Aug. 15, 2020
Decoding Shoulder Pain: Dr Gavin Nimon's insights on Diagnosis and Treatment
The player is loading ...
This is approved for 0.5 hour RACGP CPD - accredited activity
to complete - click on registration link after listenning
remember to provide RACGP member number and email
registration link
In this comprehensive Aussie Med Ed podcast episode, Orthopaedic surgeon Dr. Gavin Nimon ( Glenelg Orthopaedics) offers an in-depth exploration of shoulder pain, tailored to enhance the knowledge and practice of medical students and bgeneral practitioners. Dr. Nimon meticulously breaks down the complexities of shoulder anatomy and the diverse conditions that contribute to shoulder pain, such as rotator cuff injuries, bursitis, tendinopathy, and arthritis. Emphasizing the criticality of accurate diagnosis, he walks through effective diagnostic strategies, including the nuanced use of imaging and physical assessments.
The episode is particularly insightful in discussing the latest treatment methodologies, both surgical and non-surgical, providing GPs with up-to-date information on managing these cases. Dr. Nimon also addresses the importance of patient-centered care, highlighting the role of personalized treatment plans and rehabilitation protocols. His expert insights into the subtleties of patient communication and management of expectations are invaluable for practitioners dealing with such a common yet challenging ailment.
This episode is not just a deep dive into the medical aspects of shoulder pain but also a guide on enhancing patient outcomes. It's a must-listen for the health professional looking to expand their expertise in orthopaedics, offering practical advice and advanced knowledge to improve their day-to-day practice. The podcast promises to equip the lisytener with the tools and understanding necessary to effectively diagnose, treat, and manage shoulder pain, ultimately enhancing patient care.
Aussie Med Ed is sponsored by -HealthShare is a digital health company, that provides solutions for patients, General Practitioners and Specialists across Australia.
Aussie Med Ed is sponsored by Avant Medical Indemnity: They state that they offer holistic support to help the doctor practice safely and believe they have extensive cover that's continually evolving to meet your needs in the ever changing regulatory environment.
Transcript
WEBVTT
00:00:00.020 --> 00:00:12.901
Good day and welcome to the Aussie Med Ed, the Australian Medical Education broadcast, where we get to interview specialists in a variety of medical areas, asking their opinion on their certain conditions, obtaining their insight into how they diagnose and treat that condition.
00:00:12.901 --> 00:00:21.842
These COVID times it's a way of replacing the relaxed discussion around the hospital by allowing the listener to put forward questions to be answered addressed on their behalf.
00:00:21.842 --> 00:00:23.911
I hope you enjoyed the whole program.
00:00:23.911 --> 00:00:25.719
Welcome once again to Aussie Med Ed.
00:00:25.719 --> 00:00:31.786
In this episode we're going to present an orthopedic topic, an area of shoulder surgery which is my area of expertise.
00:00:31.786 --> 00:00:50.225
As such, in this episode I've decided to discuss the issue of shoulder pain, both the assessment of patients with the conditions, the various causes of it, how to make the diagnosis and investigations required, and the treatment of the most common causes of shoulder pain, that being the rotatoculf spectrum, including impingement and bursitis, tendinopathy and rotatoculf tears.
00:00:52.311 --> 00:00:55.500
I'm Gavin Nyman, an orthopedic surgeon based in Adelaide and South Australia.
00:00:55.500 --> 00:00:57.204
I'm the host of this podcast.
00:00:57.204 --> 00:01:06.424
I'd like to begin this podcast by acknowledging the traditional custodians of the land which this podcast has been produced and pay my respects to the elders, both past and present.
00:01:06.424 --> 00:01:09.915
Okay, a little bit about myself.
00:01:09.915 --> 00:01:16.246
I'm a orthopedic surgeon, having graduated from the University of Adelaide, worked in the United Kingdom for a period of time before heading back to Australia.
00:01:16.246 --> 00:01:23.644
I'm a fellow of the Royal Australasian College of Surgeons and also the Royal College of Surgeons of Edinburgh, and also a fellow of the Australian Orthopedic Association.
00:01:23.644 --> 00:01:30.709
I hold the senior lecturer position at the University of Adelaide and I'm involved in medical student teaching, particularly the fourth years and sixth years at university.
00:01:30.709 --> 00:01:42.447
It's my passion for orthopedics as well as teaching that's made me introduce this idea of doing this podcast, and this is actually introduced the topic of my choice, that being shoulder pain, which is a very common question that's put to me as a senior lecturer.
00:01:42.447 --> 00:01:46.611
So shoulder pain is really the most common thing that I would see in my orthopedic practice.
00:01:46.611 --> 00:01:53.685
It's really a very common question put to me by general practitioners and medical students on how you assess it and how you treat the various causes of it.
00:01:54.466 --> 00:02:08.486
Really, I start off by saying that the first, most important part of it is to actually exclude other causes of shoulder pain, as the cause In other words, depending on where the pain is actually experienced depends on whether it's actually shoulder pain or it's arising from some other area.
00:02:08.486 --> 00:02:23.235
For example, I put down the fact that the pain felt down the medial board of the scapula or in the posterior triangle of the neck is more likely to be related to the cervical spine, as well as pain on the front of the chest wall being more likely to be related to the ribs or from a muscular cause.
00:02:23.235 --> 00:02:26.729
Shoulder pain is generally felt on the front of the shoulder or laterally.
00:02:26.729 --> 00:02:34.103
Pain on the front of the shoulder is seen to arise from the glenic hemo joint, or pain laterally is more in the subacromial area, in the bursal region.
00:02:34.103 --> 00:02:40.205
One must never forget that cardiac causes can also cause shoulder pain, particularly left sided shoulder pain as well.
00:02:40.205 --> 00:02:53.225
So when we start looking at a shoulder cause, we look at the actual side of pain, and if the pain is actually either the medial board of the scapula or lower in the chest wall or in the exilla, I start thinking that it might not be related to the shoulder in itself.
00:02:53.568 --> 00:03:01.372
When we come to the causes of shoulder pain, it's really important to know the various diagnoses, and I actually like to divide this up into a simplified pattern.
00:03:01.372 --> 00:03:06.203
Really, unless you know the various diagnoses that occur in a condition, you can't actually make a diagnosis.
