most important shoulder disorder

1. SHOULDER ORTHOPEDIC
DISORDERS
DR.FAROUQ MAKKIE ALYOUZBAKI
ORTHOPEDIC SPECIALIST
NINEVAH MEDICAL COLLEGE

2. LEARNING OBJECTIVES
• 1-to define shoulder joint and shoulder girdle.
• 2-to Revise the anatomy of the shoulder joint
• 3-to enumerate the most common symptoms and signs of shoulder
disorder.
• 4-to outline the most common causes of shoulder pain.
• 5- to define rotator cuff syndrome and its divisions
• 6-impingement syndrome definition,pathogenesis,clinical feateurs
,treatment
• 7-calcific tendinitis definition and treatment .
• 8-biceps tendon disorder
• 9-definition of frozen shoulder and treatment modalities.

3. SHOULDER JOINT
• Multiaxial ball and socket type of synovial joint
• Most flexible joint in the entire human body due
to limited interference
• Formed by the articulation between the glenoid fossa
• of the scapula and the humeral head
• Shoulder girdle : humerus ,clavicle,scapula,and sternum

4. SHOULDER GIRDLE JOINTS
• GLENOHEUMERAL JOINT
• ACROMIOCLAVICULAR JOINT
• STERNOCLAVICULAR JOINT
• SCAPULOTHORASIC JOINT

5. NERVE AND BLOOD SUPPLY TO
SHOULDER JOINT
• Nerve supply:
((((Suprascapular N.,,,,Axillary N.,,,and Lateral pectoral nerve)))
BLOOD SUPPLY:
1-ANTERIOR AND POSTERIOR HUMERAL CIRCUMFLEX HUMERAL
ARTERY
2-SUPRASCAPULAR ARTERY
3-SCAPULAR CIRCUMFLEX ARTERY.

6. GLENOHEUMERAL STABILITY
• Stability depend on static and dynamic restraint
1-STATIC restraints
((glenohemeral ligements and glenoid labrum ))
2-DYNAMIC RESTAINTS
((rotator cuff muscle ,,,periscapular muscle ,,
long head of biceps))

7. SHOULDER SYMPTOMS
• Pain; in tip of the shoulder from rotator cuff or acromioclavicular (AC) joint
disorders.
• Referred pain; from neck (eg. Cervical spondylosis), mediastinum (eg. IHD).
• Stiffness (eg frozen shoulder).
• Swelling.
• Instability.
• Weakness; as in neurological disorders or
• tendon rupture.

8. SIGNS
• Expose both upper limbs, neck and chest.
• Exam from front, behind and axilla.
• Look:
• Skin; scar or sinus.
• Shape; swelling,
wasting or deformity.
• Position;

9. FEEL
• Skin: temperature.
• Bone and soft tissue points:
• Sternoclavicular joint.
• Acromioclavicular joint.
• Bicipital groove.

10. MOVE
• Active movements:
• Abduction: 0-90 degrees glenohumeral movement. Last 60
degrees is scapulothoracic movement.
• Flexion and extension:
• raise the arm forwards and backwards.

11. • Rotation; external (ask the patient to clasp fingers behind the
neck), internal (reach up the back with fingers).

12. OUTLINE OF THE CAUSES OF
SHOULDER PAIN
• I- Musculoskeletal :
• A- Traumatic
• B- Inflammatory (RA)
• C- Infectious (TB, Septic).
• D- Degenerative (Tendinitis, RCT, arthritis).
• E- Neoplasm (Bone, Soft tissues).
• II- Neurologic :
• A- Peripheral nerves.
• 1- Root compress (disc disease, Extra med tu.)
• 2- Brachial plexus (Thoracic out syndrome).
• B- CNS
• 1- Intramed. Tu. 2- Syringomyelia

13. • III – Vascular:
• A- Arterial:
• 1- Embolic.
• 2- Vasospastic.
• 3- Aneurysm.
• B- Venous:
• 1- Phlebitis.
• IV – Referred visceral pain:
• A- Cardiac.
• B- Gallbladder.
• C- Diaphragmatic.

14. ROTATOR CUFF SYNDROM
• The commonest cause of pain around the shoulder

15. ROTATOR CUFF ANATOMY
• Consist of tendons of:
• Supraspinatus.
• Infraspinatus.
• Subscapularis.
• Teres minor.
• Fused to the capsule of shoulder joint
• and insert around the greater tuberosity.
• Function: Abduction and stabilize
• the shoulder during movement.

16. ROTATOR CUFF SYNDROME CAUSED
BY FIVE CONDITIONS
• Supraspinatus tendinitis (impingement syndrome).
• Rupture of the rotator cuff.
• Acute calcific tendinitis.
• Biceps tendinitis and /or rupture.
• Adhesive capsulitis (frozen shoulder).

17. IMPINGEMENT SYNDROME
• Cause: Repetitive compression or rubbing of the supraspinatus tendon
under the coracoacromial arch during abduction of the arm;
• As in painting a wall or cleaning a window.
• Other predisposing factors:
• Acromiocalvicular joint OA,
• Gout and rheumatoid arthritis.

18. PATHOGENESIS OF SUPRASPINATOUS
TENDINITIS
((WEAR,,,TEAR,,,REPAIR))
1. Edema and swelling,
2. Minute tears develop.
3. Scarring, fibrocartilagenous metaplasia or calcification in the
tendon.
4. Healing or partial or complete tears.
5. The adjacent tendon of the long head of biceps often involved
by tendinitis or tear.

