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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

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
slide6
Muscles - wasting, winging

Deformity - malunion, scars, ACjt

Look
range of motion
Compare sides (great variation)

Passive v Active

Loss of Motion

- Mechanical

- Muscular

- Pain Inhibition

- Neurological

Range of Motion
rotator cuff disease
Muscle Strength

Impingement

ACjt Pathology

Biceps Pathology

Rotator Cuff Disease
instability
Generalised Joint Laxity

Anterior Instability

Posterior Instability (no apprehension)

Labral Pathology

Instability
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+yrs 50%

80+yrs 80%

MRI Study (asymptomatic)

19-39yrs 2% PT RCT

40-60yrs 28% 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
rotator cuff repair
Double-Row RepairRotator 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 Frozen Thawing

frozen shoulder2
Frozen Shoulder
  • Duration

months – 3 years

  • Recovery

complete – marked residual symptoms

frozen shoulder3
Frozen Shoulder
  • Management – Pain / Freezing

pain

stiffness

Pain/Freezing Frozen Thawing

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 Frozen Thawing

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
ad