00:03:06.203 --> 00:03:15.099
Example being let's you know what you're looking for when you go to assess a patient, so you can't form a formal diagnosis because you don't know the various options of diagnoses are.
00:03:15.099 --> 00:03:18.074
The way I think about it is how a patient might present.
00:03:18.074 --> 00:03:32.239
They might either come through a clinic and see them in outpatients, or they might come through emergency as a traumatic presentation, and thus we divide the traumatic presentations into things that have been caused by a trauma, such as a fracture or dislocation, and sometimes infection can present in this way.
00:03:32.239 --> 00:03:43.931
They could recall a small trauma, or they may come through casualty with severe pain, but really I divide the traumatic presentations into fractures, dislocations and infections, including this group could be acute ruptures of tendons as well.
00:03:43.931 --> 00:04:04.552
Well, the length of conditions are usually ones that present in a clinic and they relate to the condition in itself, and the shoulder relates to either rotata cuff spectrum, that being bursitis, tendinopathy with secondary rotata cuff tears, or then secondary osteoarthritis, or it can relate to arthritis of the hemal joint or another part of the joint in the shoulder, or also late, to frozen shoulders.
00:04:04.552 --> 00:04:14.370
So let's put this in a simplified fashion If a patient presents in a traumatic fashion I either had a fall or a major trauma or injury then that's a traumatic presentation.
00:04:15.253 --> 00:04:20.935
And when we think of a traumatic presentation, we think what can be a fracture, is it a dislocation or is it an infection?
00:04:20.935 --> 00:04:24.894
So, if someone falls on the football field, could it be a fracture or dislocation?
00:04:24.894 --> 00:04:26.422
Okay, what could be fractured?
00:04:26.422 --> 00:04:28.391
Obviously, the most obvious cause is a bone.
00:04:28.391 --> 00:04:30.319
What bones have made up the shoulder?
00:04:30.319 --> 00:04:35.983
There's three bones really, that being the three bones being the clavicle, the scapula and the proximal humerus.
00:04:37.045 --> 00:04:39.271
If there's a dislocation, what can be dislocated?
00:04:39.271 --> 00:04:43.007
The obvious answer is a joint, the joints that actually make up the shoulder.
00:04:43.007 --> 00:04:45.564
There's three of them, again following the rule of threes.
00:04:45.564 --> 00:04:51.531
There's a sternocular vicular joint, which is a fairly stable joint and doesn't often dislocate but can occur on occasions.
00:04:51.531 --> 00:04:54.942
There's the AC joint, which is a very common cause of dislocations.
00:04:54.942 --> 00:05:01.043
Or there's a glenohumeral joint itself, which is the main proximal humerus, dislocating out of the glenoid socket.
00:05:02.586 --> 00:05:10.151
Infection can involve either the bones or the joints and, as such, a patient may present with a traumatic episode recalling some major trauma.
00:05:10.151 --> 00:05:13.773
But really the infection has been brewing all along.
00:05:13.773 --> 00:05:17.324
In other words, once or twice a year you might see a primary infection.
00:05:17.324 --> 00:05:24.480
It's usually more commonly occurs than someone who's been immunocompromised, or in a younger age group or the older age group or if they've had a surgical procedure.
00:05:24.480 --> 00:05:31.041
The elective conditions really relate more to the main conditions that affect the joint itself.
00:05:31.041 --> 00:05:41.329
So we don't have a simplified pattern to try and think of the elective conditions but really you have to know the actual individual joint and when it comes to the shoulder, the main causes of elective presentations relate to the rotator cuff.
00:05:42.093 --> 00:05:49.252
Rotator cuff has a group of muscles that encircle the glenohumeral joint which provide stability to the shoulder and also find movements.
00:05:49.252 --> 00:05:55.103
They comprise the four muscles being the supraspinatus, infaspinatus, sub scapularis and teres minor.
00:05:55.103 --> 00:05:57.269
All of them help control the shoulder joint.
00:05:57.269 --> 00:06:03.603
In itself the supraspinatus is a depressor of the human head to allow the dill toward, to allow abduction of the shoulder.
00:06:03.603 --> 00:06:15.232
The subscapularis main function is internal rotation of the shoulder, while the infusmenutus main function is external rotation of the shoulder, along with teres minor, which also external, rotates with the arm in the abducted position.
00:06:15.232 --> 00:06:17.069
All these can present with pain.
00:06:18.024 --> 00:06:21.173
Retardocuff conditions present really as one of three or four main ways.
00:06:21.173 --> 00:06:32.831
There's the primary bursitis which occurs in the younger person when they've done a lot of overhead work and they experience pain naturally in their arm worse when abducting between 70 to 120 degrees of range of motion.
00:06:32.831 --> 00:06:45.552
As you get a bit older, the tendons themselves degenerate slightly and as such the same thing occurs, but the pain tends to linger on longer and doesn't settle quite so quickly and can often be bothering the patient more at night.
00:06:45.552 --> 00:07:05.833
As the patient deteriorates in age and hastened by other factors such as excessive overhead work or by smoking, which can degenerate to collagen fibres in the tendon, the person can go on to develop rotatocuff tears and, as with any joint, as the rotatocuffs tear then the joint becomes a little bit more unstable, which predisposes it to develop secondary arthritis.
00:07:05.833 --> 00:07:13.791
So rotatocuff spectrum presents in that same four fashion bursitis, tendinopathy, rotatocuff tears and then secondary arthritis.
00:07:14.345 --> 00:07:21.353
Other conditions that can occur in the shoulder are osteoarthritis, and this usually presents with pain foot more anteriorly in the shoulder, affecting the linear human joint.
00:07:21.353 --> 00:07:26.495
As the arthritis deteriorates, the range of motion slowly deteriorates as well.
00:07:26.495 --> 00:07:29.600
The patient might experience some crepitus or bony crepitus.
00:07:29.600 --> 00:07:31.468
That's such that they've been extremely rotate their arm.
00:07:31.468 --> 00:07:33.995
They feel or hear some noises in their shoulder.
00:07:33.995 --> 00:07:44.156
Now these noises can also be felt in the subacromial space with rotatocuff tears and this is known as a soft tissue crepitus, as opposed to the bony or hard crepitus you get with osteoarthritis.
