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DegenerativeConditionsintheShoulder
Dr JohnTrantalisOrthopaedicSurgeon
W shoulderandelbow.com.au
MyProfile• Dr JohnTrantalis• MBBSUNSW1996• GainedFellowshipinOrthopaedicSurgery2007with:– RoyalAustralasianCollegeofSurgeons– AustralianOrthopaedicAssociation
• Shoulder&ElbowFellowshipinCanadaandSydney2007/08.
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TreatmentofLocalizedDisease:LocationLocationLocation!!
PatientHistory1. Painprofile: SOCRATES
– Location– MechanicalPain?e.g shoulder
painworsewithoverheadactivities.
2. FunctionalProfile– Howdoestheproblemeffectthe
patient’sfunctionalactivities
3. JointProfile– MechanicalJointSymptoms:
Clicking,Locking,Instability,Swelling
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TreatmentofLocalizedDisease:Examination
1. Look• Wasting,Scars,Posture,etc
2. Feel• Tenderness:Location!!!!!!• Especiallyinshoulder
3. Move• Activemotion• PassiveMotion
4. Specialtests
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KeytoShoulderExamination:PassivevsActiveMotion
• ACTIVEMOTION– Patientmovesthejointontheirown
• PASSIVEMOTION– Theexaminermovesthejointforthepatient
• If the joint is stiff:
Ø Both active and passive motion will be restricted
• If all the tendons are torn off…
Ø Only active motion is affected.... Passive preserved.
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PASSIVEvs ACTIVEmotion
• Loss of active Motion• Preserved Passive Motion
Ø Massive Cuff Tear
• Loss of Active and Passive Motion
Ø Shoulder Arthritis or Frozen Shoulder
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OnlineVideoTutorial:HowtoExamineShoulders
These Video Tutorials can be viewed Online:
Shoulder: shoulderandelbow.com.au
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TheShoulderJoint
• GreatROM• VeryShallow
Socket• Mostfrequently
dislocatedjoint
• RotatorCuff
Dr John TrantalisShoulder & Elbow Surgery
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ConditionsAffectingtheAdultShoulder
• Age>40y• 85%“RotatorCuffSyndrome”
– RotatorCuffTendonosis andTears– Impingement– LongHeadofBicepsTendonPathology– Acromioclavicular JointPathology
– 10%FrozenShoulder(akaAdhesiveCapsulitis)– 4%Osteoarthritis– 1%other
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ConditionsAffectingtheAdultShoulder
• Age<30y– 85%InstabilityofGlenohumeralJoint
• LabralTears
– 15%Other
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FunctionoftheShoulderJointinHuman:PositiontheArminSpace
RECENTEVOLUTIONARYCHANGESEXPLAINTHEPATTERNOFDEGENERATIVESHOULDERCONDITIONS
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From4legsto2:TheEvolutionoftheShoulderJoint
•Hitchcock JBJS 1948
NOWLET’SFOCUSONTHEACTUALCLINICALCONDITIONS…...
TENDONOSIS:WEARANDTEAROFTENDONSOVERTIME
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Tendinosis:LifeExpectancyovertheAges
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TheShoulder:Tendonosis
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StressFatigueFailure
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HowdoesbodyCombatStressFatigue:Regeneration/Healing
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RegenerativeCapacityandVascularityofanOrgan
Muscle TendonBone
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Tendon:PoorHealingPotential
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Tendonosis increaseswithage
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DoesTendonosis leadtoTendontears
The Function of the Rotator Cuff
“Effect of Massive Rotator Cuff Tears”
Rotator Cuff
• Supraspinatus• Infraspinatus• Teres Minor• Subscapularis• Integrated Unit
Rotator Cuff Function
• Humeral head depressor / compressor
• RC always co-contracts with the deltoid.
