Shoulder examination common pathology
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Shoulder Examination & Common Pathology. Mr David Rose FRCS Consultant Shoulder & Elbow Surgeon. My Background. Medical School: Royal Free (University of London - 2000) South West Thames Ortho Rotation (St Georges) Fellowships:

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Shoulder Examination & Common Pathology

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Shoulder examination common pathology

Shoulder Examination & Common Pathology

Mr David Rose FRCS

Consultant Shoulder & Elbow Surgeon


My background

My Background

  • Medical School: Royal Free (University of London - 2000)

  • South West Thames Ortho Rotation (St Georges)

  • Fellowships:

    • Johns Hopkins, USA 2008/09 (Research – Shoulder/Upper Limb)

    • Perth Orthopaedic & Sports Medicine Centre, Perth, Australia 2012/13 (Sports Medicine Surgery)

    • Addenbrooke’s, Cambridge 2013/14 (Shoulder & Elbow Surgery)


Current position

Current Position

  • Consultant Orthopaedic Surgeon Maidstone & Tunbridge Wells NHS Trust

  • Started February 2014

  • Main Interests: Arthroscopic and Reconstructive Surgery of the Shoulder & Elbow


Examination

Look

Feel

Move

Special Tests

COMPARE SIDES

Examination


Referred pain

Cervical Spine

Thoracic Spine

Neck Examination

Cardiac Disease

Referred Pain


Shoulder examination common pathology

Muscles - wasting, winging

Deformity- malunion, scars, ACjt

Look


Shoulder examination common pathology

Scapular Wasting

Look


Shoulder examination common pathology

Winging

Look


Shoulder examination common pathology

Shoulder Bony Anatomy

Feel


Range of motion

Compare sides (great variation)

Passive v Active

Loss of Motion

- Mechanical

- Muscular

- Pain Inhibition

- Neurological

Range of Motion


Forward flexion

Forward Flexion


Abduction

ABduction


External rotation

External Rotation


Internal rotation

Internal Rotation


Special tests

Rotator Cuff Disease

Instability

Special Tests


Rotator cuff disease

Muscle Strength

Impingement

ACjt Pathology

Biceps Pathology

Rotator Cuff Disease


Supraspinatus

Jobe’s

Supraspinatus


Subscapularis

Gerber’s

Subscapularis


Subscapularis1

Napolean

Subscapularis


Impingement

Neer’s

Impingement


Impingement1

Hawkin’s

Impingement


Ac joint

Scarf

AC Joint


Biceps

Speed’s

Biceps


Biceps1

Yergason’s

Biceps


Instability

Generalised Joint Laxity

Anterior Instability

Posterior Instability (no apprehension)

Labral Pathology

Instability


Generalised joint laxity

Generalised Joint Laxity


Instability1

Sulcus Sign

Instability


Instability2

Apprehension

Instability


Instability3

Relocation Test

Instability


Posterior instability

Jerk Test

Posterior Instability


Labrum

O’Brien’s

Labrum


Shoulder pathology

Instability

Rotator Cuff Disease

Frozen Shoulder

OA / RhA

Shoulder Pathology


Common shoulder pathology

Young- Instability

Middle-Age- Rotator-Cuff & Frozen Shoulder

Elderly- Rotator-Cuff & OA

Common Shoulder Pathology


Shoulder pathology1

Instability

Rotator Cuff Disease

Frozen Shoulder

OA / RhA

Shoulder Pathology


Instability4

Instability

Traumatic v Atraumatic

Bankart Tear

Labral Tear

Capsular Laxity


Generalised joint laxity1

Muscle Patterning Problems

Teenage

Female

Uni- or Bi-lateral

Physiotherapy (specialist)

Generalised Joint Laxity


First time dislocator

Management

Reduction

Sling immobilisation until comfortable

Physiotherapy

Recurrence ↓ with ↑ age

? Rotator cuff tear > 50yrs

First Time Dislocator


Recurrent anterior dislocation

Management

Activity modification

Surgical Stabilisation – (open / arthroscopic / bony)

Recovery

- 2 - 3 wks - immobilisation

- 4 - 6 wks - day to day activities

- 4 - 6 mths- contact sports

Outcome

90 – 95 % stable at 2 years

Recurrent Anterior Dislocation


Shoulder pathology2

Instability

Rotator Cuff Disease

Frozen Shoulder

OA / RhA

Shoulder Pathology


Rotator cuff disease1

Spectrum

tendonitis

partial tear

full thickness tear

cuff arthropathy

Rotator Cuff Disease

Tendinosis

Tear


Rotator cuff disease2

Incidence of Rotator Cuff Defects

Arthrogram Study (asympt)

