1. The Shoulder Differential Diagnosis, Treatment and Rehabilitation

2. Capsular LR>ABD>MR

3. Frozen Shoulder Aka Capsulitis or adhesive capsulitis Vol of normal = 30mls Vol of frozen = 3mls 2% of normal population 20% go bilateral 11% in diabetic pop (don’t know why) W:M 60:40 Non dom gtr than dom Risk factors – diabetes, hyperthyroid, immobilisation, stroke

4. Frozen Shoulder Capsular pattern Most loss of LR, then abd, then MR Insidious onset Self limiting 2-3 years 3 Stages – freezing, frozen and thawing

5. Stage 1 Intermittent ache Not below the elbow Able to sleep on that side Elastic end feel

6. Stage 2 Constant pain Below the elbow Unable to lie on that side at night Hard end feel

7. Stage 3 As in stage 1 Resolving problem

8. Treatment of frozen shoulders Stage 1 – heat, gentle mobilisation grade A and or injection Stretch into elev and release with distraction Distraction with sh elev and longitudinal distraction

9. Treatment of frozen shoulders cont. Stage 2 – injection combined with pain relief (and slow sustained stretching, as able) Stage 3 – heat + low load sustained stretching – LR, MR and elev 20 – 30 mins

10. Home Exercise Programme

11. Other Capsular Lesions OA Electro and Grade B mobs Steroid Sensitive Arthritis Intra-artic injection

12. Non - Capsular

13. Primary impingement Associated with anatomical changes in the sub- acromial space ? cause Acromial shape Osteophytes Tendon changes – tendonitis Or tendinosis? Ligamentous thickening Bursal thickening

14. Secondary Impingement Posture, neck and thorax Tight muscle eg. Upper trapezius, pectoralis minor Weak muscles eg.lower trapezius, serratus anterior Poor timing, proprioception

15. Neer classification Stage 1 – under 25 years, oedema, inflammation, acute bursitis, tendonitis Stage 2 – 25-40 years, fibrosis, bursal thickening, fibre disruption in the tendons Stage 3 – over 40 years, bony spurs, compromised space, partial to full thickness tears

16. Sub-acromial bursitis Aka sub-deltoid bursitis, SIS Sub-acromial space – supraspin. Tendon, bursa, sup aspect of GH capsule and long head of biceps

17. On examination Overuse Gradual onset C5 pain not usually below elbow Arc and pain EOR Non capsular pattern Resisted abd and LR painful esp on release

18. Treatment of Subacromial Bursitis Pain relief Physio modalities eg acup, trig point, US, taping Injection Posture Postural stability work inc lower traps Rotator cuff strengthening Stretching upper traps, pec major, minor

19. Home Exercise Programme

20. Acromio-clavicular Joint O/E high painful arc Localised pain C4 Scarf positive EOR pain on passive movements Traumatic onset – RICE –Strapping –Mobs Gradual onset -mobs, frics and or inject

21. Contractile Lesions Strong + Painless = Normal Strong + Painful = tendon or muscle local lesion I or II Weak + Painless = Rupture III or nerve damage Weak + Painful = severe lesion eg # Pain during contraction – tendon Pain on release - bursa

22. Supraspinatus Tendinitis O/E resisted abd painful and painful arc = distal end of tendon Friction + electro + rest All frics numb + 10mins Or inject Resisted abd painful and no painful arc = MT junction Rotation Friction with arm in horizon abd, no injec

23. Subscapularis Tendinitis O/E resisted MR painful + painful arc = upper fibres + scarf test = lower fibres Friction – may be painful due to bursa Or inject

24. Infraspinatus Tendinitis O/E resisted LR painful + painful arc = distal end of tendon + no painful arc = body of tendon Friction or inject

25. Biceps Tendinitis O/E resisted flexion and supination of the elbow painful Long Head – rotation frics at bicipital groove or inject Belly – pinch grip frics or inject with LA only

26. When its not a shoulder Pins and needles / numbness Radiation to hand Neck movt aggravates pain Gastro– intestinal pathology Avascular necrosis