Management of common shoulder pathologies. Val Jones Physiotherapy Practitioner Sheffield Shoulder & Elbow Unit

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1 Management of common shoulder pathologies Val Jones Physiotherapy Practitioner Sheffield Shoulder & Elbow Unit

2 Objectives Review evidence based assessment and management of common shoulder pathologies

3 Shoulder pain incidence 3 rd most common musculoskeletal reason to seek GP advice, with 15% onward referral to physio (Linsell et al 2006) Labour Force survey 3.8 million working days lost in UK with neck and upper limb pain 17.5 days sick leave in 1 year. Annual loss 0.16 days per worker (HSE 2010)

4 Evidence of occupational risks Strong evidence for association between shoulder complaints and Manual material handling Vibration Trunk flexion or rotation Working with hands above shoulder level (Mayer et al 2011 Int Arch Occup Env Health)

5 Most common shoulder pathologies Impingement Rotator cuff tears Contracted (frozen shoulder)

6 Impingement Reduced clearance between the humeral tuberosities and coracoacromial arch during elevation, compromising vulnerable soft tissues including Rotator cuff LHB Sub-acromial bursa

7 Impingement incidence Prevalence sub acromial pain including tendinosis and cuff tears accounts for up to 70% of all shoulder problems (Mitchell et al BMJ 2005) Lifetime prevalence 22-40% (Anderson et al 2007) Incidence 2.5% age 42-46, 21% age 70

8 Cuff tear prevalence Overall cuff tear prevalence is 34% Increases with age Partial thickness more common than full thickness (Sher et al JBJS 1995)

9 Impingement demographics Race no known variation Sex equal Age most common after 40 Before age 40 consider instability

10 Rotator cuff Reinforces capsule Draws humeral head into glenoid Interdigitation (Clark & Harryman 1992) Tension in one musculotendinous unit distributed over wide area

11 Supraspinatus Active throughout Susceptible to impingement and fatigue Snugs humeral head Vertical steerer Internal and external rotator (Ihashi 1998)

12 Inferior cuff Infraspinatus and teres minor Infra horizontal steerer Posterior stabiliser Depresses humeral head

13 Clinical presentation 40+ Sudden or insidious Lateral shoulder Dull ache with sharp catches on movement Pain at night Worse especially overhead

14 Clinical tests Painful arc Usually adequate passive range Positive impingement tests Pain and or weakness on cuff testing X-ray and ultrasound

15 Impingement testing Hawkins Kennedy Neer test

16 Hawkins Kennedy

17 Neer test

18 Sensitivity For rotator cuff tear Neer 85%, Hawkins 88% For subacromial bursitis Neer 75%, Hawkins 92% MacDonald et al (2000)

19 Rotator cuff testing Empty can (Jobe) / full can Infraspinatus Subscapularis (Belly press) Lift off test (Gerber)

20 Empty can test (Jobe)

21 External rotation testing

22 Lift off test

23 Lift off test (Gerber and Krushell 1991) EMG study (Greis 1996) Showed significantly higher levels of activation in subscapularis in comparison with other muscle groups

24 Belly press (Napoleon sign)

25 Extrinsic vs intrinsic Extrinsic - Neer Irritation and inflammation from acromion Bigliani acromial type III more at risk Acromioplasty one of most commonly performed procedures

26 However Fukuda no inflammatory cells in cuff Most partial thickness tears on articular, not bursal side Loehr, Ogata, Ozaki

27 Intrinsic theory Tendon pathology that originates within the tendon usually as a consequence of overuse or overload, leading to intrinsic degeneration - Lewis

28 Intrinsic Articular fibres Smaller cross sectional area Nakajima Reduced tensile strength Vulnerable in elevation Fibre failure progressing to tears

29 So what is happening? Multifactorial Overuse leading to pain, weakness and structural failure Intrinsic failure leads to superior migration, bursal irritation, CAL and acromion? Extrinsic effects are secondary

30 Structural factors Shape coracoacromial arch AC joint pathology Bursal pathology

31 Dynamic factors Tight posterior capsule Weakness humeral head depressors Poor scapula mechanics

32 Treatment options Physiotherapy Injection therapy Surgery

33 Physiotherapy Initial course for 6 weeks If improvement after 6 weeks continue for 3 months (BESS 2014) Passive mobilisations augments beneficial effects of exercise

34 Physiotherapy Best evidence for course of exercise to restore range, strength and scapulo-humeral stability (Kuhn 2009) Can include both stretching and strengthening work

35 Physiotherapy Scapula contribution asses with scapula assistance test Asses flexibility and strength and endurance of scapula muscles Asses capsular mobility Asses cuff strength and endurance especially external rotators

36 Physiotherapy Benefits short course of NSAIDS likely to outweigh risks No evidence for heat or cold therapy Ultrasound not recommended No evidence for laser, tens, friction massage

37 Injection therapy Steroid injections only benefit in the short term, no better than NSAIDS (Buchbinder 2009) No difference between using anatomical landmarks and ultrasound guidance (Bloom et al 2012)

