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

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)

Current Position Consultant Orthopaedic Surgeon Maidstone & Tunbridge Wells NHS Trust Started February 2014 Main Interests: Arthroscopic and Reconstructive Surgery of the Shoulder & Elbow

Examination Look Feel Move Special Tests COMPARE SIDES

Referred Pain Neck Examination Cervical Spine Thoracic Spine Cardiac Disease

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

Look Scapular Wasting

Look Winging

Feel Shoulder Bony Anatomy

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

Forward Flexion

ABduction

External Rotation

Internal Rotation

Special Tests Rotator Cuff Disease Instability

Rotator Cuff Disease Muscle Strength Impingement ACjt Pathology Biceps Pathology

Supraspinatus Jobe’s

Subscapularis Gerber’s

Subscapularis Napolean

Impingement Neer’s

Impingement Hawkin’s

AC Joint Scarf

Biceps Speed’s

Biceps Yergason’s

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

Generalised Joint Laxity

Instability Sulcus Sign

Instability Apprehension

Instability Relocation Test

Posterior Instability Jerk Test

Labrum O’Brien’s

Shoulder Pathology Instability Rotator Cuff Disease Frozen Shoulder OA / RhA

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

Shoulder Pathology Instability Rotator Cuff Disease Frozen Shoulder OA / RhA

Instability Traumatic v Atraumatic Bankart Tear Labral Tear Capsular Laxity

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

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

Recurrent Anterior Dislocation Management Activity modification Surgical Stabilisation – (open / arthroscopic / bony) Recovery - 2 - 3 wks - immobilisation - 4 - 6 wks - day to day activities - 4 - 6 mths - contact sports Outcome 90 – 95 % stable at 2 years

Shoulder Pathology Instability Rotator Cuff Disease Frozen Shoulder OA / RhA

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

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

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

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

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

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

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

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

Subacromial Decompression

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

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 Outcome 85% full recovery, 10% significantly better, 5% no worse!

Shoulder Pathology Instability Rotator Cuff Disease Frozen Shoulder OA / RhA

Frozen Shoulder - 2% general population Common Condition Idiopathic - women - 40-60 Idiopathic - Diabetes - Shoulder injury / pre-existing pathology

Frozen Shoulder Time Line pain stiffness Pain/Freezing Frozen Thawing

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

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

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

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

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

Frozen Shoulder Varying Subgroups? Chambler Afw et al. The role of surgery in frozen shoulder. JBJS 2003;85-B: 789-795

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

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

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

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

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

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