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Shoulder & Elbow
INTRODUCTION &
BACKGROUND
The History is usually the most important step to a
correct Diagnosis
L Funk
HISTORY
EXAMINATION
INVESTIGATIONS
DIAGNOSIS
60%
90%
100%
• Be Systematic:
– Pain
– Function
• Loss of Movement (stiffness/weakness)
• Instability
– Swelling
– Systemic History
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Traumatic / Non-traumatic
The importance of understanding the mechanism
of injury can not be underestimated - it gives clues to the
personality of the fracture and the treatment required:
• When and how did the incident occur?
• What exactly happened to the limb?
• How much force was applied?
• Has the joint ever been injured before?
Trauma Mechanism of Injury
Non-Trauma Onset
• When and how did the symptoms start?
• How has it changed?
• Have you had this before?
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Introductions
1. How ya doin’? - Introduction
2. What are you doing here? - Main Complaint
3. Have you been before? – Past Medical History
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4. Anything else?
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IntroductionHow ya Doin’?
Patients are People Too!!
• Shake Hands
• Introduce yourself Clearly and your Position
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Main Complaint Why are you here?
1. Pain
2. Function – Loss of movement – Instability / Locking
3. Swelling / Lump
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PAIN
• Site – where exactly is the pain?
• Radiation – Does it go anywhere else?
• Nature – Can you describe the pain?
• Severity – How bad is the pain?
• Duration – How long have you had the pain?
• Frequency – How often do you get the pain?
• Aggravating factors – What makes the pain worse?
• Relieving Factors – What makes the pain better?
• Related Features – do you get any other symptoms?
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PAIN
• Localised
• Referred
• Radicular
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PAIN
• Nociceptive Pain – Local Tissue damage – Worse with movement – Opiates or NSAIDs
• Neurogenic Pain – Peripheral Nerve or Nerve Root damage – Pain >> Tissue damage – Often Sensory changes – Poor response to Opiates or NSAIDs
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Function
• Activities of Daily Living – ADL
• Sports / Recreation • What can’t you do that you used to be able to do? • Why?
– Stiffness – Weakness – Pain
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Function
1. Loss of Movement
2. Instability
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Loss of Movement
• Time of Loss of Movement
• Was there a dislocation?
• Are Active and Passive movements the same? • Stiff or Loose
• Symptoms of Neurological deficit?
• Symptoms of Tendon rupture?
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Instability
• Does the joint ‘Give Way’? – Has it ever given way?
• Does the joint lock? – What does the patient mean by this?
• Does the joint click or clunk?
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SWELLING
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• Has there been swelling?
• How much?
• How soon / how long?
• Has it changed?
• Related Features – Pain
– Function
Past Medical HistoryHave you been before?
• Musculoskeletal – Previous similar symptoms – Other joints – Arthritides – Rheumatic Fever – TB
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• Systemic – Cardiac – Respiratory – GIT – GUT – Drugs – Alcohol – Tobacco
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Past Medical HistoryHave you been before?
• Social – Work – Sports / Hobbies – Driving – Live Alone – Stairs – Walking Aids – Assistance
• Family History – Musculoskeletal
• Anaesthetic – Previous – Problems
Mnemonic
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M OI/ onset
P ain
F unction
F eeling / Sensation
W eakness
S welling
S tiffness & Stability
M ust
P ass
F ***ing
F inals
W ith
S ome
S tudying
20 year old male Dislocated his left shoulder playing rugby Ongoing Instability …
20 year old male Dislocated his left shoulder playing rugby Ongoing Instability …
1. Onset: 1. Exact
Mechanism of Injury
2. Able to continue playing?
3. Management - relocated on pitch/hospital
4. Ease of relocation
2. Pain: 1. when
2. where 3. Nature of pain 4. Associated
symptoms (clicking, locking, instability)
3. Function: 1. Able to play? 2. Able to train
(what training)?
