Diagnosis

Clinical exam

If the patient does not respond to conservative treatment, then:

• X-ray (to rule-out joint OA)
• US (to rule-out calcification or rotator cuff pathology)
• MRI (to rule-out rotator cuff tear)
  

Treatment

Conservative treatment

• Rest/activity modification
• Ice (10-20 min, 2-3X/day)
• Physiotherapy – will accelerate healing and decrease the likelihood of recurrence
• Oral or topical NSAIDs and/or pain relief medication. Opioids are not recommended
• Cortisone injections - If you do not give injections, the patient may be referred to a sports medicine doctor

Physiotherapy will initially focus on pain relief and gentle shoulder range of motion exercise. Rotator cuff and scapular strength and motor control should be addressed. The physiotherapist might also direct some treatment at the cervical and thoracic spine to help with spinal mobility and general posture. Typically, rehabilitation will take 6-12 weeks but can extend up to 6 months.

If calcific bursitis is diagnosed, you might consider referring for shock wave therapy as this treatment re-initiates a healing process. This should be followed-up with a physiotherapist-guided rehabilitation program.

Diagnosis

Clinical exam

If patient does not respond to conservative treatment:

• X-rays (to rule-out joint pathology)
• Ultrasound (to rule-out tear or calcification of tendon)
• MRI (to rule-out a rotator cuff tear/or if surgery is considered)

Research has shown that there are many people with degenerative rotator cuff tears that have no symptoms at all.

Treatment

Conservative treatment

About 80% of patients with partial rotator cuff tears improve with conservative management. Research has proven that physiotherapy will accelerate recovery and reduce the likelihood of recurrence. It may take 3-6 months for symptoms to subside with therapy. It may take longer if not treated.

Conservative treatment includes:

• Rest and/or activity modification
• Ice (10-20 min, 2-3X/day)
• Oral or topical NSAIDs and/or pain relief medication - NOTE- Recent research indicates that NSAIDs tend to slow healing of muscle/tendon pathology
• Physiotherapy
• Cortisone injections
• If you do not give injections, the patient may be referred to a sports medicine doctor

Physiotherapy treatment will initially focus on pain relief and gentle shoulder range of motion exercise. Rotator cuff and scapular strength and motor control should be addressed. The physiotherapist might also direct some treatment at the cervical and thoracic spine to help with spinal mobility and general posture. Typically, rehabilitation will take 6-12 weeks but can extend up to 6 months.

Surgical treatment

• Surgical treatment is usually only indicated if:
• Continued symptoms (pain and weakness/loss of function) despite a minimum 12-week trial of conservative treatment
• The tear is large (>3 cm or a full-thickness tear involving one or more tendons) in the younger patient

For best outcomes, the surgery is usually done within 12 weeks of the injury. The type of surgery will depend on the condition but may be arthroscopic or an open procedure. After surgery, the patient will likely be in a sling for 6 weeks and may have physiotherapy for up to 6 months.

An injury or trauma causing an acute dislocation requires an emergency room visit.

Diagnosis

• Clinical exam – positive apprehension tests

Conservative treatment

In cases of shoulder instability, conservative treatment should be attempted for at least 6 months before consulting with a surgeon.

This would include:

• Immobilization for 1-2 weeks for comfort
• Early physiotherapy
• Activity modification
• NSAIDs and /or pain relief medication. Opioids are not recommended

Physiotherapy should focus primarily on early controlled ROM exercises post-dislocation and progressive strengthening of the rotator cuff and scapular chain. To address instability, it is important that neuromuscular and proprioception training, dynamic stabilization drills and muscle strengthening exercises be included. Stretching is to be avoided. Sport or activity-specific rehabilitation exercises are essential to ensure a successful and safe return to sport.

Surgical treatment

Surgical treatment can be done either arthroscopically or with an open incision depending on the condition. After surgery, the patient will likely wear a sling temporarily and will attend physiotherapy for rehab that will take 3-6 months.

Diagnosis

• Clinical exam
• X-rays - True AP glenohumeral joint, axillary and y-lateral view

First-line treatment for shoulder arthritis is conservative.

Conservative treatment includes:

• Rest and/or activity modification
• Heat/ice
• Oral or topical (e.g.:  Voltaren Emulgel, Pensaid) NSAIDs or pain relief medication. Opioids are not recommended
• Physiotherapy
•  Cortisone injection
•  If you do not give injections, the patient may be referred to a sports medicine doctor

Physiotherapy will consist of education, general fitness, shoulder range of motion and stretching exercises, strengthening exercises for the rotator cuff and scapular muscles. The physiotherapist might also direct some treatment at the cervical and thoracic spine to help improve shoulder movement and posture. Physical activity such as aqua-fit, tai-chi, exercise class and/or a home exercise program will be recommended.

Surgical treatment

There are different types of surgery for arthritis depending on the patient’s age and condition. Joint preservation surgery is favored for patients < 50 to 60 years old or those with early stage degenerative joint disease. These would include arthroscopic debridement, capsular release, corrective osteotomies or interposition arthroplasty.  Arthrodesis (fusion) is an option for patients younger than 50 yrs old with severe arthritis or for those who are not suitable candidates for total shoulder replacement. Hemiarthroplasty or total shoulder arthroplasty will treat pain and loss of function from severe arthritis that did not respond to conservative treatment.

Diagnosis

Labral tears are often a challenge to diagnose. Research shows that SLAP lesions are often associated with rotator cuff pathology and/or traumatic instability.  A comprehensive history and physical exam combined with imaging are important.

