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

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:

    • 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

  • Consultant Orthopaedic Surgeon Maidstone & Tunbridge Wells NHS Trust

  • Started February 2014

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


Look

Feel

Move

Special Tests

COMPARE SIDES

Examination


Cervical Spine

Thoracic Spine

Neck Examination

Cardiac Disease

Referred Pain


Muscles - wasting, winging

Deformity- malunion, scars, ACjt

Look


Scapular Wasting

Look


Winging

Look


Shoulder Bony Anatomy

Feel


Compare sides (great variation)

Passive v Active

Loss of Motion

- Mechanical

- Muscular

- Pain Inhibition

- Neurological

Range of Motion


Forward Flexion


ABduction


External Rotation


Internal Rotation


Rotator Cuff Disease

Instability

Special Tests


Muscle Strength

Impingement

ACjt Pathology

Biceps Pathology

Rotator Cuff Disease


Jobe’s

Supraspinatus


Gerber’s

Subscapularis


Napolean

Subscapularis


Neer’s

Impingement


Hawkin’s

Impingement


Scarf

AC Joint


Speed’s

Biceps


Yergason’s

Biceps


Generalised Joint Laxity

Anterior Instability

Posterior Instability (no apprehension)

Labral Pathology

Instability


Generalised Joint Laxity


Sulcus Sign

Instability


Apprehension

Instability


Relocation Test

Instability


Jerk Test

Posterior Instability


O’Brien’s

Labrum


Instability

Rotator Cuff Disease

Frozen Shoulder

OA / RhA

Shoulder Pathology


Young- Instability

Middle-Age- Rotator-Cuff & Frozen Shoulder

Elderly- Rotator-Cuff & OA

Common Shoulder Pathology


Instability

Rotator Cuff Disease

Frozen Shoulder

OA / RhA

Shoulder Pathology


Instability

Traumatic v Atraumatic

Bankart Tear

Labral Tear

Capsular Laxity


Muscle Patterning Problems

Teenage

Female

Uni- or Bi-lateral

Physiotherapy (specialist)

Generalised Joint Laxity


Management

Reduction

Sling immobilisation until comfortable

Physiotherapy

Recurrence ↓ with ↑ age

? Rotator cuff tear > 50yrs

First Time Dislocator


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


Instability

Rotator Cuff Disease

Frozen Shoulder

OA / RhA

Shoulder Pathology


Spectrum

tendonitis

partial tear

full thickness tear

cuff arthropathy

Rotator Cuff Disease

Tendinosis

Tear


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


Treat the Symptoms

Non-Operative (+ activity modification)

Operative

Rotator Cuff Disease


“Orthotherapy” - 3 Phases

Control the Pain- NSAID

- Cortisone Injection

Regain ROM- Physio / exercises

Muscle Strengthening- Physio / exercises

- Activity modification

Management - non-operative


Steroid injection

  • I prefer posterior approach

  • 70-80% accuracy when performed “blind”

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


Indications for Surgery

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

Management - operative


Expectations from Surgery

Pain relief

Variable functional recovery

NOT a new shoulder –‘degenerate tissue’

Management - operative


Address the Pathology

Arthroscopic Subacromial Decompression

AC joint Excision

Rotator Cuff Repair

Arthroplasty

Muscle Transfer

Management - operative


Subacromial Decompression


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


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


Instability

Rotator Cuff Disease

Frozen Shoulder

OA / RhA

Shoulder Pathology


Common Condition

- 2% general population

- women

- 40-60

Idiopathic

- Diabetes

- Shoulder injury / pre-existing pathology

Frozen Shoulder


Frozen Shoulder

  • Time Line

pain

stiffness

Pain/Freezing FrozenThawing


Frozen Shoulder

  • Duration

    months – 3 years

  • Recovery

    complete – marked residual symptoms


Frozen Shoulder

  • Management – Pain / Freezing

pain

stiffness

Pain/Freezing FrozenThawing


Management –Freezing / Painful

Conservative /Supportive

- Supervised Neglect

- Analgesia

- Steroid Injection

- Physiotherapy

- Nerve Blocks

- Capsular Hydrodilatation

Frozen Shoulder


Frozen Shoulder

  • Management – Frozen / Thawing

pain

stiffness

Pain/Freezing FrozenThawing


Management –Frozen / Thawing

Active /Supportive

- Encouragement

- Physiotherapy

- Exercise Programme

Frozen Shoulder


Varying Subgroups?

Frozen Shoulder

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


Management –Frozen / Thawing

Prolonged immobilisation (6 + months)

→ articular cartilage

ligaments

muscles

Frozen Shoulder


Frozen Shoulder

Management – Frozen / Thawing

  • Surgical

    - MUA

    - Arthroscopic Capsular Release

    - Subacromial Decompression


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


Summary - instability

younger patient

1st time dislocation - rehabilitation

recurrent dislocation - surgery

Problems around the shoulder


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


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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