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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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    1. Shoulder Examination & Common Pathology Mr David Rose FRCS Consultant Shoulder & Elbow Surgeon

    2. 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)

    3. Current Position • Consultant Orthopaedic Surgeon Maidstone & Tunbridge Wells NHS Trust • Started February 2014 • Main Interests: Arthroscopic and Reconstructive Surgery of the Shoulder & Elbow

    4. Look Feel Move Special Tests COMPARE SIDES Examination

    5. Cervical Spine Thoracic Spine Neck Examination Cardiac Disease Referred Pain

    6. Muscles - wasting, winging Deformity - malunion, scars, ACjt Look

    7. Scapular Wasting Look

    8. Winging Look

    9. Shoulder Bony Anatomy Feel

    10. Compare sides (great variation) Passive v Active Loss of Motion - Mechanical - Muscular - Pain Inhibition - Neurological Range of Motion

    11. Forward Flexion

    12. ABduction

    13. External Rotation

    14. Internal Rotation

    15. Rotator Cuff Disease Instability Special Tests

    16. Muscle Strength Impingement ACjt Pathology Biceps Pathology Rotator Cuff Disease

    17. Jobe’s Supraspinatus

    18. Gerber’s Subscapularis

    19. Napolean Subscapularis

    20. Neer’s Impingement

    21. Hawkin’s Impingement

    22. Scarf AC Joint

    23. Speed’s Biceps

    24. Yergason’s Biceps

    25. Generalised Joint Laxity Anterior Instability Posterior Instability (no apprehension) Labral Pathology Instability

    26. Generalised Joint Laxity

    27. Sulcus Sign Instability

    28. Apprehension Instability

    29. Relocation Test Instability

    30. Jerk Test Posterior Instability

    31. O’Brien’s Labrum

    32. Instability Rotator Cuff Disease Frozen Shoulder OA / RhA Shoulder Pathology

    33. Young - Instability Middle-Age- Rotator-Cuff & Frozen Shoulder Elderly- Rotator-Cuff & OA Common Shoulder Pathology

    34. Instability Rotator Cuff Disease Frozen Shoulder OA / RhA Shoulder Pathology

    35. Instability Traumatic v Atraumatic Bankart Tear Labral Tear Capsular Laxity

    36. Muscle Patterning Problems Teenage Female Uni- or Bi-lateral Physiotherapy (specialist) Generalised Joint Laxity

    37. Management Reduction Sling immobilisation until comfortable Physiotherapy Recurrence ↓ with ↑ age ? Rotator cuff tear > 50yrs First Time Dislocator

    38. 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

    39. Instability Rotator Cuff Disease Frozen Shoulder OA / RhA Shoulder Pathology

    40. Spectrum tendonitis ↓ partial tear ↓ full thickness tear ↓ cuff arthropathy Rotator Cuff Disease Tendinosis Tear

    41. 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

    42. Treat the Symptoms Non-Operative (+ activity modification) Operative Rotator Cuff Disease

    43. “Orthotherapy” - 3 Phases Control the Pain- NSAID - Cortisone Injection Regain ROM - Physio / exercises Muscle Strengthening- Physio / exercises - Activity modification Management - non-operative

    44. Steroid injection • I prefer posterior approach • 70-80% accuracy when performed “blind” • 40mg depomedrone; 5-10mls marcaine 0.25%

    45. Indications for Surgery Failure or relapse following adequate non-operative treatment (6mths +) Management - operative

    46. Expectations from Surgery Pain relief Variable functional recovery NOT a new shoulder –‘degenerate tissue’ Management - operative

    47. Address the Pathology Arthroscopic Subacromial Decompression AC joint Excision Rotator Cuff Repair Arthroplasty Muscle Transfer Management - operative

    48. Subacromial Decompression

    49. 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

    50. 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