Adult scoliosis Scoliosis is de \201 ned as sideward bending of the spine, resulting in a deformity of the spine in the coronal plane. Adult scoliosis is broadly de \201 ned into t wo groups: \200 Idiopathic adult scoliosis: this represents scoliosis that has been present since adolescen ce, which has contin- ued to progress into adulthood. The patient may or may not present wi th superimposed degenerative changes. Adolescent idiopathic scoliosis may continue to progr ess into adulthood. This is particularly true for curves in the lumbar region which are gre ater than 50 in magnitude, and where there is signi \201 cant apical or lateral listhesi s. The prevalence of adult scoliosis is approximately 6%. Where there is pre-existing adole scent idiopathic LUMBAR SPINE: REGIONAL MUSCULOSKELETAL CONDITIONS 134 scoliosis the rate of progression is approximately 1 \200\2232 per year. De novo adult sc oliosis: as a consequence of degenera- tive changes within the spine a deformity arises de novo in a previously straight spine. De novo scoliosis tends to present in the older age gr oup, typically in patients in their 60s and 70s. The curve progression in the de novo group appears to be more rapid and averages 3 \200\2234 per year. strengthening. Pain management strategies are crucial and include the use of NSAIDs, as wel l as epidural steroid injections, facet joint injections and nerve root blocks. Obese patie nts are encouraged to lose weight, although in this elderly age group weight loss and exerc ise compliance are often poor. Surgical treatment should be reserved for patients who have severe intractable pain that is not controlled by non operative measures. Surgery is also i ndicated where, uncommonly, there is progressive neurological deterio- ration. Progression of the deformity is also a relative indication for surgical treatment. Surgery may be fairl y minimal, decompressing a single stenotic segment, but in those with progressive disease m ore extensive surgery to stabilize the spine and provide a solid arthrodesis is necessary. This is often required in a high risk population in whom preoperative assessment and medica l optimiza- tion is vital. Complications of surgery can be serious and the complication rat es are high with pseudoarthrosis demonstrated in up to 28%. There is a signi \201 cant ris k of intraoperative bleeding, graft site morbidity and neuro- logical complications. Infect ion, wound breakdown and instrumentation failure are not uncommon. History \200 The patient with de novo scoliosis typically presents with back pain. This is due to a comb ination of factors includ- ing facet joint degeneration, disc degeneration, and cost- opelv ic impingement when there is a signi \201 cant kyphotic deformity in association with the scoliosis. The patient may also present with pain secondary to osteoporotic compression fra ctures or due to muscle fatigue because of the abnormal spinal posture. Adult scoliosis pat ients may also present with spinal claudication or radiculopathy secondary to neural com- p ression. Patients may report progressively increasing deformity and loss of height. Examination Examination establishes the degree of rigidity of the curve, as well as the deg ree of coronal and sagittal imbalance. A careful neurological examination needs to be perfo rmed. Further reading Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP. Cauda equi na syndrome secondary to lumbar discherniation. A meta-analysis of surgical outcomes. Spine 2000; 25: 1515 \200\22322. Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term out- comes of surgical and non-surgical management of lumbar spinal stenosis: 8-10 year results from the Maine Lumbar Spine Study. Spine 2005; 30: 927 \200\223935. Investigations \200 Standard scoliosis radiographs including long cassette posterior-anterior and lateral X-ray s should be obtained. Bending \201 lms aid the assessment of the rigidity of the curves. MRI should be performed in all patients presenting with stenotic symptoms or with radicular symptoms, with CT myelograms reserved for those in whom MRI is contraindicated. Daubs MD, Lenke LG, Cheh G, Stobbs G, Bridwell KH. Adult spinal deformity surgery: complica tions and outcomes in patients aged over 60. Spine 2007; 32: 2238 \200\22344. Johnsson KE, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Clin Orthop Relat Res 1992; 279: 82 \200\2236. Peul WC, van Houwelingen HC, van der Hout WB, Brand R, Eekhof JAH, Tans JTJ, Thormeer RTWM, Koes BW. Surgery versus prolonged conservative treatment for sciatica. NEJM 2007; 356: 224 5 \200\22356. Treatment \200 Non-surgical treatment should initially be undertaken. Physiotherapy may help with core sta bility and muscle This page intentionally left blank THE SHOULDER 136 The shoulder The shoulder has evolved to provide ability for the hand to reach almost any position relat ive to the trunk. which the coracoid