00:07:44.156 --> 00:08:09.906
Osteoarthritis can also affect the other two joints in the body the sternocleovicular joint and that usually presents more common in ladies, as they notice it because their neckline is usually lower and they're looking in that area while they put necklace on and they'll see a lump appear at the sternocleovicular area and often some discomfort will make and then also lacticle the ac joint and this is more common, particularly in general underplayed sport or they've done a lot of push ups, such as push ups, put a lot of force through the ac joint.
00:08:09.906 --> 00:08:22.415
That can cause the ac joint to degenerate and this can lead to a lump appearing at the acromio-colivicular joint or pain when they're abducting more above the 70 degree range, they're looking more at 150 to 180 degrees or n range of motion.
00:08:22.415 --> 00:08:31.295
It's also experienced when cross arm adductions, in other words when the arm is pushed across the chest, or known as also as a scarf test when assessing that particular movement.
00:08:32.985 --> 00:08:38.652
The third main conditions that occur in the shoulder is the frozen shoulder conditions, and this is an unusual condition.
00:08:38.652 --> 00:08:39.889
It's very common.
00:08:39.889 --> 00:08:41.890
No one really knows why it occurs.
00:08:41.890 --> 00:08:51.917
There's a lot of theories and it's more associated with diabetes as well, as I have seen it in people who have had previous radiotherapy or ladies post breast cancer treatment.
00:08:51.917 --> 00:08:59.423
It needs to be differentiated from those two arthritis the both arthritis and frozen shoulders present can present with stiff shoulders.
00:08:59.423 --> 00:09:09.398
But frozen shoulder usually follows a simple pattern of initially a lot of pain felt, predominantly anteriorly or laterally in the shoulder, although some, particularly at night, it's a searing pain.
00:09:09.398 --> 00:09:16.879
It's often very emotional pain, such as the patient feels almost teary because they're exhausted from it, and then slowly the pain improves.
00:09:16.879 --> 00:09:19.629
But before the pain improves the shoulder actually becomes stiff.
00:09:19.629 --> 00:09:29.210
So it goes through a painful phase, then a painful and stiff phase, and the pain slowly settles and at this stage the patient starts feeling better in themselves, even though the shoulder is still quite stiff.
00:09:29.210 --> 00:09:36.514
Eventually the stiffness does resolve, although there's evidence that it never fully resolves, such that there's always a slight degree of minor stiffness.
00:09:36.514 --> 00:09:39.634
Here are the three main conditions that affect the shoulder.
00:09:39.634 --> 00:09:42.514
The fourth one, of course, is a double condition.
00:09:42.514 --> 00:09:45.148
Is pain referred from the neck, as we've discussed right at the beginning.
00:09:46.504 --> 00:09:51.208
Along with these traumatic presentations and elective presentations, there's variations of conditions as well.
00:09:51.208 --> 00:10:01.376
Recurrent dislocations are really an elective presentation of recurrent traumatic episodes and that's also another cause of presentations to an orthopedic surgeon.
00:10:01.376 --> 00:10:02.750
But as a part of that.
00:10:02.750 --> 00:10:26.548
You can also get subluxation episodes, which are minor, elective presentation, but really is an instability, or the labour itself, which is a stabilizing structure inside the shoulder joint around the edge of the glean would, may have torn and these labour tears can present with pain felt in the shoulder, particularly in certain positions, such as when throwing an item such as a ball, or when sleeping or putting the arm in the abducted extreme rotated position.
00:10:26.548 --> 00:10:37.250
Label tears used to be thought to be very common cause of shoulder pain, but nowadays it's thought that it's probably less likely the cause of a shoulder pain in itself and more likely an incidental finding.
00:10:37.250 --> 00:10:44.874
It certainly can be a cause of shoulder pain and particularly in patients that aren't getting better with other measures but are less common than initially thought.
00:10:46.105 --> 00:10:50.515
As part of the label tears, the long-hender bicep stender attaches to the superior aspect of the labrum.
00:10:50.515 --> 00:10:54.121
The pull of the bicep stender on the labrum can cause issues.
00:10:54.121 --> 00:11:04.828
This is the mechanism that's thought to be the cause of labortez, causing pain in the self, and one of the treatments can be releasing the biceps tendon off the labrum and reattaching outside the shoulder.
00:11:04.828 --> 00:11:11.071
Apart from that, the actual biceps itself can also become inflamed and tendinopathic and that can cause pain.
00:11:11.071 --> 00:11:23.511
This itself causes pain anteriorly in the shoulder along the long head of biceps path, which is really in the bicepial groove, which is the space between the greater tuberosity and lesser tuberosity in the proximal humerus.
00:11:23.511 --> 00:11:32.832
This can easily be felt when the arm is palpated anteriorly and the forearm and the shoulders externally and internally rotated, you'll feel the bicepial groove fairly easily.
00:11:32.832 --> 00:11:45.076
Biceps pain itself is often associated with rotator cuff spectrum and as such, the actual bicep tendon may be treated at the time of rotator cuff surgery if surgery is warranted.
00:11:46.284 --> 00:11:53.394
So as a shoulder surgeon, I've been asked to make the diagnosis of what causes the shoulder pain and I start off by saying could it be coming from the neck?
00:11:53.394 --> 00:11:55.470
Could it be coming from the chest wall itself?
00:11:55.470 --> 00:12:05.123
And in the older person it's always important to exclude cardiac cause for the left shoulder pain, in particular, once we're pretty sure it's shoulder, we're in the shoulders of causing pain.
00:12:05.123 --> 00:12:10.469
Is it more anteriorly, more with the glenohumor joint, or is it more lactically fitting with the rotator cuff spectrum?
00:12:10.469 --> 00:12:12.908
The history helps a lot.
00:12:12.908 --> 00:12:16.313
Obviously, an older person is more likely to have arthritis than a younger person.
00:12:16.313 --> 00:12:21.489
In the middle age group, ie the 20 to 50 year old is more likely to have a frozen shoulder scenario.
00:12:23.288 --> 00:12:38.236
Obviously, if they present after a traumatic episode, we're thinking of traumatic causes such as fractures, dislocations or the development of infection which has been hidden by a traumatic cause, ie the person with infection may recall some minor trauma which has triggered off their pain.
