2. Orthopaedics in Primary Care The Shoulder Andrew Pearse Worcestershire Acute Hospitals

3. Orthopaedics in Primary Care Content Anatomy Shoulder examination Diagnostic guides

4. Orthopaedics in Primary Care Introduction Shoulder pain –3rd most common MSK presentation to GPs –Most resolve in 8-10 weeks –Most patients expect imaging or referral

5. Orthopaedics in Primary Care Anatomy Bones –Humerus, Glenoid, Scapula, Clavicle Ligaments –Capsule, and a few others Muscles / Tendons –Rotator cuff, deltoid

6. Orthopaedics in Primary Care Anatomy

7. Orthopaedics in Primary Care Anatomy

8. Orthopaedics in Primary Care Anatomy

9. Orthopaedics in Primary Care Anatomy Abductor Supraspinatus Ext Rotators Infraspinatus Teres Minor

10. Orthopaedics in Primary Care Anatomy Abductor Supraspinatus Ext Rotators Infraspinatus Teres Minor Int Rotator Subscapularis ROTATOR CUFF

11. Orthopaedics in Primary Care Anatomy

12. Orthopaedics in Primary Care Anatomy

13. Orthopaedics in Primary Care Shoulder Examination Look Feel Move Special Tests (108 of them!)

14. Orthopaedics in Primary Care Look Shoulder posture and movement Muscle wasting –Deltoid –Supraspinatus –Infraspinatus Scars

15. Orthopaedics in Primary Care Look Shoulder posture and movement Muscle wasting –Deltoid –Supraspinatus –Infraspinatus Scars Swellings

16. Orthopaedics in Primary Care Feel Clavicle AC joint Acromion Scapula Cervical spine Supraclavicular fossa

17. Orthopaedics in Primary Care Feel

18. Orthopaedics in Primary Care Move Active and passive –Show me how much you can do –Let me see if I can move it further Movements: –Screening –Forward flexion –Abduction –Internal rotation –External rotation

19. Orthopaedics in Primary Care Move Forward flexion:

20. Orthopaedics in Primary Care Move Abduction:

21. Orthopaedics in Primary Care Move External rotation:

22. Orthopaedics in Primary Care Move Internal rotation:

23. Orthopaedics in Primary Care Special Tests Impingement tests Rotator cuff tests Lag tests Instability tests Biceps tendon tests Over 100 others - all pretty non-specific

24. Orthopaedics in Primary Care Special Tests Rotator Cuff Strength Tests –Isolate segment –Two fingers –Resistance tests –ABDUCTION –EXTERNAL ROTATION –INTERNAL ROTATION

25. Orthopaedics in Primary Care Special Tests Rotator Cuff Strength Tests –Abduction (supraspinatus) MOST IMPORTANT –Test in plane of muscle

26. Orthopaedics in Primary Care Special Tests Rotator Cuff Strength Tests –External rotators (Infraspinatus and teres minor)

27. Orthopaedics in Primary Care Special Tests Rotator Cuff Strength Tests –Internal rotation (subscapularis) –Multiple tests, not very sensitive

28. Orthopaedics in Primary Care Special Tests Impingement Tests –Assess impingement of greater tuberosity and rotator cuff under acromion –Two main tests used - both very sensitive

29. Orthopaedics in Primary Care Special Tests Impingement Tests

30. Orthopaedics in Primary Care Special Tests Impingement Tests

31. Orthopaedics in Primary Care Shoulder Pain Assessment RED FLAGS –Systemic illness –Trauma –Epilepsy? Electric shock –Cancer

32. Orthopaedics in Primary Care Shoulder Pain Assessment Young –Instability Middle age –Frozen shoulder –Impingement –Calcific tendinitis Older –Rotator cuff tear –Arthritis Questions to ask –Pain –Weakness –Stiffness –Functional impairment –(instability)

33. Orthopaedics in Primary Care Summary Anatomy Examination –Look, feel, move –Special test Rotator cuff strength assessment Impingement test Red flags Age-related shoulder conditions