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Set there. So today, um Kate part part of this term, basically asked me to speak to you today about the stiff shoulder. So, um, quite, it's not a massive topic this really when you break it down into sort of basics. Um But hopefully by the end of this, what we'll, what we'll be able to do is I can get my slides to change to basically cover the anatomy of the shoulder girdle girdle in a very sort of basic way. Um So I'm not going to label the point on things. I know you've done the rotator cuff last week with Mr Conant Tolo. So not gonna get over too much of that. Um The focus really on the anatomy today is gonna be looking at normal measurements um for uh the glenoid and humerus. Um, as well as looking at uh in particular, the ligamentous structures around the shoulder that can be involved in shoulder stiffness. Um We're going to look at how you diagnose and treat stiff shoulders basically. So, um, the emphasis today is not really on, on the nuts and bolts of arthroplasty. This is more about the um clinic assessment investigation and management of, of the um stiff shoulder in the outpatient setting. Um The session next week that I've got with you will be more geared around um the actual process of, of undertaking arthroplasty decision making and then what happens when it all goes wrong? Uh So hopefully, that's all right. OK. So osteology of the shoulder, so it's a joint made up basically of the humerus and the scapula, in particular, the glenoid. Um your standard normal measurements. The next sub ale the humerus is about 30 degrees. Um Your retroversion is anywhere between zero and 10 degrees is considered to be normal. Um And there is inclination can be up to five degrees, can be normal. OK. But this is obviously all of range. So this is just to bear in mind that when we come onto the Arth Plasty section next week, these are the measurements that we're looking to correct. Um So when we're talking about stiffness in shoulders, um obviously, it can be due to a number of things. So it can be either something to do with the bones themselves. Um or um there's multiple soft tissue layers around the shoulder and those can obviously contribute to it being stiff. So, bearing that in mind, we look at this diagram here, which is basically looking at the, the some of the soft tissue structures around the shoulder. Um Any of these things really can contribute to stiffness now, can can the rotator cuff contribute to stiffness. Yeah. No, nodding seven and nine. So it sort of can. Yeah, I mean, you, his question really, is it weakness or stiffness? So that comes down to what your definition of stiffness is. Um, certainly injuries to the rotator cuff can cause stiffness as a secondary consequence. But, but weakness really is, is what you'd get with a cuff cuff problem. Um The ligamentous structures there, the ones that really we're interested in are the intraarticular or the, or the sort of periarticular structures. So your crackle huber or ligament, in particular, um the other ligaments that are intraarticular will come on to in a minute. But one such as the, the C A ligament and then your um CC ligament uh complex don't really contribute to stiffness per se. E All right. Um But it's important really to appreciate the um where these structures lie. Um And then you can work out basically how they can contribute to stiffness. So you can see here that most, most of the ligaments that, that around the shoulder anterior structure is OK. Um Primarily designed to prevent translation. Um But this, this, this area here really is, is the area that causes most of the mischief. OK. Good. All right. So the ligaments themselves. So this is a bit more complicated diagram. Hopefully, everyone can see that then. So then we've got the H Huer ligament again, which is the one that we, I've mentioned being particularly important. You've got the superior glenohumeral ligament, middle glenohumeral ligament and the inferior glenohumeral ligament, which is sort of down here somewhere. It's not really on that diagram very well, but it's right down the bottom here at the inferior part of the joint. OK. So what does the CPA glenohumeral ligament do with anybody already stops the humerus from subluxing inferiorly? So if you're right, correct. Right on. Right. Yeah. So basically you can see that the way the angle of that comes down, can you imagine if you were to, to move the joint as you start to abduct, that ligament will become tart, which will basically stop it from, from translating inferiorly. All right. So again, stiffness and that you can see would contribute to a problem. So middle, middle gleno humeral ligament. What does that do? That's this one here. So stop what? Paste uh paste translation. Yeah. So it does a P translation basically because it, it's sort of if you think about it being in the middle of the joint, it's, it's sort of a check rate in both directions. OK. Now, this is obviously dependent on position of your arm. So when you're abducting, obviously, if, if that was in a neutral position, so if you're, if you're in neutral abduction there, um uh the ligaments can be slack, isn't it? So this only really comes into play when you start to abduct to about 90 degrees. Because if you imagine as that comes up that ligament will then come tough. Whereas be, whereas when you're in a neutral position, it doesn't really do that. That's where your, your superior gleno humeral ligament comes into play. All right. Now, the IGHL they love this in exams asking you about IGH LS. So firstly, how many bits has it got? 22 components of it? Two in the office, a bit more. Three, I need a little bit more. So yeah, say 55, no anything. There's three bits to it. OK. So you've got your, your posterior band, OK, which basically stops your posterior translation again, that's in an abducted position, anterior band, again, prevents your anteroinferior translation. And the su superior band rate is the most important stabilizer for the shoulder. OK. That's in all ranges of movement there. All right. Now, the cray huer ligament, which is this one here, there's only one bit of that. So it's just that one there. OK. Um Now that one is important because it, it's associated really with adhesive capsulitis. So the way that that layer runs in it, it's very closely um uh in contact with the anterior capsule of the shoulder. So, um and and it's position where as you see there, where it comes across uh into the biceps pulley. Basically, when, when you get a a frozen shoulder, it becomes contracted. So that's probably one of the main elements when you get a frozen shoulder that's at play. So it's the capsular complex. Plus the crack hum ligament. That's a problem. Ok, good. All right. So that's a little bit of revision of ligaments around the shoulder. But hopefully that makes sense as to why they, they can cause stiffness. All right. Now, direct trauma to any of the, the other ligaments but you know, not including the cray. Huer ligament doesn't tend to cause if you think about it, it doesn't cause stiffness as such because if you have a ligamentous injury, it tends to cause a problem. Uh more with the stability of the shoulder rather than it being uh being stiff. So you end up with an unstable shoulder and a stiff shoulder. Ok. But obviously, um they, they do have a role in stabilizing the shoulder in normal uh in the normal environment. Um So you can, you can end up with issues if they do if the shoulder becomes stiff itself. OK. So what constitutes the shit? What is the definition of how would you, what would you classify as being a stiff shoulder? Anyone a shoulder with a reduced range of movement? Yeah. So reduced range of movement. Anything in particular, any particular movement that tends to internal rotation? Yeah. So and with that external rotation, is there anything particular about that to say? So you're saying an absence of external rotation, but in the context of a global reduction in movement. But what particularly about the external rotation makes it stiff because I could have A I could have a cuff. Is it that it can't be passively increased? The room can't be passively increased. Yeah. Spot on. So basically, because you could have, you could have an absence of external rotation in the context of, of a big cuff tear, chronic cuff tear. If you've got, if you can't extend, you can't exter rotate, you get pseudoparalysis. So as I said to you earlier, that's, that's not stiffness, that's just weakness. Um But