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?