Identifying Shoulder Pathology with Surgical
Repairs and Replacement of the Shoulder
Dr. Terry Rzepkowski, DPT
Associate [email protected]
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Shoulder Objectives
Understanding:
• UE anatomy and musculature
• Mechanisms of injury
• Clinical testing
• Operative procedures
• Non-op Interventions
The ShoulderAnatomy
Clarification of Terms
Shoulder Complex =
Shoulder girdle
(scapula and clavicle)and
Shoulder joint
(scapula and humerus)
Scaption PositionNatural position is scaption: 30
degrees anterior to the Frontal
plane1,2
Clarification of Terms(cont’d)
Shoulder Complex
A. Sternoclavicular joint
B. Acromioclavicular joint
C. Glenohumeral joint
D. Scapulothoracic
articulation
Often imitated, never duplicated
Video
Steering and suspension
Shoulder Girdle
• Term used to discuss activities of the scapula, clavicle, and sternum
• The sternoclavicular (SC) and acromioclavicular (AC) joints allow shoulder girdle motions3-5
– Elevation and depression
– Protraction and retraction
– Upward and downward rotation
– Upward tilt-Reduction of Upward Tilt
Joint Motions Shoulder GirdleA. Elevation-depression
B. Protraction-retraction
C. Upward rotation-downward rotationD. Upward tilt-Reduction of Upward Tilt
D
Sternoclavicular Joint: Motions
Frontal planeElev/Dep
Sagittal planePost Rot
Horizontal planeProT/ReT
Ant/Post axisVertical axis
Acromioclavicular Joint: Osteokinematics
Horizontal plane
adjustments
during scapulothoracic
protraction
Sagittal plane adjustment
during scapulothoracic
elevation
Companion MotionsShoulder Joint and Shoulder Girdle
• Movement of the scapula is accompanied by movements of the glenohumeral joint and vice-versa
• Example: Shoulder flexion is accompanied by upward scapular rotation
• Impairment of one joint will also impair function at the other
Muscular Considerations
• Poor Posture
– Pec Minor tightness
– Biceps (short head) tightness
• Result
– Scapular protraction
– Decrease posterior tilt of scapula
– Decreased S-A space height
• Patient education point
– “Slouching active elevation test”
Scapulohumeral rhythm
• Shoulder Joint
– abduction
– Adduction
– flexion
– extension
– internal rotation
– external rotation
– horizontal abduction
– horizontal adduction
• Shoulder Girdle
– upward rotation
– downward rotation
– elevation/upward rot.
– Depression/downward rot.
– Abduction (protraction)
– adduction (retraction)
– adduction (retraction)
– abduction (protraction)
Active ROM Tests*Performed Bilaterally
• Apley’s Stretch Test
– Touch opposite acromion with hand of affected shoulder (add/IR)
– Reach behind the head and touch opposite shoulder from behind(abd/ER)
– Reach behind back and touch opposite scapula(add/IR)
Appley Scratch Test
• Adduction and Internal rotation: Ask the patient to place their hand behind their back, and instruct them to reach as high up their spine as possible. (T1)
• Abduction and External rotation: Ask the patient to place their hand behind their head and instruct them to reach as far down their spine as possible. (C7)
Appley Scratch Test
Video
Appley Test
The Shoulder Joint
• Also called the glenohumeral joint
– Ball-and-socket diarthrosis between head of humerus and
glenoid cavity of scapula.
– Allows more motion than any other joint
– Is the least stable
– Supported by 2 types of stabilizers:
1. Dynamic skeletal muscles and tendons
2. Static stabilizers of ligaments, labrum
The Shoulder Joint• Shoulder Ligaments
– Coraco-acromial- Causes SA compression often removed
– Coracoclavicular- Holds clavicle to scapular complex
– Acromioclavicular- Stabilizes AC joint
– Coracohumeral- Not commonly traumatized, or compromised
surgically
– Glenohumeral- Anterior dislocation and TSA
• Shoulder Separation: Acromioclavicular Joint
– Shoulder Dislocation: Glenohumeral Joint
Ligament Injuries
Shoulder Separation Shoulder Dislocation
Coracoacromial ligament
G. Coracoacromial
ligament
– Connects coracoid process to acromial process
– Roof over head of the humerus, serves as a protective arch
Shoulder Joint
Impingement Syndrome
• Very common
– Laborers
– Persons who do repetitive overhead motion
– Athletes
• Cause
– “the tendons of the rotator cuff (and subacromial bursa) are crowded, buttressed, or compressed under the Coraco-acromial arch, resulting in mechanical wear, stress, and friction”
Subacromial Space Primary Bony Impingement
• Causes for decreased subacromial space
– Degenerative changes
– Osteophyte formation
• On Acromion process
– Shape of acromion process
• Straight (Type 1)
• Slight hook (Type 2)
• Hooked (Type 3)
– Loss of scapular stabilization
Supraspinatus
• Compression, centering of humeral head
• Peak activity = 30-60° elevation
Abduction at Glenohumeral JointInitiates abduction
Active for first 110 degrees of abduction
Active 90-180 degrees of abduction
Superior dislocating component neutralized by infraspinatus, subscapularis, and teres minor
Roll/slide mechanics
Impingement: Roll-Slide Kinematics
“Roll” created by abduction not countered with “Slide” action
• Primary contributor = osseous adaptation
– Humeral retroversion
– Repetitive torsional stress (horizontal abduction and external rotation)
– Professional pitchers
– Average increase = 17° side to side
– Crockett, AJSM ’02
Adaptive Changes
“Glenohumeral Internal Rotation Deficit”(G.I.R.D.)
