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Shoulder Examination & Common Pathology Mr David Rose FRCS Consultant Shoulder & Elbow Surgeon.

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Presentation on theme: "Shoulder Examination & Common Pathology Mr David Rose FRCS Consultant Shoulder & Elbow Surgeon."— Presentation transcript:

1 Shoulder Examination & Common Pathology Mr David Rose FRCS Consultant Shoulder & Elbow Surgeon

2 My Background Medical School: Royal Free (University of London ) 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 Cervical Spine Thoracic Spine Neck Examination 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 TearLabral TearCapsular 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 ↓ partial tear ↓ full thickness tear ↓ cuff arthropathy Tendinosis Tear

41 Rotator Cuff Disease Incidence of Rotator Cuff Defects Arthrogram Study (asympt) 60+yrs50% 80+yrs80% MRI Study (asymptomatic) 19-39yrs2% PT RCT 40-60yrs28% 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 - 1 – 3 weeks sling - 3 – 6 months optimal recovery Outcome 85% full recovery, 10% significantly better, 5% no worse!

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

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

53 Frozen Shoulder Time Line Pain/Freezing FrozenThawing stiffnesspain

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

55 Frozen Shoulder Management – Pain / Freezing Pain/Freezing FrozenThawing stiffnesspain

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/Freezing FrozenThawing stiffnesspain

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 wks - intensive exercises / physio mths- optimal recovery Outcome 90 % pain free / functional recovery

63 Problems around the shoulder Summary - instability younger patient 1 st 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


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