Transcript Summmary of Talk – Shoulder Jt examination for GP VTS 2013

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