process arises from the anterolateral margin of the scapular. When viewe d from the lateral side these two processes (spine of scapular posteriorly and coracoid pro cess anteriorly) appear to arise from the region of the neck of the glenoid at the 10 \200 \231o \200\231clock and 2 \200\231o \200\231clock positions, respectively, and account for the \200\230propellar \200\231 appearance of a \200\230lateral scapular \200\231 X-ray vi ew (viewing the lateral aspect of the scapular end-on). Regional anatomy Movement in the shoulder occurs in four linked articular areas: at the ste rnoclavicular joint (SCJ), at the acromiocla- vicular joint (ACJ), at the glenohumeral join t (GHJ), and at the scapulothoracic articulation. Movement at the GHJ can occur in isolatio n, but movement at the scapulothoracic articulation is accompanied by movement at the ACJ a nd SCJ joints (See also Plate 1). Muscles either take origin from or insert into almost every aspect of the scapular, and hol d the scapular in place over the posterolateral chest wall. Bones The upper limb is attached to the axial skeleton indirectly, \201 rst by the clavic le, which articulates with the sternum at the sternoclavicular joint, and secondly by muscl es, which attach the humerus to the scapula. Joints of the shoulder Glenohumeral joint The head of the humerus lies adjacent to the glen oid and beneath the acromion process, which arches above, with a concave undersurface in bo th anteroposterior and medio- lateral directions. The humeral head is held in place by a co mbination of ligaments and muscles. The articular sur- face of the glenoid fossa on the sca pula is lined by articular cartilage (the glenoid labrum). See Figure 5.9. The clavicle The clavicle acts as a bony strut holding the shoulder joint away from the che st wall. The anterior aspect of the clavicle is convex medially and concave laterally, and the medial end is bulbous, whereas the lateral end is \202 attened. It articulates with t he sternoclavicular joint at the medial end and the acromioclavicular joint at the lateral end. Glenohumeral joint capsule The capsule is attached around the circumference of the outer ed ge of the glenoid and envelopes the humeral head, attaching to the anatomical neck of the h umeral head, around the rim of the articular surface. The capsule is lined with a synovial membrane. The scapular The scapular has a concave anterior surface and convex posterior surface. The posterior surface is crossed by the spine of the scapular, which increases in height as it crosses from the medial side to the lateral side. At the lateral end of the spine of the sc apular it sweeps superiorly and anteriorly above the glenoid, and expands to form the acrom ion process. The sternoclavicular joint The sternoclavicular joint is a synovial joint between the junct ion of manubrium and sternum medially and the medial end of the clavicle laterally. The lateral free edge of the spine is angled posterosupe- riorly and arises from the scapul ar at the same level at tendon of supraspinatus tendon of long head of biceps acromion subacromial bursa capsule head of humerus glenoid fossa labrum gleno- humeral ligaments Figure 5.9 Interior of shoulder joint. CHAPTER 5 Regional musculoskeletal anatomy and conditions 137 costovertebral ligaments coracohumeral ligament acromio- clavicular ligament 1st rib facet for clavicle sternoclavicular ligaments coraco-acromial ligament 1st thoracic vertebra c l a v i c l e costoclavicular ligament opening of subscapularis bursa articular disc coraco- clavicular ligaments scapula sternum subscapularis (cut) 1st costal cartilage loose part of capsule Figure 5.10 Bones and ligaments of the shoulder girdle. tendon of long head of biceps The acromioclavicular joint The acromioclavicular joint, a synovial joint, is the articula- tion between the clavicle and the acromion at the lateral end of the clavicle. The adjacen t bones are held together by the circumferential capsule and ligaments. See Fgure 5.10. \200 Figure 5.11 Shoulder joint: attachments of the capsule and extrinsic ligaments. lateral aspect of the proximal third of the humerus known as the \200\230deltoid tubercle \200\231. The deltoid muscle is multipennate and different regions can contract inde- pende ntly. Contraction of the anterior \201 bres aids ante- rior elevation of the humerus ( \202 exion), contraction of the lateral \201 bres aids lateral elevation (abduction), and contraction of the posterior \201 bres aids extension. Pectoralis major arises from the sternum, ribs, and medial third of the clavicle, and inserts into the lateral aspect of the intertubercular groove on the anterior aspect of the proximal humerus. It acts as an adduc tor and internal rotator of the humerus. Latissimus dorsi has an expansive origin from the six lower thoracic vertebrae and from the lumbodorsal fas- cia, which has attachments to th e posterior