Hronisks atdures sindroms, art.acromioclavicularis osteoartrīts
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Hronisks atdures sindroms, art.acromioclavicularis osteoartrīts
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Hronisks atdures sindroms, art.acromioclavicularis osteoartrīts
- 1. 1 Akromioklavikulārās locītavas osteoartrīts un hronisks atdures sindroms Reinis Riekstiņš RSU MF IV 14.02.2017.
- 2. 2 Definīcija – idiopātisks jeb neskaidras etioloģijas deģeneratīvs process, kas skar visas akromioklavikulārās locītavas struktūras Primārs OA vs sekundārs OA Epidemioloģija un etioloģija (I) Imaging of Pain. Elsevier, 2011, CHAPTER 89, 225-227. Rockwood and Matsen's The Shoulder Fifth Edition. Elsevier, 2017, Chapter 9, 365-451.e17.
- 3. 3 Bieži ir asimptomātisks Sāpes un jutīgums lokalizēts locītavā (osteofīti) Sāpes izraisa pilna abdukcija vai horizontāla addukcija. Var būt dzirdama krepitācija locītavā Simptomi Imaging of Pain. Elsevier, 2011, CHAPTER 89, 225-227. Rockwood and Matsen's The Shoulder Fifth Edition. Elsevier, 2017, Chapter 9, 365-451.e17.
- 4. 4 AC locītavas OA bieži ir saistīts ar rotatoru aproces deģenerāciju Apakšējie osteofīti - rotatoru aproces plīsums Simptomi (II) Rheumatology Sixth Edition. Elsevier, 2015, 73, 595-610. Rockwood and Matsen's The Shoulder Fifth Edition. Elsevier, 2017, Chapter 9, 365-451.e17.
- 5. 5 Bieži anamnēzē ir akromioklavikulārās locītavas trauma Sāpju intensitāte ir atkarīga no aktivitātes Rokas fleksija un addukcija (novietojot roku aiz pretējā pleca) izraisa sāpes Rentgenoloģiska izmeklēšana Anamnēze un izmeklēšana Imaging of Pain. Elsevier, 2011, CHAPTER 89, 225-227. Sabiston Textbook of Surgery 19 th edition. Elsevier Saunders, 2012
- 6. 6 Analgētiķi un NSPL Vingrinājumi i/a kortikosteroīdu injekcijas Ķirurģija – atroskopija / konvencionāla (0,5 – 1 cm) no laterālā gala Ārstēšana Traumatoloģija un ortopēdija Andra Jumtiņa redakcijā. Rīga: Rīgas Stradiņa universitāte, 2016. Sabiston Textbook of Surgery 19 th edition. Elsevier Saunders, 2012. Rheumatology Sixth Edition. Elsevier, 2015, 73, 595-610. Rockwood and Matsen's The Shoulder Fifth Edition. Elsevier, 2017, Chapter 9, 365-451.e17. Imaging of Pain. Elsevier, 2011, CHAPTER 89, 225-227.
- 8. 8 Pleca atdures sindroms ir lāpstiņas – krūškurvja kustību traucējumi, kas izraisa sāpes, var sekmēt rotatoru aproces muskuļu, visbiežāk m.supraspinatus, hroniska nospieduma veidošanos. Biežāk vidējos gados un vecākiem pacientiem (deģeneratīvas m.supraspinatus izmaiņas) Gados jauni sportiski cilvēki. Beisbols, teniss, peldēšana, darba apstākļi Hemodialīzes pacienti Epidemioloģija un etioloģija Traumatoloģija un ortopēdija Andra Jumtiņa redakcijā. Rīga: Rīgas Stradiņa universitāte, 2016.
- 9. 9 Anatomiskās īpatnības (acromion) Vecuma izraisītas deģeneratīvas pārmaiņas Tūska, asinsizplūdumi fibrotisks process deģenerācija Subakromiāls bursīts, tendinīts (m. biceps brachii caput longum et m. supraspinatus) Epidemioloģija un etioloģija (II) Campbell's Operative Orthopaedics. Elsevier, 2017, Chapter 46, 2298-2345.e7. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015, Chapter 398: Periarticular Disorders of the Extremities.
- 10. 10 Campbell's Operative Orthopaedics. Elsevier, 2017, Chapter 46, 2298-2345.e7.
- 11. 11 Pirmais aprakstīja Neer (1972) Izpratne par patoloģiju ir attīstījusies 4 tipi Dažādās slimības attīstības stadijas: 1 – 3 Atdures sindroms Primārs Sekundārs Subkorakoīds Iekšējs Campbell's Operative Orthopaedics. Elsevier, 2017, Chapter 46, 2298-2345.e7.
