Grand Rounds at Sutter Santa Rosa Regional Hospital: Evaluation and Treatment of Shoulder Pain (Pourtaheri, 2/16/2022)

Many thanks to Dr. Neema Pourtaheri of Santa Rosa Orthopedics for his presentation, Evaluation and Treatment of Shoulder Pain

A recording of his presentation is available HERE.

Shoulder pain is a very frequent complaint in primary care, can be broken down into several common categories

1) Rotator cuff and Proximal Biceps Tears (partial vs. full thickness, acute/traumatic vs. chronic/degenerative)

the rotator cuff is responsible for shoulder rotation, stabilization, and arm elevation
the rotator cuff holds the head of the humerus in the small shallow glenoid
rotator cuff muscles: supraspinatous, infraspinatous, teres minor, subscapularis
rotator cuff tear very common, 2 million people in US/year
important history in your diagnosis of rotator cuff injury: usually in dominant arm, age >40 years, pain worse at night, interferes with sleep, weakness with rotation and lifting, unable to do daily tasks (e.g. combing hair, putting on shirt)
Exam

acute traumatic usually occurs in setting of fall, trauma, significant amount of force (particularly in young patients)
chronic is degenerative, gradual onset, repetitive stress injury, occurs often in dominant arm, often as a result of bone spurs rubbing

Non-surgical management: activity modification, NSAID, cortisone?? (controversial, Dr. Pourtaheri doesn't recommend steroid injection for rotator cuff injury), PT helps with strength and pain, doesn't fix the tear, work on strengthening other tendons
All acute traumatic tears in people <60 should be fixed
"old tendons are not fixable" (no atrophy on MRI)
Shoulder arthroscopy: small incisions w/camera, nerve block for pain
Rotator cuff repair in correct candidates have 95% success rate (in terms of pain, function), improved shoulder strength and prevent tears from progressing
Post op course: 6 weeks in sling, 3 month limited lifting, PT

Many rotator cuff tears have an associated biceps tendon tear (should be repaired at the same time)

2) Impingement/Bursitis

inflammation of the bursa, usually due to overuse (overhead activity), sometimes trauma
pain exacerbated with activity, relieved with rest/NSAIDs, immobility
no-op treatment: activity modification, steroid injection, ice, ultrasound, PT
arthroscopic surgery for bursitis is generally arthroscopic bursectomy w/arthroplasty on the undersurface of the acromion
rehab is faster than rotator cuff: sling x 2 weeks, PT within 2 weeks of surgery

3) Shoulder Labrum Tear

Labrum is fibro-cartilaginous ring that attaches to the glenoid, anchor point for gleno-humeral ligaments
labrum is essential for shoulder stability in people <40
in people <40 tears are usually associated with trauma or dislocation event
in people >40, most labrum tears are physiologic and don't need treatment or surgery
PT is best non-operative management
Sometimes surgery is indicated for people who are young and failed PT

4) Shoulder arthritis

X-ray: collapsed joint space, large bone spurs, thickening of subchondral
Non operative management: NSAID, PT, steroid/cortisone injection (yes, indicated)

Operative tx: shoulder arthroscopy (to release joint capsule, usually in mild to mod arthritis)) and shoulder replacement
Shoulder replacement 90% pain relief indicated for moderate-severe arthritis of gleno-humerus
there have been significant advances in shoulder replacement techniques and technology over the last 10 years

two types of shoulder replacement: anatomic (intact rotator cuff) vs. reverse shoulder replacement (non anatomic)-- shoulder arthritis w/large rotator cuff tears

in reverse, ball goes on socket side of shoulder, socket on ball side of shoulder

Final pearls:

History and physical exam are key for assessment and diagnosis of shoulder pain
X-rays are still always a good idea as an initial evaluation (arthritis, calcific tendonitis, acromial bone spurs, for large rotator cuff tears for decision-making for surgery)
MRI definitively diagnose rotator cuff tears
Role for ultrasound? In patients who cannot get MRI (e.g. pacemaker), can use for shoulder injections (ultrasound guided)
Absolute indications for MRI in shoulder pain

fall/acute injury with sudden onset weakness in the arm likely has an acute rotator cuff tear(to evaluate for rotator cuff tear, which should be repaired within a couple months of injury for best outcome, time sensitivite)
if concern for biceps tendon "Popeye" arm (full thickness tear of biceps tendon)

Grand Rounds at Sutter Santa Rosa Regional Hospital