Typically, the patient has a history of:

• Intermittent pain with overhead activity
• Painful mechanical symptoms of clicking or catching of shoulder joint
• A feeling of instability in the shoulder
• Loss of ROM
• No pain at rest contrary to rotator cuff pathology which will often present with pain at rest
• Shoulder weakness

Clinical exam should include:

• special apprehension tests
• X-rays - True AP glenohumeral joint, axillary and y-lateral views
  

Conservative treatment

Conservative treatments have relatively positive outcomes and should be exhausted prior to considering surgery. They include:

• Rest/activity modification
• Ice (10-20 min 1-2X/day)
• NSAIDs or pain relief medication. Opioids are not recommended
• Physiotherapy

Physiotherapy will focus on exercises to improve rotator cuff strength, glenohumeral motor control, scapular stabilization and improve posture.

If the patient continues to report pain and dysfunction following a trial of 3-6 months of appropriate injury focused rehabilitation, surgery should be considered.

Surgical treatment

Frequently conservative treatment is unsuccessful with patients that have labral lesions with labral and shoulder instability. Typically, arthroscopic surgery is used for labral repairs. Surgical techniques are numerous and varied depending on the type of lesion and are tailored to the type of lesion and structures involved.

For this reason, the rehabilitation program following surgical intervention needs to be individualized. Physiotherapy will focus on enhancing dynamic stability and strength of the glenohumeral joint.

Diagnosis

Clinical exam

Findings will often include:

• Constant resting pain
• Inability to sleep
• Active AND passive shoulder ROM is limited in flexion, external rotation and internal rotation (hand behind back) when patient is in phase 2
• Minimal shoulder pain with resisted movements in relation to the pain with active or passive ROM

Blood tests, X-rays and ultrasound are not required unless other pathologies need to be ruled out.

X-rays may be ordered to r/o advanced arthrosis.

Recurrence is rare although the other shoulder can become affected in 6-17 % of patients within 5 years.

Treatment

Conservative treatment:

Frozen shoulder is commonly managed in a primary care setting.

Management is non-surgical and conservative with goals of treatment being:

• Pain control
• Increased ROM
• Decreasing duration of symptoms by encouraging movement and use of upper extremity
• Return to normal activities for the patient

Research states there is a 90% success rate with conservative treatment consisting of oral NSAIDS and active exercise-based physiotherapy over an average of 4 months (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096148/) Modalities have not proven beneficial in treatment of patients with adhesive capsulitis.

Treatment options include:

• Patient education which includes encouraging movement within and into some painful ranges while reassuring the patient that movement will hurt but not harm. Typically, once the patient is in “phase 2” (adhesive phase), they are encouraged to move into painful range frequently. This will hurt but the pain will typically disappear once the shoulder is out of the painful range. Explaining the rationale and that this is not harmful to the patient improves outcomes
• NSAIDS and over the counter pain relievers to manage Phase 1 (painful freezing phase). Opioids are not recommended
• Physiotherapy to help regain movement focusing on ROM exercises, mobilization, and pain control. It is also beneficial to rehabilitate strength and the shoulder complex muscle imbalances/kinematics, that are a result of altered shoulder motion, once the ROM is restored.
• Home exercise program - Self-stretching exercises (in flexion, external rotation, internal rotation - hand behind back) at least 2X/day. Encourage use of pulleys for increased exposure to AAROM.
• Cortisone injections
• If you do not give injections, patients can be referred to a sports medicine doctor.
• Cortisone injections have been shown to improve pain in the short-term but evidence suggests it has no effect on the natural course or recovery time
• Research indicates that a corticosteroid injection has a greatest effect when administered within the first 6 weeks

• Distention arthrography – Studies are inconclusive to support this procedure. However, if the exercises are not effective (after approximately a 6 month trial) or progress is particularly limited you might consider referring the patient to the hospital radiology department for distention arthrography (Hydrodilation) which involves controlled dilation of the joint capsule with a sterile saline solution possibly combined with a local anesthetic or steroid, guided by radiological imaging (arthrography). This procedure is performed under local anesthetic, lasts 15 minutes.
• The purpose is to break adhesions and restore mobility.
• The procedure is most successful when combined with physiotherapy.
  

Surgical treatment

Arthroscopic capsular release is a surgical procedure under general or regional anesthesia during which the contracted tissue is released. It is rarely necessary.

Diagnosis

Clinical exam

Consider that for 50% of non-traumatic cases, osteonecrosis can be also present in their hip, knee, ankle, wrist and/or elbow.

X-rays (true AP glenohumeral, Y-lateral, axillary, neutral rotation AP is best view) have <41% sensitivity for detecting early stages of the disease.

MRI is the most reliable and sensitive tool to diagnose AVN. MRI has a sensitivity and specificity of > 90% for early detection of AVN.

CT is the best technique to determine the extent and area of bone death and is more useful in a case that is in later more advanced stage.

Bone scans are not recommended as they are sensitive but have a large number of false positives.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3945237/pdf/CHSJ-35-1-023.pdf

Blood work to rule-out underlying systemic cause if not traumatic.

Conservative treatment

It is a slow-progressing disease and the earlier it is diagnosed the better the outcome as it allows conservative treatment to be effective.

In early stages of osteonecrosis, non-surgical or conservative treatment is tried first. This includes:

• Activity modification
• Pharmaceutical management (cholesterol lowering agents, vasodilators, anticoagulants, bisphosphonates) depending on the underlying cause
• Pain relief medication
• Discontinue use of tobacco and alcohol
• If on corticosteroids – review need vs risk with prescribing physician
• Physiotherapy
• ROM exercises and some gentle strengthening
• Restriction in overhead activity and lifting

Surgical treatment

If conservative treatment is not helpful in providing pain relief and improving function, surgical treatment choices are:

Early diagnosis:

• arthroscopic debridement
• core decompression - to increase blood flow

In the mild to moderate stage of the disease:

• Bone graft

In advanced stages of the disease:

• total or partial hemiarthroplasty