SHOULDER. SHOULDER OSTEOLOGY ANATOMY:MUSCLES ANATOMY:CAPSULAR ELEMENTS.

SHOULDERSHOULDER

SHOULDER OSTEOLOGYSHOULDER OSTEOLOGY

SHOULDER OSTEOLOGYSHOULDER OSTEOLOGY

ANATOMY:MUSCLESANATOMY:MUSCLES

ANATOMY:CAPSULAR ANATOMY:CAPSULAR ELEMENTSELEMENTS

IMPINGEMENT:ANATOIMPINGEMENT:ANATOMYMY

CA LIGAMENT

ACROMIAL SHAPESACROMIAL SHAPES

ACROMIAL ANATOMYACROMIAL ANATOMY

ACROMIAL SHAPEACROMIAL SHAPE TYPE 1 (FLAT)17%TYPE 1 (FLAT)17%

TYPE 2 (CURVED) 43%TYPE 2 (CURVED) 43%

TYPE 3 (ANTERIOR TYPE 3 (ANTERIOR HOOK) 40%HOOK) 40%

MORRISON & MORRISON & BIGLIANI (1987)BIGLIANI (1987)

80% PTS WITH RC 80% PTS WITH RC TEAR HAD TYPE 3 TEAR HAD TYPE 3 ACROMIONACROMION

IMPINGEMENT IMPINGEMENT SYNDROME:STAGESSYNDROME:STAGES

STAGE 1 : STAGE 1 : REVERSIBLE REVERSIBLE EDEMAEDEMA

STAGE 2: STAGE 2: FIBROSISFIBROSIS

STAGE 3: STAGE 3: ROTATOR CUFF ROTATOR CUFF TEARTEAR

IMPINGEMENT IMPINGEMENT SYNDROME :STAGE 1SYNDROME :STAGE 1

DULL ACHEDULL ACHE ACTIVITY ACTIVITY

RELATEDRELATED PALPABLE PALPABLE

TENDERNESSTENDERNESS PAIN BETWEEN PAIN BETWEEN

30-60 DEGREE 30-60 DEGREE ABDUCTIONABDUCTION

POSITIVE POSITIVE IMPINGEMENT IMPINGEMENT SIGNSSIGNS

PAIN IN PAIN IN BICIPITAL BICIPITAL GROOVEGROOVE

IMPINGEMENT IMPINGEMENT SYNDROME:STAGE 1 SYNDROME:STAGE 1

TREATMENTTREATMENT NSAIDNSAID

REST FROM PROVOCATIVE REST FROM PROVOCATIVE MANUVERSMANUVERS

PHYSICAL THERAPYPHYSICAL THERAPY

IMPINGEMENT IMPINGEMENT SYNDROME:STAGE II SYNDROME:STAGE II

DIAGNOSISDIAGNOSIS ACHING ACHING

DISCOMFORTDISCOMFORT PAIN AT PAIN AT

REST/NIGHTREST/NIGHT SUBACROMIAL SUBACROMIAL

CREPITUSCREPITUS

CATCHING CATCHING SENSATIONSENSATION

DECREASED ROMDECREASED ROM

IMPINGEMENT IMPINGEMENT SYNDROME:SYNDROME:

STAGE II TREATMENTSTAGE II TREATMENT RESTREST ICE NSAIDICE NSAID SUBACROMIAL SUBACROMIAL

INJECTIONINJECTION P.TP.T

1.R.O.M1.R.O.M

2. PAIN 2. PAIN CONTROLCONTROL

3. STRENGTH3. STRENGTH

ACROMIOPLASTYACROMIOPLASTY

86% SUCCESS IF 86% SUCCESS IF NO RC TEARNO RC TEAR

OPEN VS OPEN VS ARTHROSCOPICARTHROSCOPIC

OPEN ACROMIOPLASTYOPEN ACROMIOPLASTY

SUBACROMIAL SUBACROMIAL DECOMPRESSIONDECOMPRESSION

ROTATOR CUFF TEARSROTATOR CUFF TEARS

PREVALENCEPREVALENCE ETIOLOGYETIOLOGY PHYSICAL EXAMPHYSICAL EXAM TREATMENT TREATMENT

OPTIONSOPTIONS REHABILITATIONREHABILITATION

ROTATOR CUFF ROTATOR CUFF TEARS:INCIDENCETEARS:INCIDENCE

FULL THICKNESSFULL THICKNESS

JEROSCH ,1991-JEROSCH ,1991-30.3%30.3%

NEER ,1983- 5%NEER ,1983- 5%

UHLHOFF ,1986-20%UHLHOFF ,1986-20%

WILSON, 1943-26.5%WILSON, 1943-26.5%

AGE : KEY FACTORAGE : KEY FACTOR

PARTIAL PARTIAL THICKNESSTHICKNESS

JEROSCH, 1991-JEROSCH, 1991-28.7%28.7%

YAMANKA, 1983-YAMANKA, 1983-13%13%

FUKUDA, 1980-13%FUKUDA, 1980-13%

DEPALMA, 1973-DEPALMA, 1973-37%37%

R.C TEARS: ETIOLOGYR.C TEARS: ETIOLOGY

EXTRINSIC EXTRINSIC FACTORSFACTORS

ACROMIAL SHAPEACROMIAL SHAPE

OUTLET STENOSISOUTLET STENOSIS

AC JOINT DJDAC JOINT DJD

OS ACROMIALEOS ACROMIALE

INTRINSIC INTRINSIC FACTORSFACTORS

SUPRASPINATUS SUPRASPINATUS NERVE PALSYNERVE PALSY

GLENOHUMERAL GLENOHUMERAL INSTABILITYINSTABILITY

HYPOVASCULARITYHYPOVASCULARITY

AGINGAGING

R.C TEARS: DIAGNOSISR.C TEARS: DIAGNOSIS

PAINPAIN WEAKNESS(ABD/WEAKNESS(ABD/

ER)ER) CREPITUSCREPITUS DROP TESTDROP TEST BURSAL BURSAL

EFFUSIONEFFUSION

LONG HEAD LONG HEAD BICEPS RUTUREBICEPS RUTURE

DECREASED ROMDECREASED ROM

R.C TEAR :DIAGNOSISR.C TEAR :DIAGNOSIS

EXTERNAL ROTATION

DROP TEST

INTERNAL ROTATION

R.C TEAR : IMAGINGR.C TEAR : IMAGING

PLAIN RADIOGRAPHSPLAIN RADIOGRAPHS ULTRASONOGRAPHYULTRASONOGRAPHY ARTHROGRAMARTHROGRAM MRI: GOLD STANDARDMRI: GOLD STANDARD

R.C TEARS: IMAGINGR.C TEARS: IMAGING

INTACT NORMAL CUFF TORN ROTATOR CUFF

R.C TEARS: XRAYSR.C TEARS: XRAYS

SOUCIL SIGNSHOULDER ARTHROGRAM

ROTATOR CUFF TEAR:ROTATOR CUFF TEAR:TREATMENTTREATMENT

NON-OPERATIVENON-OPERATIVE

ROTATOR CUFF REPAIRROTATOR CUFF REPAIR

ACROMIOPLASTYACROMIOPLASTY

DISTAL CLAVICLE RESECTIONDISTAL CLAVICLE RESECTION

REPAIR OF CUFFREPAIR OF CUFF

ROTATOR CUFF REPAIRROTATOR CUFF REPAIR

ACROMIOPLASTYACROMIOPLASTY OPEN VS. ARTHROSCOPICOPEN VS. ARTHROSCOPIC

MOBILIZATION OF TENDONMOBILIZATION OF TENDON 1. BLUNT DISSECTION1. BLUNT DISSECTION 2. RELEASE FASCIAL ATTACHMENTS2. RELEASE FASCIAL ATTACHMENTS 3. INCISE CAPSULE AT GLENOID 3. INCISE CAPSULE AT GLENOID

LABRUM LABRUM

ARTHROSCOPIC ARTHROSCOPIC SUBACROMIAL SUBACROMIAL

DECOMPRESSIONDECOMPRESSION

SUBACROMIAL SPUR FINISHED ACROMIOPLASTY

ROTATOR CUFF REPAIRROTATOR CUFF REPAIR

REPAIRREPAIR

1. CREATE TROUGH1. CREATE TROUGH

2. DRILL HOLES2. DRILL HOLES

3. NON-ABSORBABLE SUTURES3. NON-ABSORBABLE SUTURES

4. SOLID DELTOID REPAIR4. SOLID DELTOID REPAIR

ROTATOR CUFF REPAIRROTATOR CUFF REPAIR

ARTHROSCOPIC ROTATOR ARTHROSCOPIC ROTATOR CUFF REPAIRCUFF REPAIR

ROTATOR CUFF REPAIR:ROTATOR CUFF REPAIR:REHABILITATIONREHABILITATION

WEEK 0-6WEEK 0-6

PASSIVE R.O.MPASSIVE R.O.M WEEK 6-12WEEK 6-12

ACTIVE R.O.MACTIVE R.O.M WEEK 12+WEEK 12+

STRENGTHENINGSTRENGTHENING

ROTATOR CUFF REPAIR:ROTATOR CUFF REPAIR:RESULTSRESULTS

NEER 1988-233 PATIENTS, 4.6 NEER 1988-233 PATIENTS, 4.6 YEAR F.U.YEAR F.U.

77% EXCELLENT/GOOD77% EXCELLENT/GOOD

14% SATISFACTORY14% SATISFACTORY

9% UNSATISFACTORY9% UNSATISFACTORY

HAWKINS 1985HAWKINS 1985

86% EXCELLENT/GOOD86% EXCELLENT/GOOD

ROTATOR CUFF REPAIR:ROTATOR CUFF REPAIR:RESULTSRESULTS

HARRYMAN, 1990- 112 PATIENTSHARRYMAN, 1990- 112 PATIENTS 4.7 YEAR F.U.4.7 YEAR F.U. 80% GOOD PAIN RELIEF80% GOOD PAIN RELIEF 80% REPIRS INTACT(S.S)80% REPIRS INTACT(S.S) 50% REPAIRS 50% REPAIRS

INTACT(IS,SUBSCAP)INTACT(IS,SUBSCAP) PAIN RELIEF INDEPENDENT OF PAIN RELIEF INDEPENDENT OF

CUFF INTEGRITYCUFF INTEGRITY DECOMPRESSION IS THE KEY!!DECOMPRESSION IS THE KEY!!

ROTATOR CUFF REPAIR:ROTATOR CUFF REPAIR:REASONS FOR FAILUREREASONS FOR FAILURE

POST-OP SCARRINGPOST-OP SCARRING DELTOID DETACHMENTDELTOID DETACHMENT INADEQUATE DECOMPRESSIONINADEQUATE DECOMPRESSION RECURRENT TEARRECURRENT TEAR