Approach

• See both shoulder joints
• ask to take off shirt to expose upper limbs

1. Look
   • SKin - scars, sinuses
   • Symmetry: deltoid, supraspinatus, infraspinatus
   • Shape:SCJ, clavicular deformity, prominent ACJ
2. Feel
   • Skin - increased temperature
   • Bones and joints - SCJ, clavicle, ACJ, acromion, humeral head, greater tuberosity, coracoidl;
   • Tendons - long head of biceps in bicipital groove
3. Move
   • Forward flexion (165')
   • Abduction - 90' gelnohumeral, scapulothoracic
     1. Difficulty initiating = rotator cuff tear
     2. Painful arc 60-120' = rotator cuff tendinitis (impingement syndrome) or minor rotator cuff tear
     3. Painful arc 140-180' = painful high arc: OA of ACJ
   • External rotation (with elbow flexed)
     1. Most commonly affected in frozen shoulder
   • Internal rotation: measured as thumb reaching mid-thoracic level T6
   • Test Power
     1. Deltoid abduction against resistance (axillary nerve)
     2. Serratus anterior: push against a wall to see winging of the scapula

Special tests

1. Supraspinatus: resisted abduction
2. Infraspinatus/teres minor: resisted internal rotation
3. Subscapularis: Gerber's lift off test with arm behind back resisting "lifting off"

Completion

1. Examine necl (joint above) and elbow (joint below)
2. Assess neurovascular status of the limb
3. Ask patient questions to assess how the condition affects his life

Causes of painful shoulder

1. Rotator cuff disorders
   • Tendinitis
   • Rupture
   • Frozen shoulder
2. Joint disorders
   • Glenohumeral arthritis
   • Acromioclavicular arthritis
3. Referred pain
   • Cervical spondylosis
   • Cardiac ischaemia
   • Mediastinal pathology
4. Instability
   • Dislocation
   • Subluxation
5. Bone lesions
   • Infection
   • Neoplasia
6. Nerve lesions
   • Suprascapular nerve entrapment

Rotator Cuff impingement

1. Repetitive rubbing of tendons under coracoacromial arch
2. Greatest wear occurs in impingement position - abduction, slight flexion and internal rotation
3. Sites of impingement: "critical area" of decreased vascularity in the supraspinatus tendon about 1cm proximal to its insertion into the greater tuberosity
4. Contributing factors to impingement: bone (OA thickening); tendon (rotator cuff swelling); bursa (bursitis)
5. Treatment of impingment
   • Avoid aggravating activity
   • Physiotherapy
   • Analgesia
   • Subacromial steroids
   • Subacromial decompression
6. Treatment of cuff tears
   • Physiotherapy
   • Cuff repair + subacromial decompression
   • Cuff debridement and subacromial decompression

Frozen Shoulder

1. Primary frozen shoulder (adhesive capsulitis)
   • Often idiopathic
   • Strong associations with diabetes / dupuytrens
   • Global contracture of shoulder joint but maximally in the rotator interval area around the coracohumeral ligament
   • Histologically contracture is made of a dense collagen matrix with numerous fibroblasts and myofibroblasts
   • May remain frozen due to slow remodelling as a result of high levels of tissue inhibitors of metalloproteinases (TIMPs) which inhibit matrix metalloproteinases (MMPs)
2. Secondary frozen shoulder
   • Intrinsic - rotator cuff injuries, trauma
   • Extrinsice - painful disorders leading to decreased movements of the shoulder - radiculopathy
3. Treatment
   • Non-surgical: pain relief, physiotherapy, MUA + steroid injection
   • Surgical: ill-defined role