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. Examination
Look
Feel
Move
Special Tests
COMPARE SIDES

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

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

7. Look
Scapular Wasting

8. Look
Winging

9. Feel
Shoulder Bony Anatomy

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

11. Forward Flexion

12. ABduction

13. External Rotation

14. Internal Rotation

15. Special Tests
Rotator Cuff Disease
Instability

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

17. Supraspinatus
Jobe’s

18. Subscapularis
Gerber’s

19. Subscapularis
Napolean

20. Impingement
Neer’s

21. Impingement
Hawkin’s

22. AC Joint
Scarf

23. Biceps
Speed’s

24. Biceps
Yergason’s

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

26. Generalised Joint Laxity

27. Instability
Sulcus Sign

28. Instability
Apprehension

29. Instability
Relocation Test

30. Posterior Instability
Jerk Test

31. Labrum
O’Brien’s

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

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

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

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

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

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

38. Recurrent Anterior Dislocation
Management
Activity modification
Surgical Stabilisation – (open / arthroscopic / bony)
Recovery
wks - immobilisation
wks - day to day activities
mths - contact sports
Outcome
90 – 95 % stable at 2 years

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

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

41. Rotator Cuff Disease 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

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

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

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

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

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

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

48. Subacromial Decompression

49. 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

50. 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 – 3 weeks sling
Outcome
85% full recovery, 10% significantly better, 5% no worse!

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

52. Frozen Shoulder - 2% general population Common Condition Idiopathic
- women
Idiopathic
- Diabetes
- Shoulder injury / pre-existing pathology

53. Frozen Shoulder
Time Line
pain
stiffness
Pain/Freezing Frozen Thawing

54. Frozen Shoulder Duration months – 3 years Recovery
complete – marked residual symptoms

55. Frozen Shoulder Management – Pain / Freezing pain stiffness
Pain/Freezing Frozen Thawing

56. Frozen Shoulder Management – Freezing / Painful
Conservative /Supportive
- Supervised Neglect
- Analgesia
- Steroid Injection
- Physiotherapy
- Nerve Blocks
- Capsular Hydrodilatation

57. Frozen Shoulder Management – Frozen / Thawing pain stiffness
Pain/Freezing Frozen Thawing

58. Frozen Shoulder Management – Frozen / Thawing Active /Supportive
- Encouragement
- Physiotherapy
- Exercise Programme

59. Frozen Shoulder Varying Subgroups?
Chambler Afw et al. The role of surgery in frozen shoulder. JBJS 2003;85-B:

60. Frozen Shoulder Management – Frozen / Thawing
Prolonged immobilisation (6 + months)
→ articular cartilage
ligaments
muscles

61. Frozen Shoulder Management – Frozen / Thawing Surgical
- MUA
- Arthroscopic Capsular Release
- Subacromial Decompression

62. Frozen Shoulder Management – protracted recovery < 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

63. Problems around the shoulder
Summary - instability
younger patient
1st time dislocation - rehabilitation
recurrent dislocation - surgery

64. 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

65. 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