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
• Cervical Spine
• Thoracic Spine
Neck Examination
• 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
Bankart Tear
Labral Tear
v
Atraumatic
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
- 4 - 6 wks
- 4 - 6 mths
- immobilisation
- day to day activities
- contact sports
• Outcome
90 – 95 % stable at 2 years
Shoulder Pathology
• Instability
• Rotator Cuff Disease
• Frozen Shoulder
• OA / RhA
Rotator Cuff Disease
Spectrum
Tendinosis
tendonitis
↓
partial tear
↓
full thickness tear
↓
cuff arthropathy
Tear
Rotator Cuff Disease
• Incidence of Rotator Cuff Defects
Arthrogram Study (asympt)
60+yrs
80+yrs
MRI Study (asymptomatic)
19-39yrs
40-60yrs
50%
80%
2% PT RCT
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 nonoperative 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: Reestablishing 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
- 3 – 6 months optimal recovery
• Outcome
85% full recovery, 10% significantly better, 5% no worse!
Shoulder Pathology
• Instability
• Rotator Cuff Disease
• Frozen Shoulder
• OA / RhA
Frozen Shoulder
• Common Condition
- 2% general population
- women
- 40-60
• Idiopathic
- Diabetes
- Shoulder injury / pre-existing pathology
Frozen Shoulder
• Time Line
pain
Pain/Freezing
Frozen
stiffness
Thawing
Frozen Shoulder
• Duration
months – 3 years
• Recovery
complete – marked
residual symptoms
Frozen Shoulder
• Management – Pain / Freezing
pain
Pain/Freezing
Frozen
stiffness
Thawing
Frozen Shoulder
Management – Freezing / Painful
• Conservative /Supportive
- Supervised Neglect
- Analgesia
- Steroid Injection
- Physiotherapy
- Nerve Blocks
- Capsular Hydrodilatation
Frozen Shoulder
• Management – Frozen / Thawing
pain
Pain/Freezing
Frozen
stiffness
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
- 2 + wks
- 3 + mths
- inpatient physio
- intensive exercises / physio
- 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 nonoperative 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