All right, did we get that? Are we seeing, we're seeing that at home? Okay, good. So we're now on to the next phase. We've made our amazing diagnosis and we have an idea of what's going on. Well, what do we do to treat? And we're gonna talk about the non-surgical treatments for common shoulder injuries. Again, I will start and Dr. Tu will come in for the save at the end. So nothing to disclose still. And just for review, what are we talking about? Well, we've been talking all morning about mainly non-traumatic injuries. We're really not gonna talk about the major trauma in today's talk. And that may come up in the last lecture when we talk about surgical issues. Non-traumatic, we talking about overuse, instability, neurogenic, adhesive capsulitis, arthropathy, arthritis, all these different things that we treat. We have this give and take between tendinopathy and tendinitis. Many times when I speak to surgeons, they say, when we do surgery, we never see tendinitis, never any inflammation, I've never seen it. And maybe that's because they're seeing the end stage. I think there is a continuum, maybe early on, younger folks getting the actual itis. And as the bone and ligaments mature, we get more of the tendinopathy that Dr. Tu was showing you in the ultrasound that we can now look to see that in real time rather than try and see it in static time on a MRI scan. We're talking about rotator cuff arthropathy, which I'll discuss how that affects causing shoulder pain, glenohumeral instability. So not just on a dislocation basis, but something we call it, it's called often micro instability that leads to shoulder pain, impingement syndrome, which is this garbage pail term of maybe all three of the above that we just talked about. We can't forget about the fact that we will treat neurogenic pain to the shoulder. So, and finally the end stage of osteoarthritic within the joint itself, which may be amenable to some of the newer injectable materials that have become available to us more recently. So what are we treating? We're treating structural injury to bone, or are we treating the inflammation? Are we treating micro versus macro instability or malalignment? And then I'm actually gonna stop sharing this for a second. And I will be right back with this. Okay, and here we are back with it. And it's got to share it again. Here it is. I'm just trying to click on the, open it up into the real, doesn't want to go. Let's see. Now it doesn't want to go into the mode of doing our, let's try up here maybe. All right, well, for now, we're just gonna have to do it this way because I can't get it to open up. I can't get it into the show. That's one more try here. Okay, so we got it back into the show and now I got to get it paired. Okay. There we go. Okay, perfect. All right, so, so we went through this and now what are we treating? So are we treating injury to the tendon? Are we treating injury to the ligament? Are we treating injury to the bone? Are we treating inflammation? Again, back to this tendonitis versus tendinosis discussion. Are we treating micro versus macro instability? And finally, are we just treating malalignment that leads to compression of outlets, muscle fatigue, equaling pain? And we'll go over all that. So there's this, again, discussion between what is tenosynovitis, what is tendonitis, what is tendinopathy and with inflammation on the itis side and irritation and wearing away on the tendinopathy side. And here's a healthy tendon with everything uniformly distributed. And here's tendinopathy with capillary ingrowth and disorganized collagen fibrils and leading to the pain. But we talked earlier about kyphosis. Are we talking about the neck or the shoulder? And oftentimes we'll have patients come in and say my shoulder hurts and they'll point to maybe trapezius. And is that the neck or the shoulder? And what does kyphotic posture have to do with this when we talked earlier about the effects that that has on the shoulder outlet causing shoulder impingement and pain? And is that where the treatment should focus? Because we know that kyphotic posture reduces the thoracic outlet and reduces the subacromial space. And reduction of the subacromial space leads to a barren upper body posture, potentially leading to the impingement of supraspinatus tendon against the anterior portion of the acromion process. Well, that sounds painful and may cause the pain that the patients are experiencing. So kyphosis over the years, how we've evolved over to the last slide, the last figure where we're now hunched over our keyboard, which I am right now and having a kyphosis as we speak. So does rotator cuff fatigue cause pain? What about rotator cuff fatigue? The leading theory, rotator cuff weakness, fatigue or shoulder dysfunction contributes to superior migration during arm elevation. And it's the superior migration that we call rotator cuff arthropathy. And that's what causes the impingement of the soft tissues in the subacromial space, this impingement zone that we see over here. And so can we use a downward force on the rotator cuff as a reducing pain? So what is our treatment menu? Well, it begins with an accurate diagnosis. Hopefully we've shown you the value and the methods of doing that today. Analgesia, we do have to reduce pain at some point. That's what the patient is interested in. Then rehab, our major modality initially. And then finally procedures, where Dr. Tu will discuss anti-inflammatory procedures, regenerative procedures. And then we had a discussion in Dr. Singh's talk about ablative procedures. And I don't know if Dr. Tu will cover that, but that's the third option, is to ablate nerves that carry pain signals and thus block pain from the joint to the brain. Treatment strategies, so non-interventional. So what are the strategies? Well, if we reduce inflammation, are we gonna reduce pain? That's one going theory. There's some discussion about that more recently from the regenerative camp, is do we want inflammation? Do we want inflammation to bring healing properties? We want to, we will then talk about our rehab program where we correct posture. This is starting to sound like an osteopathic lecture. Stretch tight muscles, strengthen weak muscles, and more on that a little bit later. Reduce instability and sport, task, work-specific training. And then finally, the Dr. Tu's strategies. So the underlying justification for conservative care is, well, I mean, we have this MRI. The MRI shows seven different findings. That means the patient needs surgery, right? Well, we know that asymptomatic rotator cuff tears are prevalent in the general population. Just because you have an MRI abnormality doesn't mean that those