Doron Sher

MBBS, MBiomedE, FRACS

www.Doron.com.au www.orthosports.com.au 160 Belmore Rd, Randwick 47-49 Burwood Rd, Concord

Dr Doron Sher Knee & Shoulder Surgery

The Painful Shoulder

Dr Doron Sher Knee & Shoulder Surgery

ANATOMY

Dr Doron Sher Knee & Shoulder Surgery

ANATOMY

Dr Doron Sher Knee & Shoulder Surgery

ANATOMY

Dr Doron Sher Knee & Shoulder Surgery

Glenoid labrum

Deepens Glenoid by 9mm sup-inf and by 5mm AP Weakest at 4 oclock

Function of labrum 1. Increases s.a. for contact with h.h. 2. Creates a buttress limiting translation 3. Acts as attachment for GH ligaments

Dr Doron Sher Knee & Shoulder Surgery

HISTORY

Dr Doron Sher Knee & Shoulder Surgery

History

Age Occupation Hand dominance Sports Injury

Dr Doron Sher Knee & Shoulder Surgery

Common Conditions
Impingement gradual onset with repetitive activity Cuff tear heavy lifting, fall, dislocation Instability external rotation/abduction, fall AC joint fall on point of shoulder SLAP ballistic movement Adhesive no trauma capsulitis
Dr Doron Sher Knee & Shoulder Surgery

MOST COMMON CONDITIONS

20 yrs to 40 yrs - impingement - instability (under diagnosed) - calcific tendonitis 30 yrs to 50 yrs - impingement - adhesive capsulitis (overdiag) 50 yrs + - impingement / r.c. tear - arthritis (uncommon)

Dr Doron Sher Knee & Shoulder Surgery

History
Pain Profile

Location ant/lat, upper arm Nature Day/night Exacerbating factors (elevation/lifting) Relieving factors

Disability- loss active ROM/ Dead arm

Dr Doron Sher Knee & Shoulder Surgery

History (Instability)

Degree of trauma Position of arm at time of dislocation Frequency of instability episodes dead arm Associated symptoms Subtle instability symptoms throwing athlete Prior medical treatment ops & type of physio

Dr Doron Sher Knee & Shoulder Surgery

CONFUSION WITH CERVICAL SPINE & OVERUSE SYMPTOMS

Posterior shoulder pain Not related to shoulder movement Pain radiates to forearm and hand Paraesthesia Occupational overuse

Dr Doron Sher Knee & Shoulder Surgery

Examination

Dr Doron Sher Knee & Shoulder Surgery

Inspection

Dr Doron Sher Knee & Shoulder Surgery

Inspection

Dr Doron Sher Knee & Shoulder Surgery

Inspection

Dr Doron Sher Knee & Shoulder Surgery

Popeye Sign

Dr Doron Sher Knee & Shoulder Surgery

Palpation

Sternoclavicular joint Acromioclavicular joint Acromion Greater tuberosity Lesser tuberosity Coracoid

Dr Doron Sher Knee & Shoulder Surgery

Range of Motion

Dr Doron Sher Knee & Shoulder Surgery

Range of Motion

Active and Passive If Active < Passive rotator cuff - neurological - pain inhibition If Active and Passive both reduced - Adhesive capsulitis, osteoarthritis, locked posterior dislocation
Dr Doron Sher Knee & Shoulder Surgery

Range of Motion
Components of motion Glenohumeral vs Scapulothoracic

Dr Doron Sher Knee & Shoulder Surgery

Rotator Cuff
Jobs Test Supraspinatus 90 degrees abduction 30 degrees forward thumbs down. Resisted elevation

Dr Doron Sher Knee & Shoulder Surgery

Rotator Cuff
Resisted External Rotation - Infraspinatus

Dr Doron Sher Knee & Shoulder Surgery

Rotator Cuff
Lift Off Test - Subscapularis

Dr Doron Sher Knee & Shoulder Surgery

Rotator Cuff
Impingement Tests

Dr Doron Sher Knee & Shoulder Surgery

Impingement Tests
Neers Hawkins

Dr Doron Sher Knee & Shoulder Surgery

Subacromial Injection
LA and Corticosteroid and retest

Dr Doron Sher Knee & Shoulder Surgery

Cross Body Adduction

Acromioclavicular joint pain

Confirm diagnosis with LA injection

Dr Doron Sher Knee & Shoulder Surgery

Instability Tests
AP Draw Apprehension/ relocation

Dr Doron Sher Knee & Shoulder Surgery

Physical examination

Apprehension signs Relocation signs Sulcus sign

Dr Doron Sher Knee & Shoulder Surgery

Instability Tests
Sulcus - inferior Jerk - Posterior

Dr Doron Sher Knee & Shoulder Surgery

Biceps
Speeds Test - resisted forward flexion with straight elbow Yergursons Test resisted supination elbow at 90 degrees