- 12. 12 Campbell's Operative Orthopaedics. Elsevier, 2017, Chapter 46, 2298-2345.e7.
- 13. 13 Atdure notiek starp rotatoru aproces muskuļiem un proc. coracoideus Fizikālā izmeklēšana – sāpīgums virs proc. coracoideus, + coracoid impingement test Lidokaīna injekcija? CT Artroskopiska / konvencionāla korakoplastija Subkorakoīds tips Campbell's Operative Orthopaedics. Elsevier, 2017, Chapter 46, 2298-2345.e7.
- 14. 14 Atdure rodas starp rotatoru aproces muskuļiem un art. glenohumerale mugurēji augšējo daļu, kad rokā ir abdukcijā, izstiepte un ārēji rotēta (sviešanas kustība). Pleca iekšējās rotācijas zudums Agrīna fizioterapija parasti ir veiksmīga Iekšējas atdures tips Campbell's Operative Orthopaedics. Elsevier, 2017, Chapter 46, 2298-2345.e7.
- 15. 15 Ārstēšana – NSPL, 1 vai vairāk subakromiālas kortikosteroīdu injekcijas Fizioterapija Artroskopiska / konvencionāla akromioplastika Primārs atdures tips Campbell's Operative Orthopaedics. Elsevier, 2017, Chapter 46, 2298-2345.e7.
- 16. 16 Anamnēze Vecums Arods Fiziskā sagatavotība Fizikālā izmeklēšana CT US MRI Rtg – loģiska izmeklēšana Anamnēze un izmeklēšana Schwartz's Principles of Surgery, 10e. New York, NY: McGraw-Hill; 2014, Chapter 43.
- 17. 17 Campbell's Operative Orthopaedics. Elsevier, 2017, Chapter 46, 2298-2345.e7. A, Neer impingement sign and impingement test. B, Hawkins- Kennedy test. C, Jobe supraspinatus test. D, Internal rotation resistance stress test. E, Gerber subcoracoid impingement test. F, Jobe apprehension-relocation test. G, Speed test. H, Yergason “supination” sign.
- 18. 18 Pēc traumas vai lielas slodzes Sāpes Diskomforts kustību laikā Nakts sāpes, apgrūtinātas kustības locītavā Simptomi Traumatoloģija un ortopēdija Andra Jumtiņa redakcijā. Rīga: Rīgas Stradiņa universitāte, 2016. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015, Chapter 398: Periarticular Disorders of the Extremities.
- 19. 19 Būtība – likvidēt sāpes un atjaunot locītavas funkciju Sākotnēji – režīms ar kustības ierobežojumu NPL, lokālas glikokortikoīdu injekcijas Fizioterapija Atroskopiska vai konvencionāla subakromiālās bursas rezekcija. Ārstēšana Traumatoloģija un ortopēdija Andra Jumtiņa redakcijā. Rīga: Rīgas Stradiņa universitāte, 2016. CURRENT Diagnosis & Treatment: Occupational & Environmental Medicine, 5e. New York, NY: McGraw-Hill; 2013, Chapter 9: Shoulder, Elbow, & Hand Injuries.
- 20. 20 Traumatoloģija un ortopēdija Andra Jumtiņa redakcijā. Rīga: Rīgas Stradiņa universitāte, 2016. Campbell's Operative Orthopaedics. Elsevier, 2017, Chapter 46, 2298-2345.e7. CURRENT Diagnosis & Treatment: Occupational & Environmental Medicine, 5e. New York, NY: McGraw-Hill; 2013, Chapter 9: Shoulder, Elbow, & Hand Injuries. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015, Chapter 398: Periarticular Disorders of the Extremities. Imaging of Pain. Elsevier, 2011, CHAPTER 89, 225-227. Rheumatology Sixth Edition. Elsevier, 2015, 73, 595-610. Rockwood and Matsen's The Shoulder Fifth Edition. Elsevier, 2017, Chapter 9, 365-451.e17. Sabiston Textbook of Surgery 19th edition. Elsevier Saunders, 2012. Schwartz's Principles of Surgery, 10e. New York, NY: McGraw-Hill; 2014, Chapter 43. http://emedicine.medscape.com/article/92974-overview Izmantotie avoti
Notas do Editor
- Acromioclavicular joint morphology appears to be associated with the development of osteoarthritis, although cadaveric studies have shown that degenerative changes occur in this joint with normal aging after 40 years of age. A previous history of joint injury is common when osteoarthritis of this joint occurs in isolation, but the joint may also be involved as part of generalized osteoarthritis. Acromioclavicular osteoarthrosis is common and frequently asymptomatic. • Incidence: Male > Female. • Most common in elderly patients and seen in younger patients following shoulder joint trauma and/or surgery. • Universal finding after the fifth decade of life. • Often a history of joint trauma.