part of the iliac crest, and the sacral and lumbar spinous processes. The muscl e \201 bres converge into a thick tendon, which inserts into the intertubercular groove. The muscle is a powerful adductor, internal rotator and extensor of the humerus. These ligaments of the ACJ are supported by ligaments separate from the joint, which hold t he lateral end of the clavicle down. These separate ligaments are the coracoclavicular liga ments, which arise from the superior surface of the coracoid and insert into the underside of the clavicle slightly medial to the ACJ. One of these ligaments resembles a cone (point of cone is inferior) and is referred to as the \200\230conoid ligament \200\231. The other ligament is more strap-like and trapezoidal in shape, and is known as the \200\230trapezo id ligament \200\231. Ligaments The ligaments comprise the glenohumeral capsule itself and longitudinal condensat ions which form bands within the substance of the capsule in a consistent arrangement. Thes e bands are the superior, middle, and inferior glenohu- meral ligaments, describing the rel ationship of each to the glenoid. The capsule and ligaments are inelastic, but are lax whil st the humerus is lying adjacent to the thorax, and become taut as the humerus is abducted and externally rotated. See Figures 5.10 and 5.11. It is important to remember that isotonic contraction of the deltoid, pectoralis major, and latissimus dorsi muscles will produce the movements mentioned above, but they play a cruci al role as stabilizers of the shoulder and achieve this with isometric contraction. Muscles of the shoulder The muscles that hold the humeral head in position and which act ac ross this joint can be thought of as either imprecise, but powerful, such as deltoid, pecto ralis major, and latissimus dorsi, or precise yet less powerful, as in the muscles of the r otator cuff. See Figure 5.12. \200 Rotator cuff This group of muscles comprises subscapularis, supraspina- tus, infraspinatus, and teres minor. They each take origin from the scapular and their tendons converge, merge with the lateral part of the glenohumeral capsule, and produce a thick aponeurotic tendon, which drapes over the humeral head from anterior to posterior. The inferior de \201 cienc y is compensated for by the inferior glenohumeral ligament. The deltoid muscle has a wide origin running around from the anterior aspect of the lateral end of the clavicle to the posterior aspect of the acromion. The muscle \201 bres conver ge to insert into a prominence on the THE SHOULDER 138 The movements of the muscles of the rotator cuff are determined by their line of pull acros s the GHJ. \200 Table 5.3 Main muscles in the shoulder girdle The subscapularis runs anteriorly and pulls the humeral head into internal rotation. Supras pinatus runs across the superior aspect of the humeral head and, thereby, initiates abducti on. Infraspinatus and teres minor have a line of pull that runs below the superior pole of the humeral head posteriorly and, therefore, produce external rotation. In addition to thei r individual movements the muscles of the rotator cuff appear to play a role in preventing the humeral head from migrating superiorly out of the gle- noid, preventing it from \200 \230impingeing \200\231 upon the underside of the acromion. Muscle Action Innervation Trapezius Rotation of scapula Spinal accessory nerve (XIth cranial) Latissimus dorsi Extensor, internal rotator and adductor Thoracodorsal nerve Rhomboid major Adducts scapula Dorsal scapular nerve Rhomboid minor Adducts scapula Dorsal scapular nerve Levator scapulae Scapular elevation and rotation C3, C4 Pectoralis major Adduction and int. rotation of humerus Medial and lateral pectoral nerves Biceps The long tendon of the biceps muscle takes origin from the supraglenoid tubercle and runs laterally, within the joint space between the superior surface of the humeral head an d the capsule before turning inferiorly to leave the capsule via the bicipital groove on th e anterior aspect of the proximal humerus. The muscle belly of the long head of biceps deve lops beyond this point and merges distally with the short head, which takes its origin from the coracoid process. Pectoralis minor Protracts scap. Medial pectoral nerve Subclavius Depresses clavicle Nerve to subclavius Long thoracic nerve Serratus anterior Protraction of scapular and prevents winging Deltoid Humeral abduction Axillary nerve Teres major Adductor, internal rotator and extensor Lower subscapular nerve Subscapularis Internal rotator and stabilizer of shoulder Upper and lower subscapular nerves The two heads insert via a tendon into the radial tuber- osity on the proximal radius and v ia an aponeurosis (the lacertus \201 brosus) that, ultimately, attaches to the proximal u lnar via the fascia overlying the common \202 exor muscles of the forearm. Supraspinatus Abductor, ext. rotator and