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Shoulder pain

Shoulder pain. EPIDEMIOLOGY. Prevalence in General Population 70 _ 260 per 1000 Common in Female Common in > 40 y Risk increases on activities that need raising the arms or working with hand tools. Causes of Shoulder pain. Intrinsic Cause:

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Shoulder pain

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  1. Shoulder pain

  2. EPIDEMIOLOGY • Prevalence in General Population 70 _ 260 per 1000 • Common in Female • Common in > 40 y • Risk increases on activities that need raising the arms or working with hand tools

  3. Causes of Shoulder pain • Intrinsic Cause: Periarticular Disorders  Glenohumeral Disorders • Extrinsic Cause:

  4. Causes of Shoulder pain • Periarticular Disorders:  Rotator cuff tendinitis or Impingement syndrome  Rotator cuff tears  Calcific tendinitis  Bicipital tendinitis  Acromioclavicular arthritis

  5. Causes of Shoulder pain • Glenohumeral Disorders:  Inflammatory Arthritis  Osteoarthritis  Osteonecrosis  Cuff Arthropathy  Septic Arthritis  Adhesive Capsulitis  Glenohumeral Instability  Glenoid Lebral Tears

  6. Causes of Shoulder pain • Extrinsic Cause:  Cervical radiculopathy  Brachial neuritis  Nerve entrapment syndromes  Sternoclavicular arthritis  Reflex sympathetic dystrophy  Fibrositis  Neoplasms  Miscellaneous Gallbladder disease , Splenic trauma , Subphrenic abscess , MI ,……

  7. Rotator cuff Tendinitis • Rotator cuff is composed of 4 musculotendinous unit :  Supraspinatus  Infraspinatus  Teres Minor  Subscapularis

  8. Rotator cuff Tendinitis A • The most common cause of shoulder pain (70%) • Rotator cuff tendinitis is clinically defined as shoulder pain exacerbated by movement against resistance when Shoulder is : A) abducted (Supraspinatus tendinitis) B) Externally Rotated (Infraspinatus tendinitis) C) Internally Rotated (Subscapularis tendinitis) B C

  9. Causes of Rotator cuff Tendinitis • Intrinsic: Poor vascular supply of the critical zone  Degenerative changes associated with aging  Local calcium deposits • Extrinsic:  Impingement

  10. Causes of Rotator cuff Tendinitis • Impingement: In the volume the tendons In the volume of bursa  Enclosed space secondary to:  acromial shape  Osteophytes  Superior migration of the humeral head

  11. Rotator cuff Tendinitis • Potential shapes of acromion A) Flat B) Curved C) Hooked A B C

  12. Rotator cuff Tendinitis Epidemiology • Middle age & Elderly • Impingement :  Stage 1 : < 25y Swimmer, Tennis player  Stage 2 : 25 _ 40y Workers, Athletes  Stage 3 : > 40y

  13. Rotator cuff Tendinitis • Clinical Feature : • Painful Arch in Abduction & Flexion (60 _ 120 degree ) • Limitation in active movement , but not in passive

  14. Rotator cuff TendinitisClinical Examination : • Neer Test (non specific) The patient’s scapula is immobilized and the painful arm is passively flexed as far as it will go

  15. Rotator cuff TendinitisClinical Examination : • Impingement Test injection of lidocaine into the subacromial bursa

  16. Rotator cuff Tendinitis Radiography • Normal in early stages • Narrowing of the acromiohumeral gap • Erosive changes of the anterior acromion • Sclerosis of anterior 1/3 acromion

  17. Rotator cuff Tendinitis • Treatment : • Rest • NSAIDs • Strengthening Exercises

  18. Rotator cuff Tears • Before 40y is rare unless: Significant acute trauma (Fall on an outstretched arm) • Acute ( 8%) • Chronic

  19. Rotator cuff TearsClinical Manifestation : • No clinical sign is pathognomonic • Pain & weakness in abduction and external rotation • Symptoms of chronic impingement • Supra & Infraspinatus atrophy (in long-standing tears)

  20. Rotator cuff TearsClinical Examination : • Drop arm test Sensitivity 98% Specificity 10% The arm is passively abducted to 90 degrees then released

  21. Clinical Examination of Rotator cuff Tears • Three positive test or twoif the patient is aged >60y are diagnostic for a rotator cuff tear (98%) A) Supraspinatus weakness B) Infraspinatus weakness C) Hawkins impingement sign in abduction & external rotation D) Hawkins impingement sign in abduction & internal rotation A B D C

  22. Rotator cuff Tears • Cuff Arthropathy should be suspected if: Acromial humeral distance less than7mm  Cyst formation within the greater tuberosity  Humeral head osteopenia

  23. Diagnostic tests in Rotator cuff Tears • Arthrography (with sensitivity & specificity > 90%) • Ultrasonography (a good screening tools) with favorable sensitivity & specificity • MRI ( very helpful in diagnosis of tears )

  24. Treatment in Rotator cuff Tears • Young adult : Surgical treatment • Elderly person : Conservative treatment for 6 to 12 months if failed surgery

