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Risch. Thank you very much. Rich Palmer going to talk to us about shoulder. Whatever thing you need to know about elective shoulders, that really is a tall order. Going to be a short right. OK, so for all of you that were here in the first session again, this is going to be a whistle stop tour. Um, uh, sign posting YouTube places and and some take home message is Okay, So this is the curriculum from, uh, the exam, so there's no way I'm going to be able to cover all that. Okay, So Monday is just focus on some basics to start with. Okay, So, uh, okay, no, your anatomy. Okay. And And you need to know it for reasons of what's your reduction? Like in a fixation? What? Your arthroplasty restoration of joint line and, um, you know, radius of curvature that you're going to choose and stuff like that. So the things to take away from this is that the heads actually off the back of the shaft, it's not in the center of the shaft. It's points backwards, and it is backwards. Okay. Uh, and you're greater. Tuberosity sits. Sorry. Your articular surfaces slightly greater tuberosity. Okay, in terms of your scapula. Okay, that actually doesn't set perpendicular to your body. So it's at 45 degrees to the Corona plane in terms of retro version of your glenoid. That's all about arthroplasty again about restoring your joint lines where it's meant to be. Um, so it's seven degrees retroverted on average, and it's three degrees super inclination, but we all tend to try to go for 00. Um, and the things that you need to know about for instability is that the third of your articular surface of the head sits on the glenoid. At any one point time, the cartilage is thicker at the edges. And then you've got your labor to try and make that a little bit more stable. Okay, then, soft tissue envelope. Yeah, you should. Don't no All your ligaments so superior, middle and inferior bladder. Huebel ligaments. And then you got your rotator cuff, okay? And hopefully you will know the muscles of the rotator cuff. I'm not gonna go into that into much detail. So what does the rotator cuff do? So essentially, you are squeezing that ball onto that glenoid. It's a golf tee on its side. It's always going to want to drop off so that rotator cuffs function is to hold that ball where it's meant to be, and then you can move your arm as you're meant to. So in terms of the biomechanics that they're your joint reactions forces and they're all meant to be balanced. Okay, now the picture on the right explains something in a little bit more detail. And that is Try not to, like I said in the first two. Or try not to think of your shoulder as a joint in isolations. Okay, it's one of its functions. Put your hand in space sense with the elbow. You know, your shoulder can't compensate for that if you fuse it. So if you've got a stable base to your glenohumeral joint, that shoulder function really well, okay, If you don't have a stable base to glenohumeral joint, then the whole thing wobbles around, and we can demonstrate that bits of physios talk about posterior slings. So if you'll stand up, let's let's wake you up a little bit, Okay? So put your right hand up in space, Okay? That feels pretty good, doesn't it? You know where you are. You can position it or you want to stand on your left leg. Now watch your right hand. Okay. Now let's destabilize you a little bit more and try and just do a half squat. And now trying, right? All the ones that's stable are the ones that actually go to the gym. Right? But you can see you are a chain. Okay? So in terms of sports injuries and things like that, you need that stability from the base all the way up to your okay. Now rather than me going through all these different sorts of pathologies, there's a set of national guidance on the best website written by far more clever people than me. Okay, but it does go through the evidence and all the theory and the treatment options and what we should be doing in the UK and the national guidance. You should really know that for your exam. Okay. As I said, you'll have the slides via voter. Now, I've just explained that the bony stuff isn't that stable. Okay? So when we start talking about instability of the shoulder, it could be multi factorial. It could be they don't have a stable base. Okay. And that's when we start talking about muscular patterning, non structural lesions, which is Istanbul triangle three. Okay, it could be due to the fact that all your ligaments relax. So you've got brilliant muscular control, but your ligaments are not sort of giving you the proprioception that you need. So that's type two. Okay, type three, which is your young dislocate er that's pulled off. A piece of labrum is type one, and usually it can be There's an element of multifactorial is that multifactorial element to their instabilities. Somebody's recurrently dislocating due to a label lesion will have a little bit of muscular patterning to it so that you need to correct that before you do your surgery, okay? And people do move. So when you're doing your surgery, you want to go up more to polar type one in terms of the reasons for your instability. So in terms of instability, repair, it's anatomical. Okay, so you are putting