1. NHS Bolton MSK Physiotherapy Service The Shoulder Vicky Lyle (Orthopaedic Practitioner) Claire Guy (Specialist Physio)

2.  Lesley Anne Fraser – MSK Service Manager –Contact: LesleyAnne.Fraser@bolton.nhs.ukLesleyAnne.Fraser@bolton.nhs.uk  Emily Barber – MSK Physio Team Leader –Contact: Emily.Barber@bolton.nhs.ukEmily.Barber@bolton.nhs.uk –01204 462504  Sue Greenhalgh – Consultant Physiotherapist & Interim Lead Clinician –Contact: Susan.Greenhalgh@bolton.nhs.ukSusan.Greenhalgh@bolton.nhs.uk –01204 462584

3. GP Training Agenda Agenda ItemEvening Session 1. Introduction 2. Subjective Examination 3. Objective Examination 4. Adhesive Capsulitis 5. Impingement Tea / Coffee Break 6. Cuff Tears 7. Orthopaedic Role 8. Practical 9. Conclusion 10. Interactive Discussion Finish

4. Introduction  Recent service review demonstrated that out of a random sample of 250 patients referred to MSK Physiotherapy, 25% were regarding the shoulder in isolation.  24% of these referrals were regarding the lumbar spine.  Are there genuinely more patients with shoulder pain that low back pain, or are we just better at managing the back pain patient?

5. Subjective History – Top Five Tips 1.When and how did your shoulder pain start ? 2.Where are the symptoms exactly ? 3.Do you have any pins & needles, numbness or weakness ? 4.Have you felt any other sensations, such as locking, clunking or instability ? 5.What helps and what makes it worse?

6. Objective History – Top Five Tips 1.Observation 2.Cervical Spine Active Range of Movement 3.Active Range of Motion Glenohumeral Joint a)Flexion, Abduction, Internal Rotation, External Rotation 4.Passive Range of Motion Glenohumeral Joint a)Flexion, Abduction, Internal Rotation, External Rotation 5.Resisted Muscle Tests

7. Tests of Contractile Function  Baseline Isometric Assessment: –Abduction→ Supraspinatus (& deltoid) –Adduction→ Teres Minor –Lateral Rotation → Infraspinatus, teres minor & possibly supraspinatus –Medial Rotation → Subscapularis –Elbow Flexion → Biceps & brachialis –Elbow Extension → Triceps

8. Adhesive Capsulitis  Codman described the first and best classical diagnostic criteria for frozen shoulders in 1934 –Global restriction of shoulder movement –Idiopathic aetiology –Usually painful at the outset –Normal X-ray –Limitation of elevation and external rotation  Classification may be primary or idiopathic  Secondary stiff shoulders can present typically after injury or surgery  Be aware of major trauma

9. Diagnosis  Age: –Typically occurring in females more than males, in the 4 th and 5 th decade.  Pain: –Constant nature, severe, affecting sleep + +. Often a toothache pain at rest, with sharp pains with forceful movements. –Pain centred in joint  Loss of External Rotation: –Commonly less than 30 °  Unguarded pain

10. Natural History 1.Freezing Phase: a)Associated with pain and loss of movement 2.Frozen Phase: a)Pain at extreme range of movement and marked stiffness 3.Thawing Phase: a)Significantly less pain and the stiffness starts to gradually resolve  Hand et al. J Shoulder and Elbow Surg. 2008; 17(2):231-6 – 90% have resolved at 3 years – 10% still have symptoms at 3 years

11. Aetiology  The frozen shoulder has been found to be more common in association with the following conditions: –Diabetes (There is a 2-4 times increased risk for diabetics of developing frozen shoulder. Insulin-dependent diabetics have a 36% chance of developing it, 10% bilaterally). –Cardiac/lipid problems. –Epilepsy. –Endocrine abnormalities, particularly hypothyroidism. –Trauma. –Drugs – MMP Inhibitors.

12. Treatment  Advice and Education –Reassurance  Physiotherapy –Exercise –Manual therapy –Pain Management  Injections – please note that we have 3 injection therapists within our MSK Physio service, and offer patients a follow-up in Physiotherapy within 10 days  Surgical Intervention

13. Impingement  During elevation of the shoulder, the humeral tuberosities pass close underneath the coracoacromial arch. Little space is left for the intervening soft tissues, which comprise (from superficial to deep), the bursa, the rotator cuff tendons and the long head of biceps.  If, for any reason, the available space reduces, these soft tissues are liable to become pinched.

14. Possible Underlying Mechanisms  Bony anatomical and pathological factors  Shoulder instability  Impaired scapulohumeral rhythm and scapular instability  Capsular tightness  Postural factors  Soft tissue changes

15. Diagnosis  Age: –Impingement spans the age ranges of other shoulder conditions, but in patients under 35 years old is likely to be secondary to instability  Mode of onset: –Can be insidious or related to a specific incident  Pain: –Felt in shoulder but can radiate into upper arm/deltoid (sergeant stripes distribution) –Typical painful arc –Night pain common –Often predictably activity-specific

16. Treatment  Physiotherapy –Relative rest and avoidance of aggravating factors beneficial in early management allowing pain and inflammation to settle –Absolute rest rarely necessary and risks precipitating pain- related illness behaviour and adhesive capsulitis –Rehabilitation is vital  NSAIDs –Benefits of a short course are likely to outweigh the risks unless contraindicated  Injections  Surgical Intervention

17. Rotator Cuff Tears  Aetiology: –There are 2 main theories for the cause:  EXTRINSIC: Due to compression and impingement of the rotator cuff.  INTRINSIC: Due to changing properties of the rotator cuff itself.  Traumatic or degenerative  Expected function/activity levels, pain and size of tear need to be consideration factors for surgical opinion.

18. When to refer to Orthopaedics?  Frozen shoulder: –Diabetic males – early surgical opinion –If Physiotherapy and injection therapy fail to settle the symptoms adequately  Impingement: –If Physiotherapy and injection therapy fail to settle the symptoms adequately  Rotator cuff tears: –Referral for all young and active cases –In sedentary or elderly (degenerative) cases, physiotherapy and injection therapy is usually sufficient

19. Conclusion  Many shoulder problems are successfully managed within Physiotherapy without the need for an Orthopaedic opinion  However, there are clear situations where an early Orthopaedic opinion/intervention is warranted, as discussed  Injections in isolation not usually effective without rehabilitation as soon as possible afterwards  Rehabilitation vital in most cases  Any questions?