Welcome & The Painful Mobile Shoulder. Charlie Talbot. Consultant Shoulder & Elbow Surgeon Harrogate & Spire Leeds
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1 Welcome & The Painful Mobile Shoulder Charlie Talbot Consultant Shoulder & Elbow Surgeon Harrogate & Spire Leeds
2 Neil Pennington Charlie Talbot Simon Boyle
3 Neil Pennington Born in Preston Practice based at Spire Elland and Spire Roundhay Trained in Yorkshire and Coventry Shoulder and elbow arthroplasty Proximal humeral replacements
4 Simon Boyle Born in Leeds Practice based at Nuffield Leeds and York Trained in Yorkshire, Annecy, Wrightington and Australia Shoulder arthroscopy and soft tissue disorders First UK surgeon to perform all arthroscopic Latarjet Professional sports
5 Charlie Talbot Born in Oxford Practice based at Duchy Harrogate and Spire Roundhay Trained in Yorkshire, Wrightington and Sheffield Shoulder arthroscopy and soft tissue disorders First Yorkshire surgeon to perform Superior Capsular Reconstruction
6 Pa5ent Info Rehab Protocols Talks Contact Informa5on yorkshireshoulder.com
7 Shoulder Pain Prevalence 7% - 26% Incidence 1.5% with age ~ 20% referred
8 Advances Understanding Diagnosis Clinical history Clinical Examina5on Imaging Arthroplasty Arthroscopy
9 Shoulder problems Trauma Weak Pain S5ff Loose
10 Diagnosis Complaint S5ff Loose / Unstable Weak Pain Diagnosis Frozen Shoulder OA Trauma5c Atrauma5c Rotator Cuff Tear Nerve lesion Impingement Calcific Tendoni5s Cuff tear ACJ
11 Diagnosis Age Young (teens -30) Middle (30-65) Older (65 +) Poten1al Diagnoses Instability ACJ disrup5on Impingement Cuff Disease Calcific Tendoni5s Frozen shoulder OA Degenera5ve cuff disease Rotator Cuff Arthropathy
12 PAIN Neck Neck ACJ SCJ Impingement / Cuff Biceps
13 Urgent Referral Sudden onset / severe unremi`ng pain Non-posi5onal NIGHT pain Wt loss Systemic infec5on / TB Acute neurological signs / symptoms Previous cancer
14 Shoulder Impingement Painful Arc
15 Subacromial Anatomy
16 Shoulder Impingement Very common Classic painful arc Bursi5s / Tendinopathy / Calcific Tendoni5s / Cuff tear High arc pain = ACJ pathology
17 Impingement teshng Hawkins Kennedy Test Neer s sign Neer s test
18 Rotator Cuff Tests Jobe s Test Supraspiantus Resisted External Rota5on Infraspinatus
19 Rotator Cuff Tests Lii off test Subscapularis Bear Hug Test Subscapularis
20 ACJ Pain Scarf test
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25 Shoulder impingement PRESENTATION Insidious Upper lateral arm pain Painful arc +ve tests TREATMENT Subacromial Injec5on Physiotherapy NSAIDs Consider USS USS Guided injec5on
26 PAINFUL ARC Moderate/Severe Mild Pathway Conservative Management 65+ X-RAY FIRST Conserva5ve Management Physiotherapy Weakness Following traumatic shoulder injury Referral Failure to Progress Weakness Esp. aier trauma Subacromial Injection Physiotherapy X-RAY Shoulder Urgent Ultrasound USS/Guided Injection One referral only No Rotator Cuff Tear Rotator Cuff Tear Shoulder Surgeon
27 Weak Shoulder Rotator Cuff tear Neurological lesion PAIN
28 Rotator Cuff
29 What do we know? Oien pa5ents do not have pain Many pa5ents will eventually have pain RCTs do not heal on their own RCTs get larger over 5me
30 Natural History RCT Progression 50% over 5 yrs Symptoma5c 50% over 5 yrs Development of cuff tear arthropathy (Yamagucci, JSES 2001, Ranebo 2017 )
31 Treatment ophons Results non-opera5ve = good Small balanced tears Deltoid compensa5on Advanced age / lower demand Results surgery = good Trauma5c tears Younger / more ac5ve / higher demand Healing achieved