Rotator Cuff Injuries
• “Internal Impingement”• Impingement of RC on
posterior-superior glenoid rim and labrum
• Extreme shoulder abduction with ER
• Contributing factors• Excessive anterior translation
• Excessive ER
• Excessive humeral retroversion
• Pain at late cocking phase
Effects of Primary and Secondary Rotator Cuff Impingement
• Scapular Weakness– Affects humeral head stabilization– “functional scapular instability”
• Affects– Scapular position during activities that causes
» “relative decrease in subacromial space”• This can cause secondary impingement
– Weak scapular muscles (serratus anterior, traps (3), rhomboid) with postural imbalance of levator and pec minor
Impingement
Possible mechanisms
Weak or inflexible rotator cuff
Small anatomical space
GH ABD + ROT
Scapular positioning and weakness
2 types of Impingement
• Primary
• Anatomical cause of rotator cuff injury
– Mechanical compression of r/c tendons
• Primarily which one?
• Secondary
• Kinesiological cause of injury
– Related to GH instability that creates reduced subacromial space
• Causes of GH instability?
MRI of RTC Impingement
ROTATOR CUFF
TENDON
Impinged Tissues
Tests for RTC Impingement
• Impingement tests:
• Neer (Coracoacromial arch)
• Hawkins Kennedy (Sub-acromial region)
• Cross Over (AC region)
• *Literature indicates that these tests are better for ruling out a condition if negative than ruling in if positive4
Requirements of All impingement tests
1. Stabilize the scapula
2. Full internal rotation
3. Taken to the end of capsular motion with overpressure
4. Note area of discomfort, is it correlative to the referral area for pain.
Neer impingement Test
RTC impingement test Coracoacromial arch
Hawkins Kennedy Test
RTC impingement Test Subacromial
Cross Over Impingement Test
RTC impingement testAcromioclavicular
Video
Impingement tests
MRI of RTC Impingement
ROTATOR CUFF
TENDON
Sub Acromial Decompression (SAD)
• Impingement (anatomical, and bio-mechanical), RTC Tendonitis, Sub acromial bursitis that is unresponsive to conservative treatment.
• The operation aims to increase the size of the subacromial area and reduce the pressure on the tendon. It involves cutting the ligament and shaving away the bone spur on the acromion bone.
Sub Acromial Decompression (SAD)• Also commonly performed preceding arthroscopic
rotator cuff repair
Video
SAD
BREAK!!
Clavicular Ligaments
E. Acromioclavicular ligament
– Hold the acromion process to the clavicle and prevents posterior dislocation of the clavicle
F. Coracoclavicular ligament
– Not directly located at the acromioclavicular joint
F1. Conoid portion - medial
F2. Trapezoid portion – lateral
AC SeparationCommonly caused by a fall
directly on the "point" of the
shoulder or a direct blow received
in a contact sport resulting in a
piano key deformity
The Bucs quarterback injured on
10/15/17 played on 10/22 and
completed 31 of 43 passes for
385 yards, three touchdowns and
one interception against one of
the best pass defenses in the
NFL—and he did that with no real
passing game, while injured, on
the road.