38 Injection therapy? Systemic effect as just as effective when placed in gluteal muscle (Ekeberg 2009) No more than 2 injections with impingement (BESS 2014) Avoid in presence of cuff tear

39 Surgery Arthroscopic Decompression No immobilisation required 4 weeks off light duties 6 8 weeks off heavier duties 3 4 months before can sleep on operated side

40 Cuff repair 2-4 weeks immobilisation Up to 12 weeks lighter duties Can only manually handle at 3 months months before reach full strength Re-tear rate 13 68%

41 Evidence No significant differences SAD vs physio (Goldberg et al 2001, Gartsman and O Connor 2007) No differences decompression with bursectomy vs bursectomy alone (Henkus et al JBJS 2009) Rotator cuff repair no evidence in over 75 s

42 Frozen shoulder A condition of uncertain aetiology characterised by significant restriction of both active and passive motion that occurs in the absence of a known intrinsic shoulder disorder ASES 1992

43 Contracted shoulder Combination pain and stiffness, with potential for long term marked disability (Bunker 2009) 38% persistent mild symptoms, 3% severe, 4.4years from onset (Hand et al 2008)

44 Diagnosis Passive external rotation reduction is fundamental to diagnosis Degree of difference to be clinically significant degrees (Kibler et al, Tveita et al)

45 Differential Diagnosis 3 causes of reduced passive external rotation?

46 X ray 1

47 X-ray 2

48 X ray 3

49 Differentiation important Differentiate from history, clinical and radiographic examination Primary global capsular restriction Secondary restriction usually specific - therefore can direct mobilisation appropriately

50 Epidemiology Insidious painful condition Up to 10% population (Hand et al 2008) Women > Men years of age Non-dominant > Dominant 20-30% will develop primary capsulitis in opposite shoulder

51 Associated with Trauma Diabetes (10-20%) Hyperparathyroidism Prolonged immobilisation CVA / MI Cervical spine pathology

52 Pathogenesis Both inflammation and fibrosis Increased vascularity and hypertrophy of capsule Walls of axillary fold adhere Reduced joint volume 3-4 ml

53 Link with dupytrens 58 primary capsulitis Dupytrens found in 52% ( over 8 x incidence in general population) Type II collagen in nodules and bands Similar distribution of fibroblasts

54 Stage 1 Less than 3/12 duration Pain dull at rest & sharp EOR Progressive decrease of active range Hypertrophic vascular synovitis Full passive range Initially impingement tests positive Signs of contracted shoulder take primacy over impingement signs (Hanchard et al 2011)

55 Stage II 3 9 months Progressive loss ROM Loss capsular volume Dense proliferative hypervascular synovitis Capsular fibroplasia with deposition of disorganised collagen fibrils No inflammatory infiltrates

56 Stage III 9 14 months Significant loss ROM Relatively pain free but stiff Patchy synovial thickening without hypervascularity Dense hypercellular collagenous tissue

57 Stage IV Thawing phase Slow steady recovery of range? Capsular remodelling No arthroscopic or histological data available

58 Treatment Options MUA Arthroscopic Release Hydrodilation Injection Manual therapy

59 Manual therapy 95% regain satisfactory range with hourly exercise (Watson Jones) O Kane (1999) - success dependent on motivation, frequency & 4 quadrants of capsular stretch Evidence for outpatient physio supplemented by home exs (Hanchard 2011)

60 Injection Does not enhance MUA (Kivimaki 2001) Beneficial if given intra-articular route, no benefit sub-acromially (Hanchard 2011) Effect short lived (Buchbinder 2009)

61 MUA 97% had pain relief and gained nearly full range (Reichmiester et al 1999), with no evidence of complications Othman & Taylor (2002) trebled Constant score at 3 years follow-up

62 Hydrodilation Radiologist mls saline Dalziel & Watson 1993 significant improvements in pain score and range Not true frozen shoulder Cochrane review showed no long term benefits, no better than steroid or alternatives

63 Cohen (2000) worse results in postsurgical stiffness. Propose scalene block Capsular Release Provides significant relief and restoration of motion within 3/12 (Nicholson 2003) Gerber (2001) effective, but outcome is related to severity of stiffness, regardless of aetiology

64 Capsular release Arthroscopic Early full movement 2 hourly stretches 6 week window of opportunity to prevent further stiffness

65 Capsular release 4-6 weeks before return to work No lifting for 6-8 weeks 3-4 months before can lie comfortably on operated side Never twice in same shoulder

66 Thank you

ROTATOR CUFF DISORDERS/IMPINGEMENT

ROTATOR CUFF DISORDERS/IMPINGEMENT Dr.KN Subramanian M.Ch Orth., FRCS (Tr & Orth), CCT Orth(UK) Consultant Orthopaedic Surgeon, Special interest: Orthopaedic Sports Injury, Shoulder and Knee Surgery, SPARSH