Slide 1

NHS Bolton MSK Physiotherapy
The Shoulder
Vicky Lyle (Orthopaedic
Claire Guy (Specialist Physio)
 Lesley Anne Fraser – MSK Service Manager
– Contact: [email protected]
 Emily Barber – MSK Physio Team Leader
– Contact: [email protected]
– 01204 462504
 Sue Greenhalgh – Consultant Physiotherapist &
Interim Lead Clinician
– Contact: [email protected]
– 01204 462584
GP Training Agenda
Agenda Item
1. Introduction
2. Subjective Examination
3. Objective Examination
4. Adhesive Capsulitis
5. Impingement
Tea / Coffee Break
6. Cuff Tears
7. Orthopaedic Role
8. Practical
9. Conclusion
10. Interactive Discussion
Evening Session
 Recent service review demonstrated that out of a
random sample of 250 patients referred to MSK
Physiotherapy, 25% were regarding the shoulder
in isolation.
 24% of these referrals were regarding the lumbar
 Are there genuinely more patients with shoulder
pain that low back pain, or are we just better at
managing the back pain patient?
Subjective History – Top Five Tips
1. When and how did your shoulder pain start ?
2. Where are the symptoms exactly ?
3. Do you have any pins & needles, numbness or
weakness ?
4. Have you felt any other sensations, such as
locking, clunking or instability ?
5. What helps and what makes it worse?
Objective History – Top Five Tips
1. Observation
2. Cervical Spine Active Range of Movement
3. Active Range of Motion Glenohumeral Joint
a) Flexion, Abduction, Internal Rotation, External
4. Passive Range of Motion Glenohumeral Joint
a) Flexion, Abduction, Internal Rotation, External
5. Resisted Muscle Tests
Tests of Contractile Function
 Baseline Isometric Assessment:
– Abduction
– Adduction
– Lateral Rotation
– Medial Rotation
– Elbow Flexion
– Elbow Extension
→ Supraspinatus (& deltoid)
→ Teres Minor
→ Infraspinatus, teres minor
& possibly supraspinatus
→ Subscapularis
→ Biceps & brachialis
→ Triceps
Adhesive Capsulitis
 Codman described the first and best classical
diagnostic criteria for frozen shoulders in 1934
Global restriction of shoulder movement
Idiopathic aetiology
Usually painful at the outset
Normal X-ray
Limitation of elevation and external rotation
 Classification may be primary or idiopathic
 Secondary stiff shoulders can present typically
after injury or surgery
 Be aware of major trauma
 Age:
– Typically occurring in females more than males, in the
4th and 5th decade.
 Pain:
– Constant nature, severe, affecting sleep + +. Often a
toothache pain at rest, with sharp pains with forceful
– Pain centred in joint
 Loss of External Rotation:
– Commonly less than 30°
 Unguarded pain
Natural History
1. Freezing Phase:
a) Associated with pain and loss of movement
2. Frozen Phase:
a) Pain at extreme range of movement and marked
3. Thawing Phase:
a) Significantly less pain and the stiffness starts to
gradually resolve
 Hand et al. J Shoulder and Elbow Surg. 2008;
– • 90% have resolved at 3 years
– • 10% still have symptoms at 3 years
 The frozen shoulder has been found to be more
common in association with the following
– Diabetes (There is a 2-4 times increased risk for diabetics
of developing frozen shoulder. Insulin-dependent diabetics
have a 36% chance of developing it, 10% bilaterally).
Cardiac/lipid problems.
Endocrine abnormalities, particularly hypothyroidism.
Drugs – MMP Inhibitors.
 Advice and Education
– Reassurance
 Physiotherapy
– Exercise
– Manual therapy
– Pain Management
 Injections – please note that we have 3 injection
therapists within our MSK Physio service, and offer
patients a follow-up in Physiotherapy within 10 days
 Surgical Intervention
 During elevation of the shoulder, the humeral
tuberosities pass close underneath the
coracoacromial arch. Little space is left for the
intervening soft tissues, which comprise (from
superficial to deep), the bursa, the rotator cuff
tendons and the long head of biceps.
 If, for any reason, the available space reduces,
these soft tissues are liable to become pinched.
Possible Underlying Mechanisms
 Bony anatomical and pathological factors
 Shoulder instability
 Impaired scapulohumeral rhythm and scapular
 Capsular tightness
 Postural factors
 Soft tissue changes
 Age:
– Impingement spans the age ranges of other shoulder
conditions, but in patients under 35 years old is likely
to be secondary to instability
 Mode of onset:
– Can be insidious or related to a specific incident
 Pain:
– Felt in shoulder but can radiate into upper arm/deltoid
(sergeant stripes distribution)
– Typical painful arc
– Night pain common
– Often predictably activity-specific
 Physiotherapy
– Relative rest and avoidance of aggravating factors
beneficial in early management allowing pain and
inflammation to settle
– Absolute rest rarely necessary and risks precipitating painrelated illness behaviour and adhesive capsulitis
– Rehabilitation is vital
– Benefits of a short course are likely to outweigh the risks
unless contraindicated
 Injections
 Surgical Intervention
Rotator Cuff Tears
 Aetiology:
– There are 2 main theories for the cause:
 EXTRINSIC: Due to compression and impingement
of the rotator cuff.
 INTRINSIC: Due to changing properties of the
rotator cuff itself.
 Traumatic or degenerative
 Expected function/activity levels, pain and size of
tear need to be consideration factors for surgical
When to refer to Orthopaedics?
 Frozen shoulder:
– Diabetic males – early surgical opinion
– If Physiotherapy and injection therapy fail to settle the
symptoms adequately
 Impingement:
– If Physiotherapy and injection therapy fail to settle the
symptoms adequately
 Rotator cuff tears:
– Referral for all young and active cases
– In sedentary or elderly (degenerative) cases,
physiotherapy and injection therapy is usually
 Many shoulder problems are successfully
managed within Physiotherapy without the need
for an Orthopaedic opinion
 However, there are clear situations where an
early Orthopaedic opinion/intervention is
warranted, as discussed
 Injections in isolation not usually effective without
rehabilitation as soon as possible afterwards
 Rehabilitation vital in most cases
 Any questions?

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