27 Minimum 10 point examination Non shoulderFunctionalGlenohumeralCuff / musclesCx SpineElevationExt RotationSupraspinatusImpingementInternal RotationInfraspinatusAbductionSubscapularisLHB
28 Positive Comparative increased pain No pain But slower Block Empty can Impingement
29 The Hallmarks of common diseases Cx stiffness/ pain: Cervical spondylosis / Cx disc prolapseElevation restriction: RCT lifting with good armImpingement sign: Bursal/cuff disease or ACJ impingementRestrictions of Global GHJ motion: Capsular contracture of Frozen shoulder or OA GHJLoss of resisted muscle power: RCT or pain inhibitionPainful resisted cuff activity: RCT/ impingementLHB signs: Biceps tendinopathy
30 10 point examination Clinical Judgement Neck Shoulder ACJ BURSA CUFF BICEPSCAPSULE AND JOINT SURFACE
31 Shoulder Scores of function Oxford Shoulder Score 4812 Questions – all relate to shoulder in last 4 wks0-4 per question. Max score 48/48 = Gd shoulderWorst,Dressing,Car,Knife,Shopping,TrayBrush,Usual,Robes,Axilla,Housewk,NightThe rotator cuff muscles act as a functional unit to maintain the humeral head centered in the glenoid during active arm elevation.
32 Does it need an XR? Yes: If referring for surgical opinion Yes: If you need it to corroborate your diagnosisYes: If possibility of calcific diseaseYes: If need to exclude arthrosis(The arthrosis of ACJThe arthrosis of the GHJ)Yes: If concerned re: malignant disease.
33 What XR’s do I find valuable? AP30° CaudalAxillary LateralStryker Notch view for GHJ instabilityClavicular views for ACJ instability
37 Ultrasound examination Examines the rotator cuffSupraspinatusInfraspinatusSubscapularisTeres MinorLong Head BicepsBursa / Impingement
38 Ultrasound examination DO NOT REQUESTIN PREFERENCE TOPLAIN XR FILM
39 MRI? Access to the films is the most important The reports may be misleading.The MRI has a picture that both clinician and patient can understandMost useful when:ACJ impingement a possibilityOther pathologies /multiple pathologies are expectedLimited use without contrast: calcific disease/ instability
40 Treatments In all cases Conservative. Analgesia Physiotherapy: Pendular exercisesTheraband exercisesEccentric Deltoid exercises“eccentric means lengthening during loading”Steroid injectionsOther injections / other treatments
42 Steroid InjectionsPrep the skin and draw up solution with separate needle to one used to inject.Portal: Soft spot – Below Postero-lateral cornerAim for Anterior acromion for bursal injectionAim for Coracoid process for GHJ injectionSuperior Summit for ACJ
43 Cures for shoulder diseases? Arthritis ACJ: Excision arthroplastyArthritis GHJ: Total shoulder replacement/ HemiRotator Cuff Arthropathy: Reverse polarity prosthesisAcute Rotator Cuff Tears: RCRImpingement with/without Tears: ASADInstabilities: Various stabilizations
44 Conditions that may not be cured Chronic Calcific Disease:Massive Cuff Tears:Degenerative RCTears without arthritis:Poor vascularitySecondary fatty infiltration and neural change to muscle/tendon unitPatients unfit for surgery:Conservative management: Steroid injections/ Eccentric Deltoid Training/ Suprascapular Nerve Blocks
45 Prognosis in shoulder conditions is largely determined by the condition of the rotator cuff and The outcome following surgery in most cases largely determined by the condition of the rotator cuff