Dr Doron Sher Knee & Shoulder Surgery

Completion

Neurovascular C Spine Ligamentous Laxity

Dr Doron Sher Knee & Shoulder Surgery

Investigations

Dr Doron Sher Knee & Shoulder Surgery

XRays

True AP Scapula Lateral Axillary Lateral Supraspinatus outlet view

Dr Doron Sher Knee & Shoulder Surgery

True AP - Looks through GH joint

Dr Doron Sher Knee & Shoulder Surgery

AP in plane of Thorax

Dr Doron Sher Knee & Shoulder Surgery

Scapula Lateral

Dr Doron Sher Knee & Shoulder Surgery

GH instability

Dr Doron Sher Knee & Shoulder Surgery

Dr Doron Sher Knee & Shoulder Surgery

West Point View

Calcified Anterior Glenoid

Dr Doron Sher Knee & Shoulder Surgery

Reverse Hill Sachs

Dr Doron Sher Knee & Shoulder Surgery

Dr Doron Sher Knee & Shoulder Surgery

AC joint not well visualised

Dr Doron Sher Knee & Shoulder Surgery

Zanca view of AC joint

Tube tipped 10-150 superiorly

Dr Doron Sher Knee & Shoulder Surgery

AC Joint Separation

Dr Doron Sher Knee & Shoulder Surgery

AVN

Dr Doron Sher Knee & Shoulder Surgery

Cuff Tear Arthropathy

Dr Doron Sher Knee & Shoulder Surgery

Calcific Tendonitis

Dr Doron Sher Knee & Shoulder Surgery

Dr Doron Sher Knee & Shoulder Surgery

Glenoid # best seen on CT

Dr Doron Sher Knee & Shoulder Surgery

Dr Doron Sher Knee & Shoulder Surgery

Type III acromion - Impingement

Dr Doron Sher Knee & Shoulder Surgery

OA

Dr Doron Sher Knee & Shoulder Surgery

Locked Posterior Dislocation

Dr Doron Sher Knee & Shoulder Surgery

Cuff tear arthropathy

GT Fracture

Dr Doron Sher Knee & Shoulder Surgery

Special Radiographs

Dr Doron Sher Knee & Shoulder Surgery

Imaging
Ultrasound - No role in imaging the rotator cuff 40% Accurate

Dr Doron Sher Knee & Shoulder Surgery

Imaging
MRI Arthrogram Soft tissue modality of choice

Dr Doron Sher Knee & Shoulder Surgery

Rotator Cuff Tears

What do we know?

Dr Doron Sher Knee & Shoulder Surgery

Rotator Cuff Tears

What do we know?

Surgery fails to repair the RC in up Many older people have RC tears to 40% of cases yet many of thosewith RC tears havegood function or near Many people have no pain and no pain and full Larger tears full function will get bigger with time Non operative management gives good outcome in many Risk of developing arthritis small

Dr Doron Sher Knee & Shoulder Surgery

Incidence Of Cuff Tears

~ 40% of 60 year olds have R.C. tears ~ 75% of 70 year olds have RC tears

Most Are Asymptomatic.

Dr Doron Sher Knee & Shoulder Surgery

Non Operative Treatment

ITOI (clin orthop 275;165, 1992) 83% good or excellent BROWN (JBJS 31B; 423, 1949) 87% good TAKAGISHI (J. jpn orth assn 52, 1978) 44% good

HAWKINS (clin orthop 321;178,1995) 58% satisfactory

Conclusion the smaller the tear the better the outcome

Dr Doron Sher Knee & Shoulder Surgery

Results Of Operative Treatment

Operative treatment fails because of failure of RC healing capacity = POOR BIOLOGY 80% to 90% patients happy (but repair is intact in only 60% - 80% of cases)

Smaller tears have good technical repairs and the larger tears more likely to fail

Dr Doron Sher Knee & Shoulder Surgery

How do we work out who will benefit From Nonop treatment??

Rotator Cuff strength Symptom duration Functional impairment We dont know!

