Transcript Slide 1
NHS Bolton MSK Physiotherapy
Service
The Shoulder
Vicky Lyle (Orthopaedic
Practitioner)
Claire Guy (Specialist Physio)
Lesley Anne Fraser – MSK Service Manager
– Contact: [email protected]
Emily Barber – MSK Physio Team Leader
– Contact: [email protected]
– 01204 462504
Sue Greenhalgh – Consultant Physiotherapist &
Interim Lead Clinician
– Contact: [email protected]
– 01204 462584
GP Training Agenda
Agenda Item
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
Evening Session
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?
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?
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
Tests of Contractile Function
Baseline Isometric Assessment:
– Abduction
– Adduction
– Lateral Rotation
– Medial Rotation
– Elbow Flexion
– Elbow Extension
→ Supraspinatus (& deltoid)
→ Teres Minor
→ Infraspinatus, teres minor
& possibly supraspinatus
→ Subscapularis
→ Biceps & brachialis
→ Triceps
Adhesive Capsulitis
Codman described the first and best classical
diagnostic criteria for frozen shoulders in 1934
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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
Diagnosis
Age:
– Typically occurring in females more than males, in the
4th and 5th 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
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
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).
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Cardiac/lipid problems.
Epilepsy.
Endocrine abnormalities, particularly hypothyroidism.
Trauma.
Drugs – MMP Inhibitors.
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
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.
Possible Underlying Mechanisms
Bony anatomical and pathological factors
Shoulder instability
Impaired scapulohumeral rhythm and scapular
instability
Capsular tightness
Postural factors
Soft tissue changes
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
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 painrelated 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
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.
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
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?