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SHOULDER

Anatomy

The shoulder joint is the second largest and most mobile joint in the human body and can be easily understood if divided into three layers. view 

Shoulder Contusion

Trauma is the term used to describe injury. Trauma is classified by its severity depending on the amount of force used to cause the injury. view 

Shoulder Fractures

Shoulder Fractures or breaks in the shoulder can occur in the humeral bone, collar bone or the in shoulder blade.  view

Shoulder Dislocations

A shoulder dislocation is classified according to the direction of the dislocation (Anterior, posterior or multi-directional), the amount of force it took to dislocate the shoulder (Traumatic or Atraumatic), and whether it is accompanied by a fracture (fracture dislocation).  view 

Shoulder Arthiritis

Shoulder Arthritis is the loss of the cartilage cushion in the joint surfaces (blue section) that allows the smooth pain free gliding required during shoulder motion. view

Shoulder Nerve Compression Syndromes

Nerve compression syndromes are normally found in adults of all ages and it is rare to find nerve compression syndromes in patients younger than 20 years of age.  view 

Shoulder Tendon Disorders

Shoulder pain is the most common presenting shoulder complaint in an orthopedic practice.  view 

Shoulder Infection

The shoulder is one of the most well perfused areas of the human body and because of this ample blood supply to the shoulder which carries circulating white blood cells, offers excellent protection against infection, consequently making a shoulder infection a rare occurrence.  view 

Frozen Shoulder

A Frozen shoulder also called adhesive capsulitis is a condition presenting with shoulder stiffness and severe shoulder pain when shoulder motion is initiated. view 

Shoulder Tumor

Tumors are divided into benign and malignant types.  view 

SHOULDER TENDON DISORDERS

Pathology

Shoulder pain is the most commonly presented shoulder complaint. Causes of Shoulder Pain

  • Intrinsic – Caused by the structures in the shoulder
  • Extrinsic – Caused by pathology outside the shoulder with the pain referred to the shoulder from another epicenter

Intrinsic Causes include Mechanical pain which occur with active motion. Most common cases of shoulder pain includes:

  • Contusions
  • Fractures
  • Arthritis
  • Tendon disorders which bring on limited motion due to pain and viable amounts of muscle weakness caused by Bursitis, Tendonitis and Rotator cuff tears

Non-mechanical pain occurs at rest without use of the shoulder caused by:

  • Nerve compressions syndromes
  • Inflammatory conditions
  • Tumors about the shoulder

All of these conditions present with a physical finding called impingement. Impingement Syndrome is pain elicited in the shoulder when the shoulder is elevated between 90°-120° overhead. It is not a diagnosis but simply a physical finding that has many causes.

Bursitis is the inflammation of the bursa (tendon lining) in the shoulder. The shoulder bursa is a cellular layer forming a sac lying under the shoulder blade roof. It produces a limited amount of synovial fluid. The synovial fluid acts to reduce friction during joint motion allowing for smooth tendon gliding.

When the bursa is inflamed due to injury or repetitive overhead activities, the bursa over secretes the synovial fluid. The fluid thickens and results in shoulder impingement pain. Shoulder tendonitis is when the tendon proper of the rotator cuff is inflamed.

SHOULDER_TENDON

Rotator Cuff Tear Causes

Intrinsic – The rotator cuff tendon bends at a sharp angle prior to inserting (attaching) onto the humeral tuberosity footprint, thus creating a differential pressure on the various tendon layers of the shoulder. A decreased blood supply to the tendon as we age is another cause.

Extrinsic – Acromial bone spurs form in the anterior and inferior part of the acromial undersurface with aging. This consequently scrapes away the tendon as we perform overhead activities until a rotator cuff tear develops.

Classifying Bone Spurs

  • Type I- flat
  • Type II- curved
  • Type III- hooked

Types II and III are larger spurs and are believed to be the ones to cause the abrasion on the rotator cuff tendon resulting in a rotator cuff tear. With rotator cuff tears, impingement pain is usually accompanied by variable amounts of rotator cuff weakness on a physical exam.

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Type I   Type II   Type III

cuff_tear

 

Classification of Rotator Cuff Tears depends on whether the five layers making up the tendon thickness are partially torn, or completely torn.

Partial can be further classified by location of tear:

  • Bursal sided tear: on the top of tendon
  • PASTA lesion (Partial Articular Supraspinatus Tendon Avulsion): tear on the joint of the tendon

Complete tear are when the tendon fibers are torn from bursal subacromial side and communicates with the joint side, allowing joint fluid to escape.Further classified by size of tear:

  • Small (<1cm)
  • Medium (1.1-3.0 cm)
  • Large (3.1-5.0 cm)
  • Massive (>5.0cms)

The larger the tear, the more associated weakness is found on a physical exam and the higher the probability of recurrence after a repair. This is why it’s recommended to repair a complete tear before it gets larger.