you'd be able to passively correct that. So stiffness is an absence of external rotation even without attempt, even with an attempt at passive improvement. OK. So you do end up with a bulk stiff shoulder that won't externally rotate. And when you're examining someone and you can see that it's, it's that it's making sure the elbow is tucked into the side and you get them to rotate out from there. OK? And if you can't move it from neutral, then, then you, you, your diagnosis sort of pathway comes right down to it being a cause of stiff shoulder rather than anything else, if you can push it out. Um You know, then you can have a global reduction in movement um in the context of a of a massive cuff problem. All right, because you, you do, you can get pseudo paralysis um with massive cuff teas. So that presents with a reduced range of movement. But the important thing to note there is that if you passively move the arm, you won't end up with it being stiff. OK. So, so that's the difference between the two really? And that really does change the way that you're then going to manage the patient. So a lot of this to start with really is, is the question that you're asking the patient about, often they'll have pain associated with this. We'll come on to a bit more about looking into the other elements of the history that might predispose to a stiff shoulder. Um But the main thing on examination is is that global reduction of movement. But the key feature really being a lack of external rotation with no passive improvement. OK. Same. What's going on here. So this comes to your clinic. Does anyone want to describe the radiograph? I will, I can see people today so I will start picking on people. No. Um This is an A P of the shoulder. Um It appears to have a light bulb sign. So I want to check a, a lateral view. Good. Yeah. So basically, it's so what, what's when you say a light bulb sign, Tom, what you, what you, what are you getting after dislocation? OK. Good. That's what I wanted to get. So this, this is this is a posterior dislocation. This actually came to Frac clinic um this week. Um So it's just to highlight that not all the causes are elective. OK. So you can't the, you know, one of the big causes of a stiff shoulder is a dislocation. Ok. It's the one you don't want to miss. So this poor patient had been to the A E department been seen by A&E, um, had these x-rays done, uh, was told everything was fine and then was sent home. Ok. So, always bear in mind. Think whatever you're thinking, think about a dislocation as a potential cause for stiff shoulder. Ok? Because this patient would not be able to rotate at all. All right. So the first thing you need to exclude from the history, um is is there any hint that this could be a dislocation? Posterior dislocations are rarer obviously than anterior dislocations. Um Most of us has probably put an anterior dislocation back in it. It, it is still possible to externally rotate an arm that's anterior dislocated, not, it's not very comfortable for the patient and you could break something, but it is possible. Um But certainly when you've had a posterior dislocation, if you try and rotate it, it won't budge at all, right, it's just totally jammed at the back. So it's never going to move. All right. So don't miss the dislocated shoulder. Ok. If you were to to manage this from, from clinic, how would you go about managing this type of shoulder stiffness? Reduce it? Yeah. So it's not rocket science. So, yeah, exactly. So, yeah. So we this needs reduction in in theater. OK. So obviously, when we were thinking about this is a cause of stiffness. All right. What we don't wanna have is the patient coming back recurrently stiff where their shoulder keeps dislocating. All right. So I thought as we're on posterior dislocations of the shoulder, we talk a little bit about the management of that in the context of, of a, of a larger uh consequence of it. So what, what do you get with, with the posterior dislocation? What can you get with a posterior dislocation in terms of a, a consequence of having it? And it was hill sa yes, the reverse hill sax lesion. Yeah. So, well, what that is basically is, is, is a, the humoral head impacts against the posterior aspect of the glenoid um and causes a, a big kind of defect in the head which depending on the size of it can be something that can engage with the, with the glenoid when the, when the shoulder rotates. So if they've got a large reverse hill sax lesion, even once you pop the shoulder back in, it can be difficult, then it will, it will pop and engage with that lesion and then get stuck again. OK. Um The, the, the way you basically classify these, the hill sa lesions is dependent on, on the, the proportion of the head that's impacted. OK. So, so you can have sort of if you think of it as a small, medium, large type of thing. So any from sort of naught to 25% is considered a small defect. 25 to 50% is, is a sort of medium size defect and anything above 50 would be a large. Ok. Now, sometimes you said reduce it seb um So obviously you try your standard maneuvers in theater to try and get it back into joint, but there's always that potential that you might have to do something else. So do you think there's any correlation between the size of heel sacs lesion and the, and the need to do an open reduction? And if you were going to open it, how would you do that? Um So I don't know, the, I'm sure there is some evidence regarding the correlation, but I'd assume a bigger hill sac lesion, the um the more difficult it would be to reduce and more likely you'll need to open in terms of getting in there. Um I suppose delta pack will show you the exposure. I think I know you would approach. So there is a slight correlation, the smaller lesions. If you think if it comes off easy, to be honest with you, it's unusual to see a paste or dislocation, isn't it? It's not back in because a larger proportion of them, the smaller ones are the ones that are gonna self reduce, um which they often do before the patient comes in. So ones where you've got these, the, the lesion is at least sort of 25% usually Ok. Uh Now, yeah, the Dota Petro pa is, is probably what most people would use to do an open red product. Um Now why do you think that might be, obviously you get, you can see what you're doing. Um But why, why might you also, so thinking more about the long term, say this is a large lesion or medium to large lesion and, and the likelihood is it will engage, which you can actually do when you're on the table, you can rotate the humeral head in and see if the lesions going to engage. Now, what's the advantage then of doing a delta pectoral approach for that type of lesion? So, I mean, you can also attempt to repair of the, of the hill sacks. This were the reverse heel sa at the same time. Yeah, actually, yeah. So do you know any techniques at all that for repairing reverse heel sacks? No, no, that's OK. Is it the procedure? So, basically, depending on the size of the lesion, you can, you can have two ways of fixing these. Ok. So, but I'm sorry, I keep picking on you. Um So 11 is uh what, what's called a re massage and subscap. OK. So if, if you're um you, you performed your arthrotomy and then when you go into the, the shoulder to do this, you would go to get into the joint, you'd have to open up uh the interval between um sutures and subscap. So you have to do a limited release of subscap anyway, um, when you're in there, once you've pulled it back, er, you, it's possible then just to put an anchor into, into the defect and essentially, um, pull down through, put sutures into subscap and pull these down into the, into the defect, er, which is effectively tightens the subscap up a bit, uh, which should stop the head then uh posteriorly uh translating, OK. The consequence of that is obviously that the patients then gonna have quite a stiff shoulder. All right. So it's important then that they, they get rehabilitated. But the whole point of it basically being that you stop that lesion from then engaging, OK. It doesn't really matter what type of anchor you use. It's just something to, to, to the cell, the tendon down into there. OK. Now, for a larger defect, obviously, that's, that's not necessarily going to work. So what mcloughlin essentially described was a less lesser tuberosity, osteotomy. Um where you, where you take the origin of, of subscap or the insertion of subscap off, sorry, and then uh shape that piece of bone to fit the defect and then hold it either with a