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Management of common shoulder
pathologies
Val Jones
Physiotherapy Practitioner
Sheffield Shoulder & Elbow Unit
Objectives
Review evidence based assessment
and management of common shoulder pathologies
Shoulder pain incidence
3rd most common musculoskeletal reason to seek GP advice, with 15% onward
referral to physio (Linsell et al 2006)
Labour Force survey – 3.8 million working days lost in UK 2008-2009 with neck and upper limb pain
17.5 days sick leave in 1 year.
Annual loss 0.16 days per worker (HSE 2010)
Evidence of occupational risks
Strong evidence for association between shoulder complaints and
Manual material handling
Vibration
Trunk flexion or rotation
Working with hands above shoulder level (Mayer et al 2011 Int Arch Occup Env Health)
Most common shoulder pathologies
Impingement
Rotator cuff tears
Contracted (frozen shoulder)
Impingement
Reduced clearance between the humeral tuberosities and coraco-acromial arch during elevation, compromising vulnerable soft tissues including
Rotator cuff
LHB
Sub-acromial bursa
Impingement incidence
Prevalence – sub acromial pain including tendinosis and cuff tears accounts for up to 70% of all shoulder problems (Mitchell et al BMJ 2005)
Lifetime prevalence 22-40% (Anderson et al
2007)
Incidence – 2.5% age 42-46, 21% age 70
Cuff tear prevalence
Overall cuff tear prevalence is 34%
Increases with age
Partial thickness more common than full thickness (Sher et al JBJS 1995)
Impingement demographics
Race – no known variation
Sex – equal
Age – most common after 40
Before age 40 consider instability
Rotator cuff
Reinforces capsule
Draws humeral head into glenoid
Interdigitation (Clark & Harryman 1992)
Tension in one musculotendinous unit distributed over wide area
Supraspinatus
Active throughout
Susceptible to impingement and fatigue
Snugs humeral head
Vertical steerer
Internal and external
rotator (Ihashi 1998)
Inferior cuff
Infraspinatus and teres minor
Infra – horizontal steerer
Posterior stabiliser
Depresses humeral head
Clinical presentation
40+
Sudden or insidious
Lateral shoulder
Dull ache with sharp catches on movement
Pain at night
Worse especially overhead
Clinical tests
Painful arc
Usually adequate passive range
Positive impingement tests
Pain and or weakness on cuff testing
X-ray and ultrasound
Impingement testing
Hawkins Kennedy
Neer test
Hawkins Kennedy
Neer test
Sensitivity
For rotator cuff tear
Neer 85% , Hawkins 88%
For subacromial bursitis
Neer 75%, Hawkins 92%
MacDonald et al (2000)
Rotator cuff testing
Empty can (Jobe) / full can
Infraspinatus
Subscapularis (Belly press)
Lift off test (Gerber)
Empty can test (Jobe)
External rotation testing
Lift off test
Lift off test (Gerber and Krushell 1991)
EMG study (Greis 1996)
Showed significantly higher levels of activation in subscapularis in comparison with other muscle groups
Belly press (Napoleon sign)
Extrinsic vs intrinsic
Extrinsic - Neer
Irritation and inflammation from acromion
Bigliani – acromial type III more at risk
Acromioplasty one of most commonly performed procedures
However
Fukuda – no inflammatory cells in cuff
Most partial thickness tears on articular, not bursal side – Loehr, Ogata, Ozaki
Intrinsic theory
Tendon pathology that originates within the tendon usually as a consequence of overuse or overload, leading to intrinsic degeneration - Lewis
Intrinsic
Articular fibres
Smaller cross sectional area – Nakajima
Reduced tensile strength
Vulnerable in elevation
Fibre failure progressing to tears
So what is happening?
