shoulder joint

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

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

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Anatomy- Deltoid

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Anatomy – Rotator Cuff

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Anatomy - Ligaments

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Anatomy - Bones

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• 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
Diagnostic Clues - Age

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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

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

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

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

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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.

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Movements

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Supraspinatus

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Infraspinatus / Teres minor

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O’briens test for ACJ/Slap
Lesion

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Gerbers Lift off for
subscapularis

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Belly Press for Subscapularis

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Neers Test

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Hawkins-Kennedy test

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Biceps tendon-Speed test

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Apprehension Tests
Apprehension Relocation Test
Sulcus Test Drawers tets

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• Supraclavicular fossa
• Neurological examination
• Vascular examination
Non-shoulder examination

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Cervical spondylosis

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Cervical spine fracture
and tumour

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• 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
Investigations – X-Rays

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• Ultrasound (one stop
clinic)
• MRI
• Arthrogram
• CT Scan
• EMG
• Bone Scan
• ARTHROSCOPY

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Impingement/ACJ Pathology
ACJ Arthritis Acromial spur

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Calcific Tendonitis

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Metastatic Fracture

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Frozen Shoulder

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

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Surface replacement
Total Shoulder
Replacement

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Reverse Delta
Shoulder replacement

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SLAP Lesion
Superior Labrum Anterior Posterior

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Bankarts Lesion

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• Activity modification
• NSAIDs / Analgesia
• Physiotherapy
• Steroid Injection
Frozen
shoulder
Calcific
tendinitis
Impingement
syndrome
AC joint
disease
Glenohumeral
arthritis

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

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Injection Techniques

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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

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• 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.

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