19. CLINICAL FEATURES
THREE CLINICAL PATTRENS
1. Subacute tendinitis (painful arc syndrome):
• Age <40 years.
• Anterior shoulder pain after vigorous or
• unaccustomed activity.
• Tenderness over the anterior edge of the acromion.
• The painful arc: pain on active abduction of the
• shoulder between 60 and 120 degrees.

20. WIDOWS CLEANING MOST COMMON CAUSE
OF PAINFUL ARC SYNDROME IN WOMEN

21. TESTS USED IN SHOULDER
EVALUATION AND SIGNIFICANCE OF
POSITIVE FINDINGS
Diagnosis suggested by
positive result
Maneuver
Test
Supraspinatous
tendionitis
Arm in full flexion
(slight abduction)
Neer's sign

22. TESTS USED IN SHOULDER
EVALUATION AND SIGNIFICANCE OF
POSITIVE FINDINGS
(CONT.)
Diagnosis suggested by
positive result
Maneuver
Test
Supraspinatus tear
Attempt to elevate the
arms against resistance
with abduction and the
thumbs are pointing down
Empty can test

23. 2-CHRONIC TENDENTIS
• Age 40-50 years.
• History of recurrent attacks of subacute tendinitis.
• Pain worse at night and on lying on affected side.
• Slight stiffness.
• Tenderness over the bicipital groove (biceps tendinitis).

24. MOST CAR DRIVERS HAVE ONE EPISODE
OF SHOULDER TENDINITIS PER YEAR

25. CUFF DISRUPTION
PARTIAL AND FULL THICKNESS TEAR
• Age >45.
• History of refractory shoulder pain with increasing stiffness and
weakness.
• Partial tears; abduction is possible but weak.
• Full-thickness tear; abduction of the arm is not possible.

27. TESTS USED IN SHOULDER
EVALUATION AND SIGNIFICANCE OF
POSITIVE FINDINGS
(CONT.)
Diagnosis suggested by
positive result
Maneuver
Test
Rotator cuff tear
Maximum degree of
abduction. Remove the
examiner hand support.
Drop-arm test

28. IMAGING
• Early; normal.
• Chronic tendinitis; erosion, sclerosis or cystic formation at
insertion of rotator cuff on the greater tuberosity.
• OA of acromioclavicular joint and glenohumral joint.
• Ultrasonography; may show large tears.
• MRI; effective in showing rotator tears.

29. MRI OF THE SHOULDER JOINT

30. CONSERVATIVE TREATMENT
• Uncomplicated impingement syndrome is often self-limiting by
eliminating the aggravating activity.
• Avoid impingement position (abduction, slight flexion and internal
rotation).
• Physiotherapy; ultrasound and active exercise.
• NSAID. If fails,
• Local injection of corticosteroid in the subacromial space.

31. SURGICAL TREATMENT
• Indications:
• Persistent symptoms >3months despite conservative
treatment.
• Younger patients with full thickness tear.
• Open or arthroscopic acromioplasty.
• Repair of rotator cuff tear.

33. CALCIFICATION OF THE ROTATOR
CUFF
ACUTE CALCIFIC TENDINITIS
Acute shoulder pain following
deposition of calcium hydroxyappatite
crystals in the supraspinatus tendon.
Cause; unknown.

34. CLINICAL FEATURE OF CALCIFIC
TENDONITIS
• Age: 30-40.
• Agonizing shoulder pain after exercise.
• Tender to palpation.
• Subside within days spontaneously.
• Treatment:
• Rest in a sling.
• NSAIDs.
• Corticosteroid local injection.
• Surgery: calcific material scooped out.

35. LESIONS OF THE BICEPS TENDON
-TENDINITIS:
• Usually associated with rotator cuff impingement.
• Tenderness over
bicipital groove.
• Treatment:
• Rest.
• Local heat and massage.
• Corticosteroid injection in the
bicipital groove.

36. RUPTURE OF LONG HEAD OF BICEPS
• Usually accompany rotator cuff
disruption.
• Age >50.
• Snap in the shoulder after lifting
an object.
• Lump in the lower arm on flexing
the elbow.
• Treatment; conservative.

37. ADHESIVE CAPSULITIS
(FROZEN SHOULDER)
• condition of the shoulder characterized by functional loss of
passive and active shoulder motion with no clear underlying cause
• more common among women
• ages 40-60 years
Pathoanatomy
•inflammatory process causing fibroblastic proliferation of joint
capsule leading to thickening, fibrosis, and adherence of the
capsule to itself and humerus
•fibroblasts/myofibroblasts with abundant Type III collagen present
•leads to mechanical block to motion

38. FROZEN SHOULDER
• Associated with:
• Diabetes mellitus.
• Dupuytren’s disease.
• Hyperlipidemia.
• Hyperthyroidism.
• Cardiac disease.
• Hemiplegia.

39. FROZEN SHOULDER
CLINICAL FEATURES
• Age: 40-60.
• Pain; gradually increasing, disappear within 6 months.
• Stiffness; gradually appears as the pain subside,
• persist for 6-12 months then start thawing.
• Passive and active movement is restricted in all directions.

40. TREATMENT
• Conservaive: during the painful stage:
• Reassurance.
• Analgesics and antiinflammatory.
• Exersice (pendulum).
• After pain subside:
• Manipulation under anesthesia with Steroid injection of
methyleprednisolone and lignocaine (risk of fracture neck of
humerus in porotic patients).

42. SURGICAL TREATMENT
• Surgical release is Indicated for persistent and disabling cases.

43. THANK YOU