Shoulder Examination

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Shoulder Examination Common Pathology
Mr David Rose FRCS Consultant Shoulder Elbow
Surgeon
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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)
• Addenbrookes, Cambridge 2013/14 (Shoulder
  Elbow Surgery)

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Current Position

• Consultant Orthopaedic Surgeon Maidstone
  Tunbridge Wells NHS Trust
• Started February 2014
• Main Interests Arthroscopic and Reconstructive
  Surgery of the Shoulder Elbow

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Examination

• Look
• Feel
• Move
• Special Tests
• COMPARE SIDES

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Referred Pain

• Cervical Spine
• Thoracic Spine
• Neck Examination
• Cardiac Disease

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Look

• Muscles - wasting, winging
• Deformity - malunion, scars, ACjt

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Look

• Scapular Wasting

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Look

• Winging

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Feel

• Shoulder Bony Anatomy

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Range of Motion

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

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Forward Flexion
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ABduction
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External Rotation
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Internal Rotation
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Special Tests

• Rotator Cuff Disease
• Instability

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Rotator Cuff Disease

• Muscle Strength
• Impingement
• ACjt Pathology
• Biceps Pathology

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Supraspinatus

• Jobes

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Subscapularis

• Gerbers

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Subscapularis

• Napolean

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Impingement

• Neers

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Impingement

• Hawkins

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AC Joint

• Scarf

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Biceps

• Speeds

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Biceps

• Yergasons

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Instability

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

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Generalised Joint Laxity
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Instability

• Sulcus Sign

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Instability

• Apprehension

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Instability

• Relocation Test

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Posterior Instability

• Jerk Test

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Labrum

• OBriens

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Shoulder Pathology

• Instability
• Rotator Cuff Disease
• Frozen Shoulder
• OA / RhA

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Common Shoulder Pathology

• Young - Instability
• Middle-Age - Rotator-Cuff Frozen Shoulder
• Elderly - Rotator-Cuff OA

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Shoulder Pathology

• Instability
• Rotator Cuff Disease
• Frozen Shoulder
• OA / RhA

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Instability

• Traumatic v Atraumatic

Bankart Tear
Labral Tear
Capsular Laxity
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Generalised Joint Laxity

• Muscle Patterning Problems
• Teenage
• Female
• Uni- or Bi-lateral
• Physiotherapy (specialist)

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First Time Dislocator

• Management
• Reduction
• Sling immobilisation until comfortable
• Physiotherapy
• Recurrence ? with ? age
• ? Rotator cuff tear gt 50yrs

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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

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Shoulder Pathology

• Instability
• Rotator Cuff Disease
• Frozen Shoulder
• OA / RhA

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Rotator Cuff Disease

• Spectrum
• tendonitis
• ?
• partial tear
• ?
• full thickness tear
• ?
• cuff arthropathy

Tendinosis
Tear
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Rotator Cuff Disease

• Incidence of Rotator Cuff Defects
• Arthrogram Study (asympt)
• 60yrs 50
• 80yrs 80
• MRI Study (asymptomatic)
• 19-39yrs 2 PT RCT
• 40-60yrs 28 RCT

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Rotator Cuff Disease

• Treat the Symptoms
• Non-Operative ( activity modification)
• Operative

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Management - non-operative

• Orthotherapy - 3 Phases
• Control the Pain - NSAID
• - Cortisone Injection
• Regain ROM - Physio / exercises
• Muscle Strengthening - Physio / exercises
• - Activity modification

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Steroid injection

• I prefer posterior approach
• 70-80 accuracy when performed blind
• 40mg depomedrone 5-10mls marcaine 0.25

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Management - operative

• Indications for Surgery
• Failure or relapse following adequate
  non-operative treatment (6mths )

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Management - operative

• Expectations from Surgery
• Pain relief
• Variable functional recovery
• NOT a new shoulder degenerate tissue

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Management - operative

• Address the Pathology
• Arthroscopic Subacromial Decompression
• AC joint Excision
• Rotator Cuff Repair
• Arthroplasty
• Muscle Transfer

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Subacromial Decompression
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Rotator Cuff Repair

• Double-Row Repair

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

• 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!

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Shoulder Pathology

• Instability
• Rotator Cuff Disease
• Frozen Shoulder
• OA / RhA

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Frozen Shoulder

• Common Condition
• - 2 general population
• - women
• - 40-60
• Idiopathic
• - Diabetes
• - Shoulder injury / pre-existing pathology

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Frozen Shoulder

• Time Line

stiffness
pain
Pain/Freezing Frozen Thawing
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Frozen Shoulder

• Duration
• months 3 years
• Recovery
• complete marked residual symptoms

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Frozen Shoulder

• Management Pain / Freezing

stiffness
pain
Pain/Freezing Frozen Thawing
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Frozen Shoulder

• Management Freezing / Painful
• Conservative /Supportive
• - Supervised Neglect
• - Analgesia
• - Steroid Injection
• - Physiotherapy
• - Nerve Blocks
• - Capsular Hydrodilatation

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Frozen Shoulder

• Management Frozen / Thawing

stiffness
pain
Pain/Freezing Frozen Thawing
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Frozen Shoulder

• Management Frozen / Thawing
• Active /Supportive
• - Encouragement
• - Physiotherapy
• - Exercise Programme

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Frozen Shoulder

• Varying Subgroups?

Chambler Afw et al. The role of surgery in frozen
shoulder. JBJS 200385-B 789-795
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Frozen Shoulder

• Management Frozen / Thawing
• Prolonged immobilisation (6 months)
• ? articular cartilage
• ligaments
• muscles

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Frozen Shoulder

• Management Frozen / Thawing
• Surgical
• - MUA
• - Arthroscopic Capsular Release
• - Subacromial Decompression

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Frozen Shoulder

• Management protracted recovery lt 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

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Problems around the shoulder

• Summary - instability
• younger patient
• 1st time dislocation - rehabilitation
• recurrent dislocation - surgery

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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

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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