1. Bsc (Hons) Physiotherapy
The Shoulder
Claire Bailey
&
Elizabeth Bowman
Bsc (Hons) Physiotherapy
April 2013

2. Aims Diagnostic categories Evidence based decision making?
Treatment options
When to refer on (or not?!)

3. Anterior GHJ Anatomy

4. The Rotator Cuff

5. Introduction Shoulder pain third most common MSK complaint
15% referred for physiotherapy in the 3 years following their initial consultations
Peak incidence 4-6th decades
50% acute GHJ pain resolves in 8-10 weeks
Linsell et al (2006)

6. Signs
<30 years
30-70 years
>70 years
Impingement pain
Instability
Secondary impingement
Subacromial impingement
Cuff tear
SAIS
ACJ pain
Osteolysis OA
GHJ pain
Inflammatory arthritis
Frozen shoulder
GHJ OA
Periscapular
Snapping scapula
Neurogenic
neurogenic

7. Red Flags History of Ca, mass, swelling etc.
Red skin, fever, systemically unwell ?infection
Trauma, epileptic fit, loss of rotation
Unexplained significant sensory or motor deficit
Visceral referred pain

8. Visceral Referral Pain

9. Pancoast Tumour

10. Frozen Shoulder
“it comes on slowly; (with) pain usually felt near the insertion of the deltoid; inability to sleep on the affected side; painful and incomplete elevation and external rotation; restriction of both spasmodic and mildly adherent type; atrophy of the spinati; little local tenderness; (&) x-rays negative except for bone atrophy”. Codman (1934)

11. Frozen shoulder cont. Elusive underlying pathology
?inflammatory ?scarring ?enzyme
Pain predominant or stiffness predominant (Hanchard et al. 2011)
Primary (unknown cause)
Secondary (to trauma)
2% population; 935 patients; 58% female
Dominant side 52%; bilateral 38%
(Chambler et al. BMJ 2003)

12. Frozen Shoulder

13. Secondary frozen shoulder
Trauma
R.Cuff tear
Post –operatively
Diabetes
Cerebral haemorrhage
Thyroid
Autoimmune disease
Cervical spine pathology
Hormonal changes
Prolonged immobilisation
Algodystrophic

14. Stages of frozen shoulder
Freezing Pain increases with movement and is often worse at night. There is a progressive loss of ROM with increasing pain. Lasts approx. 2-9/12 Frozen Pain begins to diminish, ROM much more limited (50%). Lasts approx. 4-12/12 Thawing Condition may begin to resolve. Most patients experience a gradual restoration of motion over next 12-42/12

15. Clinical Picture Insidious onset Pain at deltoid insertion Night pain
Pain at rest
Reduced AROM and PROM
Reduced ER (restriction >50% of the opposite side)
Normal x-rays

16. Frozen shoulder x-rays
NORMAL
To exclude:-
Cuff arthropathy/massive cuff tear with secondary OA changes
OA – bony end feel, osteophytes limit ER
Dislocation locked – stuck in IR causing avascular necrosis to humeral head
ALL LIMIT ER, THEREFORE, TENTATIVE DIAGNOSIS WITHOUT X-RAY

17. Treatment Neglect? (better in 2 years) Physiotherapy
Injection – improved shoulder related 6/52 (Ryans et al. 2005)
MUA / arthroscopic release – significant loss of ER not changing with 6-9 months

18. Conservative management
Explanation
Modify activities
Analgesia
Physiotherapy?
Corticosteroid injection?
CONSIDER EARLY REFERRAL IF
Patients pain is particularly disabling to them
Severe restriction in PROM inhibiting function
Considering operative or specialist management

19. Surgical management
Symptoms and function are unchanging and significantly disabling after 6/12 of conservative treatment
Arthroscopic release +/- SAD
? MUA
?hydrodilation
Suprascapular nerve block – improves pain but not movement

20. Impingement Up to 74% patients presenting in primary care SAIS
Physiotherapy first line Rx
Roy et al. (2008)
Ostar (2005)

21. Classification Primary (intrinsic) Secondary (extrinsic)
Outlet / non-outlet
External / internal impingement
Bursal side wear and tear not substantiated by histological studies – majority on articular side

22. Impingement cont. Extrinsic theory challenged
Irritation causes tendonitis and bursitis?
“sub-acromial pain syndrome” pain related to the bursa rather than the mechanical impingement effect. (Lewis 2011)
Reactive tendonopathy to tendon disrepair and subsequent degeneration.
Dysfunction of the r.cuff = bursitis and Sx

23. Impingement

24. Calcific Tendonitis

25. Impingement Rotator cuff strain Tears Calcific tendonitis
Tendonopathy due to chronic overuse
Indirect causes - GHJ instability
SLAP
Abnormal muscle patterning

26. Clinical Presentation
Difficulty with over head activities
Pain mid range arc
Constant background ache / night pain / increased pain on movement = ? Inflammation in bursa (only place to find inflammation in impingement)

27. Painful Arc

28. Diagnosis Impingement tests Neers Hawkins Weakness in ER
X-ray AP, axillary – spur formation, sclerosis, acromion type (>3/12 symptoms)
U/S to confirm and exclude cuff tear

29. Neers Test

30. Hawkins Test

31. Impingement Treatment
Physiotherapy
NSAID’s? If constant pain
?Injection – short term efficacy only and most effective at 1-2/52 when constant pain (Trojian 2005)
?Poor outcome with surgery following repeated injections
Conservative treatment minimum 8/52
Surgery SAD

