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    GP Assessment of The Shoulder: Keith Littlebury MSC Grad Dip Phys Extended Scope Physiotherapist Camden Cats Service

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    The document provides an overview of shoulder anatomy, common shoulder conditions such as impingement and rotator cuff tears, guidelines for assessing the shoulder through observation, range of motion testing, special tests, and palpation, and recommendations for imaging the shoulder. It aims to refresh knowledge of shoulder anatomy and classification of conditions, review management strategies, and provide an objective assessment approach for common shoulder presentations in primary care.

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    GP Assessment of The Shoulder: Keith Littlebury MSC Grad Dip Phys Extended Scope Physiotherapist Camden Cats Service

    Uploaded by

    apriliatna
    43 views29 pages
    The document provides an overview of shoulder anatomy, common shoulder conditions such as impingement and rotator cuff tears, guidelines for assessing the shoulder through observation, range of motion testing, special tests, and palpation, and recommendations for imaging the shoulder. It aims to refresh knowledge of shoulder anatomy and classification of conditions, review management strategies, and provide an objective assessment approach for common shoulder presentations in primary care.

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    The document provides an overview of shoulder anatomy, common shoulder conditions such as impingement and rotator cuff tears, guidelines for assessing the shoulder through observation, range of motion testing, special tests, and palpation, and recommendations for imaging the shoulder. It aims to refresh knowledge of shoulder anatomy and classification of conditions, review management strategies, and provide an objective assessment approach for common shoulder presentations in primary care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    43 views29 pages

    GP Assessment of The Shoulder: Keith Littlebury MSC Grad Dip Phys Extended Scope Physiotherapist Camden Cats Service

    Uploaded by

    apriliatna
    The document provides an overview of shoulder anatomy, common shoulder conditions such as impingement and rotator cuff tears, guidelines for assessing the shoulder through observation, range of motion testing, special tests, and palpation, and recommendations for imaging the shoulder. It aims to refresh knowledge of shoulder anatomy and classification of conditions, review management strategies, and provide an objective assessment approach for common shoulder presentations in primary care.

    Copyright:

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    GP Assessment of the Shoulder

    Keith Littlebury MSc Grad dip Phys


    Extended Scope Physiotherapist
    Camden CATS service
    Aims

    • Refresh shoulder anatomy


    • Classification of common shoulder conditions seen in
    primary care
    • Review of management strategy for shoulder pathologies
    • Objective assessment for common shoulder conditions
    • Quick shoulder assessment guide (practical)
    Shoulder Anatomy

    • GH joint
    • Labrum
    • Rotator cuff
    • Capsule
    • AC joint
    • Bursa
    • Scapula
    • Spinal/ribs
    • Neural
    Shoulder Anatomy
    Shoulder muscular anatomy
    • The rotator cuff
    • Deltoid
    • Biceps Brachii
    • Axioscapular muscles
    Basic classification
    Instability
    • Traumatic
    • Atraumatic
    • Muscle patterning
    Stiffness
    • Arthritis • Long head biceps
    • Frozen shoulder Impingement
    • Infection Shoulder Pain • Rotator Cuff
    • Tumour • Bursa
    • AVN •AC joint

    Other
    • Spinal
    • Rib
    • Non MSK
    Impingement

    Impingement
    •Rotator Cuff
    •Bursa
    •Labrum
    •AC joint

    75 % of presentations in Primary Care?


    Impingement

    Intrinsic Factors Extrinsic Factors


    • Rotator Cuff Pathology • Muscle imbalance - scapulohumeral
    • Acromial / ACJ spurs / osteophytes • Postural change
    • Sub Acromial Bursitis • Capsule laxity or tightness
    • Labral tears • Repetitive overuse
    Impingement
    Signs and Symptoms:
    • Ache around deltoid, occ. goes to wrist
    • Often associated with jobs/hobbies that involve
    overhead activities
    • May have painful arc 90-130º
    • PAIN/LOSS RANGE ABDUCTION
    • HAWKINS sign POSITIVE
    Impingement
    Treatment and management
    • Physiotherapy first
    • steroid injection
    • sub-acromial decompression
    Rotator Cuff Tears
    Partial tear or defect:

    • Difficult to differentiate between tear and tendinopathy


    • Common in elderly
    • Reduced AROM – full PROM
    • Resisted tests painful +/- weakness
    • Refer to physio re imbalance
    • Consider injection
    • Surgery not reparative ? debridement
    Stiff Shoulder

    Stiffness
    •Arthritis
    •Frozen shoulder
    •Infection
    •Tumour
    •AVN
    Stiff Shoulder (GHJ)
    If passive external rotation is very limited
    • Arthritis
    • Frozen shoulder (not <25 or >65 years ?)
    • Tumour
    • AVN
    • Infection
    Stiff Glenohumeral Joint
    • External rotation is the only pure Glenohumeral movement
    • If loss External Rotation MUST X-RAY
    • Relatively normal X-Ray = frozen shoulder

