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

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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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