This is a short presentation on common causes of shoulder pain, its clinical features,diagnostic methods and treatment modalities. This presentation would be helpful for general paractioners, orthopedic juniour registrars.

1. Dr.A.Mohan krishna
M.S.Ortho,Mch Orth (U.K),
Consutant Orthopaedic Surgeon
Apollo Hospitals.

2. PAINFUL SHOULDER-- CAUSES
Acute shoulder pain
• Fractures & Disclocations
• Calcific tendinitis
• Acute Rotator cuff tears
Chronic shoulder pain
Impingment Syndromes:
• Subacromial bursitis
• Rotator cuff tendonitis
• AC arthritis
• Hooked Acromion
Osteoarthritis Shoulder
Rheumatoid arthrits
Partial rotator cuff tears

3. IMPINGEMENT SYNDROMES
•
•
•
•
Subacromial bursitis
Rotator cuff tendonitis
AC arthritis
Hooked Acromion

4. IMPINGEMENT SYNDROMES
Impingement is due to squeeging of rotator cuff and sub
acromial bursa between the coracoacromial arch, anterior 1/3
of the acromion & AC joint above and head of Humerus
below.
Painful arc syndrome

5. SUBACROMIAL BURSITIS

6. ROTATOR CUFF TENDINITIS

7. ACROMIOCLAVICULAR ARTHRITIS

8. HOOKED ACROMION

9. IMPINGEMENT :clinical features
1.Pain: Exacerbated by overhead or above the shoulder activities
Night pain, often disturbing sleep, lying on affected shoulder.
acute :following an injury, particularly in older patients,
2.Loss of motion:
3.Weakness and inability to raise the arm

10. IMPINGEMENT :clinical features
Painful arc
Neers impingment test
Hawkins impingment test

11. IMPINGEMENT : IMAGING
• Xrays : Sometimes normal
• Xrays : shape of acromion
AC joint arthritis
• MRI
• MSK Ultrasound: Cuff tears,Bursitis
• Arthrogram

12. X RAYS
AC JOINT ARTHRITIS
HOOKED ACROMION

13. MRI: BURISTIS,ROTATOR CUFF
PATHOLOGY

14. IMPINGEMENT : TREATMENT
•
•
•
•
•
Avoidance of offending activity
Physiotherapy
NSAIDS
Corticosteroid injection
Surgery : Subacromial decompression

15. IMPINGEMENT :PHYSIO

16. IMPINGEMENT : SUBACROMIAL
INJECTION
- Out patient procedure.
- Reduces inflammation.
- Pain relief

17. IMPINGEMENT :SUBACROMIAL
DECOMPRESSION
- Excision of inflamed bursa.
-Acromioplasty
- Excision of AC joint : Acromioclavicular arthritis
-Open /Arthroscopic decompression

18. FROZEN SHOULDER
• Primary
 No underlying cause,
 Insidious onset,
 Global loss of movement

19. FROZEN SHOULDER:Secondary
• General
• Diabetes Mellitus
Impingement Syndrome • Thyroid disease
Bursitis
• Gout/Pseudogout
Synovitis
• Drugs – Phenobarbitone
Trauma
Distant
Osteoarthritis
•Myocardial infarction
•Head injury
•Pulmonary TB
•Carcinoma of Lung
•Cervical spine diseases
•Sub diaphragmatic pathology
Secondary
Local Causes

20. FROZEN SHOULDER:Pathology
Connective Tissue Disease
Inflammatory
Thick and contracted capsule with fibrosis
Recurrent haemarthrosis / Infection
Suprascapular Nerve Entrapment
Reflex Sympathetic Dystrophy

21. FROZEN SHOULDER: STAGES
• Stage 1: Freezing Painful 3 – 4 months
- Insidious onset of pain and loss of movement
• Stage 2: Frozen Stiff 6 – 12 months
- Resolution of pain, continued stiffness
• Stage 3: Thawing Improves 6 months +
- ROM improves

22. FROZEN SHOULDER:
INVESTIGATIONS
•
•
•
•
Plain X-ray: normal by definition
Arthrography: decreased joint volume
MRI: thick capsule
Arthroscopy : Tight contracted joint space
No adhesions
Synovitis
Tight axillary recess
Loss of Subscapularis bursa
Normal articular surface
• Synovial Bx - Inflammatory Synovitis!

23. FROZEN SHOULDER: TREATMENT
Stage 1: Acute Phase / Freezing
 Analgesia, maintain ROM as possible.
 Aggressive mobilisation/manipulation Contraindicated
 ?Intra-articular steroid injection?
Stage 2: Frozen
 Physiotherapy, for mobilisation and stretching
 MUA
Stage 3: Thawing
 MUA or arthroscopic release followed by physiotherapy.
 Shoulder function usually improves about 70% within 3-8
weeks

24. FROZEN SHOULDER: TREATMENT
• Frozen shoulder pathophysiology remains a
puzzle
• Clinical course to resolution may take 1 to 3 years
• May be incomplete
• MUA/Arthroscopic release has a role and speeds
up resolution