Bsc (Hons) Physiotherapy The Shoulder Claire Bailey & Elizabeth Bowman Bsc (Hons) Physiotherapy April 2013 Email: mail@roundwoodclinic.co.uk

Aims Diagnostic categories Evidence based decision making? Treatment options When to refer on (or not?!)

Anterior GHJ Anatomy

The Rotator Cuff

Introduction Shoulder pain third most common MSK complaint 15% referred for physiotherapy in the 3 years following their initial consultations Peak incidence 4-6th decades 50% acute GHJ pain resolves in 8-10 weeks Linsell et al (2006)

Signs <30 years 30-70 years >70 years Impingement pain Instability Secondary impingement Subacromial impingement Cuff tear SAIS ACJ pain Osteolysis OA GHJ pain Inflammatory arthritis Frozen shoulder GHJ OA Periscapular Snapping scapula Neurogenic neurogenic

Red Flags History of Ca, mass, swelling etc. Red skin, fever, systemically unwell ?infection Trauma, epileptic fit, loss of rotation Unexplained significant sensory or motor deficit Visceral referred pain

Visceral Referral Pain

Pancoast Tumour

Frozen Shoulder “it comes on slowly; (with) pain usually felt near the insertion of the deltoid; inability to sleep on the affected side; painful and incomplete elevation and external rotation; restriction of both spasmodic and mildly adherent type; atrophy of the spinati; little local tenderness; (&) x-rays negative except for bone atrophy”. Codman (1934)

Frozen shoulder cont. Elusive underlying pathology ?inflammatory ?scarring ?enzyme Pain predominant or stiffness predominant (Hanchard et al. 2011) Primary (unknown cause) Secondary (to trauma) 2% population; 935 patients; 58% female Dominant side 52%; bilateral 38% (Chambler et al. BMJ 2003)

Frozen Shoulder

Secondary frozen shoulder Trauma R.Cuff tear Post –operatively Diabetes Cerebral haemorrhage Thyroid Autoimmune disease Cervical spine pathology Hormonal changes Prolonged immobilisation Algodystrophic

Stages of frozen shoulder Freezing Pain increases with movement and is often worse at night. There is a progressive loss of ROM with increasing pain. Lasts approx. 2-9/12 Frozen Pain begins to diminish, ROM much more limited (50%). Lasts approx. 4-12/12 Thawing Condition may begin to resolve. Most patients experience a gradual restoration of motion over next 12-42/12

Clinical Picture Insidious onset Pain at deltoid insertion Night pain Pain at rest Reduced AROM and PROM Reduced ER (restriction >50% of the opposite side) Normal x-rays

Frozen shoulder x-rays NORMAL To exclude:- Cuff arthropathy/massive cuff tear with secondary OA changes OA – bony end feel, osteophytes limit ER Dislocation locked – stuck in IR causing avascular necrosis to humeral head ALL LIMIT ER, THEREFORE, TENTATIVE DIAGNOSIS WITHOUT X-RAY

Treatment Neglect? (better in 2 years) Physiotherapy Injection – improved shoulder related disability @ 6/52 (Ryans et al. 2005) MUA / arthroscopic release – significant loss of ER not changing with rehabilitation @ 6-9 months

Conservative management Explanation Modify activities Analgesia Physiotherapy? Corticosteroid injection? CONSIDER EARLY REFERRAL IF....... Patients pain is particularly disabling to them Severe restriction in PROM inhibiting function Considering operative or specialist management

Surgical management Symptoms and function are unchanging and significantly disabling after 6/12 of conservative treatment Arthroscopic release +/- SAD ? MUA ?hydrodilation Suprascapular nerve block – improves pain but not movement

Impingement Up to 74% patients presenting in primary care SAIS Physiotherapy first line Rx Roy et al. (2008) Ostar (2005)

Classification Primary (intrinsic) Secondary (extrinsic) Outlet / non-outlet External / internal impingement Bursal side wear and tear not substantiated by histological studies – majority on articular side

Impingement cont. Extrinsic theory challenged Irritation causes tendonitis and bursitis? “sub-acromial pain syndrome” pain related to the bursa rather than the mechanical impingement effect. (Lewis 2011) Reactive tendonopathy to tendon disrepair and subsequent degeneration. Dysfunction of the r.cuff = bursitis and Sx

Impingement

Calcific Tendonitis

Impingement Rotator cuff strain Tears Calcific tendonitis Tendonopathy due to chronic overuse Indirect causes - GHJ instability SLAP Abnormal muscle patterning

Clinical Presentation Difficulty with over head activities Pain mid range arc Constant background ache / night pain / increased pain on movement = ? Inflammation in bursa (only place to find inflammation in impingement)

Painful Arc

Diagnosis Impingement tests Neers Hawkins Weakness in ER X-ray AP, axillary – spur formation, sclerosis, acromion type (>3/12 symptoms) U/S to confirm and exclude cuff tear

Neers Test

Hawkins Test

Impingement Treatment Physiotherapy NSAID’s? If constant pain ?Injection – short term efficacy only and most effective at 1-2/52 when constant pain (Trojian 2005) ?Poor outcome with surgery following repeated injections Conservative treatment minimum 8/52 Surgery SAD