screw or, or, or some other device for, for keeping a bit of bone in there. OK. So again, it's a similar sort of principle but accepting that in this case, you, you're effectively creating a block to do that. Now, there are other things you can do for really, really big lesions. You can use um uh pieces of femoral heads that have been cut and shaped uh to repair that if you don't want to move the subscap. Um, but I would say that's probably more or less commonly done. Um, to be honest with you anyway, most of these posterior dislocation procedures are not, not terribly common. Um, in the last year, I've only had to do one rep massage procedure for a lady who had a blocked posterior dis. All right. So, but it's good to be aware because if you, if you're going in there to, to do it, um you need to have some sort of strategy, you can't leave it with it dislocating again. All right. All makes sense good. OK. So that's dislocation is a cause of a stiff shoulder. All right, same. What's going on here? I'll up a couple of films for you. OK. And an MRI, what's going on here? Someone want to describe the x-rays to me, please. So these are x-rays of the right shoulder. There appears to be some absence of the right humeral head. Yeah, with fluid seen on the MRI images in the lowest section. So this could be consistent with infection. Yeah. So that's a possibility. Absolutely. Avascular necrosis secondary to all the things that cause avascular necrosis kind of fluid collection with avascular crisis. You don't get fluid so much. No. Uh I can't see evidence of where the humeral head has gone. Yeah. So it disappeared, isn't it? Yeah. So, it's not like a, a fracture process. No. No, it doesn't look like a fracture if I was to tell you that this patient presented basically with a, with absolutely no pain whatsoever. So, they were, the shoulder wasn't painful. They came in because their shoulder was massively swollen. And the concern. Charcot. Yeah. Very good. So, it's a Charcot shoulder. Ok. So basically this is your opinion to get that. So, as you can see on the MRI slices down there, you've got this, you, the glenoid is massively erased as well. And you've got this, as you said, like loads of high signal everywhere. There's a massive fluid collection around here, right? That's not, they say the differential is infection, of course, because you've got a lytic lesion that's, that's destroyed the bone there. And you need to exclude the other possibility here would be malignancy. Uh As you're looking at some sort of large destructive lesion that's going to that that's eaten away the bone. Ok. Um So really the history there is, is the key is that, that it's a painless process, but it's massively destructive because they've got an, an absence of kind of pain fibers essentially. What, what, what the cause of this is, is either um something systemic like diabetes. But does anyone know the other potential cause for an upper limb Charcot Syrinx in the cord? Yes. Very good. Yeah. So, there we go. That's what it looks like. So, it, an MRI. So, if you were to see anything like this, it's not common again, pretty rare. But, but, you know, if you read to see some, this sort of process going on in the, in the context of a painless shoulder with this massive kind of fluid collection, that's probably probably what's going on. Yeah. It's not a very common thing to see. Um essentially what this, the Syrinx does is it affects the, the, the lateral spinal, actually you lose your um pain and temperature fibers. Um which the theory then being that you end up with um a loss of, you know, hyperemia, affecting the area, which then causes um activation of your osteoclasts. Uh and hence you get that massive bone resorption. OK? But interestingly you don't have pain, but they are stiff in the context in that they, they don't, they just won't move, right. But that's, that's just a, a slightly unusual one. So I, I do it the other way around. Get the, get the weird ones out of the way first and then do the more common stuff afterwards. OK. So again, that's just something to be aware of because again, when it comes to exams, they love picking up weird things. So if you got that, exactly, as you said, Mike, the way to work through that is, you know, what is a common thing? Infection trauma malignancy. I would say it's none of those things. Um, but then, you know, it's the key features though, is taking the history and establishing the symptoms that the patients got. Ok. Good. All right. Same. A more common cause of shoulder stiffness. Ok. Which is adhesive capsulitis, otherwise known as a frozen shoulder. All right. So who gets it? Who gets adhesive capsulitis? Ok. Diabetic patients, middle age women. Yeah. Anything else? Th th disorders, any other associations? One more diabetics is that diabetics? No, affect your hands, prolonged immobilization after a fracture. What was that? Sorry? Uh prolonged immobilization after a fracture. Yeah. So there are definitely second idiopathic causes we're talking about at the moment. Say yes, you can have it as a consequence of trauma as well. S disease. Yeah. So idiopathic ahe capitis affects women disproportionately. It tends to be uh middle aged women. Ok. The nice about shoulders is that most things you can put into age categories. So, it's unusual for 20 year olds to get um adhesive capsulitis. It's not impossible if they're diabetic, but it's unusual for, for a 20 year old to have frozen shoulder. It tends to affect people between 40 60. Um You always need to have the back of your mind arthritis because you can get some early causes of arthritis as well. But that tends to be the age group of effect. As we said, it does affect um diabetic patients. Uh people with um thyroid disorders. Uh And again, there is an association with Ron but it's, it's not a fast link. So what is, what is the actual pathological process involved in adhesive capsulitis? So, what is it a disorder of you get inflammation and contracture of the capsule? Yeah. But what, what, what causes that, what's the accumulation of fibroblasts blast disorder that, that causes, as Charlie said, you get, you get a massive inflammatory response um and contraction of the anterior capsule of the shoulder. And there's a, when they've done, when they looked at it under the microscope, there's a, there's a propensity for type three collagen, ok? With a large deposition of that within that. It's similar in a way to Duron in that, no one actually understands what the whole process that drives that. Um So it'd be fair to say, nobody knows what causes it to be fair. All right. So we've talked about the idiopathic causes, which are the ones up there. So, so there are, there are causes that the association but it can just happen. All right, without any particular cause. And nobody understands that underlying mechanism talked about secondary causes, which someone mentioned there, secondary you can be secondary to trauma. Um So it can, might, might not be the original injury. But if you've had an injury, even an innocuous injury to your shoulder, um, it can, it can present then, uh at a later date as difficulty uh with movement associated with pain initially. Um And then tertiary courses, tertiary records are basically post surgical. All right. So that is a big, big thing. Uh that, that we worry about any time you operate your shoulder, there's always a risk of it going on to become frozen in, in that rehab stage. All right. Does anyone know what the relative, what the risk of a, a frozen shoulder is associated with arthroscopic procedures? It's about 22 to 5%. Yeah, it's about 5%. So, stiffness is stiffness is about 10 to 15% chance of shoulder stiffness, post arthroscopy. But what I do when I'm consenting for an arthroscopy, as I mentioned, there is a, there's about a 5% risk of a frozen shoulder. OK. All right. And that has some bearing obviously on, on rehab uh after procedure. So it's definitely something worth mentioning when consenting. All right. So moving on. So this is Mr Kane's graft, just Mike. OK. So, so there are three phases essentially of of um uh adhesive capsulitis. So, so you have this pain, painful sort of early stage that the sort of freezing stages it were where you're moving into that bit where it's initially not too bad, you get that loss of movement, but the pain becomes worse. And then as the pain worsens loss of movement, OK. A frozen stage where essentially your, your pain subsides. OK. Which is that downward part of the curve there where your