evaluation and management of common shoulder disorders ...€¦ · common shoulder disorders arun...

Evaluation and Management of

Common Shoulder Disorders

ArunJ.Ramappa,MDChiefofSportsMedicine andShoulderSurgery

Beth IsraelDeaconess Medical Center

Medical Director,SportsPerformanceCenter

NewEngland Baptist Hospital

ChiefofOrthopedic Surgery

HarvardUniversityHealth Services

Team Physician,HarvardUniversity Athletics

Team Physician,Boston RedSox

TeamPhysician,Boston Ballet

HarvardCombinedOrthopedic Residency Program

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ConflictofInterest

ArunJ.Ramappa,MD

Ihavenofinancialrelationshipswithcommercial

entitiesproducing,marketing,re-selling,or

distributinghealthcaregoodsorservicesconsumed

by,orusedon,patientsrelevanttothecontentIam

presenting.COPYRIGHT

Disclosures

• BostonRedSox

• AmericanOrthopaedic SocietyforSports

Medicine

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Goal:SimplifyEvaluationofthePainful

Shoulder

• Canbechallenging

• Overlappingdiagnoses

• Multiplecomplaints

• Neck

• Shoulder

• Back

• Arm

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Shouldervs NeckPathology

• Verycommontohave

neckpainwithshoulder

problems

• Cervicalspinedisease:

oftenassociatedwith

symptomsbelowelbow

• PEofshouldercan

excludecervicaldisease

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ShoulderDisorders:Overview

• Anatomy

• Surface

• Deep

• History

• CommonShoulderDisorders

• Evaluation

• Management

• Injections

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Shoulder:BonyAnatomy• Threemajorbones

• Humerus

• Clavicle

• Scapula

• Fourmajorjoints:

• Acromio-clavicular

• Gleno-humeral

• Scapulo-thoracic

• Sterno-clavicular

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Shoulder:MuscularAnatomy

• Ninemajormuscles

• Synchronousaction

resultsinshoulder

motion

• Imbalanceresultsin

painCOPYRIGHT

Shoulder:MuscularAnatomy

• Supraspinatuscoursingunderacromion

• Infraspinatus

• Subscapularis

• Teres Minor

• Bicepstendondirectlyundersupraspinatus

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• Subscapularis

• Supraspinatus

• Infraspinatus

• Teres Minor

Shoulder:RotatorCuffAnatomy

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Shoulder:History

• Age

• Handdominance,occupation

• Chiefcomplaint:pain,weakness,stiffness, orinstability

• Location

• Onset

• Precipitants

• Priortreatment:meds,PT,injections

• Disability/Progression

• Neurologiccomplaints

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CommonShoulderDisorders

• Rotatorcuffimpingement

• Rotatorcufftears

• Adhesivecapsulitis

• Osteoarthritis

• ACJointDisorders

• CalcificTendinitis

• ShoulderInstability

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Case1

• 35yo physicianwithshoulderpain

• Notrauma

• PromptedERvisit

• Radiatesdownarm

• Nocomplaintsofweakness

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PhysicalExamination

• Inspection

• Palpation

• RangeofMotion

• StrengthTesting

• ProvokingManeuvers

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Shoulder:Exam- Inspection

• Atrophy

• Ecchymosis

• Deformity

• SwellingCOPYRIGHT

Shoulder:Exam- Palpation

• Tenderness

• CervicalSpine

• ACjoint

• Greatertuberosity

• Bicipital Groove

HS Gill et al, AJSM 2007

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Shoulder:Exam- RangeofMotion

• Alwayscomparesides

• Compareactivevspassivemotion

• Forwardflexion

• Externalrotationatside

• Internalrotationvetebral levelCOPYRIGHT

Shoulder:Exam- RangeofMotion

• Forwardflexion

• Externalrotationatside

• Internalrotationvetebrallevel

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Shoulder:Exam- Strength

• Alwayscomparesides

• Supraspinatus:armin

planeofscapula,

abducted90degrees

• Externalrotationat

side

• Internalrotation

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Shoulder:Exam- Impingement

• Neer sign:

• Sensitivity:85%

• Specificity:50%

• Painfularcofmotion:forwardelevation

• Compressionofrotatorcuffbetweenunderlyinghumerus andoverlyingacromion Park, et al, JBJS 2005

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Shoulder:Exam-Impingement• Hawkinssign:

• Sensitivity:75%

• Specificity:45%

• Painfularcofmotion:

• forwardelevation90+internalrotation

Park, et al, JBJS 2005

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Neck:Exam

• Spurling’s maneuver

• Checkstrengthof

bothextremities

• Assesssensation

• Assessfor

hyperreflexia

• Comparesides!!!Woodward and Best, AFP 2000

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Let’sgotothemodel

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Case1

• Exam:+Spurling’smaneuver

• Exam:- impingementsigns

• Exam:normalstrength

• Diagnosis: neckrelatedNOTshoulder

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Case2

• 45yo maleinjuredhis

shoulderwhile

throwingfootball

• Feelsaclick

• Painwithsleeping

• Painwithreaching

overhead

• Can’tplaywithkids

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Case2

• ROMissymmetric but

FEabove120degrees

ispainful

• Impingementsignsare

present

• StrengthisnormalCOPYRIGHT





• Osteoarthritis




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• Subscapularis

• Supraspinatus

• Infraspinatus

• TeresMinor

Shoulder:RotatorCuffDisease

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RotatorCuffDisease:Impingement

Syndrome• Tendinosis/Bursitis atthe

supraspinatus

• Undertheacromion

• History:painoverhead,behindback,sleep

• Physicalfindings:

• Impingementsigns

• Noweakness

Harrison and Flatlow, J Am Acad Orthop Surg 2011

Whittle and Buchbinder, Ann Intern Med 2015

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Shoulder:Exam- Impingement

• Neer sign:

• Sensitivity:85%

• Specificity:50%

• Painfularcofmotion:forwardelevation

• Compressionofrotatorcuffbetweenunderlyinghumerus andoverlyingacromion Park, et al, JBJS 2005

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Shoulder:Exam- Impingement• Hawkinssign:

• Sensitivity:75%

• Specificity:45%

• Painfularcofmotion:

• Forwardelevation90+internalrotation

Park, et al, JBJS 2005

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• Rehabilitation

• Strengthenrotatorcuffandscapularstabilizers

• Stretchposteriorcapsule

• ActivityModification

• NSAIDs

• Injections

• Lidocaine +Cortisone

• Cures80%

RotatorCuffDisease:ImpingementSyndrome

Harrison and Flatlow,

J Am Acad Orthop Surg 2011

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RotatorCuffDisease:Impingement

Syndrome

• SurgicalTreatment:

arthroscopic

• Surgery:rare

• Bursectomy

• Acromioplasty

Whittle and Buchbinder, Ann Intern Med 2015

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Case2:Treatment

• NSAIDs

• PTwithemphasisonscapularstrength

• Steroidinjection?

• RotatorcufftearVERYUNLIKELYCOPYRIGHT

Case3

• 42yo malefallsontohisshoulderwhilesnowboarding

• Difficultyraisingarm

• XRays: nofracture

• Plan?COPYRIGHT

Case3

• Inspection

• Noatrophy

• Noecchymosis

• Nodeformity

• ROM:passive>active

• RCstrength: weak

supraspinatus

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• Osteoarthritis




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• FollowImpingement

• BeginSmall

• Progress

RotatorCuffTears

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• BeginSmall

• Progress

• 174Tears:

• 61%offullthicknesstearsand44%ofpartialthickness

tearsprogressatmedianof5years

RotatorCuffTears

Keener, et al, JBJS 2015

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• BeginSmall

• Progress

• PhysicalFindings:

Weakness

RotatorCuffTears

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NormalRotatorCuff

This image cannot currently be displayed.

