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DegenerativeConditionsintheShoulder

Dr JohnTrantalisOrthopaedicSurgeon

W shoulderandelbow.com.au

MyProfile• Dr JohnTrantalis• MBBSUNSW1996• GainedFellowshipinOrthopaedicSurgery2007with:– RoyalAustralasianCollegeofSurgeons– AustralianOrthopaedicAssociation

• Shoulder&ElbowFellowshipinCanadaandSydney2007/08.


TreatmentofLocalizedDisease:LocationLocationLocation!!

PatientHistory1. Painprofile: SOCRATES

– Location– MechanicalPain?e.g shoulder

painworsewithoverheadactivities.

2. FunctionalProfile– Howdoestheproblemeffectthe

patient’sfunctionalactivities

3. JointProfile– MechanicalJointSymptoms:

Clicking,Locking,Instability,Swelling


TreatmentofLocalizedDisease:Examination

1. Look• Wasting,Scars,Posture,etc

2. Feel• Tenderness:Location!!!!!!• Especiallyinshoulder

3. Move• Activemotion• PassiveMotion

4. Specialtests


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.


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


OnlineVideoTutorial:HowtoExamineShoulders

These Video Tutorials can be viewed Online:

Shoulder: shoulderandelbow.com.au


TheShoulderJoint

• GreatROM• VeryShallow

Socket• Mostfrequently

dislocatedjoint

• RotatorCuff

Dr John TrantalisShoulder & Elbow Surgery


ConditionsAffectingtheAdultShoulder

• Age>40y• 85%“RotatorCuffSyndrome”

– RotatorCuffTendonosis andTears– Impingement– LongHeadofBicepsTendonPathology– Acromioclavicular JointPathology

– 10%FrozenShoulder(akaAdhesiveCapsulitis)– 4%Osteoarthritis– 1%other


ConditionsAffectingtheAdultShoulder

• Age<30y– 85%InstabilityofGlenohumeralJoint

• LabralTears

– 15%Other


FunctionoftheShoulderJointinHuman:PositiontheArminSpace

RECENTEVOLUTIONARYCHANGESEXPLAINTHEPATTERNOFDEGENERATIVESHOULDERCONDITIONS


From4legsto2:TheEvolutionoftheShoulderJoint

•Hitchcock JBJS 1948

NOWLET’SFOCUSONTHEACTUALCLINICALCONDITIONS…...