pain subsides and you end up with, with a no improvement in movement and then your ing stage, which is a late stage where the pain essentially disappears and you have a gradual increase in movement. OK? It's obviously quite difficult when we see patients in clinic to work out where, where they are on that, on that phase. OK. And obviously, some interventions will work better at certain stages. OK? So that probably explains to an extent why, why no one's really sure what, what the best thing to do at certain stages is because you never know where that patient is. And I'm sure that sometimes when you get someone early, you probably can prevent a lot of the inflammation from occurring before you before it gets to the stage where it becomes too stiff. Ok? Um How long can it last for? So if you had a patient in clinic that you think's got adhesive capsulitis, how long, how long can that last for 18 to 24 months? It can last up to two years. It's a long held haul for the patient and, and essentially any treatments that we're gonna discuss in a minute, uh are trying to speed that process along. It's not, they're not cure as such. Ok. Um but 24 24 months to two years is, is what, what we should be telling patients in clinic it can take that long for this to resolve. Now, will it resolve? Does it resolve on its own or does it always require intervention or that they sit, it's mostly self limiting, but you can help it along with the various procedures. It is, it is a self limiting condition. That's the other thing to tell patients as well is that it's, it's something that will get better on its own. But by the time they've got to secondary care, um, they're desperate for something to be done to try and improve the pain. Ok. All right. Same in terms of treatment. First thing we can do is physiotherapy. Ok. So the recommendation is basically that all patients should receive physiotherapy. Now, that sometimes is quite a hard sell because patients themselves, you've got a stiff shoulder. So what an a physio gonna do to help that? Ok. Now, all of the exercises around this are basically associated with increasing the stretch on the joint. Ok. So they're not, not there to, to try and improve power or anything like that. It's really just trying to stretch out the capsule. Ok. People don't tend to find that particularly useful. Um And I would say again that most people who've ended up in secondary care will have had some sort of first contact physio in the first instance. So, trying to get them to engage with that without anything else is quite difficult. Ok? If you read the guidelines though, that is what they recommend is that, that, that the physio program is the first protocol. OK. What other interventions are people aware of for, for adhesive capsulitis? Uh You can you go now for you, you go I was just gonna say you can um consider uh steroid injections. You can do um I forget what it's called now but um where you instill basically hydrodilation. Yeah. OK. So we take this one at a time. So corticosteroid injections. Uh do you, are they effective? Um how would you direct the injection just into the, into the glenohumeral joint? And I don't know how effective they are. Yeah. So it comes back to that, that kind of graft really, doesn't it? I suppose it depends what, where, where you're trying to catch them on that graft. I think generally speaking, if someone comes in and they're in that, that painful phase, so that they're having quite an increase in pain and the pain is the main issue at the moment with the reduction in movement. Then the steroid injection is probably of use. Um because you're trying to deal with the inflammatory process using the steroid. OK. I think once you've got an absence of pain and you move, you haven't, it's movement. That is the issue. It's that stiffness. That's, that's a persistent problem. Then the steroid injection probably isn't going to help a great deal because we're already past that point. You know where Charlie said that the capsule becomes constricted. So at that point, it's, it's, it's capsule stiffness. It's a problem, not the pain in the inflammatory process. So I tend to use injections more when, when the patients are coming in with the predominant problem being pain. Does that make sense? Because they let you bite your arm off if you offer them injections? Ok. And that, that's what we're trying to manage in that, that first phase. Ok. Um So injections is definitely they do have use, but I think you need to pick when you use them and I'm not sure that they have much of a role once you got to the point where you're, you're stiff already. Does that make sense? Yeah, so you mentioned um hydrodilation there, David. So you're right. So, so that is a, a fluoroscopic guided procedure. Uh which basically, as you said, involves stretching out the joint capsule with, with um saline normally. Uh and then a subsequent injection of corticosteroid after that just to help with the subsequent inflammatory response that you get from, from tearing stuff. Ok. Um Any evidence for, for that? Ok. And I don't know what the evidence is. So, so some, some places do use it. So, I mean, it's definitely something we do here at the West Suffolk. Um Again, it depends on what you're trying to achieve. I think if you've got someone who's coming in with the Calcitrate fa shoulder that's been present for ages. So, well, over a year and it's, they've had no improvement in movement. Do you do you think that injecting 20 mils of saline into the joint is going to going to overcome their problem? Probably not. Uh I mean, there are, there are cases where it could certainly, if you use it in that early stage again where there's a bit of pain still that, that you can prevent that capsular constriction from happening, I would think. Ok. Um I also use it generally for people who are not that far off being back to a normal range of movement if you see what I mean? So they're not a normal range of movement, but they're not, you know, super stiff because you, you think then that probably in that instance, you're just helping break down that catch a little bit more to get that last end range of movement. OK? Um If you read the evidence, it says a core review by uh which was basically saying that there isn't any additional benefit to conventional treatment. OK. There's probably some short term benefit. OK. Uh In terms of, of, of giving because it will, if you, if you imagine, even if you stretch it a bit, um then the patient will get some pain relief from the steroid and local anesthetic. And then because you've torn a bit of capsule, they'll probably have to move it a little bit. But in the context of then not following that up with physiotherapy, uh you end up going back to square one again. Does that make sense. So, so there's probably definite short term benefit to that anecdotally. Uh When we use it here, I would say the majority of patients get better um with it. Um But there are a proportion who will come back again, having had a short term benefit, then a subsequent, you know, relapse. Ok. Good. Any other treatments? So we've done the, the sort of physio, we've done our injection, we've done our hydrodilation. Is there anything else that we can try me ablation under anesthesia? OK. Manipulation under anesthesia. All right. So any potential risks of doing any manipulation under anesthesia? Yeah, it can, it can create a defective. Yes, you can fracture their arm. Yeah. So um personally, that's not my preferred if I'm going to intervene surgically, that's not my preferred method. All right. Um Just because I feel that uh we can be a bit more, bit more skillful. Um It is a bit crude. Um There is a risk of fracture. It has happened that that's not me personally, but I know that colleagues. Um so the idea being essentially that you're, you're manually tearing the capsule uh to improve the range of movement. All right. So not my preferred method, but it is something that people still use. OK. Any other techniques surgically that we could use to scopic release? OK. Good. So, yeah, arthroscopy, uh anterior capsular release. OK. So this, this is what I prefer to do. Uh Number one because it's a fun operation to do. Um uh it's, it's quite satisfying. Um And number two, it's a more controlled uh way of releasing uh the joint. OK. Um There is a risk associated with this. There's risk of everything, of course. Um But what, what's the risk of an arthroscopic release that you don't have with the uh manipulation thinking anatomy wise? So the