DiagnosticDiagnostic andand ManagementManagement ApproachApproach toto thethe PainfulPainful ShoulderShoulder IntroductionIntroduction

 What conditions causing pain commonly present in General Practice?  Subacromial impingement  tears  AC pathology  Adhesive capsulitis  (Instability) IntroductionIntroduction

 How do we discriminate between these conditions?  History  Acute/gradual onset  Distribution of pain  Activities worsening the pain  Activity restrictions  Night pain  Examination SubacromialSubacromial ImpingementImpingement  Impingement beneath coracoacromial arch  Intrinsic – Cuff thickening/bursitis  Extrinsic – Instability – young – Subacromial spurs – old  Pain with activity above shoulder height (and at night)  Painful arc of abduction (“hitch”)  Positive impingement signs AdhesiveAdhesive CapsulitisCapsulitis

 Capsule sticks to humeral head  GLOBAL RESTRICTION ROM  NIGHT PAIN  Cause often unknown – but beware diabetes  Painful 6/12  Restrictive 6/12  Resolution 6/12 ACAC JointJoint PathologyPathology  Pain with activity (esp overhead, or weight training)  AC Jt tender  Crepitus/clicking  Deformity RotatorRotator CuffCuff TearTear

 Requires force  Supraspinatus > Infraspinatus > subscapularis  Reduced function and night pain  Painful arc (“hitch”)  Drop test ExaminationExamination ofof thethe PainfulPainful ShoulderShoulder  Observation  Abduction (180deg) – scapular winging  Anterior – glenohumeral rhythm (2: 1)  SCJ – hitch  Clavicle  Forward flexion (180deg)  ACJ – winging  Shoulder height – rhythm  Posterior – wasting  External rotation   Supraspinatus Back scratch  Infraspinatus  (IR in abduction)

ExaminationExamination ofof thethe PainfulPainful ShoulderShoulder   Muscle Testing – SC joint – Supraspinatus – – Clavicle abduction – AC joint – Infraspinatus – external – Anterior joint rotation – – Long head biceps LH biceps – forward flexion – Greater tuberosity – Subscapularis - lift off – Posterior joint ProvocationProvocation TestsTests

 AC Joint Tests  Stability – Horizontal flexion and – Sulcus adduction – AP glide – Resisted abduction in – Apprehension and horizontal flexion relocation

 Impingement Signs  Labrum – Empty can – O’Brien’s test – Hawkins IsIs itit ReferredReferred fromfrom thethe CervicalCervical Spine?Spine?

 Median nerve – Thenar muscles – Index sensation  Ulnar nerve – 1st dorsal interossei motor – 5th finger sensation  Radial nerve – Finger extension – 1st dorsal web sensation IsIs itit ReferredReferred fromfrom thethe CervicalCervical Spine?Spine?

 Where is the pain?  Neurology – Hand over deltoid – – C5 deltoid (S, M), think shoulder biceps (R) – Hand over traps – think – C6 thumb (S), biceps neck (M), BrRad (R) – Radicular pain – think – C7 digit 3(S), triceps neck (M, R)  Examine – C8 digit 5(S), FDP/S – Cervical spine ROM (M) – – Spurlings test T1 medial (S), finger abduction (M) InvestigationInvestigation ofof ShoulderShoulder PainPain

 Local anaesthetic injection tests

 Plain XR – AP (IR and ER) – Trans-scapular – AC joint InvestigationInvestigation ofof ShoulderShoulder PainPain

 U/S scan – Cuff tears, tendinopathy, bursitis – Undercalls cuff pathology – Can inject at the same time InvestigationInvestigation ofof ShoulderShoulder PainPain

scan  MRI – Esp if referring for – Cuff tears ACJ surgery  MRA  CT – Labral pathology and – Particularly useful for instability recurrent instability TreatmentTreatment ofof ShoulderShoulder PainPain

 Analgesia  NSAID  Activity modification  Corticosteroid injection  Physical therapy  Surgery SubacromialSubacromial ImpingementImpingement  Pain with activity above shoulder height (and at night)  Painful arc of abduction (“hitch”)  Positive impingement signs  Plain XR  Ultrasound scan  Local anaesthetic test  Subacromial injection and rehabilitate  Subacromial decompression ACAC JointJoint PathologyPathology  Pain with activity (esp overhead, or weight training)  Deformity  Crepitus/clicking  Provocation tests  Plain x-rays  Bone scan  Activity modification  NSAID  CSI  Surgery AdhesiveAdhesive CapsulitisCapsulitis

 GLOBAL RESTRICTION ROM  NIGHT PAIN  Investigations often not required (glucose?)  EDUCATION – Painful 6/12 – Restrictive 6/12 – Resolution 6/12  Glenohumeral injection (or hydrodilatation)  Avoid provocation (work within limits) RotatorRotator CuffCuff TearTear

 Requires force  Reduced function and night pain  Painful arc (“hitch”)  Drop test  Plain XR and U/S  Bilateral pathology common on U/S > 50y – history and examination important  Small tear > 50y – CSI and rehab  Large tear, or < 50y – ortho opinion SubacromialSubacromial InjectionInjection –– PosteriorPosterior ApproachApproach  Prepare  Prep skin – 2ml LA  Aim at coracoid – 10mg Kenacort  Follow the curve of – 23g 1.25in – slim the acromion female  – 21g 1.5in larger Never inject against females, males resistance  Mark just below  Make good notes postero-lateral corner – No touch technique of acromion – Side effects warning  Arm resting in lap TakeTake HomeHome MessagesMessages

 Adhesive capsulitis – global restriction of ROM  Impingement – painful arc, but rotation should be preserved  Cuff pathology is common on U/S in middle age – treat the patient, not the scan (think about what YOU would want)  Don’t forget plain x-rays!