The Shoulder

Claire Bailey&

Elizabeth Bowman Bsc (Hons) Physiotherapy

April 2013

Email: mail@roundwoodclinic.co.uk

Aims

• Diagnostic categories• Evidence based decision making?• Treatment options• When to refer on (or not?!)

Anterior GHJ Anatomy

The Rotator Cuff

Introduction

Signs <30 years 30-70 years >70 years

Impingement pain Instability Secondary impingement

Subacromial impingement

Cuff tearSAIS

ACJ pain Osteolysis OA OA

GHJ pain Inflammatory arthritisInstability

Frozen shoulder GHJ OA

Periscapular Snapping scapulaInstabilityNeurogenic

InstabilityNeurogenic

neurogenic

Red Flags

• History of Ca, mass, swelling etc.• Red skin, fever, systemically unwell ?infection• Trauma, epileptic fit, loss of rotation• Unexplained significant sensory or motor

deficit• Visceral referred pain

Visceral Referral Pain

Pancoast Tumour

Frozen Shoulder

“it comes on slowly; (with) pain usually felt near the insertion of the deltoid; inability to sleep on the affected side; painful and incomplete elevation and external rotation; restriction of both spasmodic and mildly adherent type; atrophy of the spinati; little local tenderness; (&) x-rays negative except for bone atrophy”.

Codman (1934)

Frozen shoulder cont.

• Elusive underlying pathology• ?inflammatory ?scarring ?enzyme• Pain predominant or stiffness predominant

(Hanchard et al. 2011)• Primary (unknown cause)• Secondary (to trauma)• 2% population; 935 patients; 58% female• Dominant side 52%; bilateral 38% (Chambler et al. BMJ 2003)

Frozen Shoulder

Secondary frozen shoulder• Trauma• R.Cuff tear• Post –operatively• Diabetes• Cerebral haemorrhage• Thyroid• Autoimmune disease• Cervical spine pathology• Hormonal changes• Prolonged immobilisation• Algodystrophic

Stages of frozen shoulderFreezing Pain increases with movement and is often worse at night.

There is a progressive loss of ROM with increasing pain. Lasts approx. 2-9/12

FrozenPain begins to diminish, ROM much more limited (50%). Lasts

approx. 4-12/12

Thawing Condition may begin to resolve. Most patients experience a

gradual restoration of motion over next 12-42/12

Clinical Picture

• Insidious onset• Pain at deltoid insertion• Night pain• Pain at rest• Reduced AROM and PROM• Reduced ER (restriction >50% of the opposite

side)• Normal x-rays

Frozen shoulder x-rays

• NORMAL• To exclude:-1)Cuff arthropathy/massive cuff tear with

secondary OA changes2)OA – bony end feel, osteophytes limit ER3)Dislocation locked – stuck in IR causing avascular

necrosis to humeral headALL LIMIT ER, THEREFORE, TENTATIVE DIAGNOSIS

WITHOUT X-RAY

Treatment

• Neglect? (better in 2 years)• Physiotherapy• Injection – improved shoulder related

disability @ 6/52 (Ryans et al. 2005)• MUA / arthroscopic release – significant loss

of ER not changing with rehabilitation @ 6-9 months

Conservative management• Explanation• Modify activities• Analgesia• Physiotherapy?• Corticosteroid injection?• CONSIDER EARLY REFERRAL IF.......• Patients pain is particularly disabling to them• Severe restriction in PROM inhibiting function• Considering operative or specialist management

Surgical management

• Symptoms and function are unchanging and significantly disabling after 6/12 of conservative treatment

• Arthroscopic release +/- SAD• ? MUA• ?hydrodilation• Suprascapular nerve block – improves pain but

not movement

Impingement

• Up to 74% patients presenting in primary care SAIS

• Physiotherapy first line Rx• Roy et al. (2008)• Ostar (2005)

Classification

• Primary (intrinsic)• Secondary (extrinsic)• Outlet / non-outlet• External / internal impingement

• Bursal side wear and tear not substantiated by histological studies – majority on articular side

Impingement cont.

• Extrinsic theory challenged • Irritation causes tendonitis and bursitis?• “sub-acromial pain syndrome” pain related to

the bursa rather than the mechanical impingement effect. (Lewis 2011)

• Reactive tendonopathy to tendon disrepair and subsequent degeneration.

• Dysfunction of the r.cuff = bursitis and Sx

Impingement

Calcific Tendonitis

Impingement

Clinical Presentation

• Difficulty with over head activities• Pain mid range arc• Constant background ache / night pain /

increased pain on movement = ? Inflammation in bursa (only place to find inflammation in impingement)

Painful Arc

Diagnosis

• Impingement tests • Neers• Hawkins• Weakness in ER

• X-ray AP, axillary – spur formation, sclerosis, acromion type (>3/12 symptoms)

• U/S to confirm and exclude cuff tear

Neers Test

Hawkins Test

Impingement Treatment

• Physiotherapy • NSAID’s? If constant pain• ?Injection – short term efficacy only and most

effective at 1-2/52 when constant pain (Trojian 2005)

• ?Poor outcome with surgery following repeated injections

• Conservative treatment minimum 8/52• Surgery SAD

Rotator Cuff tears

• Almost all tears are chronic and degenerative in nature

• Often insidious history• Can occur after trauma or dislocations• Similar Sx to impingement• ? Clinically obvious weakness

