about shoulder pain and management

1. Shoulder Pain:
problems and
solutions

2.  The part of the body where the humerus attaches to the scapula.
 The shoulder must be mobile enough for the wide range actions of the
arms and hands, but also stable enough to allow actions such as lifting,
pushing and pulling.
 It is made up of three bones :
 Clavicle,
 Scapula
 Humerus.
INTRODUCTION

3. Bones of
Shoulder
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4. □Joints of the shoulder:
1. Glenohumeral joint (main one, ball and socket joint,
articulation between the glenoid fossa of the scapula
(shoulder blade) and the head of the humerus
2. Acromioclavicular joint (articulation between the
acromion process of the scapula and the lateral end of
the clavicle )
3. Sternoclavicular joint (articulation between sternal
end of the clavicle, and the manubrium sterni

5. ANATOMY ( cont.)
□There are two kinds of cartilage in the joint:
1. Articular cartilage : covers humerus head and
glenoid surface. It’s a white cartilage which allows the
bones to glide and move on each other. When this
type of cartilage starts to wear out (a process called
arthritis), the joint becomes painful and stiff.
2. Labrum : its a ring of rigid fibrous cartilage
surrounding the glenoid cavity, it stabilizes the ball
and socket joint

7. Muscle, Tendons, and Ligaments
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8. Rotator Cuff
Muscle

9. Shoulder Pain: Where to start?
Anamnesis & physical examination
+ Diagnostic tools

10. Causes of Shoulder Pain in the Primary Care Setting:
Impingement Syndrome >70%
Adhesive Capsulitis(Frozen Shoulder) 12%
Bicipital Tendonitis 4%
AC Joint Osteoarthritis 7%
Other (Instability, Infection) 7%
Smith, J Gen Intern Med 1992

11. 1. Shoulder Impingement Syndrome
“a collection of shoulder syndrome and
sign caused by pathology within the rotator
cuff tendon it self (intrinsic) or structures
external to it (extrinsic), causing
impingement in the narrowed space
between the acromion and humeral head”
(Sarkisian GC)

12. Clinical finding
□Pain on anterolateral aspect humerus ;
supraspinatus tendon insertion, worse by
overhead movement
□Acute or chronic
□Park et all show combination Hawkins-Kennedy
test, painful arc sign, infraspinatus muscle test
has probability 95% of impingement
□Painful arc sign, drop arm test, infraspinatus
muscle test has probability 91% of full thickness
tear

13. Testing/Provocation
Impingement: Empty Can
□Resist Forward Flexion
& Internal Rotation
□Test of Supraspinatus
Impingement

14. Impingement: Neer
□Neer Impingement
Test
■Passive forward flexion of
the forearm resulting in
pain

15. Impingement: Hawkins’ Test
Hawkins, Am J Sports Med 1980
Woodward, Am Fam Phys 2000

16. ROM examination
□Active and Passive
■Abduction
■Internal Rotation
■External Rotation
□Impingement:
Pain w/ active Abduction
(Supraspinatus Tendon)
□Adhesive Capsulitis:
Pain w: both active &
passive ROM

17. Imaging
□Plain film : AP view, scapular Y view,
axillary view
□Ultrasound : operator dependent, non
claustrophobic, identifying and measure
rotator cuff tear
□MRI : 93% sensitivity and 87% specificity

19. Indian Journal of Radiology and Imaging

20. Impingement

21. Management
□Conservative: education, physiotherapy,
NSAID
□91% satisfactory result
□NSAID vs Corticosteroid injections:
corticosteroid more effective for short term
□Extracorporeal shock wave therapy show
less benefit

22. □After 3-6 months of conservative treatment
□Subacromial decompression : debridement
bursa, acromioplasty, release CAL, posterior
capsule release, ACJ resection
□Arthroscopy is the gold standard
□Indication primary mechanical (outlet)
impingement of stage 2