• Deltoid cannot function without the RC
Deltoid contracting alone
Cantilever EFFECT: Co-Contraction of Deltoid and Rotator Cuff
Unbalanced CUFF TEARS: Massive Rotator Cuff Tears
Normal Massive tear: Proximal Humeral Migration
Consequences of a Massive Unbalanced Cuff Tear à Cuff Tear Arthropathy
ROTATORCUFFTENDONOSIS,TEARSANDSUBACROMIALIMPINGEMENET
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RCTendonosis andImpingement
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AnatomicalChangesContributingtoSubacromialImpingement
Acromial Spurs RC Tendonosis / Thickened Tendon
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ImpingementSigns
Neers Hawkins
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RotatorCuffTears:Anatomy
• Supraspinatus70%• Infraspinatus30%• Subscapularis20%• Teres Minor5%
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RotatorCuffTears:ClinicalPresentation
• Pain– Lateral/Anterior– Wakesuppatientatnight
– Worsewithoverheadactivities
• Examination– Lossofactivemotion– PreservedPassivemotion
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RotatorCuffTears:PainwithResistedtestingofmuscles
• Supraspinatus– ForwardElevation
• Infraspinatus/TeresMinor– ExternalRotation
• Subscapularis– InternalRotation
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RotatorCuffTears:PainwithResistedTestingofPower
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RotatorCuffTears:XRAY/US/MRI
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RotatorCuffTears:Non-opTreatment
• Analgesics• ModificationofActivities
• CorticosteroidInjections
• Physiotherapy
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RCT’s:SurgicalTreatment
• RepairofRotatorCuff– Open– Arthroscopic
• Longrecovery(6months)butgoodresults
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When should a patient with a Rotator Cuff Tear be offered Surgery Semi-Urgently?
MASSIVE CUFF TEARS
– Middle Aged Patient After a Shoulder Dislocation
– Shoulder Injury Leading to Loss of Ability to Lift Arm Above Head
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Acute Massive Rotator Cuff Tears
Patient can’t actively lift arm above shoulder level (but passive motion maintained)
Why is this surgery so “urgent”?
Why not trial non-operative management then surgery if this
fails?
What happens to the tendon and muscle after a cuff tear
• Tendon - contracts and shortens
• Muscle belly - Turns into fat
• These changes – Are IRREVERSIBLE– occur rapidly within 12 weeks
Tendon Retraction with Large Cuff Tears
Muscle Wasting and Fatty Infiltration
Significance of these Irreversible Cuff Changes
• Lower the chance of a successful outcome with surgery.
• Early repair of the rotator cuff àstops the progression of the changes
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MassiveCuffTearsà CuffTearArthropathy
Clinical Case: 63yo Sign Writer
2 weeks after shoulder
dislocation
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Massive Tears fixed early have a much better outcome than chronic massive tears
Acute Massive TearEasy to repair with Low Tension
Chronic Massive TearToo tight / shrunken to allow a repair
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Clinical Case: 63yo Sign Writer2 weeks after shoulder dislocation
Double Row Repair
6 months post-op
OSTEOARTHRITISOFTHEGLENOHUMERALJOINT
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GlenohumeralOsteoarthritis
• Uncommon– Notaweightbearingjoint
• UsuallyolderPopulation
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GlenohumeralOsteoarthritis
• Pain– Anterior– Chronic– Worsewithmovement
• Examination– LossofactiveANDpassivemotion
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GlenohumeralOsteoarthritis:Imaging
• XRAY– LossofGlenohumeraljointspace
– Osteophytes• “BeardOsteophyte”
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GlenohumeralOsteoarthritis:Treatment
• Non-operative– Analgesics– ModificationofActivities– CorticosteroidInjections
• Operative– ShoulderReplacement
• Half• Total
CuffTearArthropathy oftheShoulder
Unbalanced CUFF TEARS: Massive Rotator Cuff Tears
Normal Massive tear: Proximal Humeral Migration
Consequences of a Massive Unbalanced Cuff Tear à Cuff Tear Arthropathy
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CuffTearArthropathy:ClinicalFeatures
• ChronicShoulderpain– Anterior/lateral– Worsewithactivity
• Examination– ReducedActiveMotion– Variablepassivemotion
• XRAYisdiagnostic
“Normal”Osteoarthritis
XRAY Clues for Cuff Tear Arthropathy:“Proximal Migration of Humeral Head
Cuff Tear Arthropathy
- Acromiohumeral distance- Humeroscapular curve
XRAY Clues for Cuff Tear Arthropathy:“Shoulder becomes a Hip Joint”
“Normal”OsteoarthritisCuff Tear Arthropathy
Femoralisation of Humeral HeadAcetabularisation of Acromion / Glenoid
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CuffTearArthropathy:Non-OperativeManagement
• Analgesics• ModificationofActivities
• CorticosteroidInjections
• Physiotherapy:– AnteriorDeltoidStrengtheningExercises
!