Rotator Cuff Tear

Diagnosis • Drop arm test• Severe pain, profound weakness of abduction, or

an inability to maintain the arm in 90O abduction then slowly lower

• Positive infraspinatus testing (ER)• Pain that awakens the patient at night (Riddle

2001).• Tests may be better at ruling out cuff tears rather

then detecting them• ultrasound

Lift off test

Belly Press Test

Bear Hug Test

Empty Can Test

Rotator Cuff Tear

Acute rotator cuff tear

• Patients presenting with a traumatic history, sudden or progressive weakness

• Urgent U/S and referral• Consider early repair • 6-12/52 window of opportunity for best

outcome from surgery

Chronic symptomatic cuff tear

• ?non-operative management for 3-6/12• Advice / NSAID’s?/ physiotherapy• X1 steroid injection?• Failed non-operative management re-evaluation

consider U/S or MRI• Only need surgery if warranted by Sx• ?SAD for pain relief and to avoid the long rehab.

required for cuff repairs if the patient has – good movement, strength

Full thickness cuff tears – non-operative management

• “tincture of time”• Physiotherapy• NSAID’s???• Modified activities• Steroid injection??• ? Can compensate due to activation of residual

intact cuff• Partial tear vs. Impingement ?does it matter as

doesn't change outcome/type of Rx

AC Joint Dysfunction

• Traumatic v degenerative onset• Traumatic onset is usually a fall on to the

point of the shoulder and can involve– Stretching or tearing of the acromioclavicular or

coracoacromial ligaments– Subluxation/dislocation of the AC joint• Degenerative problems tend to occur in

individuals over 45 years

The ACJ

Clinical Presentation

• Degenerative– Pain with activity and ?at rest over ACJ (may radiate in

to traps region but not deltoid)– ?ROM restricted in to overhead elevation– No obvious inflammatory signs

• Traumatic– Reports a traumatic onset– May be an observable deformity

• May also be associated with sub-acromial impingement

Diagnosis

• Pain on palpation over ACJ• Pain on active adduction (Scarf test)• Pain on O’Brien’s

• X-ray may be used to exclude osteolysis/oes-acromially or to define degree of disruption in traumatic onset

Scarf Test

O'Brien's Test

Treatment

• Rockwood classification for traumatic disruption– Type I & II managed conservatively– Type III individual cases– Type IV – IV managed surgically

• Physiotherapy• ?injection therapy• Surgical options in degenerative cases if failed

conservative management

Glenohumeral Instability

• Instability is the abnormal motion of the glenohumeral joint that may include subluxation or dislocation, co-existing laxity, pain

• Involves one or more (usually a combination) of ligaments, tendons, glenoid labrum, joint capsule

• Traumatic instability v atraumatic instability

Clinical Presentation

• Tends to be in patients younger that 35• History of trauma or dislocation• “Give way” or “lock”• Repeatedly performing overhead movements

may aggravate symptoms (particularly with SLAP)

• Symptoms can be vague e.g young athletic males with activity related pains in shoulder or an inability to perform overhead throw

Diagnosis

• Apprehension/relocation• Sulcus

• ?Xray in acute dislocation• MRI/MR arthrograms

Apprehension Test

Relocation Test

Sulcus Sign

Treatment

• If first time dislocation in young population (<25 years) or high trauma injury referral on to specialist shoulder surgeon

• Recurrent dislocators• Physiotherapy would usually involve stability and

strengthening, proprioception and core stability with graduated return to activities

• Physiotherapy vital in both the conservatively and surgically managed cases though rehab period is likely to be lengthy (3-6/12)

Labral Pathologies

• SLAP v Bankart• 85% of GH dislocations likely to have a

Bankart if needed to be relocated• SLAP – may be caused be any repeated

overhead activity, eccentric or concentric contraction of biceps. May be associated with a dislocation but more commonly in sportsmen with a pull on the arm, weightlifting, throwing injury or tackle

Bankart / Hill-Sachs

SLAP Tear

Diagnosis

• Apprehension (Bankart and SLAP)• O’Brien’s (SLAP)• Biceps load I and II (SLAP)

• Difficult to diagnose clinically• MRI/MR arthrogram

Biceps Load I/II

Treatment

• Surgical v conservative remains controversial• Physiotherapy• Onward referral if failing conservative

management/ return to high level sport or occupational factors

Evidence to Implicate the Cervical and Thoracic Spines in Shoulder Pain

• Cervical spine lateral glides (Vincenzino et al 2007, 2009)• McClatchie at al (2009) – increased GH abduction and

decreased pain intensity• C5/6 joint mobilisations increases strength of GH lateral

rotators immediately and for 10 mins (Wang 2010)• Thoracic segmental restriction impacts scapula position

and cuff activation – 40% of shoulder pain patients have thoracic and rib dysfunction (Lin et al, 2010)

• Physiotherapist’s conclusions….

Upper Limb Dermatomes

Subjective Examination

• What questions would you ask?• Why are you asking these questions?• What would this lead you to consider as a

diagnosis? (clinical reasoning!)HPCSQ’sPMH

Objective Examination

If all else fails! .....

Consider:• Pain clinic• Acupuncture?• Chronic pain analgesia

Any Questions?