Anatomy Case Correlate

1
Anatomy Case Correlate

• Shoulder Pain

2
History

• 22 year old male, professional hockey player
• 6 week history of right shoulder pain
• No recent trauma
• Training heavily in the off-season
• Upper arm pain, increased with overhead activity,
  lifting

3
Physical Exam

• Normal motion
• Pain with lifting beyond 90 degrees
• Abduction 4/5 and painful
• External rotation 4/5
• Infraspinatus atrophy

4
Differential

• Rotator cuff
• Cervical spine
• Instability
• Nerve entrapment
• Labral tear
• Arthritis

5
Differential

• Inflammatory
• Tumor
• Infection
• Fracture
• Adhesive Capsulitis
• Intrathoracic
• Biceps

6
Rotator Cuff Impingement

• Dynamic pinching of the supraspinatus tendon
  between the humeral head and undersurface of
  acromion
• Force couple between deltoid and rotator cuff
  musculature

7
(No Transcript)
8
Rotator Cuff Disease

• Inflammatory
• Degeneration
• Partial Tearing
• Full Thickness Tearing
• Tears predictably begin in supraspinatus
• Part of normal aging process

9
Instability

• Static restraints
• Osseous architecture
• Capsuloligamentous restraints
• Dynamic restraints (musculature)

10
Shoulder Instability

• Dislocation
• Subluxation
• More difficult diagnosis
• Suspect in younger patient with chronic
  post-traumatic shoulder pain, with or without
  history of instabilty

11
AC JOINT

• Traumatic event (separation)
• Arthritis (post-traumatic versus degenerative)
• Well localized pain, superior shoulder

12
Labral Tear

• Variable anatomy
• SLAP lesion (superior, labrum, anterior and
  posterior)
• Most common in repetitive overhead athletes

13
(No Transcript)
14
Approaching the Problem

• Subjective complaints ? cuff tendinitis
• Abduction pain ? cuff tendinitis
• No history of instability
• Pain not localized to AC joint
• No repetitive overhead sports

15
(No Transcript)
16
Approaching the Problem

• But, infraspinatus atrophy and external rotation
  weakness
• Massive rotator cuff tear
• Suprascapular neuropathy

17
Suprascapular Nerve

• Origin C5 root or upper trunk of brachial
  plexus
• Suprascapular notch, beneath transverse scapular
  ligament
• Innervates supraspinatus
• Winds around spine of scapula
• Innervates infraspinatus

18
Further Work-up

• X-rays normal
• Electrodiagnostic studies ? injury to
  suprascapular nerve at spinoglenoid notch ?
  isolated denervation of infraspinatus
• Ganglion cyst?

19
(No Transcript)
20
Diagnosis

• Suprascapular neuropathy right shoulder
  secondary to ganglion cyst with possible superior
  labral tear at spinoglenoid notch

21
Treatment

• Right shoulder arthroscopy
• Labral debridement, arthroscopic decompression of
  the cyst
• Post op rehab, return to play at 6 weeks with
  full strength

22
Suprascapular Neuropathy

• It all starts with the anatomy
• Careful history careful exam usually results in
  diagnosis
• Imaging studies, when necessary, support what you
  suspect from above

23
(No Transcript)
24
(No Transcript)