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The Shoulder in General Practice

The Shoulder in General Practice. Mr T P Selvan MB, LRCP, FRCS Ed, MSc (Ortho), FRCS (Ortho) Consultant Orthopaedic Surgeon East Surrey Hospital, Redhill. Scope. Anatomy- Deltoid. Anatomy – Rotator Cuff. Anatomy - Ligaments. Anatomy - Bones. Diagnostic Clues - Age.

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The Shoulder in General Practice

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

  2. Scope

  3. Anatomy- Deltoid

  4. Anatomy – Rotator Cuff

  5. Anatomy - Ligaments

  6. Anatomy - Bones

  7. 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

  8. 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

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

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

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

  12. 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.

  13. Movements

  14. Supraspinatus

  15. Infraspinatus / Teres minor

  16. O’briens test for ACJ/Slap Lesion

  17. Gerbers Lift off for subscapularis

  18. Belly Press for Subscapularis

  19. Neers Test

  20. Hawkins-Kennedy test

  21. Biceps tendon-Speed test

  22. Apprehension Tests Apprehension Relocation Test Drawers tets Sulcus Test

  23. Non-shoulder examination • Supraclavicular fossa • Neurological examination • Vascular examination

  24. Cervical spondylosis

  25. Cervical spine fracture and tumour

  26. 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

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

  28. Impingement/ACJ Pathology ACJ Arthritis Acromial spur

  29. Calcific Tendonitis

  30. Metastatic Fracture

  31. Frozen Shoulder

  32. Horizontal Retracted Vertical & Horizontal Inner Substance Horizontal Vertical Rotator cuff tear

  33. Glenohumeral arthritis Surfacereplacement Total Shoulder Replacement

  34. Rotator cuff arthropathy Reverse Delta Shoulder replacement

  35. SLAP LesionSuperior Labrum Anterior Posterior

  36. Bankarts Lesion

  37. Activity modification NSAIDs / Analgesia Physiotherapy Steroid Injection Treatment at Primary Care

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

  39. Injection Techniques

  40. 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 When to Refer to a Shoulder Specialist

  41. 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.

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