1. The Shoulder in General Practice
Mr T P Selvan
MB, LRCP, FRCS Ed, MSc (Ortho), FRCS (Ortho)
Consultant Orthopaedic Surgeon
East Surrey Hospital, Redhill.

2. Look For Diagnostic Clues
Know the Anatomy
Examine Clinically
&
Look For Diagnostic Clues
Investigate
Identify the Red flags
Treat
Refer to Specialist
Scope

3. Anatomy- Deltoid

4. Anatomy – Rotator Cuff

5. Anatomy - Ligaments

6. Anatomy - Bones

7. Diagnostic Clues - Age 10-35 yrs INSTABILITY
30-50 yrs AC JOINT DISEASE TRAUMATIC CUFF TEAR
40-60 yrs FROZEN SHOULDER
>60 yrs GH ARTHRITIS
35-75 yrs ROTATOR CUFF DISEASE

8. Diagnostic Clues - History
Pain on overhead activities IMPINGEMENT
Night Pain GH ARTHRITIS FROZEN SHOULDER
CUFF TEAR ARTHROPATHY
Dead arm INSTABILITY
Apprehension INSTABILITY
Trauma FRACTURES, CUFF TEAR

9. Diagnostic Clues LOCATION OF PAIN 1. Under deltoid 2. Side of arm
3. Front of arm
Rotator cuff disease

10. LOCATION OF PAIN
Pain in the shoulder blade area is usually muscular or nerve related

11. Diagnostic clues – Deformities
ACJ DISRUPTION
SCAPULAR WINGING
DISTAL BULKING OF BICEPS
INFRASPINATUS WASTING

12. Clinical Examination Look Feel Move!!! Range of movement.
Deltoid function.
Tests for Supraspinatus function.
Tests for Infraspinatus / Teres minor function.
Tests for subscapularis function.
Tests for Biceps Tendon
Tests for ACJ and Superior labrum.

13. Movements

14. Supraspinatus

15. Infraspinatus / Teres minor

16. O’briens test for ACJ/Slap Lesion

17. Gerbers Lift off for subscapularis

18. Belly Press for Subscapularis

19. Neers Test

20. Hawkins-Kennedy test

21. Biceps tendon-Speed test

22. Apprehension Tests Apprehension Relocation Test Drawers tets
Sulcus Test

23. Non-shoulder examination
Supraclavicular fossa
Neurological examination
Vascular examination

24. Cervical spondylosis

25. Cervical spine fracture and tumour

26. Investigations – X-Rays
Frozen Shoulder To exclude other pathology
Rotator cuff disease
Impingement Sclerosis GT and Acromion
Cuff tear Superior migration of humerus(+/-)
Cuff arthropathy Humero-acromial articulation
Instability Hill Sachs lesion
Glenohumeral OA Diagnosis
ACJ dislocation/OA Diagnosis

27. Other Investigations Ultrasound (one stop clinic) MRI Arthrogram
CT Scan
EMG
Bone Scan
ARTHROSCOPY

28. Impingement/ACJ Pathology
ACJ Arthritis
Acromial spur

29. Calcific Tendonitis

30. Metastatic Fracture

31. Frozen Shoulder

32. Rotator cuff tear Horizontal Vertical Retracted Vertical & Inner
Substance

33. Glenohumeral arthritis
Surface replacement
Total Shoulder Replacement

34. Rotator cuff arthropathy
Reverse Delta Shoulder replacement

35. SLAP Lesion Superior Labrum Anterior Posterior

36. Bankarts Lesion

37. Treatment at Primary Care
Frozen shoulder
Calcific tendinitis
Impingement syndrome
AC joint disease
Glenohumeral arthritis
Activity modification
NSAIDs / Analgesia
Physiotherapy
Steroid Injection

38. Indications for Injection
Diagnostic
Subacromial impingement
AC joint pain
Aspiration
Therapeutic
Rotator cuff tendinitis / Bursitis
Calcific tendinitis
Glenohumeral OA
Long head of biceps tendinitis
Frozen Shoulder
AC joint arthritis

39. Injection Techniques

40. When to Refer to a Shoulder Specialist
Impingement not responding to conservative measures
Frozen shoulder not showing any improvement despite physiotherapy for 6 months
Suspected Rotator cuff tear.
Cuff tear arthropathy
Instability / SLAP lesions
Osteoarthritis / Rheumatoid Arthritis
Uncertainty of diagnosis.
Red flag signs

41. Infection : red hot skin, pyrexial, systemically unwell
Unreduced dislocation: h/o trauma/fit/electric shock, abnormal contour, loss of movements
Acute rotator cuff tear: acute onset pain and weakness, recent trauma, drop arm sign
Tumour: S/S of cancer, h/o cancer, abnormal mass, swelling or deformity
Neurological: severe sensori-motor deficit, unexplained muscle wasting.