32. Rotator Cuff tears
Almost all tears are chronic and degenerative in nature
Often insidious history
Can occur after trauma or dislocations
Similar Sx to impingement
? Clinically obvious weakness

33. Rotator Cuff Tear

34. Diagnosis Drop arm test
Severe pain, profound weakness of abduction, or an inability to maintain the arm in 90O abduction then slowly lower
Positive infraspinatus testing (ER)
Pain that awakens the patient at night (Riddle 2001).
Tests may be better at ruling out cuff tears rather then detecting them
ultrasound

35. Lift off test

36. Belly Press Test

37. Bear Hug Test

38. Empty Can Test

39. Rotator Cuff Tear

40. Acute rotator cuff tear
Patients presenting with a traumatic history, sudden or progressive weakness
Urgent U/S and referral
Consider early repair
6-12/52 window of opportunity for best outcome from surgery

41. Chronic symptomatic cuff tear
?non-operative management for 3-6/12
Advice / NSAID’s?/ physiotherapy
X1 steroid injection?
Failed non-operative management re-evaluation consider U/S or MRI
Only need surgery if warranted by Sx
?SAD for pain relief and to avoid the long rehab. required for cuff repairs if the patient has – good movement, strength

42. Full thickness cuff tears – non-operative management
“tincture of time”
Physiotherapy
NSAID’s???
Modified activities
Steroid injection??
? Can compensate due to activation of residual intact cuff
Partial tear vs. Impingement ?does it matter as doesn't change outcome/type of Rx

43. AC Joint Dysfunction Traumatic v degenerative onset
Traumatic onset is usually a fall on to the point of the shoulder and can involve
Stretching or tearing of the acromioclavicular or coracoacromial ligaments
Subluxation/dislocation of the AC joint
Degenerative problems tend to occur in individuals over 45 years

44. The ACJ

45. Clinical Presentation
Degenerative
Pain with activity and ?at rest over ACJ (may radiate in to traps region but not deltoid)
?ROM restricted in to overhead elevation
No obvious inflammatory signs
Traumatic
Reports a traumatic onset
May be an observable deformity
May also be associated with sub-acromial impingement

46. Diagnosis Pain on palpation over ACJ
Pain on active adduction (Scarf test)
Pain on O’Brien’s
X-ray may be used to exclude osteolysis/oes-acromially or to define degree of disruption in traumatic onset

47. Scarf Test

48. O'Brien's Test

49. Treatment Rockwood classification for traumatic disruption
Type I & II managed conservatively
Type III individual cases
Type IV – IV managed surgically
Physiotherapy
?injection therapy
Surgical options in degenerative cases if failed conservative management

50. Glenohumeral Instability
Instability is the abnormal motion of the glenohumeral joint that may include subluxation or dislocation, co-existing laxity, pain
Involves one or more (usually a combination) of ligaments, tendons, glenoid labrum, joint capsule
Traumatic instability v atraumatic instability

51. Clinical Presentation
Tends to be in patients younger that 35
History of trauma or dislocation
“Give way” or “lock”
Repeatedly performing overhead movements may aggravate symptoms (particularly with SLAP)
Symptoms can be vague e.g young athletic males with activity related pains in shoulder or an inability to perform overhead throw

52. Diagnosis Apprehension/relocation Sulcus ?Xray in acute dislocation
MRI/MR arthrograms

53. Apprehension Test

54. Relocation Test

55. Sulcus Sign

56. Treatment
If first time dislocation in young population (<25 years) or high trauma injury referral on to specialist shoulder surgeon
Recurrent dislocators
Physiotherapy would usually involve stability and strengthening, proprioception and core stability with graduated return to activities
Physiotherapy vital in both the conservatively and surgically managed cases though rehab period is likely to be lengthy (3-6/12)

57. Labral Pathologies SLAP v Bankart
85% of GH dislocations likely to have a Bankart if needed to be relocated
SLAP – may be caused be any repeated overhead activity, eccentric or concentric contraction of biceps. May be associated with a dislocation but more commonly in sportsmen with a pull on the arm, weightlifting, throwing injury or tackle

58. Bankart / Hill-Sachs

59. SLAP Tear

60. Diagnosis Apprehension (Bankart and SLAP) O’Brien’s (SLAP)
Biceps load I and II (SLAP)
Difficult to diagnose clinically
MRI/MR arthrogram

61. Biceps Load I/II

62. Treatment Surgical v conservative remains controversial Physiotherapy
Onward referral if failing conservative management/ return to high level sport or occupational factors

63. Evidence to Implicate the Cervical and Thoracic Spines in Shoulder Pain
Cervical spine lateral glides (Vincenzino et al 2007, 2009)
McClatchie at al (2009) – increased GH abduction and decreased pain intensity
C5/6 joint mobilisations increases strength of GH lateral rotators immediately and for 10 mins (Wang 2010)
Thoracic segmental restriction impacts scapula position and cuff activation – 40% of shoulder pain patients have thoracic and rib dysfunction (Lin et al, 2010)
Physiotherapist’s conclusions….

64. Upper Limb Dermatomes

65. Subjective Examination
What questions would you ask?
Why are you asking these questions?
What would this lead you to consider as a diagnosis? (clinical reasoning!)
HPC
SQ’s
PMH

66. Objective Examination

67. If all else fails! ..... Consider: Pain clinic Acupuncture?
Chronic pain analgesia

68. Any Questions?