PAINFUL SHOULDER-- CAUSES
Acute shoulder pain
• Fractures & Disclocations
• Calcific tendinitis
• Acute Rotator cuff tears
Chronic shoulder pain
Impingement Syndromes:
• Subacromial bursitis
• Rotator cuff tendonitis
• AC arthritis
• Hooked Acromion
IMPINGEMENT SYNDROMES
• Subacromial bursitis
• Rotator cuff tendonitis
• AC arthritis
• Hooked Acromion
 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
SUBACROMIAL BURSITIS
ROTATOR CUFF TENDINITIS
ACROMIOCLAVICULAR ARTHRITIS
HOOKED ACROMION
IMPINGEMENT :clinical features

1.Pain: Exacerbated by overhead or above the

shoulder activitie 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

IMPINGEMENT :clinical features

Painful arc

Neers impingement Hawkins impingement test

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

AC JOINT ARTHRITIS HOOKED ACROMION

MRI: BURISTIS,ROTATOR CUFF
PATHOLOGY
IMPINGEMENT : TREATMENT
• Avoidance of offending activity
• Physiotherapy
• NSAIDS
• Corticosteroid injection
• Surgery : Subacromial decompression
IMPINGEMENT :PHYSIO
IMPINGEMENT SUBACROMIAL
INJECTION

- Out patient procedure.

- Reduces inflammation.
- Pain relief
 IMPINGEMENT SUBACROMIAL
DECOMPRESSION

- Excision of inflamed bursa.

-Acromioplasty
- Excision of AC joint : Acromioclavicular arthritis
-Open /Arthroscopic decompression
 FROZEN SHOULDER

• Primary
 No underlying cause,
 Insidious onset,
 Global loss of movement
 FROZEN SHOULDER : Secondary
Secondary
Local General
 Diabetes Melitus
 Impingement Syndrome
Causes  Thyroid disease
 Bursitis  Gout/Pseudogout
 Synovitis  Drugs – Phenobarbitone
 Trauma  Myocardial infarction
 Osteoarthritis  Head injury
 Pulmonary TB
 Carcinoma of Lung
 Cervical spine diseases
 Sub diaphragmatic pathology
 FROZEN SHOULDER:Pathology
Connective Tissue Disease
Inflammatory
Thick and contracted
capsule with fibrosis

Recurrent haemarthrosis / Infection

Suprascapular Nerve Entrapment
Reflex Sympathetic Dystrophy
 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
 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!
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
Stage 3: Thawing
 arthroscopic release followed by physiotherapy.
 Shoulder function usually improves about 70%
within 3-8 weeks
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