process for those who don't know is that you essentially, you release the rotator interval. OK? Which is essentially that a triangle of tissue which is above subscap and, and up as far as basically your biceps and down out to the pull. OK. So you take a triangle of tissue out which is your rotator interval that contains part of that uh cray humeral ligament that we talked about and the and the anterior capsule. OK. So you're releasing those two main uh restraints to, to movement. Obviously, it's where with this being, it's not just an anterior capsule problem there. Is it the capsule surrounds the whole joint. So not you could in theory release the posterior capsule, but that's, that's not commonly done. Um But if what other part of the capsule can you release from, from using a escape posteriorly and an instrument anteriorly inferior. Yeah, the inferior cap. So if you look here, this is subscapularis. If I if you can see the mouse there, see that subscapularis tendon coming across, that's your humor head, your glenoid over here. OK. Getting the scope into the Fraser's shoulder is quite difficult because it's, it's all, it is a lot tighter than normal. OK. So it looks like it's horrible. It's all inflamed. You see down here you've got your part of your inferior gleno hum ligament coming across here. So what, what you do essentially with the instrument is, is make a radial cut into this. OK. Which then gives you the ability to do a controlled uh mua. So you finish it off basically with a, with a controlled manipulation just to try and tear the inferior capsule. OK. Um What potential risk is there though, of shoving a RF probe down that, that little tiny space, axillary nerve, the axillary nerve. Yeah. So the axillary nerve runs in quite close proximity to the inferior part of the glenoid where you're going down. So you only really want to push that down as far as you can see. All right. So you can't get all the way down, but you can get enough down that you can release it enough and then do it controlled anyway. All right. OK. Good. So that all makes sense. So you've kind of got a stepwise progression there. Things like physio and injections sort of early phase. I would say the painful phase where you've got inflammation, actively occurring. Um You know, those patients, they come to clinic, they're in tears, that kind of thing. All right. So they're the ones you're gonna try and give pain relief because that's the main thing we're trying to do initially, gita dilatation does have a role. Um, but again, I think, you know, if you were at that really stiff phase, I don't know how effective it is. And, and it's interesting, there's, there's no hard evidence to say that it's a, it's an effective treatment in itself. A so interestingly mu A essentially are, are, are, you know, probably commonly done because they're easy to do. They're quite quick. But I think if you're looking for a sort of a reliable method to me, an a capsular release seems like a more reliable thing because, you know, you've, you've taken the tissue away if that makes sense. The recurrence rate of a frozen shoulder after an anterior capsular release is very low, right? It's probably only about 10%. All right. So that, that would be a failure of the surgical procedure. So it's very unusual to get a frozen shoulder off to even a capsular release. Ok. All right. So, is there any evidence for any of this? Is there any guidelines out there for your exam that you can quote, does best have a guideline that if you're not sure, just say the name of the society. And so it's usually a joint guideline. So B A best, so there is a B A best patient care pathway for frozen shoulder. Ok. Now, it's, it's an interesting read. It is a summary of what we've talked about it, it it effective as a primary care document. So it's trying to make sure that patients have been treated effectively before they come to secondary care. Um Interestingly, they, there's, again, they say that it's dealer's choice really as to what you want to do. So there is that they don't have a suggestion as to what's effective. They just say whatever you think um is gonna give your patient the best result. So as with all guidelines, there's no guidance. Um apart from doing what you like, um it does talk a little bit about evidence for things. All right. Um there is some slightly more robust evidence than, than that best guideline. Does anyone know of any, any other evidence for the treatment of frozen shoulder big study, randomized controlled trial? Neck UK Frost? Ok. Yeah. So if you, if you get asked to, if you wanna get some, you know, high scoring in your FCS bust out UK Frost, it's easy as you remember, frozen frosty. All right. Um When you, when you look at the, what that trial essentially was looking at was um uh standard treatment being physiotherapy and corticosteroid injection versus anyway, versus um uh arthroscopic anterior capsular release. What do you think the outcome of the study was that they were all the same? Yeah, no difference between any treatment. Um ok. So again, as with all these things, it doesn't really matter what you do. All right. Um But if you were asked to say, why are you picking one over the other? You can say there's no superiority of one technique over the other. Interestingly, they, they said that um there was a slight uh benefit of mua over arthroscopic release because it required less resource. So I think that's quite an interesting thing. Now, if you look at um a lot of these pragmatic randomized controlled trials, there's not just a clinical benefit. They're looking at, they're also looking at an economic health, economic benefit. Um, but I think you could argue the toss there saying that, um, that you'd prefer to do something that doesn't break your patient's arm if you push too hard. Um, so it's up to you, but there we go. All right. So that's, that's frozen shoulders. Really? All right. So hopefully that, that gives you an idea of a stepwise kind of treatment pathway. I think you've really got to, a lot of this is just looking at the patient working out where they are on that, that, that graph, but it's quite hard to do that sometimes. Uh, and then hopefully they giving you some easy evidence that you can just roll out, uh, if you need it. Ok. Good. All right. So osteoarthritis, ok. This is the other cause of, of, of a stiff shoulder. Yeah. OK. So what differentiates, um, osteoarthritis from a, a frozen shoulder? The x-ray, the x-ray. Well, I, sorry. Yeah. So they, they will both present with uh a neutral external rotation that's not passively correctable. OK. Um, so that doesn't tell you if it's a frozen shoulder or a, um, arthri arthritic shoulder? Ok. So the only way to know is to do an x-ray. All right. So again, that is a favorite one on shorts short clinical stations. They do like giving you a stiff shoulder, they'll ask you for the differential. And how do you know which one's which? So the answer is an x-ray? Ok. So who does it affect women? What age group does it affect fifties? Yeah. Well, yeah, 60 up is the kind of, it can affect anyone, right? Depending on what the cause of the arthritis is. Ok. So it's not, I've the youngest patient, I've done a shoulder replacement on since I started I was 42. Ok. Um, so there are a number of causes of arthritis, um, which we'll go through now. Ok. But again, a little bit of a lot of shoulder things when you, if you get them in the exam, what you want to essentially be looking at is what is the age of the patient? Ok. Because most shoulder pain, you know, basic conditions related to shoulder pain, you can, you can divide up by, by, um, age. Ok. So you're thinking this is your older age group. But again, as Charlie said, would you get an x-ray if you had a, a 35 40 year old come to clinic with a stiff shoulder that didn't rotate. Would you get an x-ray? Still? Everyone's, yes, it might be dislocated. Don't know, you don't know. It could be anything else. Always get an x-ray irrespective of age, but just bear in mind that, that one thing is more likely to happen in different age groups. Ok. Right. So, how many types of arthritis are there in the shoulder? Broadly speaking, I'm looking for three categories, inflammatory, degenerative, miscellaneous cough, cough. Yeah, inflammatory. So, yeah, we've got your primary O A which is your degenerative changes. Ok. So with primary O A, what we're talking about here really is cartilage loss, isn't it? Ok. So that's, that's, that's where you, where you've got your