00:12:38.236 --> 00:12:44.250
If they present an elective presentation with an insidious onset, we're thinking more of those three main diagnoses.
00:12:44.250 --> 00:12:51.831
However, these chronic causes or these elective presentations can present after minor trauma, so we always need to keep them in mind as well.
00:12:51.831 --> 00:13:00.754
Arspectrical history always has to be taken into account as well, ie family history of dislocations or previous history of other joints being dislocated.
00:13:00.754 --> 00:13:08.350
Also, medications thereon might be worthwhile and if they're a smoker, also work factors need to be taken into account.
00:13:08.350 --> 00:13:14.916
If they do overhead work, taking a history for an exam purpose is always important to know what previous treatment they've had as well.
00:13:14.916 --> 00:13:25.556
It's always important to know whether they've received physiotherapy or received medication, whether they've tried a steroid injection into the shoulder and also whether they've had surgery.
00:13:26.125 --> 00:13:28.913
When we come to examination, we look at the look-fill-move technique.
00:13:28.913 --> 00:13:31.711
We look from the front, the side and the back.
00:13:31.711 --> 00:13:33.509
We look at the neck posture.
00:13:33.509 --> 00:13:37.240
I like to exclude the neck as a cause of shoulder pain.
00:13:37.240 --> 00:13:53.315
From the start I usually start with flexion, extension, lateral flexion, lateral rotation of the neck and a combined manoeuvre of all three extension, lateral flexion and external rotation of the neck it can cause the neuroframing to close up.
00:13:53.315 --> 00:13:56.855
This is known as Spirling's Test or a neuroframinal compression.
00:13:56.855 --> 00:14:01.496
It's a good way of excluding cervical spine entrapment as a cause of shoulder pain.
00:14:01.496 --> 00:14:08.149
If the patient experiences shoulder pain or paracetia on the hand when they do that manoeuvre, you've got to think the cervical spine is a cause.
00:14:09.451 --> 00:14:11.839
When we look at the shoulder itself, we look from the front and the side.
00:14:11.839 --> 00:14:22.520
On the back we're looking at the shape of the clavicle, the shape of the sternocovlicula and the chromoclavicula joints, any swelling in these areas, the actual shape of the deltoid.
00:14:22.520 --> 00:14:27.341
On the back we can look at the super spinatus fossil and the infant spinatus fossil looking for wasting.
00:14:27.341 --> 00:14:35.735
And from the side we can look at the posture of the arm and if there's any of the associated scars we then move the fill.
00:14:35.735 --> 00:14:38.581
It's very easy to fill around the shoulder or palpate the region.
00:14:39.191 --> 00:14:51.503
You can start the sternocovlicula area and palpate along the clavicle to the chromoclavicula joint, which is a little bump on the lateral end of the clavicle In this area where you'd put your handle of your rucksack on to help stop the rucksack falling off your shoulder.
00:14:51.503 --> 00:14:57.302
Going slightly lateral to that, you'll feel the edge of the chromium and then even more lateral to the subacromia of space.
00:14:57.302 --> 00:15:01.500
The humal head seems to sit anterior in this area.
00:15:01.500 --> 00:15:09.649
So if you fill the actual anterior, posterior dimensions of the chromium and then you'll find the humal head is actually sitting in the anterior 50% of this area, underneath the chromium.
00:15:09.649 --> 00:15:39.418
You can fill down the lateral aspect of the shoulder in the subacromial area called the subacromial bursa, and if you palpate with one hand along the anterior aspect of the proximal humerus while you internally and externally rotate the shoulder, you'll feel the bicepular groove and the tendon Medial to that and just below the ac joint is the coracoid and going posteriorly you'll feel the supraspinase fossa, filling for muscle bulk and infaspinase fossa and then move to motion or moving the shoulder.
00:15:39.690 --> 00:16:00.519
We go for the active motion first and if there's any reduced range of motion, actively within a passive motion we look at forward flexion, which is in the frontal plane, extension, which is going backwards, lateral abduction, usually with the hand externally rotated, and then we can do internal and external rotation with the arm by the side, which is a great way of assessing if there's stiffness in the clean and humal joint.
00:16:00.519 --> 00:16:07.937
Because if there is stiffness in the shoulder itself, there won't be or there will be limited external rotation, particularly assessed with the arm by the side.
00:16:07.937 --> 00:16:16.600
The reason is that the actual scapula can actually compensate for most of a lot of the shoulder motion and can fool a young examiner.
00:16:16.600 --> 00:16:26.471
However, because the scapula is stuck to the posterior chest wall, external rotation of the shoulder is not possible because the scapula has got nowhere to move to Certainly.
00:16:26.471 --> 00:16:37.081
Forward flexion is helped by the scapula rotating in the coronal plane and internal rotation of the shoulder is helped by the scapula curling around the lateral side of the chest wall.
00:16:38.071 --> 00:16:45.620
If there is limited active motion within assessed passive motion and I like to assess this by holding the scapula with my opposite hand.
00:16:45.620 --> 00:17:00.649
So if I'm examining a right shoulder, I'll put my left hand on the inferior border of the scapula and then help the forearm up in the forward flexion and abduction, assessing whether there is reduced range of motion, both passively.
00:17:00.649 --> 00:17:05.422
If the passive motion is reduced and if the scapula moves early, we're thinking a stiff, clean and humal joint.
00:17:05.422 --> 00:17:11.609
This will be seen both on forward flexion and abduction, again reinforced by external rotation with the arm by the side.
00:17:11.609 --> 00:17:22.523
If there is a stiff, clean and humal joint, both passively and actively, then I'm thinking a condition which causes stiffness in the joint, which is either osteoarthritis or frozen shoulder.
00:17:22.523 --> 00:17:30.163
An easiest way to assess between the two is by either feeling some bony crepitus or identifying on X-ray that there is arthritis.
00:17:30.163 --> 00:17:50.439
If the passive motion is very good but the active motion is limited, then I'm thinking either the rotator cuff is completely torn or a very large tear, or there's a neurological issue, such as a C5 nerve root arising from the cervical spine, causing weakness of motion, particularly external rotation or abduction.