Dr Doron Sher Knee & Shoulder Surgery

Functional Rotator Cuff Tear

Anatomically deficient Biomechanically intact

Patient has a RC tear but has no pain and good function

Dr Doron Sher Knee & Shoulder Surgery

Tear Is Not The Cause Of Pain !!!!

Loss Of Function Pain Caused By Caused By Impingement Tear location and to a Edge of tear lesser extent tear size instability Loss of force couples Synovitis where humeral head Capsulitis cannot be kept Biceps / s.l.a.p. can get bigger with time Tears centered in glenoid
(especially if they are large and there is a high demand on the shoulder)
Dr Doron Sher Knee & Shoulder Surgery

Absolute Surgical Indications

Young patient (less than 50 years)

tear is likely to get bigger

Patient involved with heavy or overhead occupation

tear likely to get bigger (usually large tears) NO ER POWER

Following dislocation in older patient

Acute & very large tear

Need Surgery Within 1 Month

Dr Doron Sher Knee & Shoulder Surgery

Relative Surgical Indications

Older patient (60 yrs plus) based on loss of e.r. power & function, plus MRI force couples disrupted Chronic and large tear in older patient with disability and good quality RC on MRI and failure of conservative treatment Failed non operative management
Dr Doron Sher Knee & Shoulder Surgery

Non Surgical Treatment

Patients over 55 years

small tears and low demand on shoulder and with force couples intact

Patients older than 65 years

RC tear and good function even if force couples not intact

Large tears with poor quality RC

Providing force couples are intact and patient not too young non op treatment is likely to be successful

Dr Doron Sher Knee & Shoulder Surgery

Non Operative Treatment

80% to 90% successful over 3 months Subacromial cortisone injections NSAIDs Physiotherapy - capsular stretches - strengthening Avoid heavy lifting & overhead activity

Dr Doron Sher Knee & Shoulder Surgery

Operative Technique

Arthroscopic Rotator Cuff Repair Biceps Tenotomy or Tenodesis often required 6 weeks in a sling 1 year for full recovery

Dr Doron Sher Knee & Shoulder Surgery

Osteoarthritis

Uncommon Non weight bearing joint Loss of active & passive motion Intraarticular cortisone NSAIDs Total shoulder replacement

Dr Doron Sher Knee & Shoulder Surgery

Normal

Arthritis

Dr Doron Sher Knee & Shoulder Surgery

AVN

Dr Doron Sher Knee & Shoulder Surgery

Osteoarthritis

Presents with pain and loss of function Forceful physio to stretch shoulder capsule makes it worse Arthroscopic debridement only helps half the time

Dr Doron Sher Knee & Shoulder Surgery

INDICATIONS FOR T.S.R.

Severe pain unresponsive to NSAIDs and analgesics Significant functional loss Interference with activities of daily living Some patients have severe O.A. on xray but few symptoms

we do not operate on the xray appearance but rather the patients symptoms
Dr Doron Sher Knee & Shoulder Surgery

TOTAL SHOULDER REPLACEMENT

R.C. must be intact Good pain relief Expect 60% normal movement only Physio post op mainly to strengthen Deltoid and R.C.

Dr Doron Sher Knee & Shoulder Surgery

The Implant

Dr Doron Sher Knee & Shoulder Surgery

Dr Doron Sher Knee & Shoulder Surgery

Cuff Tear Arthropathy

Massive R.C. tear associated with arthritis Difficult problem Reverse shoulder replacement is a good solution

Dr Doron Sher Knee & Shoulder Surgery

Dr Doron Sher Knee & Shoulder Surgery

Instability

The younger you are the more likely you are to redislocate More than one dislocation leads to arthritis of the shoulder Surgery now being offered to all first time dislocators

Dr Doron Sher Knee & Shoulder Surgery

Instability

Dislocation in an older patient usually tears the rotator cuff Cuff repair urgent They usually dont have ongoing instability

Dr Doron Sher Knee & Shoulder Surgery

MOST COMMON CONDITIONS

20 yrs to 40 yrs - impingement - instability (under diagnosed) - calcific tendonitis 30 yrs to 50 yrs - impingement - adhesive capsulitis (overdiag) 50 yrs + - impingement / r.c. tear - arthritis (uncommon)

Dr Doron Sher Knee & Shoulder Surgery

Doron Sher
MBBS, MBiomedE, FRACS

www.Doron.com.au www.orthosports.com.au 160 Belmore Rd, Randwick 47-49 Burwood Rd, Concord

Dr Doron Sher Knee & Shoulder Surgery