AC separation imaging
X-Ray is the best way to
image this, MRI is actually
harder to visually
appreciate due to the
narrow field of reference
Glenohumeral Joint Instability and Dislocation
• Anterior Dislocation
• Occurs with arm abducted, extended, ext rot (FOOSH)
• Occurs more often in men
• Occurs much more commonly than posterior
Glenohumeral Ligaments (B)
• Reinforces anterior portion of the capsule
• Not well-defined
– Superior glenohumeral ligament
– Middle glenohumeral ligament
– Inferior glenohumeral ligament
• Actually pleated folds of the capsule
The Shoulder Joint
• Socket of the Shoulder Joint
– Glenoid labrum
• Deepens socket of glenoid cavity
• Fibrous cartilage lining
• Extends past the bone
• Processes of the Shoulder Joint
– Acromion (clavicle) and coracoid process (scapula)
• Project laterally, superior to the humerus
• Help stabilize the joint
• Patient is in pain
• There is loss of the normal contour of the shoulder with a square appearance. Loss of the contour of the shoulder may appear as a step
• Anterior bulge of head of humerusmay be visible or palpable
• A gap can be palpated above the dislocated head of the humerus
• Holds the injured limb with other hand close to the trunk (carry angle)
• The shoulder is abducted and the elbow is kept flexed
X Ray anterior Dislocation of Shoulder
Anterior Shoulder dislocation•Hill Sach’s Lesion
•Can cause neurological symptoms even once reduced
Hill Sach’s imaging
GH Joint Dislocations Cont……….
• Bankart Lesions
• Occurs and classified when force of dislocation great enough to completely dislocate from the glenoid thus tearing the labrum
• “an avulsion of the capsule and labrum off the anterior aspect of the glenoid”
• Results from a traumatic ant. dislocation
Bankart lesions
Hill Sach’s and Bankart
• Hill Sachs: Posterolateral humeral head compression fracture as the humeral head comes to rest against the anterior inferior part of the glenoid.
• Bankart: Detachment of the anterior inferior labrum from the underlying glenoid. It may be labral only ("soft Bankart"), or involve the bony glenoid margin (impaction fracture) and this is called a "bony Bankart".1
Video
Bankart and Hill Sach’s
Subscapularis involvement
Cadaver dissection Relation to GH dislocation
• Anterior dislocation will weaken if not cause tearing and disruption to the subscapularis.
• Positive clinical testing for the subscapularis may indicate previous subluxation/dislocation of the GH joint
Multi-directional Instability(MDI)
• Subluxation in multiple directions
• Sports with repetitive abduction and ER
– Swimmers, gymnasts
• Symptoms
– Sensation of dislocation
– “Directional symptoms”
• Anterior: HAB, 90-90° position
• Posterior: HAD, pushing movements
• Inferior: discomfort carrying heavy objects
Sulcus sign
• Seen in CVA when there is not enough tone to resist gravity.
• Also seen in the unstable MDI shoulder when a traction force is applied.
Video
Piano key and sulcus sign
Special Tests - Instability
• Anterior apprehension sign2
Relocation Test• Following positive apprehension pain is
reduced with posterior humeral head force
Anterior Release/Surprise Test
• Place the pt. in the 90/90 position
• Apply a posterior translator humeral force
• Release quickly
• Pain on rebound is a positive test
Combination of Anterior GH Instability tests can all be done in sitting
Video
GH Dislocation tests
Bankart Lesion Repair
GH Joint Dislocation Cont……
• Hill-Sachs Lesion
• Results from an injury to head of the humerus
• Caused by anterior instability
• The actual ‘lesion’ is a compression “impaction” type fracture to the posterolateral aspect of the humeral head
• Results in “instability "and is not the cause
• Instability can occur in a multi-direction pattern: anteriorly, posteriorly, and inferiorly
Remplissage Procedure.
'Remplissage' is French for 'to fill in'.
Video
Dislocation Repair
Athletic trauma
SLAP Lesions
• Superior Labrum, Anterior to Posterior
• Traumatic
– Fall on outstretched arm
• Atraumatic
– Overhead sports
SLAP Lesions
• SLAP= Superior Labrum Anterior Posterior
• FOOSH mechanism with arm flexed to 90, in closed chain occurs in sports, weight lifting, and also MVA with avoidance pressure on the steering wheel.
Traumatic SLAP Injuries
• Traumatic events, such as falling on an outstretched arm or bracing oneself during a motor vehicle accident, may result in a SLAP lesion due to compression of the superior joint surfaces superimposed with subluxation of the humeral head.
