Short cases

AC Joint pathology

Opening

• Wash hands
• Good morning, I am Kishore , on of the exam candidates, can I know your name, age and hand dominance please?
• Hai Joe, Nice to meet you. Today I am going to examine your shoulders. That involves me look, feel and move your shoulder and some special tests. Is that ok for you?
• Before we start, does it hurt somewhere?
• Can you remove your top so that I can see and feel for the shoulder clearly? Thank you.

Look

• Prominence of AC joint, irregularity of clavicle
• Muscle wasting and scars anteriorly, laterally and posteriorly and AXILLA

Feel

• Local rise of temperature
• Tenderness over AC Joint

Move

• Instability of clavicle
• Terminal restriction due to pain

Special

• Impingement
• Scarf test
• O Brein test

Rotator cuff strength

and instability

Neurovascular and screening of c spine

Summary

• Mr Joe, 25 year old right dominant gentleman presents with prominent left AC joint which is tender and is associated with clavicle instability. There is no associated rotator cuff weakness or shoulder instability.

Investigation

• Xray
• MRI

Treatment

• Non surgical
  • activity modification
  • NSAIDS
  • Steroid inj
• Operative
  • open
  • arthroscopic resection

Impingement

Opening

• Wash hands
• Good morning, I am Kishore , one of the exam candidates, can I know your name and age please?
• Hai Joe, Nice to meet you. Today I am going to examine your shoulders. That involves me look, feel and move your shoulder and some special tests. Is that ok for you?
• Before we start, does it hurt somewhere and which hand do you use more?
• Can you remove your top so that I can see and feel for the shoulder clearly? Thank you.

Look

• Prominence of AC joint, irregularity of clavicle
• Muscle wasting and scars anteriorly, laterally and posteriorly and AXILLA

Feel

• Local rise of temperature
• Tenderness over AC Joint

Move

• Painful arc 70-120, cuff at max tension.

Special

• Impingement sign
• Hawkin test
• Scarf test
• IR resistance stress test: good ER, test is positive suggest internal impingement
• Internal impingement: impingement of posterior cuff along the posteriosuperior labrum.

Rotator cuff strength

and instability

• Normal

Neurovascular and screening of c spine

Summary

• Mr Joe, 40 year middle aged gentleman presents with pain full mid arc abduction, positive for impingement tests and no rotator cuff wasting and weakness.

Impingement

• Pain arising from the subacromial space due to narrowing of the space
  • Spur
  • thick CA ligament
• or increase in content (bursitis)
• Resent thinking also include poor cuff control with superior migration of head causing impingement

Investigation

• Xray
• MRI

management

• Non surgical:
  • cuff strengthening
  • Steroid: can affect cuff tendon healing in rat study Tillander 1999
• Sub acromial decompression
  • CSAW: Surgery has got only placebo effect

Cuff tear

Opening

• Wash hands
• Good morning, I am Kishore , on of the exam candidates, can I know your name, age and hand dominance please?
• Hai Joe, Nice to meet you. Today I am going to examine your shoulders. That involves me look, feel and move your shoulder and some special tests. Is that ok for you?
• Before we start, does it hurt somewhere?
• Can you remove your top so that I can see and feel for the shoulder clearly? Thank you.

Look

• Prominence of AC joint, irregularity of clavicle
• Muscle wasting and scars anteriorly, laterally and posteriorly and AXILLA

Feel

• Local rise of temperature
• Tenderness over AC Joint

Move

• Discrepency between active and passive movement

Special

• Impingement
• Scarf test
• O Brein test

Rotator cuff strength

and instability

• Jobs: 90 degree, scapular plane in IR
• Gerber lift off / belly press
• Hornblower: niability to hold in 90 degree abduction and ER

Lag

• ER lag sign
• Drop arm sign
• IR lag sign

Inv

• Xray
• USG
• MRI: most sensitive and allows assessment of muscle atrophy

Treatment

• Non surgical
  • Physio
• Surgical repair (open/miniopen, arthroscopic)
  • UKUFF : no difference in effectiveness and repair rate
• Massive tear is difficult and challenging problem

Massive tear

• Cofield: >5 cm tear either AP/ML
• Gerber: 2 or more tendon complete tear

Cuff

• Tendon transfer: LD/Pect Major
• Middle
  • Graft jacket superior capsular reconstruction
    • Balanced shoulder
    • no arthritis
• Old:space balloon
• Old with arthritis: reverse shoulder

Treatment

• Rehabilitation
• Salvage
  • Debridement and biceps tenotomy
  • patch augmentation
  • Tendon transfer
    • Posterior-superior: lat dorsi
    • Anterior-superior: Pect maj
• Reverse shoulder
  • cuff tear arthropathy
  • Older patient
  • deltoid functional

Neurovascular and screening of c spine

Ad capsulitis

Opening

• Wash hands
• Good morning, I am Kishore , on of the exam candidates, can I know your name, age and hand dominance please?
• Hai Joe, Nice to meet you. Today I am going to examine your shoulders. That involves me look, feel and move your shoulder and some special tests. Is that ok for you?
• Before we start, does it hurt somewhere?
• Can you remove your top so that I can see and feel for the shoulder clearly? Thank you.

Look

• Prominence of AC joint, irregularity of clavicle
• Muscle wasting and scars anteriorly, laterally and posteriorly and AXILLA

Feel

• Local rise of temperature
• Tenderness over AC Joint

Move

• Painful restriction of ER
  • Rotator interval fibrosis
    • CH lig
    • SGHL
    • Superior capsule
• All movement restriction
  • Severe disease

Special

• Difficult to do

Rotator cuff strength

and instability

• Difficult to do due to stiffness

Neurovascular and screening of c spine

• Also creen for dupuytren

Inv

• Blood sugar 70% coprevalance
• Thyroid disease
• X ray
• MRI shows reduction in capsular volume

Treatment

• Majority benefit with pain modification and supportive physic at least for 12 weeks
• In poor responding minority
  • MUA
  • Arthrographic dilatation
  • Arthroscopic arthrolyis
• UK Frost study:
  • Compares physio, MUA and arthroscopic arthrolysis completes in 2019

Ad capsulitis

• Dupuytren like disease charecterised by fibrosis of rotator interval histologically showing angiofibroblastic metaplasia and proliferation of type 3 collagen
• 3 phases
  • Freezing
  • forzen
  • thawing

GH OA

Opening

• Wash hands
• Good morning, I am Kishore , on of the exam candidates, can I know your name, age and hand dominance please?
• Hai Joe, Nice to meet you. Today I am going to examine your shoulders. That involves me look, feel and move your shoulder and some special tests. Is that ok for you?
• Before we start, does it hurt somewhere?
• Can you remove your top so that I can see and feel for the shoulder clearly? Thank you.

Look

• Prominence of AC joint, irregularity of clavicle
• Muscle wasting and scars anteriorly, laterally and posteriorly and AXILLA

Feel

• Local rise of temperature
• Tenderness over AC Joint

Move

• Instability of clavicle
• Terminal restriction due to pain

Special

• Impingement
• Scarf test
• O Brein test

Rotator cuff strength

and instability

Neurovascular and screening of c spine

History

• Mrs smith a 73 year old right handed hedmistress presents with several years of rt sided intermittent shoulder pain. I past few months she is experiencing increasing pain and stiffness of the shoulder. She denies any trauma and has difficulty in brushing teeth, washing her face. I will first consider the diagnosis of GH OA, how ever I will consider cuff tear arthropathy and cuff tear also.

Examn

• Gross restriction of shoulder movement in an elderly patient should be considered as GH OA unless proved otherwise.