00:17:50.439 --> 00:18:12.040
If, however, the active range of motion and passive range of motion are very good, but there's a painful arc in the 70 to 120 degree range of motion, I'm going to set on belief that the most likely cause of this will be the rotator cuff spectrum and, depending on the patient's age and also depending on whether they've got weakness of motion, would help me to differentiate between bursitis, tendinopathy and rotator cuff tear.
00:18:12.040 --> 00:18:21.910
If the pain, however, occurs at any range of motion, particularly if cross arm abduction, such as doing the scarf test, this would make me think AC joint pathology.
00:18:21.910 --> 00:18:30.631
If, however, the pain is predominantly anteriorly and directly over the bicep standard, I'm thinking more bycipital pain or bycipital tendinopathy.
00:18:30.631 --> 00:18:46.011
That's, by combination of a good history excluding other causes of shoulder pain, as well as a simple examination, looking at both inspection, palpation and motion, actively and passively, we can get a pretty good idea of what the underlying condition is.
00:18:47.345 --> 00:19:04.853
Once we've finished the basic look-fill move, we go to special tests and then they start off with if we're looking at rotator cuff spectrum testing muscle power, and I like to test the external rotation of the arm, the arm abducted by the side, as a way of assessing infisperinatus muscle, tendon muscle strength.
00:19:04.853 --> 00:19:17.952
I assessed internal rotation, ie with the elbow forward flexed and the palm pushing onto the belly as a belly press test, and this is a way of assessing the subscapularis.
00:19:17.952 --> 00:19:33.811
Whilst assessing subscapularis with the arm internally rotated in the plane of the scapula, which is slightly forward flexed and slightly abducted, and at about 70 degrees of abduction, I'm pushing up against the owner board of the forearm and this is a way of assessing subscapularis power.
00:19:33.811 --> 00:19:57.151
All the special tests which we need to assess are shoulder instability If there's been a history of shoulder instability or dislocation, or if there's a story of pain felt anteriorly in the shoulder or a sensation of the shoulder subluxing, or if the experience of pain went throwing, then a way to assess shoulder instability is by assessing the stability tests.
00:19:57.151 --> 00:20:02.093
Now I would say the most important part of this is actually assessing the general patient's laxity as well.
00:20:02.093 --> 00:20:10.632
Make sure they can't hyperextend their fingers or their thumbs or their elbows, hyperextend their knees or be able to touch their palms, the ground easily with their flat of their palms.
00:20:10.632 --> 00:20:16.852
These are ligament laxity tests and if they have some instability issues, they usually have some degree of ligament laxity.
00:20:16.852 --> 00:20:36.769
If these are normal and the shoulder can also be assessed by assessing sulcus sign and this is where the patient is sitting on the side of the bed, the forearms resting on the lap and gentle downward traction can put pressure on the shoulder to see if a sulcus or a little gap appears between the acromion and the proximal humerus.
00:20:36.769 --> 00:20:42.653
It is normal to have a small degree of motion, but if it is excessive then it's a positive sign.
00:20:42.653 --> 00:20:45.792
We can test apprehension, which is the most important test.
00:20:45.792 --> 00:20:48.709
This is where the patient is lying flat or can be done standing.
00:20:48.709 --> 00:21:11.692
The arm is placed in abduction, external rotation and forward pressure is placed on the proximal humerus while the arm is externally rotated, and often the patient will feel some apprehension or guarding of the shoulder or be concerned that the shoulder could dislocate or feels painful If, while doing the same test by placing posterior pressure on the proximal humerus while I'm pressing anteriorly, this is known as a positive relocation test.
00:21:11.692 --> 00:21:19.096
Finally, we can test for posterior instability by pushing the shoulder backwards with the arm adducted and flexed across the chest.
00:21:19.096 --> 00:21:29.173
So in other words, the elbow is flexed at 90 degrees, the upper arm is placed across in front of the chest and the whole forearm is pushed backwards, trying to subluxulate the proximal humerus posteriorly.
00:21:30.152 --> 00:21:37.652
So the most common cause of shoulder pain obviously is the rotator cuff spectrum, that's, the bursitis or tendinopathy of an older patient, or rotator cuff tears.
00:21:37.652 --> 00:21:48.416
As stated before, they present predominantly with a pain, worse at night, often when doing overhead activities and usually with the arm in the 70 to 120 degree range of motion.
00:21:48.416 --> 00:21:53.585
In these scenarios the treatment really is such that you need to address the cause.
00:21:53.585 --> 00:21:56.632
If they're doing a lot of overhead work, you might need to back off on that.
00:21:56.632 --> 00:22:03.311
You need to treat the pain with analgesics and you might want to try an anti-inflammatory medication if the patient's suitable to try it.
00:22:04.432 --> 00:22:17.800
Usually, with the course of physiotherapy to retrain the rest of the muscles and tone up the musculature around it, the patient improves and a bit of period of rest and then with some rehabilitation following the physiotherapy, most patients improve and don't need anything further done.
00:22:17.800 --> 00:22:23.134
If the pain continues to bother them, then a trial of a corticosteroid injection can be performed.
00:22:23.134 --> 00:22:28.974
This is often done with under an ultrasound guidance so that the actual diagnosis can be confirmed.
00:22:28.974 --> 00:22:39.634
Following that, if, following a period of time and further physiotherapy, the patient continues to experience pain, that's when a second steroid injection can be tried.
00:22:39.634 --> 00:22:42.094
Usually we wouldn't try more than one or two of them.
00:22:42.094 --> 00:22:46.704
If this continues to bother the patient, then we would consider a referral to an orthopedic surgeon.
00:22:46.704 --> 00:22:49.173
One of the first tests we would like would be an X-ray.
00:22:49.173 --> 00:23:04.132
The X-ray will look at the degree of arthritis in the AC joint and whether this could be catching on the rotator cuff, the shape of the acromine, whether it's hooked or whether it's got an underlying spur, as well as to exclude any underlying arthritis in the proximal gleniohemal joint.
00:23:04.989 --> 00:23:09.954
Often, at the time of the ultrasound for the steroid injection, the radiologist identifies a rotator cuff tear.
00:23:09.954 --> 00:23:15.305
Now some of these are actually quite small and very miniscule and don't need anything further done.
