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Shoulder Examination & Common Pathology

Shoulder Examination & Common Pathology. Mr David Rose FRCS Consultant Shoulder & Elbow Surgeon. My Background. Medical School: Royal Free (University of London - 2000) South West Thames Ortho Rotation (St Georges) Fellowships:

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Shoulder Examination & Common Pathology

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  1. Shoulder Examination & Common Pathology Mr David Rose FRCS Consultant Shoulder & Elbow Surgeon

  2. My Background • Medical School: Royal Free (University of London - 2000) • South West Thames Ortho Rotation (St Georges) • Fellowships: • Johns Hopkins, USA 2008/09 (Research – Shoulder/Upper Limb) • Perth Orthopaedic & Sports Medicine Centre, Perth, Australia 2012/13 (Sports Medicine Surgery) • Addenbrooke’s, Cambridge 2013/14 (Shoulder & Elbow Surgery)

  3. Current Position • Consultant Orthopaedic Surgeon Maidstone & Tunbridge Wells NHS Trust • Started February 2014 • Main Interests: Arthroscopic and Reconstructive Surgery of the Shoulder & Elbow

  4. Look Feel Move Special Tests COMPARE SIDES Examination

  5. Cervical Spine Thoracic Spine Neck Examination Cardiac Disease Referred Pain

  6. Muscles - wasting, winging Deformity - malunion, scars, ACjt Look

  7. Scapular Wasting Look

  8. Winging Look

  9. Shoulder Bony Anatomy Feel

  10. Compare sides (great variation) Passive v Active Loss of Motion - Mechanical - Muscular - Pain Inhibition - Neurological Range of Motion

  11. Forward Flexion

  12. ABduction

  13. External Rotation

  14. Internal Rotation

  15. Rotator Cuff Disease Instability Special Tests

  16. Muscle Strength Impingement ACjt Pathology Biceps Pathology Rotator Cuff Disease

  17. Jobe’s Supraspinatus

  18. Gerber’s Subscapularis

  19. Napolean Subscapularis

  20. Neer’s Impingement

  21. Hawkin’s Impingement

  22. Scarf AC Joint

  23. Speed’s Biceps

  24. Yergason’s Biceps

  25. Generalised Joint Laxity Anterior Instability Posterior Instability (no apprehension) Labral Pathology Instability

  26. Generalised Joint Laxity

  27. Sulcus Sign Instability

  28. Apprehension Instability

  29. Relocation Test Instability

  30. Jerk Test Posterior Instability

  31. O’Brien’s Labrum

  32. Instability Rotator Cuff Disease Frozen Shoulder OA / RhA Shoulder Pathology

  33. Young - Instability Middle-Age- Rotator-Cuff & Frozen Shoulder Elderly- Rotator-Cuff & OA Common Shoulder Pathology

  34. Instability Rotator Cuff Disease Frozen Shoulder OA / RhA Shoulder Pathology

  35. Instability Traumatic v Atraumatic Bankart Tear Labral Tear Capsular Laxity

  36. Muscle Patterning Problems Teenage Female Uni- or Bi-lateral Physiotherapy (specialist) Generalised Joint Laxity

  37. Management Reduction Sling immobilisation until comfortable Physiotherapy Recurrence ↓ with ↑ age ? Rotator cuff tear > 50yrs First Time Dislocator

  38. Management Activity modification Surgical Stabilisation – (open / arthroscopic / bony) Recovery - 2 - 3 wks - immobilisation - 4 - 6 wks - day to day activities - 4 - 6 mths - contact sports Outcome 90 – 95 % stable at 2 years Recurrent Anterior Dislocation

  39. Instability Rotator Cuff Disease Frozen Shoulder OA / RhA Shoulder Pathology

  40. Spectrum tendonitis ↓ partial tear ↓ full thickness tear ↓ cuff arthropathy Rotator Cuff Disease Tendinosis Tear

  41. Incidence of Rotator Cuff Defects Arthrogram Study (asympt) 60+yrs 50% 80+yrs 80% MRI Study (asymptomatic) 19-39yrs 2% PT RCT 40-60yrs 28% RCT Rotator Cuff Disease

  42. Treat the Symptoms Non-Operative (+ activity modification) Operative Rotator Cuff Disease

  43. “Orthotherapy” - 3 Phases Control the Pain- NSAID - Cortisone Injection Regain ROM - Physio / exercises Muscle Strengthening- Physio / exercises - Activity modification Management - non-operative

  44. Steroid injection • I prefer posterior approach • 70-80% accuracy when performed “blind” • 40mg depomedrone; 5-10mls marcaine 0.25%

  45. Indications for Surgery Failure or relapse following adequate non-operative treatment (6mths +) Management - operative

  46. Expectations from Surgery Pain relief Variable functional recovery NOT a new shoulder –‘degenerate tissue’ Management - operative

  47. Address the Pathology Arthroscopic Subacromial Decompression AC joint Excision Rotator Cuff Repair Arthroplasty Muscle Transfer Management - operative

  48. Subacromial Decompression

  49. Double-Row Repair Rotator Cuff Repair Double-row arthroscopic rotator cuff repair: Re-establishing the footprint of the rotator cuff. Lo IKY et al. Arthroscopy 2003

  50. Management – (failed non-operative / ACUTE event) arthroscopic decompression +/- rotator cuff repair Recovery ASD - immediate mobilisation - 3 – 6 months optimal recovery Cuff Repair - 1 – 3 weeks sling - 3 – 6 months optimal recovery Outcome 85% full recovery, 10% significantly better, 5% no worse! Rotator Cuff Disease

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