NON TRAUMATISK SKULDERSMERTE Impingement et entydigt begreb? FLERE PATOLOGISKE TILSTANDE maj 2002. rotatorcuffen. kapsulolabrale apparat. caput longum bicipsitis Speciallæge Arne N. Gam
EPIDEMIOLOGI. alder. ensidigt monotont arbejde. overhead aktivitet Tungt industri arbejde Sigholm G 1994 Arbejde over skulder niveau Palmerud 1995 Repetitivt arbejde - monotont Campell 1991 Håndgreb - Rotatorcuff musklerne (stabilisatorer) var mere øget end m. deltoideus Sporrong 1995, 1996. badminton, håndbold, volley: 8%/år. svømning: op til 87% over hele svømmekarrieren
Histiologi Glycosaminglycan infiltration Fibrocartilaginous transformation Tab af tenocyter Forkalkning (kadaver undersøgelser) Chard MD 1994 Riley GP 1994 Tendinit vs Tendinosis Angiofibroblastic hyperplasi (arthroskopisk) Ruptur
INSTABILITETENS CIRCULUS VITIOSUS (instability complex. Jobe, 1989) repetitive stress microtrauma to capsule attenuation (svækkelse) of capsule mild instability fatigue of rotator cuff anterior translation of humeral head secondary mechanical impingement rotatorcuff lesion
ANTERIOR SHOULDER PAIN IN THROWING ATHLETES Classification (Jobe 1989) I: Pure impingement, no instability ( > 35 years) II: Primary instability due to chronic labra microtaumata, and secondary impingement III: Instability due to hypermobility and subsequent impingement IV: Pure instability, no impingement (trauma)
CLASSIFICATION OF IMPINGEMENT AND INSTABIITY (Belling Sørensen, 2000) I: Pure impingement, no instability ( > 35 years) II: Instability and impingement. Functional instability. Unilateral instability. Multidirectional instability III: Pure instability, no impingement (trauma)
ROTATOR CUFF SYNDROM SYMPTOMER Smerter Bevægeindskrænkning Udstrålende smerter lateralt på overarmen Painful arc
ROTATORCUFF SYNDROM DIAGNOSE Ømhed (tub. majus, akromion, lig. coracoakromiale) Muskeltests Neer Impingemens tests Impingement relief test (SA-injektion) Hawkins
ROTATORCUFF SYNDROM - RADIOLOGI RØNTGEN: (Y view) UL MR
Sensitivitet = disease and test positive/disease positive UL TRASONOGRAPHY OF ROTATORCUFF TEARS Specificity = disease and test negative/disease negative Author n. patients sens./spec. sens./spec. (partial tear) (total tear) Brenneke 120 (65 lesions) 41/91 95/93 (Am J Sports Med, 1992) van Holsbeek 52 (partial lesions) 93/94 (Arthroscopy, 95) Teefey 98 (65 total,15 partielle) 67/? 100/85 (J Bone Joint Surg 2000)
MR-SCANNING OF ROTATORCUFF LESIONS Author n. shoulders sens/spec sens/spec (partial tear) (total tear) Singson 177 92/86 (fs) 100/86 (AJR, 96) Iannotti 88 67/86 93/87 (J Bone Joint Surg, 91) fs: fat suppression
INTERN IMPINGEMENT Impingement mellem den posterosuperiore del af labrum glenoidale og rotatorcuffens dybe side Eneste fund hos 17 patienter med uforklaret skuldersmerte (Walch et al. 1992)
LÆSIONER AF DET KAPSULOLABRALE KOMPLEX SYMPTOMER Instabilitet Klik, catching, aflåsning, Snurren, smerte Dead arm syndrome Impingement
Læsioner af det kapsulabrale Komplex Diagnostik Instabilitet Apprehension Relocation Active compression test Biceps load test (SLAP)
SLAP LESION BICEPS LOAD TEST Author n (patients) sens. spec. Kim 75 (64 SLAP) 91 97 (Am J Sports Med 99) Superior labrum anterior posterior
LABRUM LESION ACTIVE COMPRESSION TEST Author n (patients) sens/spec sens/spec labrum AC O Brien 318 100/99 100/97 (53 labrum, 55 AC abnormality) (Am J sports Med 98)
APICAL OBLIQUE PROJECTION - presence or absence of dislocation - glenoid fracture - Hill-Sachs lesion (Brems-Dalgaard 90, Sloth 89, Schydlowsky 98, )
ULTRASONOGRAPHY OF LABRAL LESIONS Author n (patients) sens/spec Schydlowsky 29 (26 lesions) 88/67 (Eur J Ultrasound 98) Schifter 21 (19 lesions) 90/73 (Unpublished)
MR-SCANNING OF LABRAL LESIONS - Divergerende resultater BEDST MED - højfeltmagnet - T1 og T2 sekvenser - billeder i flere planer - EXPERIENCED RADIOLOGIST ALLERBEDST MED - MR arthrography
CAPUT LONGUM BICIPITIS SYMPTOMER - Smerter DIAGNOSE - Ømhed - Yergasons test - Palm-up test RADIOLOGI - UL - MR
I. KONSERVATIV BEHANDLING 1. Heling af det inflammerede væv - Aktiv hvile, NSAID, Steroid Injektions teknik ved skuldersmerter hvor? Hollingworth GR 1983 Tenderpoint vs. Lokalisation (bursa, intraarticulært) Svagheder ved studiet: Diagnoser usikre Manglende sikring af lokalisationen Usikre parametre (smerte?) 2. Træning A. 4 P: Protectors (rotator cuff) and pivoters (m. serratus anterior, romboideerne, trapezius) B. positioners (deltoideus), propellers (pectoralis major, latissimus dorsi) - Proprioception
BEHANDLING II. KIRURGISK - PARTIEL ROTATOR CUFF LÆSION. Arthroskopisk debridement 85% tilbagevenden til sport (Andrews, 1985). Subakromiel dekompression 56% tilbagevenden til sport (Burns, 1992)
BEHANDLING II. KIRURGISK - KAPSULOLABRALE LÆSIONER. Arthroskopisk debridement (flap læsioner) 93% excellent or good (12 patients) (Payne, 1993). Capsular shift (multidirektionel instabilitet) 88% excellent or good (26 shoulders) (Bak, 2000)
BEHANDLING II. KIRURGISK - KAPSULOLABRALE LÆSIONER. Bankart operation (unidirektionel instabilitet) Open: 97% excellent or good (Rowe, 1978) Arthroscopic: 42% failure (Green, 1995) 92% excellent or good (Gartsman,2000) Arthroscopic/open: 24 /18% failure, ns (Cole, 2000)
Tak Thanks Merci Danke