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
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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
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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
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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