stabilizer Suprascapular nerve Infraspinatus External rotator and stabilizer Suprascapular nerve The main muscles around the shoulder their actions and Teres minor External rotator and stabilizer Axillary nerve innervation is presented in table 5.3. B A C Inf Sup H E S De (a) De Bi Cb H Sub G Inf S (b) L Figure 5.12 MRI of shoulder joint; (a) sagittal plane, (b) horizontal plane. Head of humeru s (H), epiphyseal line (E), glenoid labrum (L), glenoid fossa (G) and acromion (A) of scapu la (S), clavicle (C), deltoid (De), infraspinatus (Inf), supraspinatus (Sup), subscapularis (Sub), tendon of biceps (Bi), coracobrachialis (Cb). CHAPTER 5 Regional musculoskeletal anatomy and conditions 139 In \202 ammation within the subacromial bursal tissue will result in all movements of the shoulder being painful. The MRI apperances of the normal shoulder are visu- Bursa The subacromial bursa is not a true bursa in that it is not a \202 uid \201 lled space, but is made up of a number of layers of loose areolar connective tissue, enabling th e two surfaces to move smoothly against each other. \200 alised in Figure 5.12. Further reading Standring S. (Ed.) Grays Anatomy: the anatomical basis of clinical The aponeurotic tendon of the rotator cuff lies between the humeral head inferiorly and the acromion superiorly, and its smooth running beneath the acromion is achieved by the fricti on reducing effects of the subacromial bursa. practice. Section V. London, 2006. Last \200\231s Anatomy \200\223 Regional and Applied. 11th edn. THE SHOULDER GIRDLE: REGIONAL MUSCULOSKELETAL CONDITIONS 140 The shoulder girdle: regional musculoskeletal conditions Spectrum of rotator cuff disease Stage 1, where oedema and hemorrhage are present is, usual ly reversible, and affects patients mostly less than 25 years of age. Main differential diagnosis of shoulder pain Articular \200 \200 \200 \200 \200 \200 In \202 ammatory arthritis (GHJ or ACJ). Crystal arthritis. Adhesive capsulitis/frozen sho ulder. Glenohumeral instability. Osteoarthritis (GHJ or ACJ). Milwaukee shoulder (also affe cts periarticular tissues). In Stage 2, \201 brosis and tendinitis affect the rotator cuff of patients typically in t he 25 \200\22340-year age group. Pain often recurs with activity. Stage 3, with bone spurs and tendon rupture, present in individuals over 40 years of age. Key features in the history The history is dependant on both the etiology, as well as the a ge of the patient. The commonest presentation includes pain, which is generally activity re lated and in the younger patient may be acute following an injury such as throwing. A more insidious onset is typical in the older patient with pain and discomfort, and pain on speci \201 c movements. Common symptoms include pain on reaching up above the head, reaching be hind the back when dress- ing, or changing gear when driving. There may be sleep interferen ce as rolling on to the shoulder results in pain. A history of weakness may represent a ful l rotator cuff tear. Periarticular \200 \200 \200 \200 Rototor cuff disease, e.g. tendinopathy or tear. Subacromial bursitis. Calci \201 c tendin itis. Bicipital tendinitis. Referred pain \200 \200 \200 \200 \200 Cervical radiculopathy. Neuralgic amyotrophy. Spinal cord pathology. Subdiaphragmatic patho logy. Cardiac ischaemic pain. Key features on examination Physical examination involves evaluation of the range of motion , both active and passive, cuff strength testing and special shoulder tests. It should also include assessment of the cervical spine, since shoulder pain may be referred. A painful a rc is usual between 70 and 120 of abduction, with pain on both active abduction and when lowering the arm, indicating impingement. Passive movements are normal and often painless. Localized tenderness in the subacromial space is a variable \201 nding. Resisted move- me nts of individual tendons will aid the speci \201 c diagnosis. \200 Supraspinatus is tes ted with the arm abducted to 90 , with \202 exion of 30 , and internal rotation so that the thumb points down to the \202 oor. Resisted abduction is painful. In severe cases, r esisted \202 exion with the arm internally rotated may be less uncomfortable. Subscapular is muscle is tested by resisted internal rotation, with either the arm across the abdomen o r the arm behind the back. Infraspinatus and teres minor are tested by resisted external ro tation, although there is some action of supraspinatus. Biceps is tested by resisting \202 exion of the shoulder with the arm in extension (Speed \200\231s test) or resisted sup ination of the arm with the elbow at 90 of \202 exion (Yergeson \200\231s test). Imping ement is tested by a number of techniques, all of which force the subacromial bursa and rot ator cuff against the inferior surface of the acromion. Speci \201 c maneuvers include abd uction and forceful internal rotation of the arm with the elbow at 90 of \202 exion, or the arm is externally rotated from an adducted, \202 exed, and internally rotated positi on. Bicipital provocation is performed by abduction of the arm to 90 with the palm facing upwards, followed by adduction of the arm across the midline against resistance. Rotator cuff disease Rotator cuff disease is typically a continuum of pathology ranging fro m tendinitis and bursitis to partial tearing, to complete tear in one or more of the tendon s. Pathogenesis The exact mechanism of rotator cuff disease remains disputed, but the current view is that the mechanism is multifactorial, and is in \202 uenced by a genetic predispos ition, as well as intrinsic and extrinsic factors. Extrinsic factors arise when the tendons sustain mechanical injury through impingement, and intrinsic factors occur where tendon da mage and degeneration occurs through changes within the tendon itself. Extrinsic mechanisms Mechanical factors include anterosuperior stresses from impingement by the under surface of the anterior acro- mion, or more rarely posterosuperior stress from t he articular side of the supraspinatus tendon and the postero- superior edge of the glenoid cavity, or anterointernal stress from impingement of the cuff from the coracohumeral inter val. Intrinsic hypothesis Degenerative change within the supraspinatus tendon increases with age , and more severe degeneration is asso- ciated with the development of tendinopathy. Cuff t endi- nopathy is postulated to result from an imbalance between synthesis and degradation o f the tendon, perhaps due to failure to regulate speci \201 c matrix metalloproteinase (MM P) enzyme activities in response to repeated injury or mechanical strain. There is an association of deposition of amyloid within supraspinatus, in patients with chr onic degenerative tendi- nopathy, which accumulates irreversibly over time and ulti- mately leads to irreversible changes in the structure of the affected tissue. Imaging \200 Plain radiography of the shoulder should include three standard views (anteroposterior, lat eral scapular or outlet CHAPTER 5 Regional musculoskeletal anatomy and conditions 141 described, with formative and resorptive phases. The resorp- tive phase of the condition as the calcium deposits are extravasated into the subacromial bursa is typically very severe and associated with a markedly reduced range of movement. Most will resolve spontaneously. view, and axial) to provide information on the morphol- ogy of the acromion, and to exclude joint degeneration at the GHJ or ACJ, reduction of the subacromial space, etc. US and MR a re techniques that visualize the soft tissues. US has the advantage of being cheap, non-inv asive and is a dynamic investigation, allowing visualization of the structures as they move ; however, it is very operator dependent. MR is more expensive and the images are static, b ut can be interpreted by the treating clinician in the context of the clinical examination. An example of US in a ruptured supraspinatus tendon is seen in \201 gure 5.13. Management Initial management would involve analgesia and subacro- mial glucocorticoid inje ction. If the pain is not controlled by conservative means, an ultrasound-guided or arthros copic needling of the lesion releases the calcium and provides immediate pain relief. Once settled, the calcium deposits remain and can be a source of mechanical impingement. In such cases, an acromioplasty can resolve the symptoms. Frozen shoulder A frozen shoulder is a painful shoulder condition of insidi- ous onset that is associated with stiffness and dif \201 culty sleeping on the affected side. The term \200\230adhesive capsulitis \200\231 is a misnomer as there are no associated capsular adhe sions. Epidemiology The cumulative lifetime risk of developing frozen shoulder is about 2%. It com monly presents in the sixth decade with a peak age of 56. It is slightly more common in wom en than men and the non-dominant shoulder is more likely to be affected. Etiology/pathogenesis The etiology remains unclear. Histological biopsy con \201 rms synov ial in \202 ammation with subsequent reactive capsular \201 brosis. A dense matrix of ty pe I and type III collagen is laid down by \201 broblasts and myo \201 broblasts in the joint capsule. Subsequently, this tissue contracts. High expression of growth factors, cyto kines, and matrix metal- loproteinases is found in capsular biopsy specimens, which have a role in regulating \201 broblasts. Figure 5.13 A ruptured supraspinatus tendon (SST) tendon is visualized on US, with bunching of the tendon outlined in white, and \201 bres retracted by 3.46 cm (measured by the dot ted line). Management \200 The management of early stage rotator cuff disease (clinical impingement) should be treated conservatively. This involves physical therapy targeted at rehabilitation of the rotator c uff in order to restore its humeral head