MRI Imaging Case example
Case study MRI and arthroscopic findings
Atraumatic SLAP Lesions
Proposed Mechanisms of Injury• Eccentric loading
– Deceleration• Eccentric contraction of
biceps
• Tension on long head
• Tendon “pulls off” labrum
– E-stim to biceps• Separation from glenoid
• “Peel back” mechanism
– Cocked position• Torsional stress at biceps
anchor
– Pradham, AJSM ‘01• Increased superior labral strain
during late cocking
– Contribution of compressive load? (internal impingement)
Andrews, AJSM ‘85 Burkhart, Arthroscopy ‘98
SLAP Lesions
Classification (Snyder, Arthroscopy ‘90)
• Type I• Superior labral fraying
• Type II• Most common• Biceps anchor detachment from
glenoid
• Type III• Bucket handle tear of labrum• Normal biceps anchor
• Type IV• Bucket handle tear of labrum
that extends into biceps tendon• Detachment of biceps anchor
SLAP Lesions
• SLAP and Instability
• SLAP tear associated with increased G-H translation
• SLAP tear = 6mm increase in anterior translation
Pagnani, JBJS ‘95
Special Tests – SLAP Lesions
• O’Briens Test, great sensitivity not secificity
• Standing, GH joint flexed to
• 90/adducted to 15
• Forearm pronated/humerus IR
• Apply downward force and repeat in supination3
A-P Slide test
• Stabilize the scapula with heel of
the hand on the spine of the
scapula and the fingers over the
coracoid
• Isolate the head of the humerus
sliding anterior and posterior.
• SLAP will produce pain in the
opposite direction due to labral
separation. Bankart will be in the
same direction due to instability.
Special Tests – SLAP Lesions
• Compression / rotation test, good specificity, pain is 180 opposite the compression due to labral separation.
Special Tests – SLAP Lesions
Compression Rotation Test
Photos courtesy of MikeReinold.com
Biceps Load II
The patient is in the supine position with the shoulder in 120
degrees of elevation and full external rotation, while the elbow
is in 90 degrees of flexion, and the forearm in supination. The
patient is then asked to flex the elbow as the clinician
provides resistance.
Diagnostic Properties
Sensitivity: 0.897
Specificity: 0.966
SLAP and Biceps LH• Superior labral tears and detachment of the
Biceps LH
• Labral repair surgery involves re-anchoring or trimming the torn piece of cartilage.
Video
Slap repair
BREAK!!
The Muscles of the RTC
93
Rotator cuff = S.I.T.S.SupraspinatusInfraspinatusTeres MinorSubscapularis
Function of Rotator Cuff
• Large external muscles (e.g., lats, delts) create shear forces
• Rotator cuff provides
– Joint compression
– Tangential restraint (Ant, Post, Sup)
Deltoid produces superior shear force at GH joint.
Subscapularis
• Resists superior shear
• Produces simultaneous internal rotation
Infraspinatus & Teres Minor
• Resists superior shear
• Neutralizes SUBSCAP internal rotation
Summary of Active Arthrokinematics Resisting Shear
Destabilizing Action of Latissimus Dorsi
• LD pulls humerus INF
• SSP resists INF force
• INF & SUBSCAP create compressive force
Overhead Sport Skills
Overhead Mechanics
Complexities of Pitching & Overhead Serving
• Highly skilled
• High angular velocities
• High rotational torques
• High generated forces
• Tremendous flexibility/ROM
• Muscular strength
• Muscular coordination
• Synchronicity of motion
• Force transmission
• Neuromuscular control
• Dynamic stabilization
• Repetitive loading
Extraordinary demands on soft tissue, joints and
growth plates
HIGH INJURY RISK
Goals of Kinetic Chain
• Proximal segments
– Large relative muscle mass
– Primary force / kinetic energy producer
– Accelerate the chain
– Sequentially transfer energy to next distal segment
– Decelerate forces after release
• End result
– Transfer maximum force through distal segment to ball
– Dissipation of forces after release by continuing the chain movement
Functional Importance of Kinetic Chain
• Seamless transfer of energy
• Maximize use of momentum
• Minimize stress to:
– Ligaments
– Dynamic stabilizers (fatigue concerns)
– Joint
Injury-free, unrestricted participation in sport
Not the Goal of
the Kinetic Chain
Rotator Cuff Injuries
• Primary tensile cuff disease
– Undersurface RC injury tear
– Tensile overload due to deceleration
– Pain after ball release
MRI of RTC Tear
ROTATOR CUFF
TENDON
Preferred ERLS Position
“The ERLS is highly specific and
acceptably sensitive for diagnosis of full-
thickness tears, even in the case of an
isolated lesion of the supraspinatus
tendon.”5
External rotation lag sign (ERLS)
Infraspinatus / teres minor
Damage test. Drop arm 1 + 2
For the supraspinatus: 1 is against
gravity, 2 is with light distal tapping
to account for upper trap
compensation.
Video
Drop Arm
Damage test. Empty can
External rotator test
For the External rotators: a resistive test look, for
compensation
Make sure the elbows are bent with shoulders internally
rotated. This is not a deltoid C5 myotome test
Supraspinatus isolation
• If dissymmetry suspected with empty can test, perform supine isolation for external rotators with scapular stabilization, compare bilaterally.