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SupraspinatusTendinosis

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Full-ThicknessRotatorCuffTear

Tendon Edge

Muscle Belly

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• Notalltearsrequiresurgery(Esp PartialTears)!

• MRIstudy:54%ofasymptomaticcohort>65withcufftear!

• Assessmentoffunctionalgoals/comorbidconditionsESSENTIAL

• Abilitytocomply/participateinrehabilitationESSENTIAL

RotatorCuffTears

Sher, et al, JBJS 1995

This image cannot currently be displayed.

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RotatorCuffRepairImprovesStrength

• Functionaloutcomesareequivalentwhether

tearhealsornot

• Strengthsignificantly greaterwithhealing

(75%heal)

• Scapularelevationstrengthintactvs torn=5.0vs 2.6kg

Russell, et al, JBJS 2014

Keener, et al, JBJS 2010

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Case3

• Weakness after

trauma

• Suggestsrotatorcuff

tear

• MRI!!

• SurgeryCOPYRIGHT

• OpenSurgicalRepair

• RepairtoBone

• FullRecovery-Months!

• Results

• 90%SuccessatPainRelief

• 80%SuccessatFunction

RotatorCuffRepair

Zumstein, et al, JBJS 2008

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RotatorCuffRepair

• ArthroscopicRepairs

• Technology

improved

• Lowermorbidity

• Successratessimilar

toopen

Aleem and Brophy, Clin Sports Med 2012

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ClinicalMessaging

• Surgery

• Veryeffective

• Canbepainful

• 6monthsforrecovery

• Shouldnormalizepainandfunction

Moosmayer, et al, J Bone Joint Surg 2014

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RotatorCuffTear:MuscleAtrophywithDelay

• Muscleatrophyandfatinfiltrationoccurswithtime

• Surgeryunsuccessfuloncesignificantatrophyoccurs

• Donotdelayevaluation

I II III

Mall, et al, JBJS 2014

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• Osteoarthritis




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AdhesiveCapsulitis– FrozenShoulder• Painfulshoulder

• RestrictedROM(Active=Passive)

• NormalXrays

• Thickeningofshouldercapsule

• Classification

• Idiopathic– especially

DiabetesMellitus

• Posttrauma

• Postsurgical

Neviaser and Hannafin, Am J Sports Med 2010

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AdhesiveCapsulitisandDiabetes

Tighe and Oakley, South Med J 2008

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AdhesiveCapsulitis– FrozenShoulder

• Treatment

• Naturalhistory:usuallyselflimited

• NSAIDS

• PhysicalTherapy:gentlecapsularstretching

• Oralsteroids

• Intra-articularinjections

• Arthroscopicsurgeryifunresponsive

Neviaser and Hannafin, Am J Sports Med 2010

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• Osteoarthritis




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Shoulder:Osteoarthritis

• Progressivepain

• LimitationofROM(Active=Passive)

• Treatment

• NSAIDs

• PT

• Injections

• Surgery:JointReplacement Singh, et al, Cochrane Database Syst Rev 2010

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• Osteoarthritis




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ACJointDisorders

• ACjointarthritis: commonbutnotoftenpainful

• Distalclavicleosteolysis: weightlifters

• Pain:overhead,crossarmactivities

• Pointtender atACjoint

• Treatment: activitymodification,NSAIDs,injections,surgery

Buttaci, et al, Am J Phys Med Rehabil 2004

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• Osteoarthritis




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CalcificTendinitis• Calcificationofsupraspinatus

tendon

• Painfularcofmotion

• Acuteonset:VERYPAINFUL

• Treatment

• NSAIDs

• PT

• Injections

• Barbotage

• SurgerySuzuki, et al, J Am Acad Orthop Surg 2014

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• Osteoarthritis




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Case4

• 24y.o.female fallsontohershoulderwhilesnowboarding

• Deformityofshoulder

• Takenbyskipatroltomountainclinic

• Anteriorshoulderdislocation- reduced

darkroom.baltimoresun.com

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Case4

• Seesyouinoffice

• Neuroexam

• Strengthexam

• X-rayCOPYRIGHT

AnteriorInstability:Pathoanatomy

• Stability:activeandpassive

elements

• IGHL(Capsule)