traditional kind of o A loss of cartilage and proliferation of, you know, bone and your subchondral sclerosis, your cysts, your joint space. So this is your classic O A. OK. So that it's perfectly possible to get that. Um Again, we'll come onto other causes of what, what can predispose to that, but that essentially is one type. So there we're talking about things that are secondary to dislocation trauma. Um And then, and, and weirdly w we can cause arthritis with surgical treatments. Can you think of any surgical treatments that might cause arthritis? Apart from, apart from dodgy, arthroscopy technique, fixing a proximal humerus, screw, uh work related problems. Yeah, where you've had penetrations. Definitely any other procedures with my, not not hardware related can get it after um sorry, what was that? You can get it after tightening the capsule. Correct? Yes. So as a consequence of trying to stabilize a shoulder, you can cause it to then become degenerative. Ok? Because if you think about, so think about things like say we had that posterior dislocation, right? And we've, we've then uh done a mclachlin or a modified mclin procedure on them uh to essentially tighten up their shoulder. What you've essentially then done is, is um affected the contact forces going across the joint, haven't you? Because you've prevented that joint from then moving normally. Now the shoulder is a complex joint where you've got your dynamic and static stabilizers. Um But effectively, if you, if you over tighten one element of that, it's going to end up causing a disproportionate amount of force to go through the joint at, at one point. Um So absolutely, if you, if you do that, so actually trying to treat another problem, you can end up causing another problem in the form of arthritis at a later date. Is there any other commonly done procedure that ends up tight in your shoulder joint that you can think of that might cause a problem, cough breath, no cough ba they tend to cause a problem. So, uh what I'm thinking of is a, so latch procedures can cause a similar sort of thing. Ok. Partly again because you've, you've effectively put a check around through the subscapularis where you fre your, um, the piece of bone through the subscap tendon. All right. So you, you, you, your chondroid tendon going through the subscap effectively tightens that. Uh, but also you've got that, you said you've got a bit of bone that's not got articular cartilage on, that's, that's then forming past the joint. Ok. It, it, it, it's not massively high rate, but it is, it's something that can cause O A. All right. So essentially the primary A conditions are things where you've, you've ended up with something that's, that's causing damage to your cartilage. Ok. Uh So cuff arthropathy. So I say cuff arthropathy, what's, what's the difference here? What's the, what's the underlying problem? So eventually it will be the cartilage? But why, what, what's the difference between cuff arthropathy in a primary airway? It's not a trick question. So as in, as in what's the difference between, what's causing the problem in calf cough art? Yeah. What is it? It is what it is? Failure of the rotator cuff. That's all I want you to say. So it's failure of the rotator cuff. So, so here the process, the actual underlying process is, is different because you, you've got, it's not that it's now a problem of con con situation. You're, you're, now you've now got an issue where you've lost your superior strength. OK. So, so effectively loss of superior strength then causes the head to rid up hits your cranium and then your, your pain is then generated um through, through the uh through that contact. OK. And that you see that as an early sign or a more advanced sign is that you get this sclerotic looking cranium with a migrated head. Obviously, as a consequence of that, you can, what what you tend to get with cuff arthropathy over primary a way is that you get more superior wear um, where the head where it has written up. Ok, you get more superior wear on the glenoid side. Ok. So, so you do eventually end up with cartilage loss, but the initial mechanism is basically that the cuff is failed. Ok. And then the other one we said was rheumatoid slash crystal arthropathy. Yeah. Ok. So they're slightly different in the crystal arthropathies. Um, you know, they, they, they can affect cartilage, I suppose, um due to deposition of, of, you know, either urate or, or calcium pyrophosphate in, in the joint itself, which is obviously an irritant. Um, rheumatoid's awful really because it just, uh, it destroys everything. Ok. So it's, it's your soft tissues as well as the bone. All right, the rheumatoid shoulders out of all rheumatoid joints really tend to be worse, much worse in that, in that their bone quality is awful. So when they do get, um, when it does start to go, uh, they erode in a horrible, horrible way. Um, and they can be quite challenging once to then replace. All right. So effectively, you, you've got this diffuse kind of destruction of the, of the whole shoulder girdle. So everything around it is trying to keep it in and stable. It just, it just all goes to bits. All right. Um, it is very common. Shoulder arthritis is extremely common in rheumatoid patients. All right. Um, so probably about 90% of rheumatoid patients will have some sort of shoulder related issue. Ok. That's probably, that will probably go down as it has done with most rheumatoid conditions. You know, things affecting the hands. You see a lot less rheumatoid hand problems now than you used to because of, of improvements in the biological therapy. So it's much less likely to be a problem. But for some reason, it does seem to, you know, they, they do seem to, they still come through the system and they tend to be the worst shoulders. Ok. Fine. So here's an x-ray of primary O A. All right. So I'm not gonna make you do the easy bit. There's joint space narrowing there. As you can see, you have these inferior osteophytes. So you 10 that referred you as a goat's beard osteophyte. Ok. So it's a kind of long chinny chin uh osteophyte. Ok. Um There's probably some, there's is some sclerosis there, there'll be some cysts. Ok. What is the wear pattern that you tend to get with um primary O A in relation to the glenoid side, posterior, we have posterior uh subluxation of the head. OK. Uh And then you end up with posterior wear in the glenoid. OK. Um Otherwise, if you look on the A P, it looks like a relatively concentric pattern of wear. OK. So you can differentiate pretty quickly between them between the xrays as to as to whether this is a, a cuff related problem or, or a primary, a type problem. Now having primary A doesn't, doesn't mean that you don't, you don't have a cuff problem because if you, if you looked through, you know, if you looked at sort of a la of 70 year old people's rotator cuffs, you'll find some sort of degenerative tear probably in about 70% of them. Ok. But interesting, if you read the literature, it says that the incidence of rotator cuff injury associated with primary oaie a tear is only about 10% which is quite interesting because most people would, would, um, be a bit worried about doing a, an anatomic shoulder replacement in, in this type of age group because you, you're concerned about failure. But at the moment, there is a large trial going on called Rhapsody, which is essentially looking at intact cuffs in the over sixties and whether or not we should be doing anatomic or reverse shoulders in them. Ok. There's definitely a propensity now for, for more reverse shoulder replacements done to be done. Um, if you look at the NJ R figures. It's about a 400% increase over the last few years in the number of reverse shoulders going in compared to anatomic with quite a large drop off there where most uh shoulder surgeons practice now is probably um 80 to 90% reverses over anatomic. OK. So it's, it's worth bearing that in mind when you're coming to look at these kinds of things. But hopefully, Rhapsody will give us a bit of an answer and a steer on that. OK? Um So with primary, this is essentially what you're looking for in the x-rays. OK. Uh When we talk next week about the about arthroplasty in more detail, we'll come on to, to um looking more specifically at the patterns of where we in the glenoid and how we can address those uh to correct. So essentially all arthroplasty is trying to correct joint, joint kinematics, isn't it? So we'll talk about how we come on how you classify and come on to that and what