    Loss Abduction > ER impingement


    Loss ER > Abduction stiff Glenohumeral joint
    Frozen Shoulder
    • Signs and symptoms:
    • Mainly 40 to 65 year olds (frequently women)
    • Pain around shoulder, occ. Goes to wrist
    • Reduced GH joint ROM – active = passive
    • Capsular restriction – ER>Abd>IR
    • Resisted tests pain free
    Frozen Shoulder
    The treatment options range from:
    1. Nothing.
    2. Physiotherapy (GH joint mobs, caps stretches)
    3. Locally acting steroid injections
    4. Hydro-distension injections (up to 50ml)
    5. Manipulation under anaesthetic ( MUA)
    6. Open/Arthroscopic capsular release.
    Labral pathology
    History:
    • Can be degenerative or traumatic
    • Trauma often with elbow extended and forced internal rotation
    • Degenerative in throwers and repetitive overhead manual work
    • May have anterior and lateral arm pain
    Examination
    • May report clunking some mild instability sensations
    • May have co-existing impingement
    • Often has near full ROM
    • Positive labral tests
    Management
    • Surgical opinion
    Instability

    Two types… TUBS or AMBRI

    T – traumatic onset A – atraumatic (congenital/acquired)


    U – unidirectional instability M – multi-directional instability
    B – Bankhart lesion B – bilateral
    R – responds to physiotherapy
    S – surgical intervention I – inferior capsule surgery
    EXAMINATION
    Subjective history

    • Onset
    • Age: likely conditions?
    • Site
    • Spread
    • Occupation / Hobbies / Activities
    • Functional activities affected
    • Medical history
    • Investigations / treatment to date
    History

    • Age can help as a rough guide to what


    may be the problem

    Potential Problem AGE


    Instability 17 – 30 years

    Impingement 30 – 45 years

    Adhesive capsulitis 45 – 60 years

    OA >60 years
    Pain location

    • Where pain is can help with diagnosis

     Lateral shoulder Cuff tear / Impingement


     Anterior shoulder Impingement/Labrum
     Whole shoulder Frozen shoulder
     Superior shoulder AC joint
     Trapezius/scapula Neck
     P&N in hand Neck
    Basic objective shoulder
    examination

    • 1. Observation - wasting, swelling, deformity, scapula position


    • 2. Shoulder movement – active and passive
    • 3. Resisted shoulder tests - abdn, med rotn, lat rotn
    • 4. Special tests – impingement, cuff, labrum, instability
    • 5. Palpation
    1. Observation
    2. Shoulder movement

    • Any limitation in range of movement needs to be quantified:


    • Is it active or passive restriction
    • Is it limited by pain, inability, hard end feel
    • Is it a specific point in the range
    • Is external rotation stiff (BE AWARE)
    • Clear cervical spine
    3. Resisted tests

    • Myotomes if cervical spine still suspicious


    • Resisted MR, LR, Abduction and elbow flexion
    • Always compare to contra-lateral side
    • Are the resisted tests weak
    • Do they reproduce pain
    4. Special tests

    • Impingement tests
    Active abduction, Hawkins Kennedy

    • Instability tests
    Apprehension, load and shift

    • Labral tests
    Grind test
    5. Palpation

    • AC joint

    • Neck

    • Trapezius

    • Lateral acromial border


    Quick shoulder assessment
    guide
    • OBSERVATION

    • ACTIVE MOVEMENT ABDUCTION

    • PASSIVE CAPSULAR PATTERN (EXTERNAL ROTATION)

    • SPECIAL TESTS –
    • IMPINGEMENT (HAWKINS KENNEDY)
    • RESISTED TESTS (ROTATOR CUFF)
    • STABILITY (LOAD AND SHIFT)
    • LABRUM (GRIND TEST)
    • ACJ/ACROMION (PALPATION)

    • DIAGNOSIS?
    • ? FROZEN SHOULDER
    • ? IMPINGEMENT
    • ? ROTATOR CUFF TEAR
    • ? LABRUM
    • ? INSTABILITY
    Imaging
    XRAY
    • Good to check for GHJ or ACJ arthritis
    • Can pick up calcific tendinitis, os acromiale, sub-acromial spur.
    USS
    • Good to pick up rotator cuff pathology, calcific tendon, bursitis, dynamic impingement
    • Cannot see labrum
    • Must have good passive ROM for worthwhile scan.
    • Good for superficial structures
    MRI
    • Good to pick up labrum, arthritis, calcific tendinitis, rotator cuff
    • Good for deep structures
    • Not dynamic

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