SHOULDER INJURIES: What to do, when to refer

COMMON SHOULDER INJURIES:
What to do, when to refer
Todd C. Battaglia, MD, MS
Syracuse Orthopedic Specialists
March 2014
Introduction
•
Grew up in Marcellus
•
Amherst College – lacrosse & rugby
•
SUNY-Buffalo School of Medicine
•
Residency / MS (Ortho Research) at UVa
•
Fellowship at New England Baptist
Hospital (Sports Medicine & Arthroscopic
Surgery)
•
Partner / Director of Sports Medicine at
Syracuse Orthopedic Specialists
•
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:
-
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
-
decreases pain &
inflammation
-
long-term efficacy debated
lActivity
modification
lPhysical Therapy – key
-
cuff strengthening
-
builds compensatory muscles
-
relieves impingement
-
May also include heat /
massage
-
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
•
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
•
•
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:
info@syracusesportsmedicine.com
May I be excused? My brain is full.
Thanks!