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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 • • • • • • • • 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: • • • • 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? • • • • • • • • 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 • • • • • • • • • 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