- Pain and tenderness are localized to the joint, which is often prominent because of osteophyte formation. Pain is felt on full abduction or horizontal adduction and can also be reproduced with adduction of the extended arm. Crepitus is frequently localized to the joint. Gradual onset of anterosuperior pain with abnormal range of motion of the acromioclavicular (AC) joint. • Effusion may be present. • Crepitus may be present. • Clicking or catching sensation may be present. • Provocation of AC pain (positive result) with cross-body adduction test. • Gradual decrease in range of motion.
- It is important to note that osteoarthritis of the joint is often seen in association with rotator cuff degeneration and that inferior osteophytes at the acromioclavicular joint may contribute to the development of a rotator cuff tear. Clinical features of both conditions frequently coexist, especially in an older patient.
- Radiography: • Lordotic and oblique views. • MRI: • Part of assessment of rotator cuff in patients with impingement. • US: • Demonstrates only the superior aspect of the joint. • May be used to identify dynamic instability. • Guides therapeutic injections. Imaging findings • Osteophytes, sclerosis, and subchondral cysts. • MRI also demonstrates: • Marrow edema. • Capsular thickening. • Pericapsular edema. • Associated subacromial bursitis and osteophyte impingement on the rotator cuff. • AC joint synovial cysts in association with rotator cuff tears: • “Geyser” phenomenon. Other recommended testing • Intra-articular injection of contrast agent and local anesthetic. • Laboratory testing to rule out inflammatory arthritis. • Joint aspiration to rule out crystal arthropathies. • Joint aspiration to rule out infection.
- Initial management consists of local modalities and the use of analgesic or antiinflammatory drugs. An exercise program should be prescribed to restore normal scapulohumeral rhythm, glenohumeral range of motion, and deltoid and rotator cuff strength once the symptoms have settled. Intraarticular corticosteroid injection usually provides relief of symptoms but often needs to be repeated. Cases resistant to conservative treatment may require surgery, which consists of excision arthroplasty of the joint while ensuring that instability is minimized. Careful assessment of rotator cuff function is important, and in the presence of a significant tear, rotator cuff repair or acromioplasty may be indicated. Excision arthroplasty may also be indicated in a younger patient with chronic symptoms, whether caused by degenerative change, osteolysis, or instability. Treatment • Conservative treatment consisting of local heat, cold, simple analgesics, and nonsteroidal anti-inflammatory agents will improve symptoms in many cases. • Physical therapy, including gentle stretching, range-of-motion exercises, and deep heat modalities, may be beneficial in selected patients. • Intra-articular injection with local anesthetic and steroid will provide symptomatic relief if conservative therapy fails or the pain is limiting activities of daily living. • Surgery may be required for persistent pain or progressive functional disability.
- Other investigators have suggested that the shape of the acromion and the coracoacromial ligament are not the primary problems, but rather that intrinsic rotator cuff degeneration is the primary cause with subacromial changes occurring secondarily. Senescence of the tendon fibroblasts with resulting disruption of the tendon architecture is a common finding in the rotator cuff with aging. Age-related degenerative changes, including decreased cellularity, fascicular thinning and disruption, accumulation of granulation tissue, and dystrophic calcification, all have been noted and are likely irreversible. A zone of relative hypovascularity also is present on the articular surface of the rotator cuff. Differential shear stress within the tendon layers also has been cited as a cause of the disruption of the tendon fibers. Others have suggested that the rotator cuff tendons may fail in tension as a result of throwing a baseball or other overhead sports. Intrinsic degeneration leads to loss of the force couples, leading to superior humeral head translation and impingement.