3. If not, why? (pain,
weakness or instability)
4. ADL 4. Instability:
1. When 2. What position(s) /
Activity 3. Disloc / Sublux /
Loose 4. Clicking / Locking 5. Associated pain?
Considerations: Labral tear; capsular tear; fracture; rotator cuff tear; laxity; other joints
58 year old Female Insidious onset shoulder pain 2 months ago Pain extremely severe and unable to sleep
58 year old Female Insidious onset shoulder pain 2 months ago Pain extremely severe and unable to sleep
1. Onset: 1. Gradual /
Sudden 2. Worsening /
improving / no change
3. Previous similar?
2. Pain: 1. when 2. where 3. Nature of pain 4. Associated
symptoms (clicking, locking, instability)
5. Relieving factors
3. Function: 1. ADL 2. Sleep 3. Work 4. Recreation
Considerations: Calcific tendonitis (most likely); Frozen Shoulder; ACJ Arthritis; Degenerative cuff tear; Tumour;
Infection; Radicular origin
58 year old Female Fell 3 months ago injuring shoulder Normal x-rays, but still painful and
struggling with gardening & housework
58 year old Female Fell 3 months ago injuring shoulder Normal x-rays, but still painful and struggling with gardening
& housework
Considerations: Rotator cuff tear; Greater tuberosity fracture; Post-traumatic Frozen Shoulder
NOT Labral injury!
1. Onset: 1. Exact
Mechanism of Injury
2. Able to continue with ADL?
3. Management at the time
2. Pain: 1. when 2. where 3. Nature of pain
4. Associated symptoms
3. Function: 1. ADL 2. Sleep 3. Recreation 4. Work
72 year old Farmer Elbow pain for 2 years Increasing in severity
72 year old Farmer Elbow pain for 2 years Increasing in severity
Considerations: Arthritis (most likely); Epicondylitis; Biceps/Triceps Tendonitis
1. Onset: 1. Gradual /
Sudden 2. Worsening /
improving / no change
3. Previous similar?
2. Pain: 1. when 2. where
(lateral/medial)
3. Nature of pain 4. Associated
symptoms (clicking, locking, instability)
5. Relieving factors
3. Function: 1. ADL 2. Sleep 3. Work 4. Recreation
Case 5
21 year old Rugby player Fell onto outstretched hand Felt a clunk Very painful medial side of elbow
Case 521 year old Rugby player Fell onto outstretched hand Felt a clunk Very painful medial side of elbow
1. Onset: 1. Exact
Mechanism of Injury
2. Able to continue playing?
3. Management - ? dislocated / subluxed - ?relocated on pitch/hospital
4. Ease of relocation
2. Pain: 1. when 2. where 3. Nature of pain 4. Associated
symptoms (clicking, locking, instability)
3. Function: 1. Able to play? 2. Able to train
(what training)?
3. If not, why? (pain, weakness or instability)
4. ADL 4. Instability:
1. When 2. What position(s) /
Activity 3. Disloc / Sublux /
Loose 4. Clicking / Locking 5. Associated pain?
Considerations: Traumatic instability; fractures
Case 6
18 year old female Right handed Keen tennis player Painful & clicking right scapula No recollection of injury
Case 6 18 year old female Right handed Keen tennis player Painful & clicking right scapula No recollection of injury
1. Onset: 1. Gradual /
Sudden 2. Worsening /
improving / no change
3. Previous similar?
2. Pain: 1. when 2. where 3. Nature of pain 4. Associated
symptoms (clicking, locking, instability)
5. Relieving factors
3. Function: 1. ADL 2. Sleep 3. Work 4. Recreation
4. Other: 1. Other joints 2. Family Hx 3. Spinal
Considerations: Snapping Scapula; Scapula Dyskinesis; Secondary to GHJ Instability; Hyperlaxity; Overhead Athlete
Thank You Lennard Funk, 2015