things are available to help. OK. But this is really today just as we're talking in the context of stiffness, what what you're looking for in an x-ray to diagnose it. OK. So, cu arthropathy, this is what cuff arthropathy looks like. OK. So that's horrible, isn't it? OK. You can see the difference between the two. So you've got here this again, you know, it's like the sheen's line of the shoulder. All right, for those who are more hip orientated. You can see that the inferior aspect of the glenoid is there. So normally this would sit with the co car of the humerus. Ok. So you already know that that's migrated and there's been failure of the cuff. OK. The other massive clear is there's absolutely no subcranial space. All right. So you can see that that's extremely sclerotic there. Um Hopefully this one demonstrates it nice. You can see there's a, there's a large amount of superior wear here. Can you see where that, that goes in at the top? You see that little ridge there and then it's completely narrowed off. Um So you can see in the context of this, that this is quite advanced cuff arthropathy and a and actually this is more likely to be stiff than anything else. So what I was saying earlier with regards to C day paralysis, when you examine this patient, they will be genuinely stiff. So they're not likely to be passively corrected. Ok. But with early cuff arthropathy, particularly where you've got massive cuff tears, it, they, you will still be able to possibly move them, but it doesn't mean that they, they're not arthritic if you see what I mean. Ok. Um So this is, this is your kind of worse nasty cuff arthropathy. And I think I've got to do that next week. Lovely. That'd be nice. Um So with that one, obviously, the, the the decision making here is quite easy because, because you're, you're looking really at, if you're going to operate, it's gonna be reversed because of, because you've lost your superior strength in your calf. Ok. So we haven't talked about a VN yet. That's, that's another, another cause of stiffness. Ok. Why does it cause stiffness though? Because the humeral head is uh lost its route, globular shape. Global shape. So, yeah. No, you, yeah, you do end up with uh uh incongruity of the joint. That's fine. I love globular. That's good. Um uh Yes. So part of it is due to due to the uh loss of the conformity of the joint. Um The other thing as well is that if you think about it, you'll get an inflammatory action again, won't you when you've got, when you've got an underlying process there? So it, as we said earlier, it can be, you can get a secondary frozen shoulder as a consequence of having, having a massive inflammatory response where you effectively got bone dying off within the humeral head. OK. What are, what are the causes of a VN? This is a great question because this can be for any joint. You see. So this is good revision for you. OK. So what, what are the causes of A BN C coughing disorders such as clo when you say clotting disorders? What do you mean clotting disorders? Do you mean another hematological problem? Sick, sickle cell unit? Yeah. So uh when I was working on fellowship in Nottingham. We had a sickle cell unit there. I would say almost every on call we got called to see someone with a VN of, of a joint. All right. So sickle cell that's very common, particularly them because it, again, it says abnormal um, blood cells getting caught in the capillaries and they infarct basically. So that's quite a common cause. Any other cause, steroid steroid use. Yeah. Alcohol, alcohol, drink it. Any others proximal humerus fractures? Yes. Trauma. Yeah. Don't forget trauma. OK. What's the rate of nonunion with a four part proximal humerus fracture? More than 75% or you're not fixing them well enough? 40%. Yeah, about 40 to 45% risk of nonunion. So ones that are fractured and dislocated, the rate is almost 100%. Uh when you've got a full part fracture, if you're able to fix it. Well, it is about 40 to 45% still. OK. Even with a three part one, that's not that bad and valves impacted, you're still looking at about sort of 15 to 20% risk of non union. OK. So uh out of all of those trauma is probably the most common cause I would say of AVN uh for probably in steroids and then sickle cell. OK. Um So you've done the causes. So obviously it's to do with a disruption to the blood supply. So the inevitable question, if you got this in an exam would be. What is the blood supply to the proximal humerus? Good advice that, that uh anterior, posterior circumflex, humeral arter. Yeah, it's just like a hip. Yes, it's anterior posterior circumflex. Which one, which one supplies the uh, the, the bulk of the blood supply? Uh, posterior. Very good. Ok. Yeah. So there you go. So that's affect your branches of the anxi artery. That's the anterior and posterior circumflex. A small feeding amount from the, from the superior cuff vessels. But it's very tiny. The predominant amount comes through the, the uh the posterior hum circle. But that it's about 60 I think about 60 or 70% comes through that. Ok. So that will come up if you get AVN, I'll ask you about the blood supply to your humerus. OK. All right. So that's, that's AVN. So AVM can cause it basically as, as uh septe for loss of your globular ness of your uh humerus. Um But also you get an inflammatory response which can cause a second face and shoulder. Ok. Good. All right. Let's have a look. So, treatment for stiff arthritic shoulders. So, first part of call for treatment wise is what it's on the screen. Physio physio. Good. So the answer to everything as an initial treatment is physiotherapy. Ok. So, again, you have this difficulty in engaging people with physiotherapy because effectively, they'll say my joint hurts and it doesn't move. What good is physio? All right. Um Is there a particular category out of those arthritic type patients that might benefit from a, a type of physiotherapy. And if it, if they, if say whi what, what specifically would you ask a physio to do with them? So, of our primary, the cuff ones? Yeah. Good. Penelope. What, what would you ask the physio to do with the cuff arthro? I would like them to focus on the deltoid and the anterior deltoid. Excellent. Yes, good. So, so what is talking about there is there's a specific physio protocol for rehab which looks at strengthening the anterior deltoid. Ok. So there, there is a proportion of patients um who will improve with anterior deltoid training because if effectively, what you're doing is doing part of what happens when you do a shoulder replacement, the reverse shoulder replacement is you're, you're getting the deltoid to take over the work of the calf muscles. Ok. So you don't lose anything by sending someone with a cuff arthropathy off for an anterior deltoid training. Because if, if they engage with the physio program, when you, if you end up doing a reverse anyway, they've already sort of pre habilitated as it were for their operation. So yes, of course, for, for patients with, with primary glenohumeral joint arthritis, what you're really looking at doing is is preserving as much mobility as possible and keeping their cuff strong because ju you, if you think about it, if you did an anatomic shoulder replacement. And you've got a patient who hasn't really moved their shoulder. Yes, their cuff might be intact. But, but if they've got fatty infiltration within their muscles, it's not, they're not gonna benefit from any of the, you know, the, the movement that they would achieve by having a muscle that hasn't moved for ages. So, it is important to inform your patients that, that as much engagement with physio as possible, um, is in, in their benefit, even if we get to the point of an operation, it's not in spite, you know, it's not, instead of an operation or in spite of that, you have to, they both go hand in hand. Ok. And as Penelope said, with a, with a cuff arthropathy, you want that anterior deltoid training there because um, some uh proportion of patients will improve and not require any further intervention for a while beyond that. But some, if that you're inevitably gonna get to a cuff with anyway, once you've got, um, once you've got them, uh, you know, strong enough that will benefit them postoperatively. Ok. Good. All right. So, physio, definitely, what else can we do? Analgesia, analgesia. Good. Well done. Everyone forgets analgesia. Ok. Pills. All right, tablets, tablets are effective. All right, if used. So a lot of times you get patients coming in saying they're in pain, certainly