- Since Neer's original description, the concept of impingement syndrome has evolved to encompass four types of impingement: (1) primary impingement, (2) secondary impingement, (3) subcoracoid impingement, and (4) internal impingement. Primary impingement is subcategorized further into intrinsic and extrinsic types. Primary impingement is the classic version and occurs without any other contributing pathology. Secondary impingement occurs when there is instability of the glenohumeral joint allowing translation of the humeral head, typically anteriorly, resulting in contact of the rotator cuff against the coracoacromial arch. When the structures passing beneath the coracoacromial arch become enlarged resulting in abutment against the arch, the cause of the impingement is considered to be intrinsic. Examples of this condition include thickening of the rotator cuff, calcium deposits within the rotator cuff, and thickening of the subacromial bursa. Extrinsic impingement occurs when the space available for the rotator cuff is diminished; examples include subacromial spurring, acromial fracture or pathologic os acromiale, osteophytes off the undersurface of the acromioclavicular joint, and exostoses at the greater tuberosity. The rotator cuff consists of the tendons of the supraspinatus, infraspinatus, subscapularis, and teres minor muscles, and inserts on the humeral tuberosities. Of the tendons forming the rotator cuff, the supraspinatus tendon is the most often affected, probably because of its repeated impingement (impingement syndrome) between the humeral head and the undersurface of the anterior third of the acromion and coracoacromial ligament above as well as the reduction in its blood supply that occurs with abduction of the arm (Fig. 398-1). The tendon of the infraspinatus and that of the long head of the biceps are less commonly involved. The process begins with edema and hemorrhage of the rotator cuff, which evolves to fibrotic thickening and eventually to rotator cuff degeneration with tendon tears and bone spurs. Subacromial bursitis also accompanies this syndrome. Symptoms usually appear after injury or overuse, especially with activities involving elevation of the arm with some degree of forward flexion. Impingement syndrome occurs in persons participating in baseball, tennis, swimming, or occupations that require repeated elevation of the arm. Those over age 40 are particularly susceptible. Patients complain of a dull aching in the shoulder, which may interfere with sleep. Severe pain is experienced when the arm is actively abducted into an overhead position. Patients may tear the supraspinatus tendon acutely by falling on an outstretched arm or lifting a heavy object. Symptoms are pain along with weakness of abduction and external rotation of the shoulder. Atrophy of the supraspinatus muscles develops. The diagnosis is established by arthrogram, ultrasound, or magnetic resonance imaging (MRI). Surgical repair may be necessary in patients who fail to respond to conservative measures. In patients with moderate-to-severe tears and functional loss, surgery is indicated. Causes Primary impingement Increased subacromial loading Acromial morphology (A hooked acromion, presence of an os acromiale or osteophyte, and/or calcific deposits in the subacromial space make patients more predisposed for primary impingement.) Acromioclavicular arthrosis (inferior osteophytes) Coracoacromial ligament hypertrophy Coracoid impingement Subacromial bursal thickening and fibrosis Prominent humeral greater tuberosity Trauma (direct macrotrauma or repetitive microtrauma) Overhead activity (athletic and nonathletic) Secondary impingement Rotator cuff overload/soft tissue imbalance Eccentric muscle overload Glenohumeral laxity/instability Long head of the biceps tendon laxity/weakness Glenoid labral lesions Muscle imbalance Scapular dyskinesia Posterior capsular tightness Trapezius paralysis
- Goldthwait, in 1909, first described pain in the shoulder caused by contact between the rotator cuff and the coracoid process. Gerber et al. suggested that this painful contact might be caused by a prominent coracoid, for which there may be numerous reasons, including idiopathic and iatrogenic conditions. Physical findings attributed to this condition include tenderness over the coracoid and a positive coracoid impingement test (see Fig. 46-1E ). An injection of lidocaine into the subcoracoid region similar to the Neer impingement test (see Fig. 46-1A ) has been used to evaluate patients for coracoid impingement. Relief of pain suggests the diagnosis, but the proximity of multiple structures in the subcoracoid region, including the glenohumeral joint itself, makes the accuracy of these injections questionable. For suspected impingement, open or arthroscopic coracoplasty has been recommended.
- Internal Impingement In this condition, internal contact of the rotator cuff occurs with the posterosuperior aspect of the glenoid when the arm is abducted, extended, and externally rotated as in the cocked position of the throwing motion. This contact probably is a normal phenomenon but becomes pathologic in certain patients. It often occurs in throwers who have lost internal rotation of the shoulder. Early in the course of the condition, aggressive physical therapy with attention to regaining internal rotation and rotator cuff strengthening often is successful.