23. Physiotherapy Medication Surgery

24. Full-thickness tear

25. Rotator Cuff Repair

26. 2. Adhesive Capsulitis ( Frozen
Shoulder )
□Most cases will
resolve without
surgery
□The inflammatory
process “burns itself
out”
□Freezing, frozen,
thawing stages
□Pain and
discomfort can be
severe, therefore
attempts are made
to shorten the
process
□Steroids
■Tablets in some
cases
■Injections
□Some patients go
on to need surgical
release of the
capsule and
manipulation of the
shoulder under
anaesthesia
□Gentle
physiotherapy
□Pool exercises

27. Adhesive
Capsulitis

28. Treatment (Adhesive Capsulitis)
Pain w/ Active ROM & Passive ROM
so :
□Reduce offending activities
□Physical Therapy
□NSAIDs or subacromial steroid injection
■Most resolve with conservative treatment:
Stretching/Exercises x 18 months;
■Orthopedic Referral

29. Simple
Exercise
Pendulum Exercise
Stand with your good
hand resting on a
chair. Let your other
arm hang down and
try to swing it gently
backwards and
forwards and in
circular motion.
Repeat abaout 5
times. Try this 2-3
times a day
Shoulder Stretch
Stand and raise your
shoulders. Hold for 5
seconds. Squeeze your
shoulder blades back
and together and hold
for 5 seconds. Pull
your shoulder blades
downward and hold
for 5 seconds. Relax
and repeat 10 times.
Door Lean
Stand in a doorway
with both arms on the
wall slightly above
your head. Slowly lean
forward until you feel
a stretch in the front
of your shoulders.
Hold for 15-30
seconds. Repeat 3
times. This isn’t
suitable exercise if you
have a shoulder
impingement
Door Press
Stand in a doorway with
your elbow bent at a
right angle and the back
of your wrist againts the
door frame. Try to push
your arm outwards
againts the door frame.
Hold for 5 seconds. Do
3 sets of 10 repetitions
on each side.
Use your other arm and,
still with your elbow at
the right angle, push
your palm towards the
doors frame. Hold for 5
seconds. Do 3 sets of 10
repetitions on each side.

30. 3. AC Joint arthritis

31. Treatment
Options
Often seen on Xrays
and MRIs without
causing symptoms
If symptomatic:
■Anti-
inflammatories
■Steroid + local
anaesthetic
injections
■Keyhole surgery
to shave down the
arthritic bone
ends

32. 3. Biceps Tendonitis
□Inflammation of long head of biceps tendon
□Repetitive lifting, overhead reaching or supination
□Anterior humeral pain; tenderness bicipital groove
Tear of Biceps Tendon:
□Chronically inflamed tendon
□Loss of flexion/supination
□“Popeye Sign”—proximal to
antecubital fossa
Holtby, Arthroscopy 2004

33. Biceps Tendonitis
Speed’s Test
With elbow extended
and hand supinated,
palpate bicipital groove
while patient attempts to
forward flex shoulder 30
degrees against
resistance
Siegel, Am Fam Phys 1999

34. www.icareunit.com

35. TREATMENT (Biceps Tendonitis)
□Eliminate Offending Activity
□NSAIDs/Steroid Injection (Subacromial
after age 50 – tendon rupture)
□Ice/Physical Therapy/Exercises
□Biceps Tendon Rupture  surgical repair

36. 5 to 10 pounds;
Arm kept vertical and close to the body
Swing arm back and forth or in a small diameter circle
(no greater than one foot in any direction).
20 biceps curls 1-2 x/day
Increase weight every 5 days as
tolerated
Biceps Tendonitis Exercise

37. 4. Shoulder Arthritis

38. Treatment
Options
Injections
■Steroid + local
anaesthetic
(reduces
inflammation)
Arthroscopy
■In some
situations, keyhole
surgery to “clean
out” the inflamed
tissue, shave loose
flaps of cartilage,
and smooth bone
spurs may be
considered
■Results are usually
temporary
Shoulder
Replacement
■The most
definitive way to
treat shoulder
arthritis
■Longevity of the
replacement will be
negatively affected
by heavy use of the
shoulder or high
impact activities

39. Shoulder Replacement

40. Terima Kasih
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