common shoulder conditions, assessment & differential ......common shoulder conditions,...
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Shoulder
Paul Allan Regional Clinical Lead - South
Common Shoulder Conditions,
Assessment & Differential Diagnosis
Aims
• Refresh shoulder anatomy
• Review common shoulder conditions seen in
primary care
• Improvement of management strategy selection
for shoulder pathology
The shoulder
• The shoulder complex primarily functions to position and control
the elbow and hand in order to perform a huge variety of functions
from fine tasks to explosive overhead movements.
• To perform these functions the shoulder complex has a ROM that
exceeds any other region in the body.
Shoulder bony anatomy
• Shoulder bones:
- Scapula
- Proximal Humerus
- Clavicle
• Joints of the shoulder girdle:
- SC joint
- AC joint
- Glenohumeral joint
- Scapulothoracic mechanism
Shoulder bony anatomy
Shoulder capsule & labrum
• Glenoid labrum – narrow wedge shaped
fibrocatrilagenous band
• Capsule – supported by 4 ligaments
Shoulder muscular anatomy
• The rotator cuff
• Deltoid
• Biceps Brachii
Basic classification
Instability
• Traumatic
• Atraumatic
• Muscle patterning
Stiffness
• Arthritis
• Frozen shoulder
• Infection
• Tumour
• AVN
Other
• Spinal
• Rib
• Non MSK
Shoulder Pain
Impingement
• Rotator Cuff
• Bursa
• Labrum
• AC joint
• Long head biceps
Subjective history
• Onset
• Age: likely conditions?
• Site
• Spread
• Occupation / Hobbies / Activities
• Duration
• Behaviour
• Symptoms
• Medical History
• Investigations / treatment to date
History
Age can help as a rough guide to what may be the problem
Potential Problem AGE
Instability 17 – 30 years
Impingement 30 – 45 years
Adhesive capsulitis 45 – 60 years
OA >60 years
• Where pain is can help with diagnosis
• Pain elsewhere? – ask about cervical / thoracic spine specifically
• Anaesthesia / paraesthesia
• Lateral shoulder Cuff tear / Impingement
• Anterior shoulder Impingement / Labrum
• Whole shoulder Frozen shoulder
• Superior shoulder AC joint
History / pain location
Basic shoulder assessment format
• Observation – wasting, swelling, deformity, scapula position
• Shoulder movement – active and passive
• Resisted shoulder tests
• Special tests – impingement, cuff, biceps, instability
• Palpation
Case study 1
Scenario:
48 year old self-employed painter and decorator attends with a gradual onset of 4 month history of superior lateral shoulder pain in his dominant arm. He is managing at work but it is more painful after a busy day. He has had no previous problems with his shoulder. He is
otherwise fit and well. He has taken some paracetamol but it has not been helpful.
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In Small Groups…………..
1) From the subjective history what are the possible differential diagnoses?
2) Objectively which tests could you perform to differentiate? 3) What would you do with this patient?
How would this differ with the following information?
- 48 year old self-employed painter and decorator attends after he
fell from his ladders yesterday and he is having difficulty moving his arm.
- 48 year old self-employed painter and decorator attends with gradual onset of shoulder pain and stiffness.
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69 year old retired lady attends with pain in her left shoulder, she localises this to her anterior shoulder/ axilla. Symptoms started
gradually as a stiffness and then started to aslo becoming painful. She is struffling now to get dresssed and with household tasks, she is also not sleeping well due to the pain. She gives a history of breast cancer 2 years ago on the right side and was treated with surgery and
chemotherapy. She has no other medical history of note.
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Case Study 2
In Small Groups…………..
1) From the subjective history what are the possible differential diagnoses?
2) Objectively which tests could you perform to differentiate? 3) What would you do with this patient?
How would this differ with the following information?
- 69 year old retired lady attends with severe shoulder pain which is unremitting and started suddenly.
- 41 year old lady attends with gradual onset of shoulder pain and stiffness.
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Paul Allan Regional Clinical Lead - South
Any Questions?
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