00:23:15.305 --> 00:23:19.751
But if there's a larger tear, this may be something that could be addressed if the patient doesn't settle on their own.
00:23:19.751 --> 00:23:24.596
I'd state that most rotator cuff tears don't cause long-term problems.
00:23:24.596 --> 00:23:33.250
The vast majority of people can live with a rotator cuff tear and actually by rehabilitating with physiotherapy and building up the muscles around it, they actually don't even know they've got a problem.
00:23:34.829 --> 00:23:48.154
There was one school of thought that the rotator cuff tears can become bigger and cause issues later in life, but often these don't, and if they do become more painful and continue to bother the patient, that's when rotator cuff tear would not be addressed anyway.
00:23:48.154 --> 00:23:50.484
So usually we'd try these simple measures first.
00:23:50.484 --> 00:24:04.285
But if the patient's not settling either with a rotator cuff tear or without, then they'll be referred to an orthopedic surgeon where the X-ray would be assessing whether there's a subacromial spur, whether they see joint arthritis and also whether there's any.
00:24:04.285 --> 00:24:07.809
They would also want to exclude the underlying arthritis in the proximal glial hemodroint.
00:24:07.809 --> 00:24:38.272
Assuming there's either impingement from an underlying spur or ac joint arthritis or there's a rotator cuff tear, surgery might be considered and in that scenario what we would do, either open or arthroscopically would assess the rotator cuff, repair the tendon by roughing the bone of the greater tuberosity and tying it down using sutures or with or without anchors into the proximal shoulder and then take away any underlying bone catching on the tendon, either from the ac joint or the lateral chromium.
00:24:38.272 --> 00:24:46.477
This is known as a shoulder arthroscopic or open decompression or, say to me, cuff repair.
00:24:46.477 --> 00:25:05.045
And as part of that we may, if there is arthritis of the AC joint or chromicular joint, excise the latch-winded clavicle or if there's bicep tendinopathy or labial tear that's causing issues, either repair the labrum or release the biceps from the labrum and reattach it outside the shoulder, known as a proximal biceps tinnodesis.
00:25:05.045 --> 00:25:10.691
This is where the long-headed biceps is tied down to the proximal humerus so that it doesn't retract.
00:25:10.691 --> 00:25:20.016
There's a lot of evidence that actually the biceps can be released without issues, although some people might notice a deformity and that can be concerning to the patient.
00:25:20.016 --> 00:25:24.641
But usually the vast majority of patients don't have any issues from having the biceps released.
00:25:24.641 --> 00:25:30.470
But often we try and attach it outside the shoulder so that doesn't cause any shoulder cosmetic abnormality.
00:25:31.513 --> 00:25:34.185
The second most common cause of shoulder pain is frozen shoulder.
00:25:34.185 --> 00:25:39.711
This presents with pain and then pain, the stiffness and then the pain goes away and it remains stiff.
00:25:39.711 --> 00:25:49.944
Usually, in the first few stages there's probably the worst time to treat the patient because the shoulder for some reason isn't flamed and often if treatment is done too early, the condition can just flare up once again.
00:25:49.944 --> 00:25:55.328
However, if despite time and the patient is not settling, treatment is offered.
00:25:55.328 --> 00:26:02.583
The most important treatment initially is both diagnosis to exclude anything sinister, and then reassurance that it will get better with time.
00:26:02.583 --> 00:26:16.938
Sometimes analgesics and hydrotherapy are useful, but if all that fails, then the options of treatment involve either a steel injection into the shoulder joint with or without a bit of fabric, a fluid being put in called a hydro dilatation to try and stretch the capsule up.
00:26:16.938 --> 00:26:22.242
Other options involve manipulating the shoulder joint or doing a telescopic release of the shoulder joint.
00:26:22.242 --> 00:26:24.509
All of these have benefits and merits.
00:26:24.509 --> 00:26:29.765
However, it's been proven a lot of these shoulders will improve with time even without any further treatment.
00:26:29.765 --> 00:26:35.570
The reason for treatment is to help try and help the patient get through the period and speed up the recovery.
00:26:37.238 --> 00:26:40.468
The final pain diagnosis in the shoulder joint selectively, is arthritis.
00:26:40.468 --> 00:26:56.804
Now I like to think of arthritis as being either primary osteoarthritis, secondary, following trauma or inflection or inflammation, or post metabolic cause, such as gout or hemochromatosis, or an inflammatory arthritis, such as rheumatoid or psoriatic arthritis.
00:26:56.804 --> 00:27:09.989
Either way, the main treatment of arthritis is initially well non-surgical, involving analgesics or, if it's an inflammatory condition, anti-inflammatory medication advised by the rheumatologist.
00:27:09.989 --> 00:27:17.976
But if the shoulder pain continues and there's a lot of deformity of the humerus and the glenarum joint, then a shoulder replacement may be warranted.
00:27:18.597 --> 00:27:23.663
Depending on whether the rotator cuff is intact or not depends on the type of shoulder replacements that is performed.
00:27:23.663 --> 00:27:32.813
With an intact rotator cuff we do a standard anatomical shoulder replacement where the ball is replaced with an artificial ball and the socket is replaced with an artificial socket.
00:27:32.813 --> 00:27:37.107
However, in the last 20 years, reverse shoulder replacements have become very common.
00:27:37.107 --> 00:27:49.594
These type of shoulder replacements involve replacing the proximal glenarum joint with still an artificial socket and an artificial ball, but the ball is placed on the socket side and the socket is placed on the ball side.
00:27:49.594 --> 00:27:51.983
That's why it's called a reverse shoulder replacement.
00:27:51.983 --> 00:28:14.727
The advantage of this is it compensates for any torn or deficient tendons that may occur with age or with rotator cuff tears, such that if you don't have a intact rotator cuff, if you do an anatomical shoulder placement and put the ball and socket in the anatomical position, there will be instability in the shoulder, just like we talked about before, with a torn rotator cuff leading the secondary arthritis.
00:28:14.727 --> 00:28:17.304
This instability will lead to loosening of the plastic socket.
00:28:17.304 --> 00:28:24.602
Therefore, the reverse shoulder replacement helps hold the ball in the linoid side and allows a deltoid to do the function for it.
00:28:24.602 --> 00:28:30.771
These are probably the most common ones being done nowadays in South Australia and Australia on the shoulder registry.
