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Shoulder problems and Clinical Diagnosis

Today's programme. Clinical anatomy of shoulderShoulder painImpingement

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Shoulder problems and Clinical Diagnosis

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    1. Shoulder problems and Clinical Diagnosis Prof. Mohammad Maqsood Consultant Trauma & Orthopaedic surgery

    2. Today’s programme Clinical anatomy of shoulder Shoulder pain Impingement & Rotator Cuff Tear Frozen shoulder Instabilities/Dislocations How to diagnose a shoulder problem?

    3. shoulder problem in general Practice 11 general practices took part 35,150 patients- registered/year 11.2% shoulder problems 29% were rotator cuff problems; impingent, RC-tears etc 2% instabilities 5 % arthropathies

    4. Shoulder; Wayne Burkhead said Bony anatomy is un-usual Tendon configuration is strange Stability depends on factors Popular place for referred pain Red and Blue pipes, and yellow cables Diagnosis is tricky Imaging is technical “Therefore shoulder joint; not an easy joint”

    5. Unique joint Most Mobile Big ball and small socket Most unstable Has got shelf(canopy) Tendon passing through the joint 4 joints; GHJ, ACJ, St. CJ, Sc.TJ

    6. Golf ball-on-a-tee design

    7. Deep Anatomy

    8. Anatomy of the right Shoulder

    9. Ligament and LH. of Biceps tendon

    10. Posterior view

    11. Rotator cuff 4 muscles- SITS Arising from the scapula Holding humeral head Make a confluence Unique function; rotators, stabilisers, depressors , elevators etc. Mal-functioning is disabling

    12. Front view

    13. Repairing RCT

    14. Shoulder Problems Pain Unstable/Dislocating Inability to move- stiffness Inability to move- Weakness Degenerative arthropathy Inflammatory arthropathy

    15. Shoulder pain is not shoulder pain Cervical Radiculopathy Cardiac problems Gastric problems Mediastinal problems Diaphragm problems Hepatic and Gall Bladder problems Thoracic outlet/inlet syndromes

    16. My way to look at shoulder Rotator cuff- when intact Rotator cuff- when torn Instability/dislocation Others Arthropathy, Tendinopathy, ACJ problem, Frozen shoulder

    17. Impingement Syndrome Painful arc of movement Disturbed scapulo-thoracic motion Tenderness over the cuff insertion Positive impingement signs Neer’s and Hawkin’s Coarse crepitation on passive movement

    18. Vicious cycle

    19. Cuff disruption Partial tear; A) bursal B) articular Complete Tear; A) Follow a long period of tendinosis B) Out of blue ? Sprain or jerking movement

    20. Current concepts Tendinitis or tendinosis NSAIDs Steroids How much is risk?

    21. Cuff tear-later on Some recovery of abduction Weak Wasted cuff muscle; SIT Old tear of Biceps tendon -Speed test or Yergason’s test ACJ tenderness -Scarf test

    22. Clinical presentation of RCT Abduction is impossible Attempt causes “characteristic shrug” Passive abduction is full Once above 90- can keep it up “abduction paradox” When lowers side ways-suddenly drops-the “ drop arm sign”

    23. Frozen Shoulder (adhesive Capsulitis) Common over 40 yrs of age No known cause ?trauma Phases; 18 months Pain Stiffness resolving

    24. Causes Ideopathic Autoimmune response to local tissue break down products Following: hemiplegia, Myocardial infarction Trauma to upper limbs; Colle’s fracture, elbow injuries etc

    25. Instabilities/Dislocations Traumatic /Atraumatic

    26. Instabilities Acute /chronic Traumatic/ Atraumatic Habitual/ syndromal Anterior/ Posterior/Multidirectional

    27. Rules of management AMBRI Atraumatic, Mutildirectional, Bilateral, Rehabilitation, Inferior capsulorraphy TUBS Traumatic, Unidirectional, Bankart’s Surgery

    28. Current concepts Anterior dislocation; young patients; Bankart’s lesion, H-S lesion older patients; Rotator cuff tear Posterior dislocation ACJ disruption

    29. Examination of shoulder Very focussed examination

    30. Before the shoulder examination Cervical spine examination alignment ROM Palpation Neurological examination

    31. Golden tips Trapezius pain is not shoulder pain Pain radiating below elbow is more likely a radicular cervical Pain on top of shoulder more likely ACJ pain Night pain is typical of rotator cuff Places hand on Deliod Pain at Deltiod insertion; intrinsic/adhesive

    32. Shoulder problems are complex Quick screening

    33. Quick screening test “Scratch test”

    34. Basic Principles Clinical examination Look Feel Move Special tests

    35. Look Contour of shoulder Symmetry of shoulder Muscle wasting Bony prominence Scar, sinus and discharge etc.

    36. (Surface anatomy) Look

    37. What is diagnosis?

    38. What is the diagnosis?

    39. Clinical Picture?

    40. Feel (palpation) Temperature Organised and systematic Start from supra-sternal notch to the ACJ Acromion, spine of scapula, scapular borders, head of humerus, front and back Do not forget axilla

    41. Palpation(Feel)

    42. Move Active then passive Demonstrate the patient what movement Forward elevation then extension External rotations then internal Some joined movements touching back of head touch the lower end of scapula touching opposite shoulder tip

    43. Move Abduction and forward elevation

    44. (MOVE) Forward elevation

    45. (Move) Adduction and internal rotation

    46. (MOVE) External rotation and Abduction Abduction External rotation

    47. Special tests History gives a kind of diagnosis Examination Look feel and move give the provisional diagnosis Special test support your diagnosis

    48. Special tests Impingement

    49. Neer’s impingement test

    50. Hawkin’s test

    51. Special test For Rotator cuff

    52. Supraspinatus testing

    53. Testing for infra-spinatus and Teres minor

    54. Subscapularis testing Gerber’s test

    55. Special test Acromio-clavicular problems

    56. Cross chest adduction “scarf test”

    57. Special test Biceps tendinitis / SLAP lesion

    58. Long Head of Biceps

    59. Yergason’s test (resisted supination)

    60. Speed test SLAP/ LHB tendinosis

    61. Biceps tendon rupture

    62. Special test instabilities

    63. Apprehension test for anterior instability

    64. Relocation test

    65. Global/syndromal instability Hyperlaxity of other joints As well Collagen disorders Related to some syndromes Ehler Danlos syndrome Multidirectional instability

    66. Sulcus Sign

    67. Special test Labral tear

    68. Crank test (Labral tear)

    69. Common Findings and Diagnosis Finding Probable diagnosis Scapular winging, trauma, recent viral illness -Serratus anterior or trapezius dysfunction Seizure and inability to passively or actively rotate affected arm externally -Posterior shoulder dislocation Supraspinatus/infraspinatus wasting -Rotator cuff tear/Suprascapular nerve entrapment Pain radiating below elbow; decreased cervical range of motion -Cervical disc disease Shoulder pain in throwing athletes; anterior glenohumeral joint pain and impingement -Glenohumeral joint instability Pain or "clunking" sound with overhead motion -Labral disorder Night time shoulder pain -Impingement Generalized ligamentous laxity -Multidirectional instability >40 fall-unable to lift arm up - Rotator cuff tear

    70. Thank you Any question?

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