  25. Calcific Tendinitis • Definition :A painful condition about the rotator cuff , association with deposition of calcium salts • Etiology : Unknown . but, degeneration of tendon is the commonly accepted cause • incidence :2.7-20 % in asymptomatic individuals inDiabetic patient , Uremia , Hypervitaminosis D • Average age :40 _ 50y • Common in the right shoulder , 6% bilateral • More than 50% occurs in Supraspinatus tendon • Up to ¾ of patients are Female

  26. Clinical Manifestation of Calcific Tendinitis • Three clinical pictures occur : Silent(discovered incidentally, never cause symptoms) Chronic Calcific Tendinitis( chronic aching , increased pain on flexion & abduction) Acute Calcific Tendinitis(sudden excruciating shoulder pain , radiates toward deltoid insertion & base of the neck , guarding the afflicted arm , supporting with good hand , unable to move the arm , can not sleep at night)

  27. Calcific Tendinitis

  28. Treatment of Calcific Tendinitis • Depends on the clinical presentation and the presence of impingement  Local Glucocorticoid injection  NSAIDs  Colchicine Lithotripsy

  29. Bicipital Tendinitis • 95% is associated with Rotator cuff disease and impingement • Chief Complaint :Anterior Shoulder pain , which may extend to biceps muscle belly Dose not radiate to the neck • Pain worsens with lifting , carrying and may worsen at night

  30. Clinical Examination of Bicipital Tendinitis • Point tenderness (5-7 cm below the acromion) • Speed’s Test : Flexion against resistance with the elbow extended and forearm supinated causes pain over the biceps tendon

  31. Clinical Examination of Bicipital Tendinitis • Yergason’s Sign : Supination of the forearm against resistance when the elbow is flexed causes pain over proximal anteromedial arm

  32. Treatment of Bicipital Tendinitis • Rest the arm and discontinuation of activities that cause pain • NSAIDs • Subacromial steroid injection (no more than once )

  33. Rupture of Biceps Tendon • Uncommon in young • Occurs when the muscle contracts forcefully unexpectedly • In middle aged & elderly with a history of chronic shoulder pain • Local steroid injection

  34. Clinical Examination in Rupture of Biceps Tendon • Ludington Test : Patient puts both hands behind his head and flexes the biceps , rupture causes a distal bulging

  35. Rupture of Biceps Tendon • Imaging :  Plain radiography  Ultrasonography  MRI & CT arthrography • Treatment :  Surgery in young adult Conservative in elderly

  36. Adhesive capsulitis • Limitation of motion of shoulder joint • Pain at the extremes of motion • The exact cause is unknown • Conditions associated with :  Trauma  Diabetes mellitus  Parkinsonism  Thyroid disorders  Cardiovascular disease  TB …….

  37. Adhesive capsulitis • Epidemiology :  2-3 % of general population  11-19 % of diabetes  slightly more common in female  common in 50-70 y (rare < 40y) 5-25 % bilateral

  38. Adhesive capsulitis • Clinical manifestation : Diffuse shoulder pain  Night pain  Loss of mobility (active & passive mobility is limited , even by using Xylocaine injection)

  39. Adhesive capsulitis • Three Clinical Stage :  Freezing (a few weeks or months) severe pain  Frozen (4 to 12 months) marked stiffness , less pain  Thawing (5 to 26 months) resolution

  40. Adhesive capsulitis • Diagnosis :A diagnosis of exclusion  Chronic posterior dislocation  Rotator cuff disease  Septic arthritis  Avascular necrosis  Fracture  Bony or Pulmonary neoplasm  Osteoarthritis , …….

  41. Adhesive capsulitis • Para clinic : CBC , ESR , TFT , Serum chemistry  Radiography (PA & axillary view)  Arthrogram

  42. Adhesive capsulitis • Treatment :  Moist heat  NSAIDs  Analgesics  Oral steroids  Exercise

  43. Reflex Sympathetic Dystrophy • Algodystrophy , Sudeck’s atrophy Shoulder-hand syndrome Complex Regional Pain Syndrome • Extremity pain • Swelling • Stiffness • Discoloration

  44. Reflex Sympathetic Dystrophy • Cause is unknown • Prevalence is not known • Associated conditions : Trauma  Ischemic heart Disease  Cerebrovascular Disease  Fractures  Herpes zoster  Epilepsy  Brain Tumors , ……….

  45. Reflex Sympathetic Dystrophy • Clinical Features :  Severe Pain (aggravated by motion)  Swelling  Diffusely tender  Limited shoulder motion  Allodynia

  46. Reflex Sympathetic Dystrophy • Clinical Finding : Swelling (pitting or non pitting)  Discoloration  Increased Sweating  Shiny skin  Weakness  Tremor

  47. Reflex Sympathetic Dystrophy • Diagnosis is made clinically • Radiography show patchy or spotty osteopenia • Bone scanning with technetium

  48. Reflex Sympathetic Dystrophy • Prevention :Early mobilization after MI , trauma and strokes • Early treatment lead to a better outcome • Treatment :Corticosteroids Calcitonin Sympathetic blockade

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