00:28:30.771 --> 00:28:50.862
So I think that hopefully that outlines my approach to treating a painful shoulder and hopefully it gives some direction to a medical student preparing for an exam and such that they can actually divide the actual different conditions into certain little pockets of conditions, such that they can help perform a diagnosis and then offer treatment options.
00:28:51.523 --> 00:28:59.905
Once again, I thank you very much for listening to my podcast and we look forward to the next episode where we'll be interviewing another specialist in the area on a different condition.
00:28:59.905 --> 00:29:03.162
Thank you very much and thank you for listening.
00:29:03.162 --> 00:29:15.413
The information provided today is designed to complement information provided to you in your local region and should supplement your readings and teachings in that area.
00:29:15.413 --> 00:29:22.813
Please don't take it as the only way of treating this condition or assessing a condition, but really is one of one of the various ways of assessing these conditions.
00:29:22.813 --> 00:29:32.667
Please be also be aware that the information provided today is really just general medical advice and isn't designed to actually be a source of medical information regarding your particular condition.
00:29:32.667 --> 00:29:38.582
Remember to consult your specialist or medical practitioner if you have concerns about condition raised in this podcast.
00:29:39.084 --> 00:29:40.807
Thanks once again for listening to our podcast.
00:29:40.807 --> 00:29:45.603
Aussie Med Ed or the Australian Medical Education Podcast Really enjoy hosting this podcast.
00:29:45.603 --> 00:29:49.248
I hope you find it useful to give a pragmatic approach to everyday conditions.
00:29:49.248 --> 00:30:00.983
If you have any questions or information you want to ask about us or you'd like to put a suggestion for a topic, please don't hesitate to email us at gabiniteedcomau.
00:30:00.983 --> 00:30:06.949
Once again, hope you enjoy listening to it and we look forward to hosting it next fortnight when we introduce a new topic.
00:30:06.949 --> 00:30:07.690
Thank you,
00:00:00.020 --> 00:00:12.901
00:00:12.901 --> 00:00:21.842
00:00:21.842 --> 00:00:23.911
00:00:23.911 --> 00:00:25.719
00:00:25.719 --> 00:00:31.786
00:00:31.786 --> 00:00:50.225
00:00:52.311 --> 00:00:55.500
00:00:55.500 --> 00:00:57.204
00:00:57.204 --> 00:01:06.424
00:01:06.424 --> 00:01:09.915
00:01:09.915 --> 00:01:16.246
00:01:16.246 --> 00:01:23.644
00:01:23.644 --> 00:01:30.709
00:01:30.709 --> 00:01:42.447
00:01:42.447 --> 00:01:46.611
00:01:46.611 --> 00:01:53.685
00:01:54.466 --> 00:02:08.486
00:02:08.486 --> 00:02:23.235
00:02:23.235 --> 00:02:26.729
00:02:26.729 --> 00:02:34.103
00:02:34.103 --> 00:02:40.205
00:02:40.205 --> 00:02:53.225
00:02:53.568 --> 00:03:01.372
00:03:01.372 --> 00:03:06.203
00:03:06.203 --> 00:03:15.099
00:03:15.099 --> 00:03:18.074
00:03:18.074 --> 00:03:32.239
00:03:32.239 --> 00:03:43.931
00:03:43.931 --> 00:04:04.552
00:04:04.552 --> 00:04:14.370
00:04:15.253 --> 00:04:20.935
00:04:20.935 --> 00:04:24.894
00:04:24.894 --> 00:04:26.422
00:04:26.422 --> 00:04:28.391
00:04:28.391 --> 00:04:30.319
00:04:30.319 --> 00:04:35.983
00:04:37.045 --> 00:04:39.271
00:04:39.271 --> 00:04:43.007
00:04:43.007 --> 00:04:45.564
00:04:45.564 --> 00:04:51.531
00:04:51.531 --> 00:04:54.942
00:04:54.942 --> 00:05:01.043
00:05:02.586 --> 00:05:10.151
00:05:10.151 --> 00:05:13.773
00:05:13.773 --> 00:05:17.324
00:05:17.324 --> 00:05:24.480
00:05:24.480 --> 00:05:31.041
00:05:31.041 --> 00:05:41.329
00:05:42.093 --> 00:05:49.252
00:05:49.252 --> 00:05:55.103
00:05:55.103 --> 00:05:57.269
00:05:57.269 --> 00:06:03.603
00:06:03.603 --> 00:06:15.232
00:06:15.232 --> 00:06:17.069
00:06:18.024 --> 00:06:21.173
00:06:21.173 --> 00:06:32.831
00:06:32.831 --> 00:06:45.552
00:06:45.552 --> 00:07:05.833
00:07:05.833 --> 00:07:13.791
00:07:14.345 --> 00:07:21.353
00:07:21.353 --> 00:07:26.495
00:07:26.495 --> 00:07:29.600
00:07:29.600 --> 00:07:31.468
00:07:31.468 --> 00:07:33.995
00:07:33.995 --> 00:07:44.156
00:07:44.156 --> 00:08:09.906
00:08:09.906 --> 00:08:22.415
00:08:22.415 --> 00:08:31.295
00:08:32.985 --> 00:08:38.652
00:08:38.652 --> 00:08:39.889
00:08:39.889 --> 00:08:41.890
00:08:41.890 --> 00:08:51.917
00:08:51.917 --> 00:08:59.423
00:08:59.423 --> 00:09:09.398