Damage test, Gerber Lift Off
subscapularis test
For the subscapularis: likely present with GH dislocation test, but
can be seen without, may be present in overuse (swimmers)
Internal Rotation LAG sign IRLS
For the subscapularis: performed only if Gerber is positive
Video
RTC tests
RTC repair• For tears and/or detachment of the any of the
RTC tendons, open and arthroscopically
• repair surgery involves trimming damaged ends and re-anchoring the torn section of tendon.
Video
Arthroscopic RTC repair
Video
Open RTC repair
What is Regenerative Medicine?
Regenerative medicine (Ortho Biologics) seeks to
decrease pain and improve function by using your
body’s own natural cellular mechanisms to accelerate
healing, reduce pain and inflammation, and potentially
regenerate tissue.
Ortho BiologicsOrtho
Biologics(addresses the
root cause)
Prolotherapy
PRP
Growth factors
BMAC
Stem cell
Not All Procedures are uniform• Differences can include:
• Where the stem cells are harvested from (fat cells more cosmetic uses, Bone marrow more applicable to joints)
• How stem cells, or platelets in PRP are separated from the rest of the harvested tissue
• How PRP or stem cells are delivered to the arthritic joint
• These differences are further complicated by more unknowns. For example, how many stem cells are needed for a particular treatment? And how do we determine if a patient’s own stem cells are competent enough to aid in healing?
Injection Procedures
Video
Type 1 PRP
Video
Type II PRP
RTC repair vs ortho biologicBasic Ex progression
Surgical
• Immobilize for 4-6 wks.
• Sling off for bathing and dressing only
• Ice and meds for pain
• Wks 4-6: Gradual return to AAROM
• Wks. 6-12: Gradual return to strengthening
• After wk. 12: Focus on return to sport/activity
Ortho biologic injection
• Gentle PROM-AROM as tolerated
• No lifting. No sudden lifting, no pushing, no overhead reaching
• Heat prior to ROM, meds for pain
• Day 4-Week 2: Begin scapular exercises
• Wks 3-9: Gradual return to strengthening
• Wk 7: return to sport/activity no restrictions
Regenerative Non Surgical Coverage• What does Insurance pay for?
• Evaluation, diagnostic imaging and reading of findings (ALL)
• Ortho biologic treatments: Worker’s comp and other self-insured companies that are self-funded.
• Major Insurance companies as of yet do not cover treatments, but will pay for any therapy and bracing following treatment.
• Cost Examples vary by condition this is an approximation, actual costs vary depending on pathology
• Ortho biologic injection of labrum and adjacent tendinopathies
• PRP alone $1200
• Amnio fix growth factor alone $800
• Combination PRP and Growth factor $1800
• 3 phase stem cell injection $6950
Xray and MRI for Arthritic shoulder
Total Shoulder Arthroplasty (TSR/TSA)
• Indications
– Degenerative changes in articular surfaces
– Late-stage OA, RA, Traumatic Arthritis
– Cuff-Tear Arthropathy (CTA)
– Osteonecrosis (avascular necrosis) of the head of the humerus
– Goal is to:
• Relieve pain
• Improve shoulder mobility and stability
• Improve functional use for ADL’s
TSA Implant design, materials, fixation• Implant Design- high-density
polyethylene glenoid component (usually all plastic) with a humeral component made of a metal which resembles biomechanical features of human bone
• Fixation- press-fit, bio-ingrowth, cement
• Depends upon surgeon’s preference of design as well as strength and integrity of patient’s bone----?????bone cement
TSA Prosthetic Designs• Unconstrained-stemmed humeral component, used
with intact/strong RC
• Semi-constrained-erosion of the glenoid fossa but still can have rotator cuff repair
• Reversed ball and socket -appropriate for patients with very damaged and irreparable RC
TSA/RSA Surgical Approach
• Anterior Approach-Deltopectoral Incision
• Tenotomy –Release the subscap tendon from its attachment on lesser tuberosity
• Osteotomy of humeral head
• ‘Rebalancing of soft tissues intraoperative lengthening or tightening, particularly the rotator cuff
• Repair/Reattachment of the subscapularis
• Dislocation Precautions: “Reaching hand into back pocket” movement to retrieve wallet (men) and fastening bra from behind (women
TSA and Rev TSA• TSA: involves anatomically replacing the humeral
head and glenoid surfaces
• Rev TSA: involves anatomically reversing the humeral head and glenoid surfaces
Video
TSA
Reversed anatomy and convex-concave rule, Dislocations tend to occur more posterior-inferior
Reverse Implant
Video
Reverse TSA
Questions