DR. M.ABBASIRHEUMATOLOGIST

QUMS

Periarthritis Of Shoulder Joint

EPIDEMIOLOGY

Shoulder pain

16-26% of all musculoskeletal complaints

Is the third most common MSK pain

I- LBP II- Knee pain III- Shoulder pain%50 of the population will suffer

during their life60% may experience symptoms

for a year or moreEspecially common in diabetic

patient Female>maleRight shoulder>Left shoulder In iran 14/5%

Anatomy of the shoulder

Anatomy of the shoulder

JointsJoints

The shoulder consists of three joints: 1-Acromioclavicular 2-Sternoclavicular

3-Glenohumeral joint

And two gliding planes: 1-Scapulothoracic

2-Suacromial

shoulder joint is the most mobile joint of the body

Range of motion

Periarticular disorders

>80%

Referral pain <15%

Arthritis & OA 5%

common causes of

periarticular disorders of

shoulder

Rotator cuff (R.C.) tendinitis or impingement syndrome

Rotator cuff tearCalcific tendinitisBicipital tendinitisFrozen shoulder

Rotator cuff tendinitis

Impingement may be defined as the encroachment

of the acromion, coracoid process or AC joint on the

rotator cuff as it passes beneath them during

glenohumeral motion

Rotator cuffRotator cuff

It is composed of four muscular units:

Supraspinatus Infraspinatus

Teres minor Subscapularis

ANATOMY AND FUNCTION

Movement is created by the 4 RC. Muscles,originate from the scapula & insert at the greater tuberosity

Movement is facilitated by a subacromial bursa, lies above supraspinatus muscleRC. plays a significant role in stabilizing the GH J.

Supraspinatus Initiates Abd

Infraspinatus Initiates Ex.R

Subscapularis Initiates In.R

Teres minor Initiates Add

Rotator cuff tendinopathy

Epidemiology of

70% shoulder pain(most common)High prevalence in female workers Athletes Age over 40 yearsThe prevalence increases with age

Etiology and pathogenesis

* Extrinsic compression

*Osteophytic spurring of

acromion

* Calcific tendinitis

* Instability

* Trauma

*Diminished vascular supply

*Intrinsic, degenerative event

*Age related degeneration

*Overuse

Clinical sign and symptoms

Mechanical shoulder pain(especially during overhead activity, Ext.Rot)

Dull Site of pain:anterolateral

aspect

Night pain (Especially when is lateral decubitus)

Weakness & pain(impingement syndrom +RC tear)

Physical examination

Inspection:

Atrophy, asymmetry, deformity

swelling(seldom)

palpation:

Tenderness point in subacromion

Ac joint, bicipital groove

ROM:

Active (Abd,Ext.Rot)

Clinical tests: painful arc

Neer impingement sign

Clancy test

impingement sign

Sensitivity 95% Sensitivity 95%

Specificity 95%

Clancy test

Sensitivity:95%

Specificity : 95%

Is predominantly clinical

A woman or man with: More than 40 years old

Mechanical shoulder painespecially during overhead activities

Impingement sign

Diagnosis

*Rest(cessation of repetitive overhead activity)

*NSAIDs

*Physical modalities

*Steroid Injection: used when the patient has

significant pain(3-injection)

*Opiate- based drugs used in the acute setting (fall)

*Exercise is mainstay of treatment

Control of symptoms stretching RC.

Improving symptoms return to normal overhead activities (sporting)

Rotator cuff tear

Rotator cuff tearing

SIZE:Small: <1cmMedium: 1-3 cmLarge: 3-5 cmMassive:>5 cmETIOLOGY: RA, SLE, renal

osteodystrophyGlucocorticoidsStage III rotator cuff

tendinitis

Etiology

Can be acute or chronic ,complete or incomplete

Acute: predominantly in young patient (falling on an outstretch- arm)

Chronic : predominantly in old patient>50 Y

History of trauma (50%)History of chronic

impingement (95%)Decreased vascularity

&cellularity

Clinical sign and symptoms

.