abnormalities are actually causing pain. And if such abnormalities are present in patients who don't have pain, then maybe just rehab and anti-inflammatory treatments is enough. They are positively associated with a common in the contralateral shoulder, the shoulder that doesn't hurt, who are being treated for shoulder pain or asymptomatic rotator cuff tear. So injury does not necessarily mean pain. Thus, maybe we treat the patient holistically and the patient gets better regardless of what's going on on the pictures. So what are the options? Well, we talked about anti-inflammatory medications, drugs. Problem is, I guess there's only really low to moderate evidence existing that nonsteroidal anti-inflammatory medications are helpful. This is the latest way of delivering anti-inflammatory medication through gel or patch formats to avoid systemic effects. What about analgesics? Muscle relaxants, Tylenol, opioids, anything else? Actually, I did a search and actually zero evidence exists for generalized word of shoulder pain and any of these things. There's zero evidence available to help or refute the use of analgesics. So we come back to rehab. And so what does rehab actually gonna mean and rehab gonna look like and what it's gonna do? Well, the first thing in rehab is what not to do. So we talked about repetitive use, repetitive strain, and I can't say how often I've seen patients with shoulder pain go to therapy, go to physical therapy, come back six weeks later and say, I'm not better, I'm worse. What do you mean you're worse? What'd you do? Well, they had me on this thing where I roll my arm and shoulder on this crank thing over and over and over again for half an hour. Oh, I'm like, well, isn't that why you got here in the first place? Overuse of your shoulder subacromial. And we talked about kyphosis and sitting at the computer. Isn't this just mimicking sitting at the computer and accelerating kyphosis? And yet we see physical therapists doing this over and over and over again. What not to do? Again, isn't this kind of motion just impinging? Isn't that the impingement motion? So aren't we just irritating things? And again, here, aren't we just irritating things by focusing only on the shoulder joint? So rehab strategies. Instead, why don't we stretch tight muscles, strengthen weak ones, correct posture alignment, restore the outlet and thereby reducing the pain regardless of the underlying pathology. And there was a gentleman from Europe called Yannick Vladimir Yanda who developed what's called the upper cross syndrome. Something that we see over and over and over again. And this certainly looks like the kyphotic picture that we were discussing earlier. And it consists of inhibited or weak deep flexor muscles. So some muscles are weak or inhibited and other muscles are tight. Pectoralis, trapezius, levator scapulae. Inhibited lower trap, rhomboids, serratus anterior. And the combination of this leads to this accelerated kyphosis and upper cross syndrome. So maybe if we just attack that, then we might have reduced pain in happy patients. And these are the, again, just reiterating what we said. In 2003, there's multiple publications earlier than that from Yanda on this. And so that there formed the idea of scapular rehab. And it was really made, brought to the surgery public as well as the rehab public by Ben Kibler who you saw his name earlier. And Kevin Wilk was the physical therapist who designed the program. And it was brought to a international consensus early 2000 and something. And basically suggesting that scapular dyskinesis is present in a high percentage of most shoulder injuries. The exact role of dyskinesis is not clearly defined. Shoulder impingement syndromes are particularly affected by scapular dyskinesis. Scapular dyskinesis is most aptly viewed as a potential impairment of soldier function, shoulder function. Treatment strategies for shoulder injury can be more effectively implemented by evaluation of this dyskinesis. We've talked about the lateral scapular slide test. A reliable observational clinical evaluation method for dyskinesis is available. And then the rehabilitation programs to restore scapular position and motion can be effective within a more comprehensive shoulder and rehabilitation program. And so therefore was born different ideas about scapular rehab. And here's just one algorithm of where you talk about strain control of the scapular muscles and how it interacts with the glenohumeral muscles and utilizing mobilization and osteopathic manipulations along with stretching and strengthening exercises. And so our target is first stretch. And here's a nice look at it up in this corner. Yes versus no. And then strengthen scapular retraction in many different formats. And so I'll show you some of these. We've seen these kinds of pictures utilizing bands or machines in a row and a nice posture opening up the outlet. Here's another method of scapular stabilization. And here's another one utilizing bands. And then finally, we talked about sport work task specific and how it's really not useful if the patient can't use it. So we have to make sure that not only are they strong from a static perspective, but that patients are strong from a functional perspective no matter what it is they do with their time. And then we talk about prevention. Well, how did we get this place to begin with? Remember that last, that slide I showed and we shouldn't be hunching at the desk. We need to teach our patients correct ergonomics, sitting nicely and upper and good posture and where the arm should be. We talk about 90, 90, 90, 90, everything is a 90 and that maybe this can prevent some of the disability. And then finally, conjunctive treatment. So a lot of times patients where it's really significant posture difficulty until they're able to get stronger, you might want to take them up. And there's some good studies about efficacy of kinesio taping. Although some didn't show such great improvement, others did show some improvement. So one showed improvement, one showed little improvement at the same time. But the thought is it helps improve circulation through this taping system and mainly allows for motion. And maybe a lot of times, it's just a reminder to patients to keep those shoulders back. And there's a lot of different, you can be very, you see the Olympic athletes with this, you can be very, you can, there's a lot of different ways you can tape. And so there's a lot of ways to do it. And here are my references. And now we're going to move on to what we can do with interventional treatments from.

shoulder injuries

non-surgical treatment

scapular rehabilitation

ergonomic practices

kinesio taping