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The Shoulder in General Practice
Mr T P SelvanMB, LRCP, FRCS Ed, MSc (Ortho), FRCS (Ortho)
Consultant Orthopaedic SurgeonEast Surrey Hospital, Redhill.
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Scope
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Anatomy- Deltoid
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Anatomy – Rotator Cuff
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Anatomy - Ligaments
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Anatomy - Bones
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• 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 - Age
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Diagnostic Clues - History• Pain on overhead activities IMPINGEMENT
• Night Pain GH ARTHRITISFROZEN SHOULDER
CUFF TEAR ARTHROPATHY
• Dead arm INSTABILITY
• Apprehension INSTABILITY• Trauma FRACTURES, CUFF TEAR
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LOCATION OF PAIN
Rotator cuff disease
1. Under deltoid
2. Side of arm
3. Front of arm
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Pain in the shoulder blade area is usually muscular or nerve related
LOCATION OF PAIN
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Diagnostic clues – DeformitiesACJ DISRUPTION
DISTAL BULKING OF BICEPS
INFRASPINATUS WASTING
SCAPULAR WINGING
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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.
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Movements
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Supraspinatus
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Infraspinatus / Teres minor
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O’briens test for ACJ/Slap Lesion
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Gerbers Lift off for subscapularis
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Belly Press for Subscapularis
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Neers Test
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Hawkins-Kennedy test
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Biceps tendon-Speed test
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Apprehension Tests
Apprehension Relocation Test
Sulcus Test Drawers tets
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• Supraclavicular fossa
• Neurological examination
• Vascular examination
Non-shoulder examination
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Cervical spondylosis
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Cervical spine fracture and tumour
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• 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
Investigations – X-Rays
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• Ultrasound (one stop clinic)
• MRI • Arthrogram• CT Scan• EMG• Bone Scan• ARTHROSCOPY
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Impingement/ACJ Pathology
ACJ Arthritis Acromial spur
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Calcific Tendonitis
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Metastatic Fracture
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Frozen Shoulder
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Rotator cuff tear
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Surface replacement Total Shoulder Replacement
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Reverse Delta Shoulder replacement
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SLAP LesionSuperior Labrum Anterior Posterior
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Bankarts Lesion
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• Activity modification
• NSAIDs / Analgesia
• Physiotherapy
• Steroid Injection
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Indications for Injection
• 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
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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
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• 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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