the chop back labrum is like putting a little piece of wood under your tire. It just gives you a little bit stability to stop it rolling. Okay, so you're putting that back along that is attached the ligament. So you're tightening that back up. So you're giving that more stability from the soft tissue, and then you're giving them appropriate reception back as well. Okay, so it's an anatomical repair, and that's what you need to remember to why you would do bank art surgery. Yeah, however, if you have bone loss, you already know that it's a golf tee on its side. If you've got a piece of bone missing that makes that whole thing with a lot more unstable. So failed soft tissue surgery could be that fact that you've missed a bony lesion or it's not being addressed as it should be, or over recurrent instability that warm bits of bone away, and they just become more unstable. Toy has a brilliant little paper that explains all that with beautiful diagrams. So have a look at that and just have a read of the instability that happens with the different bits of bone. But what you need to know is if you have a big Hill Sachs, it's going to fall off the front. Okay, if you have a bony glenoid fracture, you've got less of a glenoid two falls off. Okay, if you've got both, it's going to fall off a lot easier to simple as that. And there's different ways to address that. And that will either be bony procedures in terms of latter J's uh, or bone box or rum. Plus, it's which is McLaughlin, where you put some gap into it or you put infraspinatus into it the back and that you're basically limiting rotation to give stability. OK, impingement. It's not a diagnosis, Okay? It's a It's a syndrome of pain. There's loads of reasons that you can get impingement. Okay, Could be a see Joe. Uh, it could be a scaffold. Dyskinesis e You've got a wobbly scapular, which is then making your head wobble, as we just demonstrated, which then sets off pain, partial cuff tears, full thickness cup to get cuff tears. If you've got a young person with impingement thinking stability, okay, because you don't tend to get true impingement until you're older. Is it calcific tendinitis? Is it capsulitis? Is it the neck? All these things are defined through your history and your examination, okay? And you need to know how to define those for your exam so you can go right. The classic history is ex classic history is why the examination think is in terms of, um, papers for your seven and eight marks. Cecil set the world on fire. Um, can shoulder arthroscopy work. Um, even Johnny reasons now, current best presidente who is one of the investigators said they shouldn't have used that title. Okay, um, it explained it sort of said that surgery doesn't work, and we shouldn't do it, but there's lots of factors in that, but it's one to know, because it has decreased the number of subacromial decompression that are done in the UK. Okay, Grasp is another, um, Lancet paper, which shows about physiotherapy supervisor physiotherapy, steroid injections that came out in the last couple of years. So it's just worthwhile knowing about that. Okay. Mhm frozen shoulder. Uh, it's described really well in the best guidance, except they haven't mentioned it. Says UK Frost is in and is being performed, but hasn't actually stated the results. And it's Whitney. It's updated. So, um, all you need to know is that can get capsulitis can be primary. It can be secondary. Um, no. Your treatment options, which are do nothing steroid injection. Hydro Dilatation is the one that isn't in UK Frost but is used quite regularly. Um, and UK Frost basically looked at em. Us versus arthroscopic capsular releases. Okay. And physiotherapy cuff tea diseases controversial. If you go into this, you could be talking about loads of stuff and loads of time. And it's a spectrum of disease. Okay, we have two or three day conferences on this, so you can see why you can end up in a lovely conversation going in any direction. But essentially, from the cuff point of view, it starts off as a Dema. And then once it's torn and you've got instability, it will lead to arthritis. I rotator cuff arthritis. Okay, um, all our clinical tests are rubbish. Okay, So what you need to be able to say in the exam is actually the specificity and sensitivity of rubbish. But you learn a particular method that you know what the results are going in your hands. OK, so I do things a particular way. But I know what the findings mean for me. Okay? They talk about extrinsic theory is an intrinsic theory. So they talk about the type one. Type two type three chromium with the hook and the hook pressing on the cuff. That's the extrinsic theory that's old fashioned. The intrinsic theory is there's a problem within the cuff, which then leads to cough disease, which then you get a secondary calcification in the C a ligament. Okay, Transcript. Which one cuff tears appear a symptomatically as you get older, so there's lots of studies done. I think it's in Japan, where they scanned older people and loads of people had cuff tears I didn't even know about. So I When I talk to patient's, I talked about an elastic band, and as it gets older, it gets less springy and tears and cracks and then camping quite easily. And it's