00:09:09.398 --> 00:09:16.879
00:09:16.879 --> 00:09:19.629
00:09:19.629 --> 00:09:29.210
00:09:29.210 --> 00:09:36.514
00:09:36.514 --> 00:09:39.634
00:09:39.634 --> 00:09:42.514
00:09:42.514 --> 00:09:45.148
00:09:46.504 --> 00:09:51.208
00:09:51.208 --> 00:10:01.376
00:10:01.376 --> 00:10:02.750
00:10:02.750 --> 00:10:26.548
00:10:26.548 --> 00:10:37.250
00:10:37.250 --> 00:10:44.874
00:10:46.105 --> 00:10:50.515
00:10:50.515 --> 00:10:54.121
00:10:54.121 --> 00:11:04.828
00:11:04.828 --> 00:11:11.071
00:11:11.071 --> 00:11:23.511
00:11:23.511 --> 00:11:32.832
00:11:32.832 --> 00:11:45.076
00:11:46.284 --> 00:11:53.394
00:11:53.394 --> 00:11:55.470
00:11:55.470 --> 00:12:05.123
00:12:05.123 --> 00:12:10.469
00:12:10.469 --> 00:12:12.908
00:12:12.908 --> 00:12:16.313
00:12:16.313 --> 00:12:21.489
00:12:23.288 --> 00:12:38.236
00:12:38.236 --> 00:12:44.250
00:12:44.250 --> 00:12:51.831
00:12:51.831 --> 00:13:00.754
00:13:00.754 --> 00:13:08.350
00:13:08.350 --> 00:13:14.916
00:13:14.916 --> 00:13:25.556
00:13:26.125 --> 00:13:28.913
00:13:28.913 --> 00:13:31.711
00:13:31.711 --> 00:13:33.509
00:13:33.509 --> 00:13:37.240
00:13:37.240 --> 00:13:53.315
00:13:53.315 --> 00:13:56.855
00:13:56.855 --> 00:14:01.496
00:14:01.496 --> 00:14:08.149
00:14:09.451 --> 00:14:11.839
00:14:11.839 --> 00:14:22.520
00:14:22.520 --> 00:14:27.341
00:14:27.341 --> 00:14:35.735
00:14:35.735 --> 00:14:38.581
00:14:39.191 --> 00:14:51.503
00:14:51.503 --> 00:14:57.302
00:14:57.302 --> 00:15:01.500
00:15:01.500 --> 00:15:09.649
00:15:09.649 --> 00:15:39.418
00:15:39.690 --> 00:16:00.519
00:16:00.519 --> 00:16:07.937
00:16:07.937 --> 00:16:16.600
00:16:16.600 --> 00:16:26.471
00:16:26.471 --> 00:16:37.081
00:16:38.071 --> 00:16:45.620
00:16:45.620 --> 00:17:00.649
00:17:00.649 --> 00:17:05.422
00:17:05.422 --> 00:17:11.609
00:17:11.609 --> 00:17:22.523
00:17:22.523 --> 00:17:30.163
00:17:30.163 --> 00:17:50.439
00:17:50.439 --> 00:18:12.040
00:18:12.040 --> 00:18:21.910
00:18:21.910 --> 00:18:30.631
00:18:30.631 --> 00:18:46.011
00:18:47.345 --> 00:19:04.853
00:19:04.853 --> 00:19:17.952
00:19:17.952 --> 00:19:33.811
00:19:33.811 --> 00:19:57.151
00:19:57.151 --> 00:20:02.093
00:20:02.093 --> 00:20:10.632
00:20:10.632 --> 00:20:16.852
00:20:16.852 --> 00:20:36.769
00:20:36.769 --> 00:20:42.653
00:20:42.653 --> 00:20:45.792
00:20:45.792 --> 00:20:48.709
00:20:48.709 --> 00:21:11.692
00:21:11.692 --> 00:21:19.096
00:21:19.096 --> 00:21:29.173
00:21:30.152 --> 00:21:37.652
00:21:37.652 --> 00:21:48.416
00:21:48.416 --> 00:21:53.585
00:21:53.585 --> 00:21:56.632
00:21:56.632 --> 00:22:03.311
00:22:04.432 --> 00:22:17.800
00:22:17.800 --> 00:22:23.134
00:22:23.134 --> 00:22:28.974
00:22:28.974 --> 00:22:39.634
00:22:39.634 --> 00:22:42.094
00:22:42.094 --> 00:22:46.704
00:22:46.704 --> 00:22:49.173
00:22:49.173 --> 00:23:04.132
00:23:04.989 --> 00:23:09.954
00:23:09.954 --> 00:23:15.305
00:23:15.305 --> 00:23:19.751
00:23:19.751 --> 00:23:24.596
00:23:24.596 --> 00:23:33.250
00:23:34.829 --> 00:23:48.154
00:23:48.154 --> 00:23:50.484
00:23:50.484 --> 00:24:04.285
00:24:04.285 --> 00:24:07.809
00:24:07.809 --> 00:24:38.272
00:24:38.272 --> 00:24:46.477
00:24:46.477 --> 00:25:05.045
00:25:05.045 --> 00:25:10.691
00:25:10.691 --> 00:25:20.016
00:25:20.016 --> 00:25:24.641
00:25:24.641 --> 00:25:30.470
00:25:31.513 --> 00:25:34.185
00:25:34.185 --> 00:25:39.711
00:25:39.711 --> 00:25:49.944
00:25:49.944 --> 00:25:55.328
00:25:55.328 --> 00:26:02.583
00:26:02.583 --> 00:26:16.938
00:26:16.938 --> 00:26:22.242
00:26:22.242 --> 00:26:24.509
00:26:24.509 --> 00:26:29.765
00:26:29.765 --> 00:26:35.570
00:26:37.238 --> 00:26:40.468
00:26:40.468 --> 00:26:56.804
00:26:56.804 --> 00:27:09.989
00:27:09.989 --> 00:27:17.976
00:27:18.597 --> 00:27:23.663
00:27:23.663 --> 00:27:32.813
00:27:32.813 --> 00:27:37.107
00:27:37.107 --> 00:27:49.594
00:27:49.594 --> 00:27:51.983
00:27:51.983 --> 00:28:14.727
00:28:14.727 --> 00:28:17.304
00:28:17.304 --> 00:28:24.602
00:28:24.602 --> 00:28:30.771
00:28:30.771 --> 00:28:50.862
00:28:51.523 --> 00:28:59.905
00:28:59.905 --> 00:29:03.162
00:29:03.162 --> 00:29:15.413
00:29:15.413 --> 00:29:22.813
00:29:22.813 --> 00:29:32.667
00:29:32.667 --> 00:29:38.582
00:29:39.084 --> 00:29:40.807
00:29:40.807 --> 00:29:45.603
00:29:45.603 --> 00:29:49.248
00:29:49.248 --> 00:30:00.983
00:30:00.983 --> 00:30:06.949
00:30:06.949 --> 00:30:07.690