!
CuffTearArthropathy:SurgicalManagement
• Reverse Total Shoulder Replacement
• Good for improving pain AND active motion
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WhatisaREVERSEShoulderReplacement?BallandSocketReversed.
Normal Shoulder Standard Shoulder Replacement Reverse Shoulder
Replacement
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Can’tdo“Standard”ShoulderReplacement:Glenoidloosens
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ReverseTSR:WorksbyLeverMechanism
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Acromioclavicular Joint:Anatomy
• SmallFibrocartilaginousJoint
• StabilizedmainlybyCoracoclavicularLigaments
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Acromioclavicular Joint:DegenerativeArthritis
• PresentonXrays inalmostallindividuals>50yearsBUT
• Usuallynotsymptomatic
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Acromioclavicular Joint:DegenerativeArthritis
• Pain– Superior,directlyoverACjoint
– Worsewithactivitiy
• Examination– TendernessdirectlyoverACjoint
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Acromioclavicular JointOA:Exam
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Acromioclavicular Joint OA:Imaging
• Xray– NarrowingofACJoint– OsteophytesfromAC
joint
• MRI– ACjt degeneration– Oedema inlateralend
ofclavicle
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Acromioclavicular JointOsteoarthritis:Treatment
• Non-operative– Analgesics,– Corticosteroidinjections– ModificationofActivities
• Operative– Excisionsoflateralendofclavicle
• Open• Arthroscopic
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LongHeadofBiceps:Anatomy
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EvolutionaryAnatomy
• Quadrupeds(e.g horse)– Bicepsonlyhasoneheadproximally– Importantforelevatinglimbafterstance,andlockinglimbinstancephase
– thebicepstendonfitsoverthehumeralheadandlockstheforelimbformingthepassivestayapparatusinstance.
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From4legsto2:TheINvolution oftheLongHeadofBiceps
4 legs --------------------------à 2 legs
Anatomical Changes indicate that the role of the biceps tendon in the shoulder is lessening
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LongHeadofBicepsTendon
• Tendinitis• Instability• LongitudinalTears/Splits
• Tendinopathy• Rupture(Popeye)
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BicepsTendonProblems:History
• Pain– Anterior– Radiatesdownthefrontofthearm
– Worsewithactivity
• Clicking– Withbicepsinstability
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BicepsTendonProblems:Examination
• Tenderness– OverBicepsTendonanteriorly
• Painwithresistedforwardelevation
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BicepsTendonProblems:Investigation
• XRAY(screeningtest)
• MRI
• Ultrasound:dynamic
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BicepsTendonProblems:Treatment
• Non-operative• Analgesics,• Corticosteroidinjections• ModificationofActivities
• Operative• Tenotomy
• Justcutitandletitdrop• Tenodesis
• Attachittothehumerus
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KeyPoints
• Increaseinlifeexpectancyiscoincidentwiththemechanicalfailureoftherotatorcuff.
• Tendonosis andCuffTearsaremostlyawearandtearphenomenonoftheshoulder.
Thank You
Lake Louise, Alberta, Canada