TENDONOSIS:WEARANDTEAROFTENDONSOVERTIME


Tendinosis:LifeExpectancyovertheAges


TheShoulder:Tendonosis


StressFatigueFailure


HowdoesbodyCombatStressFatigue:Regeneration/Healing


RegenerativeCapacityandVascularityofanOrgan

Muscle TendonBone


Tendon:PoorHealingPotential


Tendonosis increaseswithage


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


RCTendonosis andImpingement


AnatomicalChangesContributingtoSubacromialImpingement

Acromial Spurs RC Tendonosis / Thickened Tendon


ImpingementSigns

Neers Hawkins


RotatorCuffTears:Anatomy

• Supraspinatus70%• Infraspinatus30%• Subscapularis20%• Teres Minor5%


RotatorCuffTears:ClinicalPresentation

• Pain– Lateral/Anterior– Wakesuppatientatnight

– Worsewithoverheadactivities

• Examination– Lossofactivemotion– PreservedPassivemotion


RotatorCuffTears:PainwithResistedtestingofmuscles

• Supraspinatus– ForwardElevation

• Infraspinatus/TeresMinor– ExternalRotation

• Subscapularis– InternalRotation


RotatorCuffTears:PainwithResistedTestingofPower


RotatorCuffTears:XRAY/US/MRI


RotatorCuffTears:Non-opTreatment

• Analgesics• ModificationofActivities

• CorticosteroidInjections

• Physiotherapy


RCT’s:SurgicalTreatment

• RepairofRotatorCuff– Open– Arthroscopic

• Longrecovery(6months)butgoodresults


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


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


MassiveCuffTearsà CuffTearArthropathy

Clinical Case: 63yo Sign Writer

2 weeks after shoulder

dislocation


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


Clinical Case: 63yo Sign Writer2 weeks after shoulder dislocation

Double Row Repair

6 months post-op

OSTEOARTHRITISOFTHEGLENOHUMERALJOINT


GlenohumeralOsteoarthritis

• Uncommon– Notaweightbearingjoint

• UsuallyolderPopulation


GlenohumeralOsteoarthritis

• Pain– Anterior– Chronic– Worsewithmovement

• Examination– LossofactiveANDpassivemotion


GlenohumeralOsteoarthritis:Imaging

• XRAY– LossofGlenohumeraljointspace

– Osteophytes• “BeardOsteophyte”


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


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


CuffTearArthropathy:Non-OperativeManagement

• Analgesics• ModificationofActivities

• CorticosteroidInjections

• Physiotherapy:– AnteriorDeltoidStrengtheningExercises

!

!

CuffTearArthropathy:SurgicalManagement

• Reverse Total Shoulder Replacement

• Good for improving pain AND active motion


WhatisaREVERSEShoulderReplacement?BallandSocketReversed.

Normal Shoulder Standard Shoulder Replacement Reverse Shoulder

Replacement


Can’tdo“Standard”ShoulderReplacement:Glenoidloosens


ReverseTSR:WorksbyLeverMechanism


Acromioclavicular Joint:Anatomy

• SmallFibrocartilaginousJoint

• StabilizedmainlybyCoracoclavicularLigaments


Acromioclavicular Joint:DegenerativeArthritis

• PresentonXrays inalmostallindividuals>50yearsBUT

• Usuallynotsymptomatic


Acromioclavicular Joint:DegenerativeArthritis

• Pain– Superior,directlyoverACjoint

– Worsewithactivitiy

• Examination– TendernessdirectlyoverACjoint


Acromioclavicular JointOA:Exam


Acromioclavicular Joint OA:Imaging

• Xray– NarrowingofACJoint– OsteophytesfromAC

joint

• MRI– ACjt degeneration– Oedema inlateralend

ofclavicle


Acromioclavicular JointOsteoarthritis:Treatment

• Non-operative– Analgesics,– Corticosteroidinjections– ModificationofActivities

• Operative– Excisionsoflateralendofclavicle

• Open• Arthroscopic


LongHeadofBiceps:Anatomy


EvolutionaryAnatomy

• Quadrupeds(e.g horse)– Bicepsonlyhasoneheadproximally– Importantforelevatinglimbafterstance,andlockinglimbinstancephase

– thebicepstendonfitsoverthehumeralheadandlockstheforelimbformingthepassivestayapparatusinstance.


From4legsto2:TheINvolution oftheLongHeadofBiceps

4 legs --------------------------à 2 legs

Anatomical Changes indicate that the role of the biceps tendon in the shoulder is lessening


LongHeadofBicepsTendon

• Tendinitis• Instability• LongitudinalTears/Splits

• Tendinopathy• Rupture(Popeye)


BicepsTendonProblems:History

• Pain– Anterior– Radiatesdownthefrontofthearm

– Worsewithactivity

• Clicking– Withbicepsinstability


BicepsTendonProblems:Examination

• Tenderness– OverBicepsTendonanteriorly

• Painwithresistedforwardelevation


BicepsTendonProblems:Investigation

• XRAY(screeningtest)

• MRI

• Ultrasound:dynamic


BicepsTendonProblems:Treatment

• Non-operative• Analgesics,• Corticosteroidinjections• ModificationofActivities

• Operative• Tenotomy

• Justcutitandletitdrop• Tenodesis

• Attachittothehumerus


KeyPoints

• Increaseinlifeexpectancyiscoincidentwiththemechanicalfailureoftherotatorcuff.

• Tendonosis andCuffTearsaremostlyawearandtearphenomenonoftheshoulder.

Thank You

Lake Louise, Alberta, Canada

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