The Shoulder in General Practice Mr T P Selvan MB, LRCP, FRCS Ed, MSc (Ortho), FRCS (Ortho) Consultant Orthopaedic Surgeon East Surrey Hospital, Redhill.

Look For Diagnostic Clues Know the Anatomy Examine Clinically & Look For Diagnostic Clues Investigate Identify the Red flags Treat Refer to Specialist Scope

Anatomy- Deltoid

Anatomy – Rotator Cuff

Anatomy - Ligaments

Anatomy - Bones

Diagnostic Clues - Age 10-35 yrs INSTABILITY 30-50 yrs AC JOINT DISEASE TRAUMATIC CUFF TEAR 40-60 yrs FROZEN SHOULDER >60 yrs GH ARTHRITIS 35-75 yrs ROTATOR CUFF DISEASE

Diagnostic Clues - History Pain on overhead activities IMPINGEMENT Night Pain GH ARTHRITIS FROZEN SHOULDER CUFF TEAR ARTHROPATHY Dead arm INSTABILITY Apprehension INSTABILITY Trauma FRACTURES, CUFF TEAR

Diagnostic Clues LOCATION OF PAIN 1. Under deltoid 2. Side of arm 3. Front of arm Rotator cuff disease

LOCATION OF PAIN Pain in the shoulder blade area is usually muscular or nerve related

Diagnostic clues – Deformities ACJ DISRUPTION SCAPULAR WINGING DISTAL BULKING OF BICEPS INFRASPINATUS WASTING

Clinical Examination Look Feel Move!!! Range of movement. Deltoid function. Tests for Supraspinatus function. Tests for Infraspinatus / Teres minor function. Tests for subscapularis function. Tests for Biceps Tendon Tests for ACJ and Superior labrum.

Movements

Supraspinatus

Infraspinatus / Teres minor

O’briens test for ACJ/Slap Lesion

Gerbers Lift off for subscapularis

Belly Press for Subscapularis

Neers Test

Hawkins-Kennedy test

Biceps tendon-Speed test

Apprehension Tests Apprehension Relocation Test Drawers tets Sulcus Test

Non-shoulder examination Supraclavicular fossa Neurological examination Vascular examination

Cervical spondylosis

Cervical spine fracture and tumour

Investigations – X-Rays Frozen Shoulder To exclude other pathology Rotator cuff disease Impingement Sclerosis GT and Acromion Cuff tear Superior migration of humerus(+/-) Cuff arthropathy Humero-acromial articulation Instability Hill Sachs lesion Glenohumeral OA Diagnosis ACJ dislocation/OA Diagnosis

Other Investigations Ultrasound (one stop clinic) MRI Arthrogram CT Scan EMG Bone Scan ARTHROSCOPY

Impingement/ACJ Pathology ACJ Arthritis Acromial spur

Calcific Tendonitis

Metastatic Fracture

Frozen Shoulder

Rotator cuff tear Horizontal Vertical Retracted Vertical & Inner Substance

Glenohumeral arthritis Surface replacement Total Shoulder Replacement

Rotator cuff arthropathy Reverse Delta Shoulder replacement

SLAP Lesion Superior Labrum Anterior Posterior

Bankarts Lesion

Treatment at Primary Care Frozen shoulder Calcific tendinitis Impingement syndrome AC joint disease Glenohumeral arthritis Activity modification NSAIDs / Analgesia Physiotherapy Steroid Injection

Indications for Injection Diagnostic Subacromial impingement AC joint pain Aspiration Therapeutic Rotator cuff tendinitis / Bursitis Calcific tendinitis Glenohumeral OA Long head of biceps tendinitis Frozen Shoulder AC joint arthritis

Injection Techniques

When to Refer to a Shoulder Specialist Impingement not responding to conservative measures Frozen shoulder not showing any improvement despite physiotherapy for 6 months Suspected Rotator cuff tear. Cuff tear arthropathy Instability / SLAP lesions Osteoarthritis / Rheumatoid Arthritis Uncertainty of diagnosis. Red flag signs

Infection : red hot skin, pyrexial, systemically unwell Unreduced dislocation: h/o trauma/fit/electric shock, abnormal contour, loss of movements Acute rotator cuff tear: acute onset pain and weakness, recent trauma, drop arm sign Tumour: S/S of cancer, h/o cancer, abnormal mass, swelling or deformity Neurological: severe sensori-motor deficit, unexplained muscle wasting.