Download Shoulder Disorders in Primary Care

RHEUM UPDATE—V
SHOULDER
DISORDERS
“Doc my wing is killing me every night!”
Mark A. McQuillan MD FACP SFHM
June 16, 2016
DISCLOSURES (COI)
• none
OUTLINE
• Shoulder Disorders
• Differential Diagnosis
• Anatomy
• History
• Physical Findings
• Diagnosis
• Management
• Referral
• Outcomes
SHOULDER DISORDERS
• Common
• Persistent (1-18mo)
• Stubborn
• Pernicious
• Painful
• Disrupt sleep
• QALY
• NOT permanent
PHYSICAL FINDINGS
• IPPA
• Inspection
• Percussion
• Palpation
• Auscultation
• Dynamic Testing
• ROM
• Resistance
• Performance
ROM EXERCISES FOR THE
SHOULDER(S)
• 5 types
• Pendulum
• Windmill
• Baton
• Wall-walking
• Pulley
ROM SHOULDER
EXERCISES
• Early institution prevents
FROZEN SHOULDER
• “Adhesive Capsulitis”
• Final common pathway
• Multi-factorial
• Coexistent etiologies
TYPES OF SHOULDER PAIN
• Anterior
• Posterior
• Distal
• Lateral
• Bursal
• Deltoid
• Bicipital
• RC Rotator Cuff
• Scapulo-thoracic
SHOULDER PAIN
ETIOLOGY
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Acute
Sub-acute
Chronic
Repetitive
Episodic
Weekend warrior
Hemarthrosis
Tears:
• Insufficiency/thin
• Partial
• Complete
SHOULDER PAIN
IMAGING
• Plain films
• Ultrasound
• CT
• MR
• arthrogram
SHOULDER PAIN
ETIOLOGY
• Degenerative/OA
• Trauma
• Impact/collision
• Occupational
• Crystalline/CPPD
• Endocrine
• AVN
• Hemarthrosis
• Hemoglobinopathy
SLEEP AND SHOULDER
PAIN
• Positioning
• Ergonomics
• Vascular supply
• Outcomes
• Dynamic testing
SHOULDER INJECTIONS
• Evidence-basis
• Type of injection
• Frequency
• RCT
• PT
• Self-management
• Outcomes
SHOULDER MISCELLANEA
• Shoulder pad sign
• Radiculopathy
• Referred pain
• Visceral pain
• Cervical
SURGICAL OUTCOMES
RC TEARS
• John E. Kuhn MD, Chief of Shoulder surgery Vanderbilt
University
• 5 key points:
• RC full thickness tears are VERY COMMON; present in 10
% of US adults over age 65; 2010 Census identified 57
Million over age 65; there are about 275,000 RC repair
procedures in US annually; 5% of pts with RC tears
undergo surgery, 95% do not;
• Symptoms do not correlate well with severity of RC tear;
no relationship between severity of tear and pain level,
symptom duration, or activity level;
KUHN JE, VANDERBILT
• 5 key points:
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•
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COMMON
Symptoms do not correlate well with RC tear severity
FAILURE of repair occurs in 30%
PT is very effective for pain control, in 80% of pts and
duration of relief is at least two years; pt expectation is
important because patients who feel that PT won’t work
are more likely to eventually undergo surgery; patients
with intact repairs have superior strength; two controlled
trials with at least 2 yrs follow up
• Moonmayer 76% success rate
• Kukkonen 92 % success rate
• Surgical indications are therefore unclear
WHO GETS RC TEAR
SURGERY?
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PT is a reasonable option if RC tear is atraumatic
Early repair results are superior than later
Strength is better with surgery, if RC repair is intact (70%)
If PAIN is the main problem, PT may result in
improvement in 80% and lasts at least 2 years
If WEAKNESS or FUNCTIONAL LOSS is the main problem,
surgery may be preferred;
30% of surgical repairs fail
Patient expectations about likelihood of PT success is
very important;
Kuhn JE, Am J Orthopedics, Feb 2016
ALTERNATIVE THERAPIES
FOR RC TEAR
• Besides PT and surgery or combination
• Shoulder injection
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IA steroids
Prolotherapy
Platelet-rich plasma
Stem cell therapy
Sleep position--effective
Kinesio-tape NOT effective
TAI CHI-mixed results
MASSAGE
ACUPUNCTURE
ARTHROPLASTY
OUTCOMES
• Alternatives of total shouler replacement vs reverse
arthroplasty
• Pt satisfaction at 2 and 5 yrs
• Reverse arthroplasty applies the ball to the scapular
glenoid, and the cup to the humerus; allows overhead
reach by utilizing the deltoid as a lever; this is a semiconstrained, marginally restricted
• Controlled trials underway
• Rehab is extensive
• Patient expectations and functional level varies widely