Shoulder Joint examination Overview Introduction Presentation Examination Anatomy Investigations Injections Key points A J Chakrabarti FRCS(Orth) Introduction Shoulder pain is very common Can be Recalcitrant Many get better spontaneously without treatment Costly Introduction Rheumatology 2006;45:215–221 Prevalence Overall 7% 26% in elderly Shoulder Pain in Adults Not getting better spontaneously What is the actual diagnosis? Are there specific considerations for this particular patient? When should I refer? Shoulder examination Basic steps History Examination Clinical tests Investigations XR/US What is the diagnosis ? Don’t be too hasty in simply diagnosing “Frozen shoulder” Patient factors of importance Lifestyle Occupation Handedness Sports/Hobbies PMH / PSH DH Expectations Previous treatments Shoulder Complaints Pain Stiffness Instability Weakness/ Functional loss Swelling Deformity Electrical disturbance/ Vascular disturbance Shoulder Complaints Pain That keeps patient awake at night Shoulder Complaints Pain Keeps partner / spouse up! Shoulder Complaint Pain Onset Injury Duration Site Severity Nature Periodicity Timing Night pain Exacerbating Relieving factors Treatments tried Tablets Response to Rxs Shoulder Complaint Pain Injury Nature Bleeding/ Bruising Snap. Crack “General Feel” Position of arm Pre-existing state Site of Pain Radiating to forearm/hand infrequent Radiating to neck Does not arise form intrinsic shoulder problems (except ACJ- to base of neck) Shoulder Complaint Pain Open Palm v Finger sign Deltoid sited pain Subacromial space / Rotator cuff. GHJ Superiorly sited pain Acromioclavicular joint Shoulder Instability Traumatic Atraumatic GLL Muscle patterning disorder History of fits Event Ease Frequency Subtle instabilities Pain Dead arm Shoulder Weakness Pain causes weakness Weakness of muscles –neural, musculotendinous or other mechanical Patients exact meaning Association with any pain. Painful Shoulder Remember that pain experienced in the shoulder can arise from outside the shoulder Shoulder Complaints Neck Brachial plexus pain Viscera. Intrathoracic/ subphrenic Chronic regional pain syndromes Shoulder Complaints Neck Brachial plexus pain Viscera. Intrathoracic/ subphrenic Chronic regional pain syndromes Shoulder examination Multiple techniques No best single way! Compare sides Assessing a Shoulder Anatomic sites Three True Joints Three areas Glenohumeral joint Acromioclavicular joint Sternoclavicular joint Subacromial space Rotator Cuff Scapulothoracic articulation Think anatomically ! The Rotator cuff 4 muscles with their tendons acting as a functional unit to maintain the humeral head centered on the glenoid The Rotator cuff Clinical Examination Look Feel Move Stand Sit Lie Clinical Examination Inspection Localising Tenderness Neck Examination CxSp Neuro exam Functional assess •Elevation •Impingement •ER •IR •Abduction RPA •Cuff testing 3 pt •Biceps Minimum 10 point Clinical Examination Inspection Localising Tenderness Neck Examination CxSp Neuro exam Functional assess •Elevation •Impingement •ER •IR •Abduction RPA •Cuff testing 3 pt •Biceps Minimum 10 point examination Non shoulder Functional Glenohumeral Cuff / muscles Cx Spine Elevation Ext Rotation Supraspinatus Impingement Internal Rotation Infraspinatus Abduction Subscapularis LHB • Positive Comparative increased pain No pain But slower Block Empty can Impingement The Hallmarks of common diseases Cx stiffness/ pain: Cervical spondylosis / Cx disc prolapse Elevation restriction: RCT lifting with good arm Impingement sign: Bursal/cuff disease or ACJ impingement Restrictions of Global GHJ motion: Capsular contracture of Frozen shoulder or OA GHJ Loss of resisted muscle power: RCT or pain inhibition Painful resisted cuff activity: RCT/ impingement LHB signs: Biceps tendinopathy 10 point examination Clinical Judgement Neck Shoulder ACJ BURSA CUFF BICEPS CAPSULE AND JOINT SURFACE Shoulder Scores of function Oxford Shoulder Score 48 12 Questions – all relate to shoulder in last 4 wks 0-4 per question. Max score 48/48 = Gd shoulder Worst,Dressing,Car,Knife,Shopping,Tray Brush,Usual,Robes,Axilla,Housewk,Night Does it need an XR? Yes: Yes: Yes: Yes: If referring for surgical opinion If you need it to corroborate your diagnosis If possibility of calcific disease If need to exclude arthrosis (The arthrosis of ACJ The arthrosis of the GHJ) Yes: If concerned re: malignant disease What XR’s do I find valuable? AP 30° Caudal Axillary Lateral Stryker Notch view for GHJ instability Clavicular views for ACJ instability “Sourcil” sign 30° Caudal view - useful to gauge 3D anatomy of Acromion 30° Caudal view Ultrasound examination Examines the rotator cuff Supraspinatus Infraspinatus Subscapularis Teres Minor Long Head Biceps Bursa / Impingement Ultrasound examination DO NOT REQUEST IN PREFERENCE TO PLAIN XR FILM MRI? Access to the films is the most important The reports may be misleading. The MRI has a picture that both clinician and patient can understand Most useful when: ACJ impingement a possibility Other pathologies /multiple pathologies are expected Limited use without contrast: calcific disease/ instability Treatments In all cases Conservative. Analgesia Physiotherapy: Pendular exercises Theraband exercises Eccentric Deltoid exercises “eccentric means lengthening during loading” Steroid injections Other injections / other treatments Treatments Theraband exercises Steroid Injections Prep the skin and draw up solution with separate needle to one used to inject. Portal: Soft spot – Below Postero-lateral corner Aim for Anterior acromion for bursal injection Aim for Coracoid process for GHJ injection Superior Summit for ACJ Cures for shoulder diseases? Arthritis ACJ: Arthritis GHJ: Excision arthroplasty Total shoulder replacement/ Hemi Rotator Cuff Arthropathy: Reverse polarity prosthesis Acute Rotator Cuff Tears: RCR Impingement with/without Tears: ASAD Instabilities: Various stabilizations Conditions that may not be cured Chronic Calcific Disease: Massive Cuff Tears: Degenerative RCTears without arthritis: Poor vascularity Secondary fatty infiltration and neural change to muscle/tendon unit Patients unfit for surgery: Conservative management: Steroid injections/ Eccentric Deltoid Training/ Suprascapular Nerve Blocks Prognosis in shoulder conditions is largely determined by the condition of the rotator cuff and The outcome following surgery in most cases largely determined by the condition of the rotator cuff