Acute tearing Pain & weakness of abduction and ext-Rotation

Chronic tearing Crepitation, stiffness, atrophy and weakness

Supraspinatus tearing Inability to abduction, drop arm test Infraspinatus tearing Inability to Ext. Rotation, can't reach spoon to mouth, inability to combingext- rotation lag test

Subscapularis tearing Internal rotation lag test

External rotation lag test(sup.&inf. )

Internal rotation lag test (subscapularis)

Depend in the degree of

tear

Partial or full thickness -

tears

Age, functional status

Degree of pain

Acute

Acute Ruptures in a young or active patient (a athlete with overhead activity)

only early Surgery In an older or less active patient

Conservative 3 -6 months no acceptable function

Surgery

(Subacromial decompression, cuff repair)

Treatment

Chronic

Treatment is conservative

Surgery:1. young patients with massive tearing and weakness

2.Old patients with sever pain that don’t control 3.RC tearing +biceps tendon tearing

Response to conservative treatment (90% )

Flexion and supination of the forearm

Forward elevation of the shoulder

Biceps tendon

Anatomy of the shoulder

Epidemiology of

Bicipital

tendinitis

Men (halter)Women (gymnastic, repetitive carrying of small children)

Clinical sign and symptom

*Pain over ant- aspect of the

shoulder radiates to bicipital

groove

*Pain is exacerbated with

overhead activities, shoulder

extention & elbow flexion

Diagnostic maneuvers

The most common finding

Point tenderness by palpation

of the bicipital grooveYergason's testSpeed's test

Speed's Test

Yergason's TestYergason's Test

aa

Elbow flexed 90° with forearm pronated Patient supinates the forearm and flex the elbow against resistance. Pain in the biciptal groove indicates long head of biceps tendon pathology

*Acute rupture result from overuse in

young patient(weight-lifting)

Sudden pain

(most common)

*In older patient thinning & eventual

rupture occur spontaneously

Bicipital rupture

popeyepopeye

Clinical feature

Paraclinic

Plain radiography Degenerative changes in

superior border of glenoid or bicipital groove

Imaging

Ultrasonography (US)

For detection of:

Subluxation

Diagnosis of tears & tendinitis

Provides an excellent visualization for:

Superior labral complex

Biceps tendon

Bicipital groove

Bony osteophytes

Biceps tendon tears

dislocation

Treatment

Treatment of tearing Conservative Young patients(sports) : surgery Treatment of tendinitis Rest , physiotherapy, NSAIDS laser , injection in tendon sheet

Surgery Refractory bicipital tendinitisRecurrent symptom of subluxation

Calcific tendinitis

*Deposition of calcium hydroxyapatite *Symptoms develop in 35% to 45% *Age 40 to 60 y *More frequent in female ( 57% to 77%)

*Usual presentation: chronic painful condition Around the RC.(chronic impingement syndrome) *Acute presentation(7%)

pathophysiology

Precalcific: formative phase

Relatively painless

Calcific: calcium crystals are

deposited in matrix(quiescent)

Postcalcific: resorptive phase

Tends to be painful

Resorption of calcium crystals

Acute subacromial & subdeltoid bursitis

Migration of hydroxyapatite microcrystals to

bursa: induce acute inflammation

Age: 50-60 y, female

Clinical history

Acute severe pain

limiting active & passive movement

Occasionally erythema

Sometimes swelling

No history of injury or overuse

Imaging

Int & Ext

Rotational view

management

Chronic symptoms

conservative treatment

Subacromial arthroscopy(stable

phase)

Acute stage

Resting, the arm in sling

NSAIDs

Steroid injection (subacromial)

Prednisolone: 15-20mg/day - Rapidly taper

Recovery in few days or weeks

FROZEN SHOULDER (RETRACTILE CAPSULITIS)

EPIDEMIOLOGY

Etiology

Prevalence:2-3% Women 40-50 years Primary or idiopathicSecondary:Diabetes, parkinsonism, TB,

thyroid disorder, MI, lung tumor, Cervical radiculopathy

Major skeletal trauma and soft tissue injury

Change from simple or acute tendinitis to capsulitis(mixed shoulder)

pathophysiology

Stage IDiffuse inflammatory synovitis

Stage II Adherence of the capsule

Stage III Loss of ROMof normal joint

thickening and narrowing of

joint capsule

Initiation :3-8mo

Acute or insidious onset, pain at the extreme of motion, background ache in the

suprascapular and deltoid regions

Adhesive phase :4-12mo

Pain gradually decrease

Severe limitation of active & passive ROM

Resolution phase :

ROM gradually will be better, duration without treatment lasts 1-3 y

Signs and symptoms

Paraclinic

X ray : at first is normal Later :Decalcification of humerus head, joint surface are intactArthrography : the capacity of joint capsule from 28-35 cc changes to 0.5 -3 cc Radioisotope scan

Arthrography

Arthrography

Treatment

Exercise is the main treatmentGentle stretching

Stage INSAIDSteroid injection Oral steroid Ice packs, ultrasound Trans cutaneous electro neuron stimulation(TENS)

Refractory conditionsClose manipulationHydraulic distentionSurgeryArthroscopic capsulotomy

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