- Primary (External) Impingement The initial treatment of a patient with tendinopathy caused by classic primary extrinsic impingement is a well-planned and well-executed nonoperative regimen including antiinflammatory medications and one or at most two subacromial cortisone injections. Medical treatment is followed by a physical therapy program focusing on stretching for full shoulder motion and strengthening the rotator cuff. Arthroscopic or open acromioplasty when indicated is the surgical treatment of choice for external impingement syndrome. We believe that either open or arthroscopic acromioplasty is satisfactory if the main principles of the original procedure as described by Neer are kept in mind, as follows: ▪ Release (but not resection) of the coracoacromial ligament ▪ Removal of the anterior lip and lateral edge of the acromion ▪ Removal of part of the acromion anterior to the anterior border of the clavicle ▪ Removal of the distal 1 to 1.5 cm of clavicle if significant degenerative changes are
- History Age Patients younger than 40 years - Usually glenohumeral instability, and acromioclavicular joint disease/injury Patients older than 40 years - Consider glenohumeral impingement syndrome/rotator cuff disease and glenohumeral joint degenerative disease Occupation Individuals at highest risk for shoulder impingement are laborers and those working in jobs that require repetitive overhead activity. Athletes (eg, swimming, throwing sports, tennis, volleyball) Athletic activity Onset of symptoms in relation to specific phases of the athletic event performed Duration and frequency of play Duration and frequency of practice Level of play (eg, little league, high school, college, professional) Actual playing time (eg, starter, backup, bench player) and position played Lack of periodization in training - Athlete participating in same overhead sport year-round
- On physical examination, patients begin to experience anterior shoulder pain when the arm is abducted to 30–40 degrees or flexed forward to 90 degrees or more. With the elbow flexed at 90 degrees, active external rotation usually does not cause discomfort. However, internal rotation (when the patient attempts to place his or her thumb on the opposite inferior angle of the scapula) is painful. With significant disruption of the rotator cuff, a patient may have no active elevation past 90 degrees of flexion or weakness to external rotation. However, patients can have full-thickness tears of the rotator cuff without lost motion. Point tenderness anterior to the acromion over the subacromial bursa is common. Two common tests for impingement are the supraspinatus isolation test (empty can test), and the Hawkins-Kennedy test (Figure 9–1) Symptoms Onset: Sudden onset of sharp pain in the shoulder with tearing sensation is suggestive of a rotator cuff tear. Gradual increase in shoulder pain with overhead activities is suggestive of an impingement problem. Chronicity of symptoms Location: Pain usually is reported over the lateral, superior, anterior shoulder; occasionally refers to the deltoid region. Posterior shoulder capsule pain usually is consistent with anterior instability, causing posterior tightness. Setting during which symptoms arise (eg, pain during sleep, in various sleeping positions, at night, with activity, types of activities, while resting) Quality of pain (eg, sharp, dull, radiating, throbbing, burning, constant, intermittent, occasional) Quantity of pain (on a scale of 0-10, 10 being the worst) Alleviating factors (eg, change of position, medication, rest) Aggravating factors (eg, change of position, medication, increase in practice, increase in play, change in athletic gear/foot wear, change in position played) Functional symptoms - Patient changed mechanics (eg, throwing motion, swim stroke) to compensate for pain Associated manifestations (eg, possibly chest pain, dizziness, abdominal pain, shortness of breath) Provocative position: Pain with humerus in forward-flexed and internally rotated position suggests rotator cuff impingement. Pain with humerus in abducted and externally rotated position suggests anterior glenohumeral instability and laxity.
- The goal of treatment is to reduce pain and restore function. Initial treatment is generally nonsurgical and based on rest,NSAIDs, and physical therapy. If pain is not relieved, an injection of a local anesthetic and a cortisone preparation may be helpful. ++If conservative treatment does not relieve pain, surgery is recommended, with the goal to excise the bursa and create more subacromial space. Generally, surgery is performed arthroscopically and encompasses bursectomy and subacromial decompression via acromioplasty. If the rotator cuff (supraspinatus tendon) is also injured, arthroscopic repair is usually indicated to restore function, sometimes is accompanied by a bony resection of the inferior portion of the acromion. This usually can be accomplished with nonoperative treatment. Patients with less severe symptoms can be started on anti-inflammatory medications, pendulum exercises, and shoulder rotator cuff exercises. Patients are taught to do this using resistance exercises such as with an elastic band (Thera-Band), with the arm at the side, elbow flexed 90 degrees, applying force in internal and external rotation. The fastest way to resolve impingement symptoms is to inject the subacromial space with corticosteroid and local anesthetic (eg, triamcinolone 40 mg and 1% lidocaine 4 cc). The diagnosis is made when the patient's symptoms are relieved immediately. The patient then is started on progressive resistance exercises. Patients who respond only temporarily to the injection or who develop recurrence after two or three injections and who have participated in proper exercises may be candidates for surgery or arthroscopic surgery to decompress the subacromial space. This includes removal of bone from the undersurface of the acromion and AC joint, bursectomy, and cuff debridement and repair as necessary.