Multifactorial
Overuse leading to pain, weakness and structural failure
Intrinsic failure leads to superior migration, bursal irritation, CAL and acromion
? Extrinsic effects are secondary
Structural factors
Shape coraco-
acromial arch
Bursal pathology
AC joint pathology
Dynamic factors
Tight posterior capsule
Poor scapula
mechanics
Weakness humeral
head depressors
Treatment options
Physiotherapy
Injection therapy
Surgery
Physiotherapy
Initial course for 6 weeks
If improvement after 6 weeks continue for 3 months (BESS 2014)
Passive mobilisations augments beneficial effects of exercise
Physiotherapy
Best evidence for
course of exercise to restore range, strength and scapulo-humeral stability (Kuhn 2009)
Can include both stretching and strengthening work
Physiotherapy
Scapula contribution – asses with scapula assistance test
Asses flexibility and strength and endurance of scapula muscles
Asses capsular mobility
Asses cuff strength and endurance especially external rotators
Physiotherapy
Benefits short course of NSAIDS likely to outweigh risks
No evidence for heat or cold therapy
Ultrasound not recommended
No evidence for laser, tens, friction massage
Injection therapy
Steroid injections only benefit in the short term, no better than NSAIDS (Buchbinder 2009)
No difference between using anatomical landmarks and ultrasound guidance (Bloom et al 2012)
Injection therapy
? Systemic effect as just as effective when placed in gluteal muscle (Ekeberg 2009)
No more than 2 injections with impingement (BESS 2014)
Avoid in presence of cuff tear
Surgery
Arthroscopic Decompression
No immobilisation required
4 weeks off light duties
6 – 8 weeks off heavier duties
3 – 4 months before can sleep on operated side
Cuff repair
2-4 weeks immobilisation
Up to 12 weeks lighter duties
Can only manually handle at 3 months
12- 18 months before reach full strength
Re-tear rate 13 – 68%
Evidence
No significant differences SAD vs physio (Goldberg et al 2001, Gartsman and O’Connor
2007)
No differences decompression with bursectomy vs bursectomy alone (Henkus et al JBJS 2009)
Rotator cuff repair – no evidence in over 75’s
Frozen shoulder
A condition of uncertain aetiology characterised by significant restriction of both active and passive motion that occurs in the absence of a known intrinsic shoulder disorder
ASES 1992
Contracted shoulder
Combination pain and stiffness, with potential for long term marked disability (Bunker 2009)
38% persistent mild symptoms, 3% severe, 4.4years from onset (Hand et al
2008)
Diagnosis
Passive external rotation reduction is fundamental to diagnosis
Degree of difference to be clinically significant 10-13 degrees (Kibler et al,
Tveita et al)
Differential Diagnosis
3 causes of reduced passive external rotation?
X ray 1
X-ray 2
X ray 3
Differentiation important
Differentiate from history, clinical and radiographic examination
Primary – global capsular restriction
Secondary – restriction usually specific
- therefore can direct mobilisation appropriately
Epidemiology
Insidious painful condition
Up to 10% population (Hand et al 2008)
Women > Men
40 – 65 years of age
Non-dominant > Dominant
20-30% will develop primary capsulitis in opposite shoulder
Associated with
Trauma
Diabetes (10-20%)
Hyperparathyroidism
Prolonged immobilisation
CVA / MI
Cervical spine pathology
Pathogenesis
Both inflammation and fibrosis
Increased vascularity and hypertrophy of capsule
Walls of axillary fold adhere
Reduced joint volume – 3-4 ml
Link with dupytrens
58 primary capsulitis
Dupytrens found in 52% ( over 8 x incidence in general population)
Type II collagen in nodules and bands
Similar distribution of fibroblasts
Stage 1
Less than 3/12 duration
Pain dull at rest & sharp EOR
Progressive decrease of active range
Hypertrophic vascular synovitis
Full passive range
Initially impingement tests positive
Signs of contracted shoulder take primacy over impingement signs (Hanchard et al 2011)
Stage II
3 – 9 months
Progressive loss ROM
Loss capsular volume
Dense proliferative hypervascular synovitis
Capsular fibroplasia with deposition of disorganised collagen fibrils
No inflammatory infiltrates
Stage III
9 – 14 months
Significant loss ROM
Relatively pain free but stiff
Patchy synovial thickening without hypervascularity
Dense hypercellular collagenous tissue
Stage IV
Thawing phase
Slow steady recovery of range
? Capsular remodelling
No arthroscopic or histological data available
Treatment Options
MUA
Arthroscopic Release
Hydrodilation
Injection
Manual therapy
Manual therapy
95% regain satisfactory range with hourly exercise (Watson – Jones)
O’Kane (1999) - success dependent on motivation, frequency & 4 quadrants of capsular stretch
Evidence for outpatient physio supplemented by home exs (Hanchard 2011)
Injection
Does not enhance MUA (Kivimaki 2001)
Beneficial if given intra-articular route, no benefit sub-acromially (Hanchard 2011)
Effect short lived (Buchbinder 2009)
MUA
97% had pain relief and gained nearly full range (Reichmiester et al 1999), with no evidence of complications
Othman & Taylor (2002) trebled Constant score at 3 years follow-up
Hydrodilation
Radiologist
60-100 mls saline
Dalziel & Watson 1993 – significant improvements in pain score and range
Not true frozen shoulder
Cochrane review showed no long term benefits, no better than steroid or alternatives
Capsular Release
Provides significant relief and restoration of motion within 3/12 (Nicholson 2003)
Gerber (2001) effective, but outcome is related to severity of stiffness, regardless of aetiology
Cohen (2000) worse results in post-surgical stiffness. Propose scalene block
Capsular release
Arthroscopic
Early full movement
2 hourly stretches
6 week window of opportunity to prevent further stiffness
Capsular release
4- 6 weeks before return to work
No lifting for 6-8 weeks
3-4 months before can lie comfortably on operated side
Never twice in same shoulder