32 Who should we fix?
33 Management ConsideraHon Trauma5c vs. degenera5ve Asymptoma5c vs. symptoma5c Pa5ents and their demographic factors Reparability of the cuff
34 Non-operaHve NSAIDs Steroid injec5ons Physiotherapy Deltoid strengthening Failure to progress should trigger referral
35 Decompression & Debridement Par5al thickness tears <50% thick Debridement & ASD Debridement small & medium FT tears (Levy) 60% sa5sfied <60 yrs 87% sa5sfied >60 yrs 25 % re-opera5on with 13 / 12 PASTA lesion Older / less ac5ve ASD only
36 Historical Results of Repairs Small 94% Medium 85% Large 74% Massive 27% Good or excellent results pa5ents 13 yr f/u COFIELD
37 UKUFF Randomised Control Trial Open vs. arthroscopic No difference Mean OSS improvement = (MAX OSS = 48) Healed repairs = 0SS 44 * Re-tear = OSS 41 Irreparable = OSS 35 NON-OP control abandoned as high numbers required surgery Andy Carr BJJ 2017
38 Healing!! Pa5ent factors Age Size of tear Chronicity Degenerate PATIENT SELECTION SURGICAL FACTORS?
39 Irreparable Cuff Tears Deltoid strengthening / Injec5ons / Ac5vity Modifica5on ASD / Debridement +/- Biceps tenotomy +/- Par5al cuff repair Balloon Spacer / Patch Lat Dorsi Transfer Superior Capsular Reconstruc5on (SCR) REVERSE SHOULDER REPLACEMENT
40 Superior Capsule ReconstrucHon Japan No reverse un5l 2014 No allograi Teruhisa Mihata MD PhD Reverse Trampoline Effect
41
42 Instability Stanmore Classifica5on Trauma5c or Atrauma5c
43 INSTABILITY TRAUMATIC Proven history of dislocation(s) ATRAUMATIC PHYSIOTHERAPY SHOULDER SURGEON
44 Surgery Instability Trauma5c Atrauma5c Bankart repair Reverse Bankart Capsular plica5on Bone block transfer Latarjet
45 SHff Shoulder Global loss ROM Passive & Ac5ve LOSS External Rota5on <65 or >65
46 STIFF SHOULDER - Atraumatic - Reduced external rotation < 65 > 65 Diabetic Post Operative Post Traumatic T Pr d FROZEN X-RAY Shoulder CONSERVATIVE MANAGEMENT NO OSTEOARTHRITIS Take frozen pathway END STAGE OSTEOARTHRITIS NON END STAGE PHYSIOTHERAPY CONSERVATIVE MANAGEMENT HYDRODISTENSION Organised by Physiotherpist Non surgical candidate GLENOHUMERAL JOINT INJECTION SHOULDER SURGEON
47 SHff Shoulder Frozen Shoulder Quality of Life Decision Coping Not Coping Injec5on Physiotherapy NSAIDs Distension or Capsular Release
48 Shoulder OA More elderly LOSS External Rota5on X-RAY Direct referral if Surgical candidate PAIN
49 Surgery SHff Shoulders
50 ACJ Disorders Acute Acute Displaced Athlete Young manual Consider Surgery Chronic Displaced Symptoma5c or OA
51 ACJ Pathology Acute Disrup5on Chronic Degenera1ve Osteolysis Isolated ACROMIOCLAVICULAR JOINT PAIN High arc pain Localised to AC Joint Positive crossover/scarf test Conservative Management X-RAY of AC Joint Physiotherapy AC Joint Injection Shoulder Surgeon
52 Surgery ACJ disorders
53 Who to refer? Those who? need surgery Those who have failed medical therapy Those who want / need op5ons explained
54 Who? needs surgery Young pa5ents + cuff tear Subscapularis tears Trauma5c instability + athle5c ACJ / young athle5c Symptoma5c Osteoarthri5s
55 Failed medical treatment Persistent impingement Frozen shoulder Calcific tendoni5s Instability Symptoma5c degenera5ve cuff tears ACJ disrup5on / pain
56 OpHons Frozen shoulder Calcific tendoni5s Instability Cuff disease Arthri5s
57 Neil Pennington Charlie Talbot Simon Boyle
58 Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial
59 Subacromial decompression Harrogate January 2015 now 40 ASD only cases 23 full results OSS Pre-op 24/48 Pre-discharge 38/48 MEAN INCREASE 14 POINTS
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