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Shoulder Pain

Shoulder Pain

Statistics

  • 15% of men and 24% of women report weekly shoulder pain
  • Lifetime prevalence is 70%
  • Pope et al 20% of population suffer from shoulder pain
  • Only 50% of patients better within six months
  • 60 % within a year
  • 30% of people with shoulder pain report limitations in daily life

Factors

  • Age
  • Family history
  • Work history
  • Previous injury

Spectrum of Disease

  • Range from mild tendon irritation to complete tears

Where Does Shoulder Pain Come From?

  • Rotator cuff
  • Frozen shoulder
  • Arthritis
  • Instability

The Rotator Cuff

  • Single most important muscle group in the shoulder
  • Accounts for the overwhelming majority of painful conditions
    • 80 % in 1 month

Clinical Shoulder

Clinical Shoulder | Shoulder Pain

Rotator Cuff

Rotator Cuff | Shoulder Pain

Rotator Cuff Internal View

Rotator Cuff Internal View | Shoulder Pain

Impingement

  • Tendonitis
  • Bursitis
  • Gradual onset of symptoms
  • Risk associated with anatomy
  • Vague achy pain
  • Aggravated by certain activities
    • Overhead
    • Lifting
  • Night pain

Impingement Treatment

  • Exercises
    • Home exercises
    • PT
  • NSAIDS
    • Intermittent
    • Avoiding complications
  • Injections
    • Limited
  • Surgical decompression
Impingement | Shoulder Pain

Rotator Cuff Tears

  • Occur in up to 40 % of people over 50
  • Most not associated with an injury
    • Can worsen with an injury
  • Insidious onset of shoulder pain
  • Night pain
  • Weakness
  • Mechanical symptoms
    • Catching
    • Locking

Rotator Cuff Tears Treatment

  • Evolving
  • Influenced by size
  • Age
  • Chronicity

Rotator Cuff Tears By Size

Small Tears

  • Evolving
  • Role for therapy, possibly injections
  • Tend to get bigger over time
  • Role for surgery
    • Easier to repair
    • Better chance to heal
    • Avoid issues of larger tears

Medium Tears

  • Weakness
  • Overhead activity aggravates pain
  • Early fatigue
  • Larger with injury
  • Treatment largely surgical
    • Outcomes better
    • Good healing potential
  • Limited role for conservative management

Large Tears

  • Significant weakness
  • Loss of function
  • Mechanical symptoms more prominent
  • Often acute on chronic
    • Sudden worsening of long lasting symptoms
  • Limited role for non operative treatment

Massive/Irreparable Tears

  • Special case
  • Profound functional loss
  • Pseudoparalytic shoulder
  • Surgical treatment is evolving
    • Repair
    • Shoulder replacement

Rotator Cuff Tears By Age

Young Patients

  • Smallest group
  • Largest potential for disability
  • Best potential for healing
  • Limited role for non operative management

Middle Aged (40-65)

  • Largest group
  • Most cases gradual
  • Often related to an injury
  • Pain a primary feature
  • Mostly surgical

Older Than 65

  • Second largest group
  • Pain less prevalent
  • Weakness and loss of function
  • May do well with therapy and activity modification
  • Surgical
    • Primary repair
    • Reverse total shoulder

Mini Open Repair

  • Deltoid not removed from bone
  • Quicker recovery
  • Less stiffness

Shoulder Arthroscopy

  • Minimally invasive
  • Allows for a more complete assessment of the rotator cuff
  • Less pain
  • Quicker return to function

All Arthroscopic Repair

  • Least violation of the deltoid
  • Less painful
  • Less scarring, less stiffness
  • More complete visualization

Outcomes

  • Improved strength and stamina
  • Less night pain
  • Improved overall shoulder use

Frozen Shoulder

  • Inflammatory condition
  • More common in diabetics
  • Varied presentation
  • Most commonly misdiagnosed shoulder condition
Impingement | Shoulder Pain

Frozen Shoulder Symptoms

  • Vague onset of dull pain
  • Sometimes preceded by mild trauma
  • Pain with all motions (not just overhead)
  • Gradual loss of motion

Frozen Shoulder Treatment

  • Most resolve with conservative management
  • Key is cortisone injection in the joint to manage the inflammation
  • Therapy can help regain motion after pain resolves
  • Relatively high recurrence rates
  • Manipulation
  • Arthroscopic cauterization of inflammation
  • Intense daily PT

Glenohumeral Arthritis

  • Least common of the major joints
  • Can be secondary to trauma, chronic rotator cuff deficiency and necrosis of the humeral head

X-Ray

  • Joint space narrows
  • Spur forms on the ball
  • Bone becomes more dense
  • Cysts

Shoulder Arthritis Treatment

  • NSAIDs
  • Injections
  • Home exercise
  • Shoulder clean out (arthroscopy)
  • Shoulder replacement
    • Total shoulder
    • Reverse total shoulder (combined arthritis and cuff tear
  • Conservative
    • Injections
  • Operative
    • Replacement

When Should I See An Orthopedic Surgeon?

  • Pain that lasts more than 2 weeks
    • Despite NSAIDs, rest or other treatment
  • Sudden change in shoulder function
    • Weakness, especially after injury
    • Loss of stamina, early fatigue
  • Pain that does not respond to treatment
    • Worse rather than better
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