Shoulder Complaints: Diagnosis and Management

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Kelley Carson
7 years ago
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1 GP Education Series Shoulder Complaints: Diagnosis and Management GP Moderator: Dr. Sharon Stay

2 Case 1 Lachlan is a 17 year old student. He suffered an injury skiing on the weekend. Whilst skiing, he fell onto his left arm, heard a clunk and suffered acute pain. It has remained painful since, however he can move it in all directions with discomfort.

3 Question 1 What are the possible causes of Lachlan s pain?

4 Surgical Assessment Possible causes of pain? Differential Diagnosis Changes with age of patient

5 Question 2 Are there any specific questions you would ask in the history?

6 Surgical Assessment Patient s clinical history: Mechanism Position of arm Awareness of joint dislocating fully or partially» Out front or back Burner or stinger Deformity A.C. joint Sulcus

7 Question 3 What specific physical examination findings would you look for?

8 Surgical Assessment Physical Examination: Inspection Deformity Ligamentous laxity Systemic conditions Acute setting can be limited examination Chronic anterior and posterior apprehension testing Crepitus audible, palpable

9 Physical Examination:

10 Question 4 What investigations would you consider?

11 Surgical Assessment What investigations to consider: Plain x-ray Confirm located Posterior dislocations can be missed Bone injury» Glenoid» Humerus

12 What investigations to consider: Plain X-Ray

13 Surgical Assessment What investigations to consider: MRI Plain verse arthrogram Labral tears Capsular injuries Bone bruising Associated injuries eg. Rotator cuff

14 What investigations to consider:

15 What investigations to consider:

16 What investigations to consider:

17 What investigations to consider:

18 Professor Wayne Gibbon: What are the advantages/disadvantages of different imaging modalities? What information would you require from the GP on the referral form? What does the X-ray show? What does the MRI show? What information and recommendation would you provide in the report?

19 X-RAY

20 Hill Sachs Lesion Anterior Glenohumeral Dislocation Bony Bankart Lesion

21 MRI

22 Bankart Lesion Bi-Directional Instability Bi-Directional Instability with SLAP Lesion Reversed Bankart Lesion

23 CT Arthrography Patients unsuitable for MR Arthrography Glenohumeral Instability SLAP Tears Loose Bodies Failed MRI Adhesive Capsulitis (Diagnosis and Treatment)

24 Prone Oblique Positioning Double-Contrast CT Arthrography

25 SHOULDER: MRI vs Ultrasound Demonstrated well on MRI but not at all on US

26 Demonstrated well on MRI but not at all on US SLAP lesions (better as MR Arthrography) Glenohumeral Instability (better as MR Arthrography) Posterior Internal Impingement (better as intravenous contrast-enhanced MRI) Early OA

27 What are the options and principles of management of dislocation management? Surgery vs Non-surgical management: Age Dr Dale Rimmington: Activity Stage of season Associated injury Bony injury First time less capsular stretch

28 What are the options and principles of management of dislocation management?

29 What are the options and principles of management of dislocation management?

30 Questions/Discussion

31 Case 2 Lucy is a 62 year old active female who has competed in a triathlon and is a gardener. She also enjoys yoga and lifting weights. She originally injured her shoulder last year and for months thought she had pulled a muscle and tried rest. She has had to reduce activity and has trouble with daily tasks including drying her hair, snapping her bra and turning the key in her car.

32 GP Moderator: Question 1 What are the possible causes of Lucy s pain?

33 Surgical Assessment Possible causes of pain: Broad differential - Age of patient - Clues- above shoulder height - Moving arm away from chest to deodorant onfrozen - Abduction external rotation apprehension Don t forget cervical spine

34 GP Moderator: Question 2 Are there any specific questions you would ask in the history?

35 Surgical Assessment Patient s clinical history: Symptoms prior to pulling a muscle Other functional questions High shelf Driving Clothes on the line Nocturnal symptoms Neurological symptoms Change in severity- eg. freezing to frozen

36 Question 3 What specific physical examination findings would you look for?

37 Surgical Assessment Physical examination: Look, feel, move, X-ray Movement- active, passive and power Special tests Impingement A.C. Joint Long head of biceps Cervical spine/ neurology Must test active and passive range

38 Question 4 What investigations would you consider?

39 Surgical Assessment What investigations would you consider? X-ray still important

40 Surgical Assessment

41 Surgical Assessment

42 Professor Wayne Gibbon: What are the advantages and disadvantages of ultrasound and MRI in this case? What information would you require from the GP on the referral form? What does the ultrasound show? What does the MRI show? What information and recommendation would you provide in the report?

43 X-RAY

44 Normal for comparison t

45 MRI

46 SHOULDER: MRI versus Ultrasound Demonstrated better on US than MRI

47 Demonstrated better on US than MRI Early Subacromial Impingement Early Rotator Cuff Tendinopathy

48 Early Sub-Acromial Impingement (Ultrasound)

49 Dynamic Clues For Shoulder Pathology Sub-acromial Impingement Severe Adhesive Capsulitis or Severe Gleno- Humeral Joint Arthritis High Arc / Acromio- Clavicular Joint Impingement Mild Adhesive Capsulitis or Severe Acromio- Clavicular Joint Arthritis Loss of ACTIVE abduction Loss of PASSIVE abduction Loss of ACTIVE abduction >90 Loss of PASSIVE abduction >90

50 SHOULDER: MRI versus Ultrasound Demonstrated well on US but not on MRI

51 Demonstrated well on US but not on MRI Early Adhesive Capsulitis High Arc / Acromioclavicular Impingement

52 Severe Acromio-Clavicular High Arc Impingement (Ultrasound)

53 Adhesive Capsulitis Frozen Shoulder (Ultrasound)

54 NB. At Different Times All Imaging Modalities Can Be Useful? Bony Impingement Superior Surface Supraspinatus Tendon Sub-Acromial Impingement Secondary to an Os Acromiale (CT)

55 Dr Dale Rimmington: Advantages/Disadvantages of Ultrasound and MRI in this cases Addition of HCLA with ultrasound when indicated What are the options and principles of management for a rotator cuff tear?

56 Surgery vs non-surgical management Factors Patient age- physiological vs chronological Patient- co-morbidities Smoking, diabetes, dental health Patient demands Chronicity of tear What treatment already tried Severity of symptoms Tear factors Wasting of muscle bellies on examination Loss of passive range of motion Number of tendons Retraction and size of tear Presence of arthritis or proximal humeral migration Atrophy or fat infiltration of cuff muscle bellies

57 Surgery vs non-surgical management

58 Questions/Discussion

59 Thank you

Refer to Specialist. The Diagnosis and Management of Shoulder Pain 1. SLAP lesions, types 1 through 4

Refer to Specialist. The Diagnosis and Management of Shoulder Pain 1. SLAP lesions, types 1 through 4 The Diagnosis Management of Shoulder Pain 1 Significant Hisry -Age -Extremity Dominance -Hisry of trauma, dislocation, subluxation -Weakness, numbness, paresthesias -Sports participation -Past medical