• RotatorCuff

• Activestability

• Labrum

• Cartilageringthatdeepens

fossa

• Attachesto

capsule/ligaments AAOS Comprehensive Orthopaedic Review. 2009

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AnteriorShoulderInstability

• Incidence:1.7%

• Recurrencerates:

• <25y.o.havehigh

rates

• >40y.o.havelow

rates

• 80-90%inteens

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AnteriorShoulderInstability:Associated Injuries


• Age>40:30%

• Age>60:80%

• Axillarynerve

injury

• Greatertuberosity

fractures

Arun J. Ramappa, MD BIDMC – Sports Medicine & Shoulder Surgery

617-667-7678 bidmc.org/sports

Neviaser, R.J., et al. Clin Orthop Relat Res. 1993

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AnteriorShoulderInstability:History

• Mechanismofinjury

• Armpositionatinjury

• Dislocation?

• Requirereduction?

• Isthisrecurrent?

• Armpositionstoavoidsi.com

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AnteriorShoulderInstability:Exam

• Generalized Laxity

• Load-and-shift

• Apprehensionsign

• Relocationtest

• Sulcussign

• Posterior

apprehension

AAOS Comprehensive Orthopaedic Review. 2009

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AnteriorShoulderInstability:Imaging

• X-rays

• ShoulderAP,

scapularAP,and

axillary

• MRI/CT+Arthrogram

AAOS Comprehensive Orthopaedic Review. 2009

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AnteriorShoulderInstability:Treatment• Nonsurgical

• Initialdislocation

• BriefperiodofimmobilizationthenPT

• SurgicalIndications

• Recurrentepisodes

• Patients<25y.o.areathighrisk

• LargebonyinjuriesorRCtears

• Contraindications

• Volitional

• Comorbidities Gray’s Basic Anatomy. 2012

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AnteriorShoulderInstability:FirstTimeDislocation

Godin, J., Sekiya, J.K. Sports Health. 2010

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ShoulderCorticosteroidInjections

• Office


• Calcific tendinitis

• Ultrasound/Fluoroscopic guided


• Osteoarthritis

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ShoulderCorticosteroid Injections

• Subacromial

• Accuracy:80-90%

• Glenohumeral

• ACjoint

Marder, et al, JBJS 2012

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ShoulderCorticosteroidInjections:Subacromial

• Rotatorcuffdisease/Impingement

• Posteriorapproach

• Betadine orChlorhexidineprep

• 5cclidocaine w/oepi

• 1-2ccoftriamcinolone(40mg/ml)

• Angleneedleupwardparallel toacromion

• Diagnostic&therapeuticMarder, et al, JBJS 2012

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ShoulderCorticosteroidInjections

• Subacromial

• Glenohumeral

• Lowaccuracy

forlandmarkinjection

• Anterior:64%

• Posterior:45%

• Supraclavicular:45%

• ACjoint

Tobola, et al, JSES 2011

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ShoulderCorticosteroid Injections

• Subacromial

• Glenohumeral

• ACjoint

• Lowaccuracy

• 43%intra-articular

• 23%partially

intra-articular

• 33%extra-articular

Wasserman, et al, Am J Sports Med 2013

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ShoulderCorticosteroidInjections:ACJoint

• Acromioclavicular disease

• Anteriorapproach

• Betadine orChlorhexidine prep

• 1cclidocaine w/oepi

• 1ccoftriamcinolone(40mg/ml)

• Canbedifficult

Wasserman, et al, Am J Sports Med 2013

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ShoulderInjections:PRPandStemCells