 

10 Things to Know About Rotator Cuff Tears (RCT)

1. RCT do not heal on their own. Surgery is required for healing.

2. RCT will increase in size over time. The rate of progression is unknown.

3. It is rare for a person less than 40 years old to incur an RCT without a prior significant injury.

4. The incidence of RCT increase with age, starting at 40 years of age and are present in about 50% of people after the age of 60 years.

5. The presence of an RCT does not necessarily mean symptoms will also be present.

6. The larger the RCT, the more likely a tear will recur over time after a repair. Lifting discretions are permanently advised after repairing a large or massive tear.

7. If a massive RCT separates from its attachment site and retracts, the muscle will begin to atrophy. If left unrepaired for six months, a successful repair is less likely.

8. RCT repairs can be performed with open or arthroscopic techniques depending on the training and experience of the surgeon.

9. After a RCT is repaired, the healing time and the return of good functionality depends on:

  • Size of the tear
  • Quality of the tendon
  • Bone density where the suture anchors are placed (greater tuberosity footprint)
  • Age of the patient – The repaired tendon has to take root on the repair site. This takes an average of 4 months.

10. The assigned level of therapy after surgery depends on:

  • Size of the tear
  • Quality of the tendon
  • Quality of the bone
  • Amount of tension on the repair. Tension depends on how long a cuff tear was retracted prior to being repaired

If pain is felt during exercises after a rotator cuff repair, it is an indication the therapy is too aggressive and the exercises should be curtailed.

 

Biceps Tendon

biceps-tendon

 

Biceps Muscle

The biceps muscle has two tendons of origin. One begins on the very top of the glenoid and the other originates on the coracoid bone of the shoulder blade (shown above). The biceps muscle serves to bend the elbow and rotate the forearm in a palm up position.

Long Head of the Biceps Tendon

  • Comes off the glenoid bone/labral junction
  • Common site of a biceps tendon rupture
  • Occurs with increasing age/activity and Minor exertion

The long head tendon travels through the humeral groove, and is constantly having the humeral bone slide past it back and forth with arm motion. In time, depending on the shape of the groove, the tendon wears away and partially tears until a complete rupture is experienced.

Symptoms of a Torn Long Head Bicep Tendon Tear consist of first a sudden pop in the shoulder is felt, followed by:

  • Discoloration of the upper arm
  • Muscle spasms of the upper arm
  • Appearance of a bulge in the mid arm called a œpopeye muscle

Because there are two tendon origins of the biceps muscle, the lack of the long head of the biceps rarely causes a functional deficit and repair is not normally recommended.

 

Treatment

arthroscopic_shoulder

Arthroscopic Shoulder subacromial decompression and rotator cuff repair

 

 

reverse_total

Reverse Total Shoulder Prosthesis for massive irreparable rotator cuff tears

 

Impingement syndromes may manifest as a result of:

  • Bursitis
  • Tendonitis
  • Rotator cuff tears failing after a non-operative 3-6 month trial of: Activity modification, Anti-inflammatory medication, Steroid injections, A good therapy program is considered for surgical intervention.

If impingement syndromes appear, the patient is recommended for surgery. Surgery most often involves an arthroscopic procedure to remove:

  • The inflammatory bursa
  • Partial tendon tears
  • Acromial bony spurs

When a rotator cuff tear is present, it is repaired at ROC arthroscopically in all cases. Open rotator cuff repairs are still performed by many competent surgeons but the rehabilitation, discomfort from surgery and scars from an open approach makes the arthroscopic method our preferred method.

 

Reverse Shoulder Prosthesis

A new technique uses the deltoid instead of the rotator cuff to power the arm to elevate to near normal ranges. Qualifying for a Reverse Shoulder Prosthesis:

  • Massive rotator cuff is irreparable
  • Patient is unable to elevate their arm overhead causing a significant functional deficit
  • Patient is otherwise healthy and older than 65 years

biceps tendonesis

Biceps Tendodesis

This procedure buries the tendon stump in the bicipital groove or is tied to local soft tissues. It is preformed through a small open incision or through the use of the arthroscope during an acute tear. A larger incision is used if 2-4 weeks have passed since the injury.

When repairing a rotator cuff during a routine arthroscopic procedure and a near complete biceps tendon tear is inadvertently found, a biceps tenodesis is often also performed at the same setting through the arthroscope.

Qualifying for Biceps Tendodesis

  • Spontaneous rupture causes persistent pain and muscles spasms in the mid arm
  • Non-operative treatment has gone on for at least six months without success