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Shoulder Joint examination Overview

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Presentation on theme: "Shoulder Joint examination Overview"— Presentation transcript:

1 Shoulder Joint examination Overview
Introduction Presentation Examination Anatomy Investigations Injections Key points A J Chakrabarti FRCS(Orth)

2 Introduction Shoulder pain is very common Can be Recalcitrant
Many get better spontaneously without treatment Costly

3 Introduction Prevalence Overall 7% 26% in elderly
Rheumatology 2006;45:215–221 Prevalence Overall 7% 26% in elderly

4 Shoulder Pain in Adults
Secondary Care Rxs 20% Manages 80% Primary Care Community 50-80% Do not present

5 Not getting better spontaneously
What is the actual diagnosis? Are there specific considerations for this particular patient? When should I refer?

6 Shoulder examination Basic steps What is the diagnosis ? History
Clinical tests Investigations XR/US What is the diagnosis ? Don’t be too hasty in simply diagnosing “Frozen shoulder”

7 Patient factors of importance
Lifestyle Occupation Handedness Sports/Hobbies PMH / PSH DH Expectations Previous treatments

8 Shoulder Complaints Pain Stiffness Instability
Weakness/ Functional loss Swelling Deformity Electrical disturbance/ Vascular disturbance

9 Shoulder Complaints Pain That keeps patient awake at night

10 Shoulder Complaints Pain Keeps partner / spouse up! Groan

11 Shoulder Complaint Pain
Onset Injury Duration Site Severity Nature Periodicity Timing Night pain Exacerbating Relieving factors Treatments tried Tablets Response to Rxs

12 Shoulder Complaint Pain
Injury Nature Bleeding/ Bruising Snap. Crack “General Feel” Position of arm Pre-existing state

13 Site of Pain Radiating to forearm/hand Radiating to neck infrequent
Does not arise form intrinsic shoulder problems (except ACJ- to base of neck)

14 Shoulder Complaint Pain
Open Palm v Finger sign Deltoid sited pain Subacromial space / Rotator cuff. GHJ Superiorly sited pain Acromioclavicular joint

15 Shoulder Instability Traumatic Atraumatic Event Ease Frequency GLL
Muscle patterning disorder History of fits Event Ease Frequency Subtle instabilities Pain Dead arm

16 Shoulder Weakness Pain causes weakness Patients exact meaning
Weakness of muscles –neural, musculotendinous or other mechanical Patients exact meaning Association with any pain.

17 Painful Shoulder Remember that pain experienced in the shoulder can arise from outside the shoulder

18 Shoulder Complaints Neck Brachial plexus pain
Viscera. Intrathoracic/ subphrenic Chronic regional pain syndromes

19 Shoulder Complaints Neck Brachial plexus pain
Viscera. Intrathoracic/ subphrenic Chronic regional pain syndromes

20 Shoulder examination Multiple techniques No best single way!
Compare sides

21 Assessing a Shoulder Anatomic sites
Three True Joints Three areas Glenohumeral joint Acromioclavicular joint Sternoclavicular joint Subacromial space Rotator Cuff Scapulothoracic articulation Think anatomically !

22 The Rotator cuff 4 muscles with their tendons acting as a functional unit to maintain the humeral head centered on the glenoid

23 The Rotator cuff

24 Clinical Examination Look Feel Move Stand Sit Lie

25 Clinical Examination Elevation Impingement ER IR CxSp Abduction RPA
Inspection Localising Tenderness Neck Examination CxSp Neuro exam Functional assess Elevation Impingement ER IR Abduction RPA Cuff testing 3 pt Biceps

26 Minimum 10 point Clinical Examination
Inspection Localising Tenderness Neck Examination CxSp Neuro exam Functional assess Elevation Impingement ER IR Abduction RPA Cuff testing 3 pt Biceps

27 Minimum 10 point examination
Non shoulder Functional Glenohumeral Cuff / muscles Cx Spine Elevation Ext Rotation Supraspinatus Impingement Internal Rotation Infraspinatus Abduction Subscapularis LHB

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 prolapse Elevation restriction: RCT lifting with good arm Impingement sign: Bursal/cuff disease or ACJ impingement Restrictions of Global GHJ motion: Capsular contracture of Frozen shoulder or OA GHJ Loss of resisted muscle power: RCT or pain inhibition Painful resisted cuff activity: RCT/ impingement LHB signs: Biceps tendinopathy

30 10 point examination Clinical Judgement Neck Shoulder ACJ BURSA CUFF

31 Shoulder Scores of function
Oxford Shoulder Score 48 12 Questions – all relate to shoulder in last 4 wks 0-4 per question. Max score 48/48 = Gd shoulder Worst,Dressing,Car,Knife,Shopping,Tray Brush,Usual,Robes,Axilla,Housewk,Night The 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 diagnosis Yes: If possibility of calcific disease Yes: If need to exclude arthrosis (The arthrosis of ACJ The arthrosis of the GHJ) Yes: If concerned re: malignant disease .

33 What XR’s do I find valuable?
AP 30° Caudal Axillary Lateral Stryker Notch view for GHJ instability Clavicular views for ACJ instability

34 “Sourcil” sign

35 30° Caudal view - useful to gauge 3D anatomy of Acromion

36 30° Caudal view

37 Ultrasound examination
Examines the rotator cuff Supraspinatus Infraspinatus Subscapularis Teres Minor Long Head Biceps Bursa / Impingement

38 Ultrasound examination

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 understand Most useful when: ACJ impingement a possibility Other pathologies /multiple pathologies are expected Limited use without contrast: calcific disease/ instability

40 Treatments In all cases Conservative. Analgesia
Physiotherapy: Pendular exercises Theraband exercises Eccentric Deltoid exercises “eccentric means lengthening during loading” Steroid injections Other injections / other treatments

41 Treatments Theraband exercises

42 Steroid Injections Prep the skin and draw up solution with separate needle to one used to inject. Portal: Soft spot – Below Postero-lateral corner Aim for Anterior acromion for bursal injection Aim for Coracoid process for GHJ injection Superior Summit for ACJ

43 Cures for shoulder diseases?
Arthritis ACJ: Excision arthroplasty Arthritis GHJ: Total shoulder replacement/ Hemi Rotator Cuff Arthropathy: Reverse polarity prosthesis Acute Rotator Cuff Tears: RCR Impingement with/without Tears: ASAD Instabilities: Various stabilizations

44 Conditions that may not be cured
Chronic Calcific Disease: Massive Cuff Tears: Degenerative RCTears without arthritis: Poor vascularity Secondary fatty infiltration and neural change to muscle/tendon unit Patients 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

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