• PRPandStemCells

• Evidencelacking

• Consideredexperimental

• Expensive.out ofpocket:

$500to$5000++

• Popularizedbyathletes

• NOindicationsforuseat

thistime

https://www.npr.org/sections/heal

th-

shots/2014/06/11/320971966/plat

elet-rich-plasma-therapy-gains-

fans-but-remains-unproven

Schneider, et al, Curr Rev Musculoskelet Med 2018

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ClinicalMessaging

• Ifinjection

• Willbemoresoreforacoupleofdays

• Typicallystartsworkingafter48-72hours

• Willimproveoverthenext6-8weeks

• Self-limitedprocess

• Reassess andconsideranMRI

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SpecialConsiderationsBeforeInjection

• Pts withDiabetes

• Injectionmayraise

bloodglucoselevels

• Pts withHIV

• Waryifonprotease

inhibitor

• Ex.Ritonavir/Norvir

• Cancauseiatrogenic

Cushing’sresponse

Moon, et al, Am J Phys Med Rehabil 2014

Maviki, et al, Skeletal Radiol 2013

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ShoulderDisorders:Summary

• RefertoPT,but

consideradelayin

specialist referral

• Shoulderpainwith

goodROMand

strengthCOPYRIGHT

ShoulderDisorders:Summary

• WhentoRefer?

• ALLFractures

• ALLDislocationsor

Instability

• Traumaticeventwith

NEWWeakness

• Wheneverindoubt

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References

• Harrison and Flatlow. Subacromial Impingement Syndrome. J Am Acad OrthopSurg 2011

• Whittle and Buchbinder. In the clinic: rotator cuff disease. Ann Intern Med 2015

• Park, et al. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement. JBJS 2005

• Keener, et al. A prospective evaluation of survivorship of asymptomatic degenerative rotator cuff tears. JBJS 2015

• Sher, et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders. JBJS 1995

• Zumstein, et al. The clinical and structural long-term results of open repair of massive tears of the rotator cuff. JBJS 2008

• Aleem and Brophy. Outcomes of rotator cuff surgery. Clin Sports Med 2012

• Moosmayer, et al. Tendon repair compared with physiotherapy in the treatment of rotator cuff tears. JBJS 2014

• Mall, et al. Factors affecting rotator cuff healing. JBJS 2014

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References• Neviaser and Hannafin. Adhesive capsulitis: a review of current treatment. Am J Sports Med 2010

• Tighe, et al. The prevalence a diabetic condition and adhesive capsulitis of the shoulder. South Med

J 2008

• Singh, et al. Surgery for shoulder osteoarthritis. Cochrane Database Syst Rev 2010

• Buttaci, et al. Osteoarthritis of the acromioclavicular joint: a review of anatomy, biomechanics,

diagnosis and treatment. Am J Phys Med Rehabil 2004

• Suzuki, et al. Calcific tendinitis of the rotator cuff: management options. J Am Acad Orthop Surg

2014

• Marder, et al. Injection of the subacromial bursa in patients with rotator cuff syndrome. JBJS 2012

• Wasserman, et al. Accuracy of acromioclavicular joint injections. Am J Sports Med 2013

• Schneider, et al. Platelet-rich plasma and the shoulder: clinical indications and outcomes. Rev

Musculoskelet Med 2018

• Moon, et al. Changes in blood glucose and cortisol levels after epidural or shoulder intra-articular

glucocorticoid injections in diabetic or nondiabetic patients. Am J Phys Med Rehabil 2014

• Maviki, et al. Injecting epidural and intra-articular triamcinolone in HIV-positive patients on ritonavir:

beware iatrogenic Cushing’s syndrome. Skeletal Radiol 2013

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Questions?COPYRIGHT

ThankYou!!

• Questionsplease

• Referral: 617-667-3940

• Doctor-DoctorLine:617-667-

2020

• bidmc.org/sports

• [email protected]

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