centering mechanism. This can be aided by pain-rel ieving measures, such as oral NSAIDs or subacromial gluco- corticoid injections, particular ly in the presence of bursitis. The duration of conservative management is the subject of c ontroversy, being quoted at anything between 6 weeks and 6 months. If conservative manageme nt fails, surgical treatment in the form of arthroscopic subacromial decompression is indic ated. A high (around 90%) rate of satisfactory results is achieved. For symptomatic tears, the threshold for surgery is lower. Partial and small full thickness tears can be successfu lly treated by decompression alone, although this does not stop the progression of cuff dis ease. Most cuff tears will progress, either in size or in symptoms. If pain relief and rest oration of function is not achieved with rehabilitation, repair of the cuff, by open means or arthroscopic is indicated. A rate of around 95% satisfac- tory results is quoted in most of the recent outcome studies. Clinical features Frozen shoulder is characterized by restriction of active and passive mov ement of the shoulder that occurs in the absence of a known intrinsic shoulder disorder. Th e disease process particularly affects the anterosuperior joint capsule, the inferior reces s and the coracohumeral ligament. The condition is ultimately self-limiting. There are thre e overlapping phases: \200 Painful freezing phase (duration 10 \200\22336 weeks): pain and stiffness around the should er with no history of injury. There is a constant nagging pain, worse at night. Adhesive ph ase (occurs at 4 \200\22312 months). The pain gradually subsides, but stiffness remains. Pa in is apparent only at the extremes of movement and there is global reduction of glenohumer al range of movement. Resolution phase (takes 12 \200\22342 months). Risk factors Frozen shoulder can be idiopathic or it may be associated with a number of ris k factors: \200 Diabetes mellitus: the incidence of frozen shoulder in diabetes patients is reported to be 10 \200\22336%. The inci- dence in type 1 and type 2 diabetes is similar. Frozen shoulder i n diabetics is often more severe and more prolonged. Dupytren \200\231s disease. Shoulder s urgery. Rarer associations: hyperthyroidism, hypothyroidism, hypoadrenalism, Parkinson \200 \231s disease, cardiac disease, pul- monary disease, and cerebrovascular accident. Calci \201 c tendinitis Epidemiology Calci \201 c tendinitis of the rotator cuff affects 10% of the population, although it is often asymptomatic. \200 \200 Clinical presentation It can present with nagging discomfort in the region of the affected tendon, but it frequently presents with acute onset of severe pain. Distinct phases of deve lopment are THE SHOULDER GIRDLE: REGIONAL MUSCULOSKELETAL CONDITIONS 142 Clinical presentation, however, normally represents a continuum between the three groups. Non-shoulder surgery such as cardiac surgery has also been associated with secondary frozen shoulder. Investigations Radiographs can help assess the integrity of the glenoid and humeral head. C T is helpful if a bony lesion is suspected and the radiographs do not demonstrate the osseo us architecture adequately. MR arthrography is the investigation of choice (80 \200\22390% sensitivity and speci \201 city for labral pathology). In those cases, where etiology rema in uncertain, examination under anesthesia and diagnostic arthroscopy can be of assistance. Investigations The diagnosis is essentially clinical. Imaging is used to rule out other pat hologies presenting with pain and stiffness, such as degenerative joint disease. \200 Plain radiographs are typically normal, although they may show disuse osteopenia. MR and US may demonstrate thickening in the joint capsule and the coracohumeral ligament. Isotope bo ne scans may demonstrate an increased uptake of contrast. Treatment Treatment is directed towards the cause of the instability. \200 None of these investigations are diagnostic. In recurrent dislocations of the traumatic structural group, surgical treatment is indicate d. If the damage is to the labrum, a labrum repair resolves the symptoms in over 90% of cas es. If the cause is a bony defect, bone grafting of the defect is carried out, either with a cora- coid block (Bristow-Latarjet procedure) or an iliac crest graft. Atraumatic structu ral instabilities are amenable to reha- bilitation. This involves improving muscle control and proprioception. If this is not suf \201 cient, surgery is used to reduce the volume of the capsule and retighten the glenohumeral ligaments. Muscle patterning disorders are rare . Treatment is difficult and requires a specialist multidisciplinary approach, involving a shoulder surgeon, a shoulder physiotherapist and on occasions psychological support. Treatment The treatment of frozen shoulder should be tailored to the stage of the disease. It is also important to offer