SHOULDERS MADE DR DR CHRIS MILNE SPORTS PHYSICIAN

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Bernard Shepherd
5 years ago
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1 SHOULDERS MADE SHOULDERS MADE SIMPLE SIMPLE Yeah Right DR DR CHRIS MILNE MILNE SPORTS PHYSICIAN SPORTS PHYSICIAN Yeah Right

2 SHOULDER ANATOMY

3 OUTLINE History Examination Investigations

4 MY SHOULDER HURTS!

5 SHOULDER INJURIES- MANY DIFFERENT MECHANISMS

6 HISTORY Mechanism of injury Types of mechanism 1-FOOSH-arm abducted- axial loading 2-FOOSH-arm flexed- posterior translation of humeral head 3-Forced external rotation- ant translation of humeral head 4-Repetitive abduction + flexion 5-Fall onto shoulder- direct contusion

7 HISTORY CONTINUED Any first aid treatment eg attempted reduction, ice pack Presentation to first clinician -Initial diagnosis, investigations, treatment Subsequent clinicians seen -Diagnosis, investigations, treatment Time course since injury -Better/worse/same

8 HOW LONG HAS THIS BEEN GOING ON?

9 HISTORY CONTINUED Location/severity of pain Associated symptoms/provocateurs- these can be clues to the diagnosis 1-Overhead work/behind back-? Rotator cuf f 2-Cross body movement-? AC joint 3-Sense of disruption/dead arm- instability 4-Pain down the arm-? Referred from neck 5-Stif fness-? Frozen shoulder 6-Night pain-?rotator cuf f or frozen shoulder

10 HISTORY CONTINUED Effect on work, ADL, training for sport Current situation? Off work or on modified duties Medications used and their effect

11 PAST HISTORY Previous shoulder problems and their treatment? Ongoing sequelae Other injuries especially neck Medical conditions/allergies

12 INITIAL WORKING DIAGNOSIS History should provide many clues to the diagnosis, unless the patient was intoxicated or is just a vague/unreliable historian If so, seek corroborative evidence from other family members, team mates, workmates

13 TRY TO MAKE A PROVISIONAL DIAGNOSIS AFTER THE HISTORY TAKING

14 EXAMINATION Hand dominance Check the neck-?? Referred pain Look- deformity, wasting- deltoid [axillary nerve], supra/infraspinatus [suprascapular nerve or massive cuff tear with retraction] Feel- tenderness- greater tuberosity, along LH of biceps tendon, AC joint

15 LOOK FOR MUSCLE WASTING

16 EXAMINATION CONTINUED Movements 1-Flexion- normal 180 degrees 2- Abduction- normal 180 degrees- look for painful arc 3-With arm adducted by the side- check external rotation and compared to opposite [normal] side- normal 30 to 60 degrees 4-With arm abducted to 90 degrees- External rotation- normal 90 degrees Internal rotation- normal 90 degrees, but may get painful restriction from as little as 10 degrees if have rotator cuf f irritation NB- check for power loss with these movements

17 SEQUENCE OF MUSCLE TESTING- ACTIVE, PASSIVE, RESISTED

18 EXAMINATION CONTINUED- SPECIAL TESTS AC joint- pain with cross body movement, pain with resisted horizontal abduction Impingement- Empty can sign, Hawkins impingement sign NB- Impingement is a clinical not ultrasound diagnosis Instability - Sulcus test Apprehension/rel ocati on test Anterior/posteri or drawer test Labral tests- O Brien s test Speeds test Crank test NB- No single test is diagnostic or refutes a diagnosis, rather it is the collective picture based on all tests conducted

19 ANTERIOR DISLOCATIONS ARE THE MOST COMMON

20 INVESTIGATIONS Plain X-rays an essential first investigation. Can show the following 1-Fractures 2-Dislocatrions eg AC joint, G-H joint 3-Evidence of previous dislocations ask for a West Point view to show evidence of previous bony Bankart lesion of the anterior rim of the glenoid 4- Arthritis- AC joint, G-H joint 5-Osteolysis of the distal clavicle 6-Osteomyelitis- bone infection 7-Tumours- primary and secondary deposits 8-Calcific deposits- if large 9-Bony contributors to impingement 10-Shape of the acromion- may contribute to impingement

21 PLAIN X-RAYS OF SHOULDER

22 INVESTIGATIONS CONTINUED Ultrasound scans Can show 1-Rotator cuff tears- unless tiny or the patient is obese, which degrades the image quality. 2-Retraction of rotator cuf f tendons, especially with large full thickness tears 3-Bursitis- which may be relevant if the bursal sac is large 4-Calcific deposits, even if relatively small

23 ULTRASOUND SCAN Ultrasound is very operator dependent The better clinical information you give, the more the sonographer can help you

24 MRI AND CT SCANS MRI scans-can show a wide range of pathology, both bone and soft tissue MR arthrograms- can show labral tears better that plain MRI scans CT scans- can show bony problems in greater detail than other scans. Especially good for complex glenoid fractures. 3D reconstructions give amazing detail

25 MRI- MULTI-PLANAR IMAGING

26 CT SCAN FOR BONY ANATOMY

27 SUMMARY Clinical evaluation can diagnose more that you think The history should give you pointers as to which structures to pay special attention to on the examination Examination findings are helpful in further honing in on the diagnosis Investigations should always start with plain x -rays. An ultrasound, on its own, is an inadequate investigation for the shoulder

28 Footy show arm wrestle not so humerus

29 THANK YOU

Diagnostic and Management Approach to the Painful Shoulder

Diagnostic and Management Approach to the Painful Shoulder Introduction What conditions causing shoulder pain commonly present in General Practice? Subacromial impingement Rotator cuff tears AC joint pathology