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“Older” Shoulders

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  1. “Older” Shoulders Rotator Cuff Disease

  2. Rotator Cuff Tears Anatomy

  3. Rotator Cuff Tears Anatomy

  4. Rotator Cuff Tears DefinitionPathologic changes of therotator cuff tendons

  5. Rotator Cuff Tears Progressive thinning and weakening with  age

  6. Rotator Cuff Tears CauseTraumaDegenerative

  7. Rotator Cuff Tears TypesTendinitisPartial thickness tearFull thickness tear

  8. Rotator Cuff Tears Partial Thickness Tear

  9. How to Recognize ComplaintsPain,  sleep, overhead, weakness, stiffness, catching, popping

  10. How to Recognize HistoryAcute (traumatic)vs. Chronic (insidious)

  11. How to Recognize ExamAtrophy, ecchymosis, weakness, subacromial roughness, pain,positive injection test

  12. How to Recognize Atrophy

  13. How to Recognize Subacromial Roughness

  14. How to Recognize Weakness

  15. How to Recognize Pain

  16. Differential Diagnosis • Acromioclavicular arthritis • Frozen shoulder • Glenohumeral arthritis • Herniated cervical disc • Suprascapular nerve entrapment • Fracture (Skier’s)

  17. How to Work-Up X-raysGreater tuberosity reactive changes, acromial sourcil/spur, high-riding humeral head

  18. How to Work-Up Greater tuberosity reactive changes,acromial sourcil/spur

  19. How to Work-Up High-riding humeral head

  20. How to Work-Up Other Imaging StudiesArthrogramUltrasoundMRI

  21. How to Work-Up Positive arthrogram with dye leakage Acromion Humeral Head

  22. Ambulatory Treatment Conservative - rest, ROM, NSAID,s, injection (?), time, avoidance, modifications, education, compensatory muscle strengthening, progressive resumption of activities (except acute tear in young/active?)

  23. Ambulatory Treatment Progressive Range of Motion

  24. Ambulatory Treatment Compensatory Muscle Strengthening

  25. Outcome Most do well with appropriate conservative management

  26. Other Thoughts Wheelchair/Crutch AmbulatorsDifficult, rehab, rehab, rehab, rarely if ever repair

  27. Other Thoughts After dislocation in > 40 y.o.Beware potential for RCT,image those doing poorly with rehab EARLY

  28. Other Thoughts Calcific Tendinitis

  29. Other Thoughts Calcific Tendinitis- Insidious onset…PAIN!- Try conservative approach- May need to remove or decompress if symptoms persist

  30. “Impingement”

  31. “Impingement” Question what it is…Triad!- posterior capsular tightness- subacromial bursitis- cuff pathology (-itis vs. tear)

  32. When to Refer AcuteWeakness, bruising,positive study,especially young/active pts.

  33. When to Refer ChronicAfter several months, positive study, failure of conservative care, continued/worsening pain & dysfunction, difficulty sleeping

  34. How We Treat It • More Rehab/Avoidance/Modification • Meds/Injections • Explanation of risks/benefits • Surgery - arthroscopic or open subacromial smoothing/debridement vs. repair

  35. How We Treat It RCT  RCR

  36. How We Treat It  Age (> 70)  Chronicity Atraumatic Prognostic indicators for RCR Failure  Injections  # tendons Smoking

  37. How We Treat It Open rotator cuff repair

  38. Outcome Most do well extremely well with near complete recovery of function and relief of pain

  39. Outcome

  40. Rotator Cuff Tears Summary- VERY common problem- Can be acute or chronic- Many will improve adequately with conservative care- Some require surgery

  41. Rotator Cuff Tears Summary- In young/active/traumatic tears…think early referral - In elderly/sedentary/insidious tears…think rehab, refer prn

  42. “Older” Shoulders Stiffness

  43. Capsular Laxity

  44. “Frozen Shoulder” • Definition - Symptomatic limitation of passive motion in a shoulder • Cause - Stiffening of joint capsule after inflammation

  45. Inflammation

  46. Adhesions

  47. Actually… Four Types (etiologies) of StiffnessIdiopathic Frozen ShoulderDiabetic Stiff ShoulderPost-Traumatic Stiff ShoulderPost-Surgical Stiff Shoulder

  48. Capsular Contracture

  49. How to Recognize • History - loss of comfort & function (inability to sleep comfortably ) • Exam - limited range of flexion, external rotation, internal rotation and/or cross body motion • X-rays - normal

  50. Peak age = 55 years