Orthopaedic Masterclass

Spire hospital, Warrington

05/07/14

SHOULDER Mr Chris Peach

www.shouldersandelbows.co.uk

TENNIS ELBOW

Degenerative condition rpted wear & tear

If the history is of an acute injury, followed by persisting pain this is

an acute tear of the extensor tendon NOT tennis elbow.
Need to refer to orthos or do USS

Mx

1. Physio eccentric loading exercises

Grip an object with a weight & then slowly lower the object (i.e. fist
back of hand facing upwards, gently flex the wrist to lower it), to
slowly stretch the extensor muscles / tendon

2. Acupuncture

3. Deep tissue massage

4. PLP Injections Plasma Rich platelet injections

Take 30ml sample of blood
Centrifuge - spin off the plasma
Inject the plasma into the site
The platelets release tissue regenerating factors

5. NOT steroid injection Steroids stop the healing process by

shutting down the healing mechanism
They help with pain, but at 6-9/12, those with steroids do less well.
Most tennis elbows will get better on their own within 12/12

INJECTIONS

No difference between Depo medrone / Kenalog

No difference with LA bupivicaine, marcaine, lidocaine although
lidocaine 1% has quickest action
No difference between 40 & 80 mg
For all joints (except AC jt), make volume up to 10ml with LA makes
it easier for steroid to disperse . AC jt is 2ml

INDICATIONS TO REINJECT

1. If pain has not settled completely e.g. gone from 10/10 to 5/10

2. If worked in the past & now sx come back (but not if pain can=m
back within a few days etc)

SHOULDER EXAMINATION & DIAGNOSES

HISTORY

If trauma- any hx of (transient) dislocation

AGE of pat
Young dislocation injury / trauma
Middle age frozen shoulder / impingement
Old degenerative / OA / frozen

Pain radiation
to front / side shoulder pathology
to back neck pathology
to hand usually neck pathology radicular pain, but can be frozen
shoulder this is the only shoulder pathology that radiates to the
hand

Pain worse lying on shoulder OA

Pain worse lying off shoulder Impingement / rotator cuff (can throb
in ANY position)

Affecting activities reaching out to get things / catches =

impingement
Stiff frozen shoulder or OA (check what pts mean by stiffness- need
to examine)

EXAMINATION

Ext rotation arm tucked in, bring arm out with elbow flexed if +ve
= frozen shoulder / OA do x-ray

Hawkins - +ve if pain reduced (arm out, flex at elbow, push forearm
up & down)

Scarf test bring arm across ask where is pain coming from if +ve
= OA AC joint

Supraspinatus arm extended, thumb down resisted abduction if

+ve = impingement / rotator cuff pathology (degenerative disease
e.g. calcific tendonitis, or rotator cuff tear)

PASSIVE ABDUCTION Can do with rotator cuff tear, NOT with

frozen shoulder

INJECTIONS

Impingement inject into subacromial bursa

OA or frozen shoulder inject into glenohumeral

Rotator cuff tear NOT injections they need physio if anything
that will delay healing & affect post-op healing
DIAGNOSES

IMPINGEMENT

3 causes of impingement
1. Tendonitis esp supraspinatus tendonitis - the commonest cause
2. Due to calcification of tendon (not just calcium speckles) which
then causes friction under acromion & inflammation of the bursa
3. rotator cuff - degeneration or tear do USS if tear suspected

Hx

Pain on reaching out e.g. cupboard, or if catches on certain

positions

Throbs at night in ANY position

Examination

painful arc

pain on resisted abduction

Rx

1. If large calcium deposits arthroscopy to remove calcium deposits

2. If impingement inject subacromial bursa

spine scapula
go to lateral edge
down 2cm & in 2cm
aim towards tip of anterior acromion i.e. AIM UP & OUTWARDS if
you hit the underside of the acromion that is fine, it shows you are
almost in the right place
You are aiming to inject into the subacromial bursa
before you inject, wiggle the needle to ensure you can move it if you
are in the tendon, you will not be able to in which case, withdraw
slightly & re-position just ABOVE the tendon
OA SHOULDER / FROZEN

Frozen shoulder is a dx of exclusion need to r/o OA, and can only

do that by x-ray

Can take 1-2 yrs to settle

If present, consider NIDDM (if already diabetic, optimise control &

refer orthos, as they rarely get better on their own)

Physio do PASSIVE stretches (not active e.g. not raise your arm
etc)

Hold a work surface with the palms of your hands laying flat on the
surface & move backwards until you feel the arm muscles puling
place had down in between shoulders

2. Place hand to the side and twist your body outwards this slowly
exercises the rotation muscle groups

Rx
1. physio
2. NSAIDS
3. Inject will reduce pain but not stiffness

spine scapula
go to lateral edge
down 2cm & in 2cm
aim towards tip of coracoid process i.e. AIM INWARDS &
HORIZONTAL
if you hit the humerus head, then rotate arm outwards, and this will
open up the joint
OA AC JOINT

Very common
Pain on lying on shoulder
Can often pinpoint it

OA of AC jt is peri-articular disease, not intra articular

EXAMINATION - +ve scarf test

RX - INJECT
In the supraclavicular fossa, in the soft area, go along the clavicle,
until you reach the top of the triangle & hit bone.
Then go fwds and that is the AC jt

40mg steroid made up to 2ml

BICEPS TENDON RUPTURE

Mainly in
Males
Bodybuilders steroid & Growth hormone use
(GH causes the muscles to bulk up so much that they outgrow the
tendon)

If seen, look for degenerative signs at the shoulder -CHECK

SHOULDER

Doesnt matter if long head rupture v short head

Important thing is If DISTAL TENDON has gone (long head of biceps),

refer same day to fracture clinic

Needs surgery within 2-3/52 otherwise the tendon then starts to

contract & difficult to re-attach

Test - flex elbow and feel for a tendon in the cubital fossa -Coat
Hook Sign

If not there = RUPTURE OF DISTAL TENDON

If it is there but painful if you twang it PARTIAL rupture

Both will create the Popeye signs

If partial rupture & there is weakness, ttm is physio not surgery

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