Shoulder Joint examination

OverviewIntroductionIntroduction

PresentationPresentation

ExaminationExamination

Anatomy Anatomy

InvestigationsInvestigations

InjectionsInjections

Key pointsKey pointsA J Chakrabarti FRCS(Orth)A J Chakrabarti FRCS(Orth)

Introduction

Shoulder pain is very common

Can be Recalcitrant

Many get better spontaneously without treatment

Costly

Introduction

Prevalence Overall 7%26% in elderly

Rheumatology 2006;45:215–221

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 ComplaintPain

OnsetInjuryDurationSiteSeverityNaturePeriodicityTiming

Night pain

Exacerbating

Relieving factors

Treatments tried

Tablets

Response to Rxs

Shoulder ComplaintPain

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 ComplaintPain

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

NeckBrachial plexus painViscera. Intrathoracic/ subphrenicChronic regional pain syndromes

Shoulder Complaints

NeckBrachial plexus painViscera. Intrathoracic/ subphrenicChronic regional pain syndromes

Shoulder examination

Multiple techniques

No best single way!

Compare sides

Assessing a ShoulderAnatomic sites

Glenohumeral joint

Acromioclavicular joint

Sternoclavicular joint

Subacromial space

Rotator Cuff

Scapulothoracic articulation

Think anatomically !

Three True Joints Three areas

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

CxSpNeuro exam

Functional assess

•Elevation

•Impingement

•ER

•IR

•Abduction RPA

•Cuff testing 3 pt

•Biceps

Minimum 10 point Clinical Examination

Inspection

Localising Tenderness

Neck Examination

CxSpNeuro exam

Functional assess

•Elevation

•Impingement

•ER

•IR

•Abduction RPA

•Cuff testing 3 pt

•Biceps

Minimum 10 point examination

Cx Spine Elevation Ext Rotation Supraspinatus

Impingement Internal Rotation

Infraspinatus

Abduction Subscapularis

LHB

Non shoulder Functional Glenohumeral Cuff / muscles

 Empty can Impingement  

•  Positive

Comparative increased pain

No pain But slower

Block

  

The Hallmarks of common diseases

Cx stiffness/ pain: Cervical spondylosis / Cx disc prolapseElevation restriction: RCT lifting with good armImpingement sign: Bursal/cuff disease or ACJ impingementRestrictions of Global GHJ motion: Capsular contracture of Frozen shoulder or OA GHJLoss of resisted muscle power: RCT or pain inhibitionPainful resisted cuff activity: RCT/ impingementLHB signs: Biceps tendinopathy

Clinical Judgement

Neck

Shoulder

ACJ

BURSA

CUFF

BICEPS

CAPSULE AND JOINT SURFACE

10 point examination

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: If referring for surgical opinion

Yes: If you need it to corroborate your diagnosis

Yes: If possibility of calcific disease

Yes: 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?

AP30° CaudalAxillary Lateral

Stryker Notch view for GHJ instabilityClavicular 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: Excision arthroplasty

Arthritis GHJ: 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