DiagnosticDiagnostic andand ManagementManagement ApproachApproach toto thethe PainfulPainful ShoulderShoulder IntroductionIntroduction What conditions causing shoulder pain commonly present in General Practice? Subacromial impingement Rotator cuff tears AC joint 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 Palpation 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 elbow (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 Bone scan MRI – Esp if referring for – Cuff tears ACJ surgery MRA CT arthrogram – 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!.