Painful shoulder

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This is a short presentation on common causes of shoulder pain, its clinical features,diagnostic methods and treatment modalities. This presentation would be helpful for general paractioners, orthopedic juniour registrars.

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Painful shoulder

  1. 1. Dr.A.Mohan krishna M.S.Ortho,Mch Orth (U.K), Consutant Orthopaedic Surgeon Apollo Hospitals.
  2. 2. PAINFUL SHOULDER-- CAUSES Acute shoulder pain • Fractures & Disclocations • Calcific tendinitis • Acute Rotator cuff tears Chronic shoulder pain Impingment Syndromes: • Subacromial bursitis • Rotator cuff tendonitis • AC arthritis • Hooked Acromion Osteoarthritis Shoulder Rheumatoid arthrits Partial rotator cuff tears
  3. 3. IMPINGEMENT SYNDROMES • • • • Subacromial bursitis Rotator cuff tendonitis AC arthritis Hooked Acromion
  4. 4. IMPINGEMENT SYNDROMES Impingement is due to squeeging of rotator cuff and sub acromial bursa between the coracoacromial arch, anterior 1/3 of the acromion & AC joint above and head of Humerus below. Painful arc syndrome
  5. 5. SUBACROMIAL BURSITIS
  6. 6. ROTATOR CUFF TENDINITIS
  7. 7. ACROMIOCLAVICULAR ARTHRITIS
  8. 8. HOOKED ACROMION
  9. 9. IMPINGEMENT :clinical features 1.Pain: Exacerbated by overhead or above the shoulder activities Night pain, often disturbing sleep, lying on affected shoulder. acute :following an injury, particularly in older patients, 2.Loss of motion: 3.Weakness and inability to raise the arm
  10. 10. IMPINGEMENT :clinical features Painful arc Neers impingment test Hawkins impingment test
  11. 11. IMPINGEMENT : IMAGING • Xrays : Sometimes normal • Xrays : shape of acromion AC joint arthritis • MRI • MSK Ultrasound: Cuff tears,Bursitis • Arthrogram
  12. 12. X RAYS AC JOINT ARTHRITIS HOOKED ACROMION
  13. 13. MRI: BURISTIS,ROTATOR CUFF PATHOLOGY
  14. 14. IMPINGEMENT : TREATMENT • • • • • Avoidance of offending activity Physiotherapy NSAIDS Corticosteroid injection Surgery : Subacromial decompression
  15. 15. IMPINGEMENT :PHYSIO
  16. 16. IMPINGEMENT : SUBACROMIAL INJECTION - Out patient procedure. - Reduces inflammation. - Pain relief
  17. 17. IMPINGEMENT :SUBACROMIAL DECOMPRESSION - Excision of inflamed bursa. -Acromioplasty - Excision of AC joint : Acromioclavicular arthritis -Open /Arthroscopic decompression
  18. 18. FROZEN SHOULDER • Primary  No underlying cause,  Insidious onset,  Global loss of movement
  19. 19. FROZEN SHOULDER:Secondary • General • Diabetes Mellitus Impingement Syndrome • Thyroid disease Bursitis • Gout/Pseudogout Synovitis • Drugs – Phenobarbitone Trauma Distant Osteoarthritis •Myocardial infarction •Head injury •Pulmonary TB •Carcinoma of Lung •Cervical spine diseases •Sub diaphragmatic pathology Secondary Local Causes
  20. 20. FROZEN SHOULDER:Pathology Connective Tissue Disease Inflammatory Thick and contracted capsule with fibrosis Recurrent haemarthrosis / Infection Suprascapular Nerve Entrapment Reflex Sympathetic Dystrophy
  21. 21. FROZEN SHOULDER: STAGES • Stage 1: Freezing Painful 3 – 4 months - Insidious onset of pain and loss of movement • Stage 2: Frozen Stiff 6 – 12 months - Resolution of pain, continued stiffness • Stage 3: Thawing Improves 6 months + - ROM improves
  22. 22. FROZEN SHOULDER: INVESTIGATIONS • • • • Plain X-ray: normal by definition Arthrography: decreased joint volume MRI: thick capsule Arthroscopy : Tight contracted joint space No adhesions Synovitis Tight axillary recess Loss of Subscapularis bursa Normal articular surface • Synovial Bx - Inflammatory Synovitis!
  23. 23. FROZEN SHOULDER: TREATMENT Stage 1: Acute Phase / Freezing  Analgesia, maintain ROM as possible.  Aggressive mobilisation/manipulation Contraindicated  ?Intra-articular steroid injection? Stage 2: Frozen  Physiotherapy, for mobilisation and stretching  MUA Stage 3: Thawing  MUA or arthroscopic release followed by physiotherapy.  Shoulder function usually improves about 70% within 3-8 weeks
  24. 24. FROZEN SHOULDER: TREATMENT • Frozen shoulder pathophysiology remains a puzzle • Clinical course to resolution may take 1 to 3 years • May be incomplete • MUA/Arthroscopic release has a role and speeds up resolution
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