reassur- ance that the condition will spontaneously resolve, although there may be some residual reduction in the range of movement. \200 Treatment in the painful freezing stage will be directed towards controlling pain with anal gesia or NSAIDs. The role of glucocorticoid injection and physiotherapy remain controversia l, with little evidence to suggest that either signi \201 cantly shortens the time to reso lution of symptoms. Hydrodilatation provides good pain relief and improvement in the range of motion. During the adhesive phase, if the stiffness is functionally limiting or pain per sists, contracture release is indicated in rare cases. This has traditionally been achieved with manipulation under anesthesia, although there is a high incidence of iatrogenic damag e to the cuff, articular sur- face, and labrum. The procedure of choice to release the cont racture in an arthroscopic arthrolysis. This, com- bined with continuous interscalene anest hesia during the early postoperative period, allows early functional restoration. Arthritis of the shoulder The shoulder joint is a functional unit composed of several joint s: glenohumeral, acromioclavicular, sternoclavicular, scapulothoraic, and subacromial. The first three are susceptible to degenerative joint disease. Acromioclavicular/sternoclavicular osteoarthritis Osteoarthritis can happen at either end o f the clavicle. On the acromial side osteoarthritis is very common, although not always sym ptomatic. Sternoclavicular joints rarely become degenerate and osteoarthritis is associated with trauma, instability, and in \202 ammatory arthropathies. The US appearances of an os teoarthritic acromioclavicular joint are demonstrated in Figure 5.14. Shoulder instability The shoulder is the most mobile joint in the body. Stability on moveme nt is provided both by static (glenoid surface, labrum, and glenohumeral ligaments) and dyn amic (rotator cuff and extrinsic muscle balance) mechanisms. Conditions that affect any of these can result in recurrent instability. Shoulder stability can be classi \201 ed by the direction of the abnormal movement, the severity and by the cause. The Stanmore Classi \201 cation of Shoulder Instability is based on the characteristics of three main groups: \200 Traumatic structural: where there is a de \201 nite history of trauma, usually anterior an d unilateral, resulting in damage to the labrum (Bankart lesion). The treatment is surgical , in the form of a Bankart repair. Atraumatic structural: it is due to capsular dysfunction due to repetitive microtrauma, usually in a background of increased laxity or structural a bnormalities of the articular surfaces. It is not uncommonly bilateral. Habitual non-struct ural (muscle patterning): there is no history of trauma, no structural damage to the articu lar surfaces, but an altered muscle patterning. This can start as a voluntary action (party trick), but becomes uncon- trolled. The diagnosis is dif \201 cult and sometimes requires EMG studies. Figure 5.14 Capsular proliferation around the acromioclavicular joint is visualized on US, and is identi \201 ed here by the solid arrows. The broken arrows demonstrate osteophytes. The joint space is narrowed and obliterated as a consequence and is not clearly seen. CHAPTER 5 Regional musculoskeletal anatomy and conditions 143 Treatment Treatment is initially conservative, with activity modi \201 cation and analgesi a. Symptomatic acromio/sternoclavicular os- teoarthritis that does not respond to conservat ive therapy may be treated with excision arthroplasty. At the acromial end, it is usually e xcised arthroscopically. On the sternal side, an open excision arthroplasty is carried out due to the proximity of big vessels. gaining a painless range of movement, involving gleno- humeral joint synovectomy with a sub acromial bursec- tomy. If rotator cuff disease is present it can be addressed at the time b y means of an acromioplasty and release of the coracoacromial ligament. Once articular cart ilage loss has occurred prosthetic replacement using either a hemiarthroplasty or total joi nt replacement is usually necessary. The results for rheumatoid arthritis patients are not as good as in patients with osteoarthritis. Osteoarthritis of the glenohumeral joint Osteoarthritis of the GHJ is rare and there is nor mally a predisposing factor, such as trauma, avascular necrosis of the humeral head, or in \202 ammatory disease. The articular cartilage in the GHJ is exposed to less force than we ight- bearing joints, making osteoarthritis less common. Typical presentation is of poorly localized shoulder pain with discomfort in the upper arm in an elderly patient. Examina- ti on reveals globaly restricted movements and the presence of an effusion. Prioritizing of surgical procedures Although the most symptomatic joint should be treated \201 rst, lower limb surgery normally takes priority over upper