This document provides an overview of common shoulder problems, including impingement and rotator cuff tears, massive irreparable rotator cuff tears, shoulder instability, biceps labrum complex lesions, proximal humerus fractures, and shoulder osteoarthritis. It discusses the clinical presentation, diagnostic tools, and management options for these conditions. Key points include that rotator cuff tears tend to progress in size if left untreated, massive cuff tears can be addressed with novel techniques like balloon arthroplasty, and the evidence on surgical versus non-surgical treatment of proximal humerus fractures remains unclear.

1. Assessment & Management of
Common Shoulder Problems
▪ Prof. Bijayendra Singh
▪ FRCS (Tr & Orth), FRCS, MS, DNB
▪ Consultant Orthopaedic & Upper Limb Surgeon
▪ Medway NHS Foundation Trust
▪ Visiting Professor, Canterbury Christchurch University
1

2. •Shoulder
• Cuff Disease
• Biceps Labrum Complex Lesion
• Fractures
• Instability
• Frozen Shoulder
• OA (Primary / CTA)

3. Impingement
&
Cuff Tear
3

4. Most common cause of shoulder pain
Usually > 40, if > 65 suspect cuff tear
Pain
Worsening on stretching / overhead activites
Difficulty in sleeping on side
Problem with other ADL
May have weakness
4
If pain worse on bringing arm down -
High suspicion of tear

5. 5
Impingement is a
CLINICAL DIAGNOSIS

6. 6

7. US or MRI
7

8. 3
8

9. 9

10. Management
▪ Non Operative
▪ Surgical
▪ Arthroscopic
▪ Open
10

11. Cuff Tears
11

12. Do we need to fix cuff tears
12

13. Natural History of Non operatively Treated Symptomatic
Rotator Cuff Tears in <60 yrs. (5mm or more)
Safran et al: Am Jr. Sports Medicine, 39(4), 710 - 714
• F/U: 25 - 39 months
• Ultrasonography by same sonographer
• 51/61 evaluated
– 30 (49%) tears increased in size
– 26 (41%) no change
– 5 (8%) reduced
– 10(25%) found to have new tears
• No correlation between change in tear size,
– patient age
– prior trauma
– size of tear at index
• Co-relation between considerable pain & increase in tear size
14

14. Massive / Irreparable Cuff Tears
15

15. Introduction
● Massive irreparable rotator cuff - Challenge
● Presents with ‘Pain & Loss of function’
● Progressive degeneration of the shoulder joint
● The functional status + dynamic stability of shoulder are
used as a guide for treatment

17. Clinical Presentation
• Pain
• Stiffness & Adhesive capsulitis
• ACJ pain
• Disability
• Weakness away from body
• Pseudoparalysis
• Weakness

18. • Clinically
Anterosuperior escape - static dynamic

19. What is the Balloon
●Novel surgical technique
●Use of a bio-degradable material
● L-lactide-co-E-caprolactone
●As sub acromial spacer ( bursa)
●Promoting frictionless gliding / movement between HH
& Acromion
●CE marked in July 2010 and in use in Europe

20. Cuff Tear Arthropathy
21

21. 22

22. 23

23. PRINCIPLES

24. 25

25. Instability
26

26. Definition of Instability
Inability to maintain the humeral head in the glenoid

27. Recurrent Dislocation
(Instability)
TUBS
Traumatic,
Unidirectional,
Bankart,
Surgery
AMBRI
Atraumatic (Micro_
Multidirectional
Bilateral
Rehabiliation
Inferior Capsular Shift, Rotator Interval 28

28. Combined Atraumatic & Traumatic
29

29. Physical
Demonstrate dislocation/subluxation ?
Laxity tests
Stability tests
30
Laxity tests
Drawer
Sulcus
Push - pull
Stability tests
Fulcrum
Apprehension (crank )
Jerk
Strength tests

30. MR Arthrogram
31

31. Biceps Labral Complex Lesion
32

32. 33

33. Tests
34
★ O'Brien Active Compression
★ Speed
★ Dynamic Labral Shear (Mayo Shear)
★ Biceps Load II (Kim)
★ Resisted Supination External Rotation (Labral Tension)
★ Upper Cut
★ Kibler Anterior Slide
★ Compression Rotation

34. Fracture Proximal Humerus
35

35. Literature
• Pubmed (2015)
•Proximal Humerus - 3461
•PH Fracture - 2438
•PH Fixation - 118
•Humerus Hemiarthroplasty - 210
•PH Complications - 1123
•PH Reverse - 109
•Pubmed (2014)
•Proximal Humerus - 3032
•PH Fracture - 2079
•PH Fixation - 101
•PH Hemiarthroplasty - 179
•PH Complications - 978
•PH Reverse - 53

36. Epidemiology
• 5% of all fractures
• 70 per 100000 population
• 15 - 20% present challenge
• Common in osteopenic bone

37. Management
• Fracture Personality:
–Type of fracture & Quality of bone
• Patient Personality
–Elderly / frail patient
–Medical comorbidities
–Reliability
• Surgical skills
• Inventory

38. Cochrane Review 2012
▪ 23 studies, 1238 patients
▪ Unclear
▪ if surgery is better even for specific type
of fracture
▪ What surgical method
▪ When to start physio
39
Insufficient evidence to inform the
management of these fractures

39. ProfHER
▪ Multi Centre Trial
▪ Inclusion Criteria
▪ Pragmatic!!!
▪ Exclusion Criteria
▪ Clear Surgical Indication!!
40

40. ProFHER
The ProFHER trial has provided robust
clinically relevant evidence showing that
current surgical practice does not result in a
better outcome for most patients with a
displaced fracture of the proximal humerus
involving the surgical neck and that, in
addition, it is not cost-effective in the UK
setting.
41

41. PRINCIPLES

42. 6m Post Op
62

44. Summary
▪ Cuff Tears Progress if not managed early
▪ Double vs Single Row Repairs
▪ Balloon Arthroplasty
▪ Excellent Results of Reverse in Fracture
45

45. Thank You