Rotator Cuff tears Almost all tears are chronic and degenerative in nature Often insidious history Can occur after trauma or dislocations Similar Sx to impingement ? Clinically obvious weakness

Rotator Cuff Tear

Diagnosis Drop arm test Severe pain, profound weakness of abduction, or an inability to maintain the arm in 90O abduction then slowly lower Positive infraspinatus testing (ER) Pain that awakens the patient at night (Riddle 2001). Tests may be better at ruling out cuff tears rather then detecting them ultrasound

Lift off test

Belly Press Test

Bear Hug Test

Empty Can Test

Rotator Cuff Tear

Acute rotator cuff tear Patients presenting with a traumatic history, sudden or progressive weakness Urgent U/S and referral Consider early repair 6-12/52 window of opportunity for best outcome from surgery

Chronic symptomatic cuff tear ?non-operative management for 3-6/12 Advice / NSAID’s?/ physiotherapy X1 steroid injection? Failed non-operative management re-evaluation consider U/S or MRI Only need surgery if warranted by Sx ?SAD for pain relief and to avoid the long rehab. required for cuff repairs if the patient has – good movement, strength

Full thickness cuff tears – non-operative management “tincture of time” Physiotherapy NSAID’s??? Modified activities Steroid injection?? ? Can compensate due to activation of residual intact cuff Partial tear vs. Impingement ?does it matter as doesn't change outcome/type of Rx

AC Joint Dysfunction Traumatic v degenerative onset Traumatic onset is usually a fall on to the point of the shoulder and can involve Stretching or tearing of the acromioclavicular or coracoacromial ligaments Subluxation/dislocation of the AC joint Degenerative problems tend to occur in individuals over 45 years

The ACJ

Clinical Presentation Degenerative Pain with activity and ?at rest over ACJ (may radiate in to traps region but not deltoid) ?ROM restricted in to overhead elevation No obvious inflammatory signs Traumatic Reports a traumatic onset May be an observable deformity May also be associated with sub-acromial impingement

Diagnosis Pain on palpation over ACJ Pain on active adduction (Scarf test) Pain on O’Brien’s X-ray may be used to exclude osteolysis/oes-acromially or to define degree of disruption in traumatic onset

Scarf Test

O'Brien's Test

Treatment Rockwood classification for traumatic disruption Type I & II managed conservatively Type III individual cases Type IV – IV managed surgically Physiotherapy ?injection therapy Surgical options in degenerative cases if failed conservative management

Glenohumeral Instability Instability is the abnormal motion of the glenohumeral joint that may include subluxation or dislocation, co-existing laxity, pain Involves one or more (usually a combination) of ligaments, tendons, glenoid labrum, joint capsule Traumatic instability v atraumatic instability

Clinical Presentation Tends to be in patients younger that 35 History of trauma or dislocation “Give way” or “lock” Repeatedly performing overhead movements may aggravate symptoms (particularly with SLAP) Symptoms can be vague e.g young athletic males with activity related pains in shoulder or an inability to perform overhead throw

Diagnosis Apprehension/relocation Sulcus ?Xray in acute dislocation MRI/MR arthrograms

Apprehension Test

Relocation Test

Sulcus Sign

Treatment If first time dislocation in young population (<25 years) or high trauma injury referral on to specialist shoulder surgeon Recurrent dislocators Physiotherapy would usually involve stability and strengthening, proprioception and core stability with graduated return to activities Physiotherapy vital in both the conservatively and surgically managed cases though rehab period is likely to be lengthy (3-6/12)

Labral Pathologies SLAP v Bankart 85% of GH dislocations likely to have a Bankart if needed to be relocated SLAP – may be caused be any repeated overhead activity, eccentric or concentric contraction of biceps. May be associated with a dislocation but more commonly in sportsmen with a pull on the arm, weightlifting, throwing injury or tackle

Bankart / Hill-Sachs

SLAP Tear

Diagnosis Apprehension (Bankart and SLAP) O’Brien’s (SLAP) Biceps load I and II (SLAP) Difficult to diagnose clinically MRI/MR arthrogram

Biceps Load I/II

Treatment Surgical v conservative remains controversial Physiotherapy Onward referral if failing conservative management/ return to high level sport or occupational factors

Evidence to Implicate the Cervical and Thoracic Spines in Shoulder Pain Cervical spine lateral glides (Vincenzino et al 2007, 2009) McClatchie at al (2009) – increased GH abduction and decreased pain intensity C5/6 joint mobilisations increases strength of GH lateral rotators immediately and for 10 mins (Wang 2010) Thoracic segmental restriction impacts scapula position and cuff activation – 40% of shoulder pain patients have thoracic and rib dysfunction (Lin et al, 2010) Physiotherapist’s conclusions….

Upper Limb Dermatomes

Subjective Examination What questions would you ask? Why are you asking these questions? What would this lead you to consider as a diagnosis? (clinical reasoning!) HPC SQ’s PMH

Objective Examination

If all else fails! ..... Consider: Pain clinic Acupuncture? Chronic pain analgesia

Any Questions?