just a good way of conceptualizing it for another person. And then you've got controversy over. Should we do it open? Should we do arthroscopic? As Andy said, Arthroscopic sexy? Is there any difference? A. You cough big trial in the UK, there is no difference. Okay, and then you get into single road repairs. Double road pears, balloons, SCR, which is super cap capsule reconstructions. B a r uh, which is something, Matt Ravens. Crofts, come up with, But they're all newish things with not a huge amount of evidence for them. Okay, Mhm. This is a treatment algorithm. And it's as you can see, it's busy because this this is where why they can talk about it. You can go in any direction, depend on whether they're honestly an aesthetically fit or they're not an aesthetically fit. Essentially, if you've got a cuff tear and you've got superior migration because you've got cuffing balance and it's arthritic, that's a reverse that that's an easy win. Okay, if you got cuffed at rehab, them first. So you you're talking about your conservative management. Always really have them first. If they're happy. Brilliant. If they're still symptomatic, then you need to look at where you're gonna go. Okay? If they not fit for a haircut, essentially, then you can do a balloon or super super scapula nerve ablation. Okay, if they're fit and they've got good predictors for their cuff repair, repair the cuff. If they're young and active and they've got a massive tear that you're like, I can't really do that. Okay? Then you need to think about these different things. Okay, um, tendon transfers seem to be going out of vogue at the present moment. Augments biological augments. S e r s B a r again. Not a huge amount of evidence at the moment. There's loads of people trying it. Okay, poor predictors. Gator reverse. Okay, So in terms of arthroplasty for your exam, you need to know the difference between an an atomic and a reverse, except the fact that it's the reverse anatomy. Do you Do you know how they function? No, no, no. Okay, so the an atomic, as it says, needs anatomy. You need your rotator cuff. Okay, so it needs that squeeze of the cuff to hold it against that piece of plastic and keep it in joint. Okay, Now, if you lose that, you'll get superior migration because your superior cuff tends to go before your anterior poster, and it basically pops it up in between the two. Also, one of the modes of failure of an an atomic, um, replacement is that you tend to go through subscapular front to replace okay, and that can ping off. It doesn't heal or you end up with a dissertation or something, and then that can lead to instability and a revision. Now what the reverse does is that it changes it round, but it's in fury arises and medialize is the center of rotation, and the reason it does that is that it can work without the rotator cuff. So it's a sphere. And then what it's doing is using the deltoid as a lever on. So it increases the lever arm with the delta to move your reverse. Okay, The original prostheses. We're all great mantra prosthesis, or the Delta three, which worked in a particular way, where they talk about lateral ization and medialization. Essentially, the earlier ones tended to dislocate, whereas the more later ones have less complications from Capitol, an option and dislocation that way beyond the scope of your exam in. If you get into that sort of detail, you you've you've passed with flying colors. Okay, there's a couple of useful links here, um scapular winging house and has already brought up. But lemon funks websites got all the different reasons for scapular winging um, and their exam spotters. And David Cloak has done a YouTube video just explaining it from an examiners point of view, because I'm not an examiner of what to expect from various shoulder and elbow conditions, um, in the exam and how to score the higher points. And it's It's about 20 minutes. 30 minutes long. Yeah, research. So past research that you need to know about UK Frost Seesaw grasp. Okay, um, ongoing research, partial cuff tears. We don't know whether we should be repairing. I'm sure whether we shouldn't be repairing them is there's something called procure that's going on. There's Rhapsody. So in an an atomic replacements, a concentric wear. Okay, um, you tend to get muscular atrophy of your rotator cuff. What we don't know is, is that disused due to pain? Or is that a cuff about to fail? Okay, so we don't know whether doing an an atomic actually leads to the cuff regenerating and being better or whether it's a mode of failure. So that's what's going on there. Regeneration is a bio inductive augment for a rotator cuff repair for huge test that's going on at the moment. And Racer, too, is another trial that's going on, which is self directed. Rehab versus lots of physiotherapy, um, in rotator cuff repair. Again, if you're getting on to all this sort of stuff you're flying. Okay, If you want to email me with any questions or anything like that, then please do so Or you can ask any now. But it's getting late in the day. And you're probably what? Beer To top up the stuff from last night, don't you? Thanks very much, Richard. Uh, tall order, but very nicely done. Thank you very much. Any questions for for Risch on shoulders?