60+yrs50%

80+yrs80%

MRI Study (asymptomatic)

19-39yrs2% PT RCT

40-60yrs28% RCT

Rotator Cuff Disease


Rotator cuff disease3

Treat the Symptoms

Non-Operative (+ activity modification)

Operative

Rotator Cuff Disease


Management non operative

“Orthotherapy” - 3 Phases

Control the Pain- NSAID

- Cortisone Injection

Regain ROM- Physio / exercises

Muscle Strengthening- Physio / exercises

- Activity modification

Management - non-operative


Steroid injection

Steroid injection

  • I prefer posterior approach

  • 70-80% accuracy when performed “blind”

  • 40mg depomedrone; 5-10mls marcaine 0.25%


Management operative

Indications for Surgery

Failure or relapse following adequate non-operative treatment (6mths +)

Management - operative


Management operative1

Expectations from Surgery

Pain relief

Variable functional recovery

NOT a new shoulder –‘degenerate tissue’

Management - operative


Management operative2

Address the Pathology

Arthroscopic Subacromial Decompression

AC joint Excision

Rotator Cuff Repair

Arthroplasty

Muscle Transfer

Management - operative


Subacromial decompression

Subacromial Decompression


Rotator cuff repair

Double-Row Repair

Rotator Cuff Repair

Double-row arthroscopic rotator cuff repair: Re-establishing the footprint of the rotator cuff. Lo IKY et al. Arthroscopy 2003


Rotator cuff disease4

Management – (failed non-operative / ACUTE event)

arthroscopic decompression +/- rotator cuff repair

Recovery

ASD - immediate mobilisation

- 3 – 6 months optimal recovery

Cuff Repair - 1 – 3 weeks sling

- 3 – 6 months optimal recovery

Outcome

85% full recovery, 10% significantly better, 5% no worse!

Rotator Cuff Disease


Shoulder pathology3

Instability

Rotator Cuff Disease

Frozen Shoulder

OA / RhA

Shoulder Pathology


Frozen shoulder

Common Condition

- 2% general population

- women

- 40-60

Idiopathic

- Diabetes

- Shoulder injury / pre-existing pathology

Frozen Shoulder


Frozen shoulder1

Frozen Shoulder

  • Time Line

pain

stiffness

Pain/Freezing FrozenThawing


Frozen shoulder2

Frozen Shoulder

  • Duration

    months – 3 years

  • Recovery

    complete – marked residual symptoms


Frozen shoulder3

Frozen Shoulder

  • Management – Pain / Freezing

pain

stiffness

Pain/Freezing FrozenThawing


Frozen shoulder4

Management –Freezing / Painful

Conservative /Supportive

- Supervised Neglect

- Analgesia

- Steroid Injection

- Physiotherapy

- Nerve Blocks

- Capsular Hydrodilatation

Frozen Shoulder


Frozen shoulder5

Frozen Shoulder

  • Management – Frozen / Thawing

pain

stiffness

Pain/Freezing FrozenThawing


Frozen shoulder6

Management –Frozen / Thawing

Active /Supportive

- Encouragement

- Physiotherapy

- Exercise Programme

Frozen Shoulder


Frozen shoulder7

Varying Subgroups?

Frozen Shoulder

Chambler Afw et al. The role of surgery in frozen shoulder. JBJS 2003;85-B: 789-795


Frozen shoulder8

Management –Frozen / Thawing

Prolonged immobilisation (6 + months)

→ articular cartilage

ligaments

muscles

Frozen Shoulder


Frozen shoulder9

Frozen Shoulder

Management – Frozen / Thawing

  • Surgical

    - MUA

    - Arthroscopic Capsular Release

    - Subacromial Decompression


Frozen shoulder10

Management – protracted recovery < 9+ mths

arthroscopic capsular release + ASD

Recovery

- 2 days - inpatient physio

- 2 + wks - intensive exercises / physio

- 3 + mths- optimal recovery

Outcome

90 % pain free / functional recovery

Frozen Shoulder


Problems around the shoulder

Summary - instability

younger patient

1st time dislocation - rehabilitation

recurrent dislocation - surgery

Problems around the shoulder


Problems around the shoulder1

Summary - rotator cuff

middle-age + patient

asymptomatic pathology common

treatment aimed at symptoms - NSAID, analgesia, physio

acute vs chronic

surgical intervention after failure of non-operative management

Problems around the shoulder


Problems around the shoulder2

Summary – frozen shoulder

40 – 60 years

3 phases

treatment - pain= supportive

- frozen= supportive / physio

- thawing= physio

- frozen/thaw= surgery (non-improvers)

Surgery for failure of non-operative treatment

Problems around the shoulder


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