New Concepts and Advances (Arthroscopic) for the Treatment of Shoulder Pain

William F Bennett MD

The Simple Shoulder

While a complex joint with complex function, general approaches to determining the non-descript, cause….is easy!

I.e., intrinsic versus extrinsic

Intrinsic versus Extrinsic

Intrinsic- later and more descript…means pain coming from the shoulder joint itself

Extrinsic- pain that may cause shoulder pain but comes from sources outside the shoulder

Extrinsic

Most common- cervical spine Pancoast tumors of the lung Thoracic spine Peritoneal/Splenic irritation can cause pain at

Erb’s point Angina/MI Metabolic/Oncologic problems, ie., bone marrow

involvement like lymphoma/leukemia, parathyroid

Extrinsic-Cervical Spine

General rule--trapezial pain-cervical

-deltoid pain- intrinsic or from the shoulder

Can have both shoulder and cervical spine affected which makes it more difficult

Cervical spine may have radicular involvement

Intrinsic

Once extrinsic has been ruled out then one can focus on the intrinsic causes.

If a certain shoulder motion whether it be flexion, abduction, external rotation or internal rotation causes pain in the deltoid area and not in the trapezial area, one is probably dealing with an intrinsic problem

Before discussing intrinsic Causes

Lets diverge and discuss the anatomy and function of the shoulder

Anatomy

4 joints-two are articulations– Glenohumeral joint– Acromioclavicular joint– Scapulothoracic articulation– Sternocalvicular articulation/joint

– Discuss Bones-Bone models

Ligaments/Capsule

Capsule is the “sac”– Normal sac allows motion in various planes– Abnormal sac restricts motion in various planes

Ligaments- hold bone to bone– Glenohumeral ligaments– Coracohumeral ligaments– Coracoacromial ligaments– Coracoclavicular ligaments

Muscles/Tendons Rotator Cuff are a confluence of 4 tendons from the

following respective muscle bellies– Supraspinatus– Subscapularis– Infraspinatus– Teres minor

– Biceps– Deltoid

Bone models

Bursae/Cartilage/Meniscus Subacromial Bursae Subdeltoid bursae Subcoracoid bursae Glenohumeral articular

cartilage Acromioclavicular meniscus

Intrinsic Diagnoses

Impingement– Tendonitis– Bursitis– Rotator Cuff tear-complete– Rotator Cuff tear-partial– others

Intrinsic Diagnoses

Acromioclavicular joint irritation/arthritis Glenohumeral joint osteoarthritis Rheumatologic joint Pigmented Villonodular synovitis Chondrometaplasia Tumors-giant cell, synovial sarcoma

Intrinsic Diagnoses

Instability/Subluxation-repetitive/chronicAtraumatic/multidirectional

Dislocation– Traumatic unidirectional

Biceps– Inflammation– Instability/subluxation– Tendonitis/avulsion

Intrinsic Diagnoses History compatible Physical exam compatible Radiologic exam compatible MRI/MRA compatible Less so- blood work, others

– Each is a piece of the puzzle

Physical Exam

Observation Palpation Range of Motion Strength Test Specific Tests for lesions Hoppenfeld- Examination of the Extremies

Treatment “ITIS”- inflammation- tendonitis, bursitis

– Rest, avoidance, NSAIDS, injections, therapy Osteoarthritis- above plus possible total shoulder

replacement, ac joint Rotator Cuff Tears-above +/- repair Instability/Dislocation-+/- repair Frozen Shoulder Biceps Inflammation

– The arthroscope has become an important tool for diagnosis and treatment in virtually all afflictions of the shoulder

Arthroscope Fiber optic device Triangulate-the surgeon never sees the

actual inside of the joint- it is projected upon a monitor and as such, the working tools, “triangulate’ to the point of focus

Minimally invasive Less pain Less rehabilitation

Treatment

Nsaids- short-term Physical therapy Injections Surgery

Physical Therapy

Treat Inflammation-

Iontophoresis

Treat Tight Areas

Stretch

Treat Weakness

Strentghen- rotator cuff muscles

scapular stabilizers

Injections

Must have correct diagnosis Patient may have more than one pain

location Lidocaine Injection test Areas-

– Subacromial space– Glenohumeral joint– Ac joint– Bicipital sheath

Shoulder Pain-traditionally was treated with long delays in surgical intervention-Why?

Shoulder pathology not well understood Open repair required extensive incisions Rehabilitation was long

– Most importantly, in times past, the primary care givers was, in general, “under-the-impression” that shoulder surgical intervention was not that effective

Arthroscopic Interventionutilized in Impingement-bursitis, tendonitis Rotator cuff tears Instability or dislocation AC joint arthritis

And yes even in Osteoarthritis

Arthroscope has allowed for the further identification of subtle shoulder pathology, previously not identified See articles-

1) Bennett WF. Subscapularis, Medial and Lateral Head Coracohumeral Ligament Insertion Anatomy: Arthroscopic Appearance and Incidence of "Hidden" Rotator Interval Lesions. Arthroscopy. 2001 Feb. 17(2) 173-180

2) Bennett WF. Visualization of the Anatomy of the Rotator Interval. Arthroscopy. 2001 17 107-111

Arthroscopic Prospective outcomes are now Published See Articles-

Bennett WF: Arthroscopic Repair of Bennett WF: Arthroscopic Repair of Complete Anterosuperior Rotator Cuff Tears. 2 Year Follow-up. Arthroscopy, January 2003

Bennett WF: Arthroscopic Repair of Complete Subscapularis Tears. 2 Year Follow-up.

Arthroscopy, February 2003

Bennett WF: Arthroscopic Repair of Complete Supraspinatus Tears. 2 Year Follow-up.

Arthroscopy, March 2003  Bennett WF: Arthroscopic Repair of Massive Rotator Cuff Tears. 2-Year Follow-up

Arthroscopy, April 2003

Natural History of Rotator Cuff Tears Recurrence of pain Tears get bigger with time Results of surgical intervention deteriorates

with time Muscle turns to fat Tendon becomes inelastic

At this Point

Most recently anatomy surrounding the rotator cuff and its interrelationship with the bicipital sheath has been identified, clarified, classified, arthroscopic reapir techniques developed and outcome studies published.

At this point I will move to the details of clinical research that I have been performing for the last 12 years.