limb surgery, with upper l imb surgery normally deferred until the use of ambulatory aids is no longer required. The e lbow takes precedence over the shoulder, as a superior functional result is achieved when t he elbow is operated on before the shoulder. Treatment \200 Bicipital tendinitis Tenosynovitis of the long head of biceps is uncommon and is characteri zed by pain and tenderness over the long head of biceps in the bicipital groove of the hume rus. It may occur in association with degenerative disease of the rota- tor cuff but in the majority of cases occurs as a result of localized friction from the bone of the humeral bi cipital groove. The history is one of localized anterior shoulder pain which is exacerbated by use of the arm. Pain in the bicipital groove is exacerbated by resisted \202 exion an d supination of the forearm. Conservative treatment is normally sufficient with physiotherapy and analgesia. Arthroscopi c techniques are useful in the younger patient with shoulder symptoms and allow treatment o f co-existing soft tissue pathology, for example, subacro- mial decompression, capsular rel ease, and arthroscopic debridement. Severe glenohumeral disease often requires hemiarthro- plasty or total shoulder replacement. Both procedures result in signi \201 cant pain relie f, increased range of move- ment and function. The two types of prosthesis in com- mon use are either surface replacements or traditional stemmed implants. Up to 35% of patients who require a shoulder arthroplasty have rotator cuff tears. These should be repaired at the sa me time as the arthroplasty to achieve the best results. In general, the results of total s houlder replacement are superior to hemiarthroplasty with better functional results and les s pain. Treatment Conservative treatment is normally successful, although a localized glucocorticoi d injection is required in more severe cases. Rupture of the tendon of long head of biceps Rupture of the tendon of the long head of bice ps is not uncommon and often occurs in association with rotator cuff pathology. \200 The rheumatoid shoulder Shoulder symptoms are common in patients with estab- lished RA with more than 90% of patients having shoulder pain at 5 years following onset of in \202 amma tory disease. Patients present with symptoms of pain, swelling and a decreased range of mot ion. Rotator cuff insuf \201 ciency is common affecting more than 70% with approximately 3 0% developing full thickness tears. Rupture may be preceded by pain, but is often painless, and presents with bruising and, mor e characteristically, a \200\230Popeye \200\231 muscle as the muscle belly bulges distally . Rupture of the long head does not appear to have any signi \201 cant adverse effect on f unction and so nothing more than reassurance is required. Avulsion of the distal tendon ins ertion from the radial tuberosity, however, is a very different situation. This is rare and tends to occur in younger patients and particu- larly in body builders who overload the te ndon inser- tion. The rupture is painful as it occurs, but the pain quickly settles. The di agnosis is obtained from the his- tory and an inablity to palpate the cord-like structure o f the tendon in the antecubital fossa. The distal tendon of the biceps is a powerful supina tor of the forearm, as well as elbow \202 exor, and so surgical repair, by reattachment, is required. Non-surgical management In early shoulder involvement, there are no signi \201 cant osseou s changes, and treatment is medical, with analgesia, NSAIDs, and overall control of disease activity. Activity modi \201 cation, intra-articular, or subacromial glucocorticoid injec tions may also be helpful. Physiotherapy is useful in maintaining and regaining range of mo tion depending on the stage of the disease. Surgical management \200 Surgical management is indicated when conservative treatment has failed to control pain and maintain function. The choice of procedure is determined by the extent of disease in the a rticular cartilage, bone, and the periarticular soft tissues. Synovectomy and debridement a re indicated when there is articular cartilage preservation. The procedure can be performed open or arthroscopically with up to 80% Nerve disorders around the shoulder Peripheral nerves are highly susceptible to injury from stretch or compression, resulting in nerve ischaemia, oedema and conduction impairment. Th ese changes are proportional to the magnitude and duration of the insult, and eventually le ad to irreversible damage. THE SHOULDER GIRDLE: REGIONAL MUSCULOSKELETAL CONDITIONS 144 Suprascapular nerve Etiology The commonest locations of injury include the suprascap- ular notch, the spinoglenoid notch, and between the spine of the scapula, and the medial tendino us margin of infraspi- natus and supraspinatus during extreme abduction and internal rotati on of the shoulder. Causes include: \200 