Shoulder pain (1).pdf

Shoulder pain Dr. Zahraa Hussein Altemimi OBJECTIVES To know common causes of shoulder pain What is shoulder impingement, epidemiology, risk factors, pathophysiology, and management.  NOTES ON APPLIED ANATOMY The anatomy of the shoulder is uniquely adapted to allow freedom of movem...

Shoulder pain Dr. Zahraa Hussein Altemimi OBJECTIVES To know common causes of shoulder pain What is shoulder impingement, epidemiology, risk factors, pathophysiology, and management.  NOTES ON APPLIED ANATOMY The anatomy of the shoulder is uniquely adapted to allow freedom of movement and maximum reach for the hand. Five ‘articulations’ are involved: the glenohumeral joint the pseudojoint between the humerus and the coracoacromial arch the sternoclavicular joint the acromioclavicular joint the scapulothoracic articulation.  Rotator cuff muscles Supraspinatus Infraspinatus Teres minor Subscapularis * contraction of the individual muscles exerts a rotational pull on the proximal end of the humerus, the other function of it is to draw the head of the humerus firmly into the glenoid socket and stabilize it there when the deltoid muscle contracts and abducts the arm. Movement of the humeral head within the glenoid and of the scapulothoracic articulation achieves motion in multiple planes ( flexion, extension, internal rotation, external rotation, abduction, adduction) Causes of shoulder pain 1- local cause 2- referred pain: ex: nerve roots compressionC4,C5, myocardial ischemia….  Definition and epidemiology Subacromial impingement syndrome (SIS; shoulder impingement) refers to a combination of shoulder symptoms, examination findings, and radiologic signs attributable to the compression of structures around the glenohumeral joint that occurs with shoulder elevation. Such compression causes persistent pain and dysfunction. Shoulder pain is highly prevalent within the general population, second only to lower back pain. SIS is the most common cause of shoulder pain.  Risk factors Repetitive activity at or above the shoulder during work or sports represents the main risk factor for SIS. These sports may include swimming, throwing, tennis, weightlifting, golf, volleyball, and gymnastics. Overhead work activities that can increase risk for developing SIS include painting, stocking shelves, and mechanical repair increasing age also predisposes to SIS. Instability of the glenohumeral joint. Glenohumeral joint laxity Scapular instability Upper extremity inflexibility, particular acromion anatomy,  Pathology It is thought to arise from repetitive compression or rubbing of the tendons (mainly supraspinatus) under the coracoacromial arch. Normally, when the arm is abducted, the conjoint tendon slides under the coracoacromial arch. As abduction approaches 90 degrees, there is a natural tendency to externally rotate the arm, thus allowing the rotator cuff to occupy the widest part of the subacromial space. If the arm is held persistently in abduction and then moved to and fro in internal and external rotation (as in cleaning a window, painting a wall or polishing a flat surface), the rotator cuff may be compressed and irritated as it comes in contact with the anterior edge of the acromion process and the taut coracoacromial ligament. This attitude (abduction, slight flexion and internal rotation) has been called the ‘impingement position’. The site of impingement is also the ‘critical area’ of diminished vascularity in the supraspinatus tendon about 1 cm proximal to its insertion into the greater tuberosity. SIS consists of a spectrum of clinical findings, not injury to a specific structure. This spectrum consists of the following stages: Stage 1: Edema and hemorrhage (patient generally 40 years).  CLINICAL PRESENTATION AND Patients EXAMINATION complain of pain with overhead activity. The pain may localize to the deltoid area or lateral arm and often occurs at night or when lying on the affected shoulder. Complete neck examination. Inspection for atrophy or disfigurement. Evaluation of glenohumeral range of motion (including a comparison of passive versus active motion). Specialty testing (painful arc), Neer straight arm raise and Hawkins-Kennedy internal rotation maneuvers are sensitive for SIS. Single tests, although suggestive if positive, are insufficient to rule in or rule out SIS. Three or more positive tests improve the diagnostic likelihood.  pain typically appears over the front and lateral aspect of the shoulder during activities with the arm abducted and medially rotated, but it may be present even with the arm at rest. Tenderness is felt at the anterior edge of the acromion. Glenohumeral range of motion limited by pain (eg, positive painful arc test). Reproduction of pain with specialty testing eg, Neer , Hawkins-Kennedy Atrophy of posterior shoulder musculature if impingement is chronic. Shoulder strength normal, except in some cases of long-standing impingement.  DIAGNOSTIC IMAGING Plain radiographs — are unnecessary for the diagnosis of SIS but can be obtained to rule out other associated pathology. Musculoskeletal ultrasound —is an accurate tool for the evaluation of superficial tendon and muscle lesions of the shoulder, as well as bursitis, and enables dynamic examination at the bedside. Magnetic resonance imaging — (MRI) is most useful for assessing rotator cuff pathologies other than SIS, including labral tears, biceps tendon injuries, and intra-articular injuries that may benefit from surgery.  DIAGNOSIS SIS is a clinical diagnosis made on the basis of a suggestive history and confirmatory examination findings. Imaging findings can help to confirm the diagnosis. DIFFERENTIAL DIAGNOSIS 1- Rotator cuff tears (most often involving the supraspinatus) frequently cause weakness in addition to pain and are associated with a positive drop arm test and weakness with resisted external rotation. Most develop chronically in adults over 40 years of age and may be a complication of long-standing subacromial impingement. Tears in older adolescents and young adults are more often sustained acutely during sport. Musculoskeletal ultrasound and MRI can aid diagnosis. 2- Adhesive capsulitis (frozen shoulder) – Patients complain of increasing motion restrictions associated with pain and dysfunction while performing activities of daily living. They often give a history of recent shoulder injury or surgery and may be diabetic. The condition manifests as restricted active and passive glenohumeral motion. MRI often reveals characteristic capsular thickening and adhesions.  Treatment Cryotherapy – Ice may decrease acute swelling and inflammation and provide some analgesia. Rest – This means avoiding activities that aggravate symptoms, including all overhead activities. Nonsteroidal antiinflammatory drugs (NSAIDs):short course (2-4 weeks) of scheduled NSAID therapy. Thereafter, patients may use an NSAID as needed. Physical therapy: effectively treat most patients with SIS and should be implemented prior to surgical referral.  Subacromial injection — a subacromial injection of glucocorticoid to patients with persistent pain and dysfunction despite six weeks of acute treatment and physical therapy. Refer patients with SIS for orthopedic evaluation if three months of conservative treatment (including appropriate physical therapy) fails to improve symptoms and function. REFERENCES Apley and Solomon’s System of Orthopaedics and Trauma. 10TH edition. uptodate THANK YOU