a lot come from my clinic. Um, you ask them what painkillers they're taking, they're not taking anything. Ok? All right. So, non-steroidal anti-inflammatories definitely have a role. Ok. Again. Uh, yes, the arthritis is a mechanical uh, process. But what you're effectively doing with that is it, it, it is an, it's an inflammatory process at the end of the day, isn't it? It's not just bone rubbing on bone. That's the problem. It's, it's the inflammation that, that, that causes and all the inflammatory cytokines and everything that then stimulate your pain fibers that then cause pain, right? So, if you can get on top of the inflammatory process with, with the medication, then that's, that's a good part, first port of call. Ok. And certainly someone that should be exhausted before you start heading down the route of, of offering anything more invasive. Ok. Good. So, physio and pain relief. All right. So you've had physio and pain relief to come back. What? Still painful? What are you gonna do? Inject, inject? Thank you. The, so, injections, we'll come on to that in a minute. But injections have a role. Ok. Um, but I'll come onto that in a second. Ok. So if they've had injections, let's say those haven't worked. What options have you then got. So we've essentially exhausted everything we can do in a clinic. Operate. Yeah, we all have operations. So, so in terms of operations, what operations are available for, for uh you know, arthritis of the shoulder, um, reverse or anatomic shoulder replacements. Um I'm not else, David, I love but is there anything else you can do? Uh So let's say, let's say, for example, you've got a patient who's got a massive rotator cuff tear, right? So they've got cuff arthropathy but not as bad as the one that shade you. Ok, let's say that they've got pain. Um, and they're, I don't know, let's say they're 55. Are you gonna put a reverse in them straight away? No. So what, what could you do as a, as a protect? So everything we're doing is geared around pain relief, right? What could you do instead? It's not a reverse, do denervation or blocks. Yeah. So that, yes. So that's very good, Charlie. Yeah. So you can, again, that's under your injection, sort of remit uh any surgical intervention short of debridement. Debridement. Yeah. So arthroscopic debridement is an option. OK. Essentially what you're, what you're doing is performing a subcranial decompression essentially to try and increase the space. All right. Um Sometimes they can get pain if they've got massive cuff tears from, from the, you know, if you just De Bride the edges of the tear sometimes that helps you use biceps if it's still hanging on. So, yeah, that's an interesting question, Charlie. So should you re release bice or should you leave? It depends if they think that's the source of the some of the pain. Yeah, that's true. So it can be a pain. So if you get in there and it's flat as a pancake and red and injected then yeah, you could do that because that could be that. But what's the potential benefit of leaving a biceps intact? Sort of acting as a um superior restraint as well? It is. Yeah. So, so, so it depends really what you think as you say. It's, it, it can be a pain generator. So it's definitely worth considering taking it. Um But if it doesn't look too bad, um I'll tend to leave it in that situation because it i it is sort of acting as a, as a restraint. Now, I'm sure I'm probably kidding myself a bit. Uh That, that's gonna make a massive difference because I think you, you know, essentially when you've been in there and debrided that, that, that's the last thing you're gonna do arthroscopically. Um But yeah, there's an interesting question about that. Whether you take it or not is, is I think a personal choice, but because the, the consequence is probably gonna be the same in the long run, isn't it that you're gonna end up having a, a reverse at some point? But if some believe that if you leave, leave it in, then it is acting as a superior strain. OK. Good. And then David, because he's had a taste of it. Now he wants, he wants more shoulder replacements. He loves it. So there you go. All right. OK. So injection should Charlie talk then about injections? OK. So you mentioned that is. So, so where can you inject to try and help with a, with a, an arthritic shoulder? So, if they got rotator cuff, arthropathy, you can do a steroid into anywhere, it'll end up in the same. Generally. Doesn't matter. Like what I do if I, if I've got arthropathy is I just shove the needle in, hit the humoral head and inject away. It doesn't really matter where you put it because there's a big hole there. It will just float around. All right. Again, what I tell patients when I'm giving them steroid injections, intraarticular is that this is, you have to, I know it sounds stupid but you sort of have to stress them that this is not treating the arthritis. All right. Um That and all this is doing is it I is dampening down the inflammation associated with it? Ok. I sort of tend to find that, that the, you, there will be a proportion of patients that, that love having injections. All right. Um, but they, there is a law of diminishing returns with shoulder injections. Ok. The, the first one is always the best, uh, and then you'll get effect from them as it goes on. Ok. Um What do you feel about, uh, how would you leave an interval between injecting someone's shoulder and then replacing it? Do you think there's any, you don't want to be doing surgery within at least three months until six months before increase the risk of infection. Indeed. There's not, there's not any kind of hard evidence out about that, but most people would feel uncomfortable about doing a subsequent joint replacement, certainly within three months of an injection. Right. It's difficult at the moment because, because we've got a lot of, um, patients who are post COVID, you know, long waiters. It's difficult juggling that because they're obviously in pain. So you want to do something to help them, but you don't know when they coming up on the list. So it's worth bearing in mind, but it, it is, it can be useful as a temporizing measure. And what about we've talked all about steroids? Is, you know, is there any other things you that, that you've heard of that can be injected into joints to try and help with arthritis, PRPs, PR P? Yeah. Is there any evidence of PR P? I don't know. Yeah. So if you don't know, the answer is probably no. Um And the other thing is, have you seen a lot of it? No. So it's the, the, the evidence for PRP is extremely limited at the moment. It's certainly not something that's recommended or, or even at the moment, there was a recent best guideline out about um, tennis elbow and that did not recommend PRP as a treatment. So I think there was this initial sort of craze for PRP but um as more, more is being looked into, it doesn't really have a role. Certainly not within an arthritic shoulder. Ok. Um Any other things you can inject in the Hyaluronic acid? Yeah. So Hyalur acid again, weak evidence. So, so it doesn't really matter what you inject, there's not much evidence for anything. Just do whatever you think is gonna help with pain. All right. But corticosteroid injection into your shoulder is probably the more commonly done thing. Now, Charlie, you mentioned something else earlier about, about blocks. Yeah, you can do a separate. What's that? Sorry, sorry, sorry. Suprascapular nerve block. Yeah. Suprascapular nerve block. OK. So this can be quite an effective treatment. So your suprascapular nerve essentially runs, runs in the, in the, in the notch. So suprascapular notch. So it sits roughly in the middle of that. Ok? It supplies about 70% of the pain fibers to your shoulder. Ok? So an option if you've got somebody say who's, who's not fit for surgery, um, or doesn't want an operation particularly at that stage, uh would be to do a nerve block around that. Now, there's various techniques you can use that. You can do it as a landmark technique where you essentially work out roughly where the middle of the notch is using your hand. You put your hand on the, on the scapular spine, usually where your middle finger is is roughly where you go down, you go down, hit the bone, pull back. Um I put loads in, I I put about 20 mils of locally with some steroid just to, because you're trying to hit and hope really. So, uh if it, if that's effective, then you can send them off to, to either it's normally the pain service that can then do an ablation of the nerve. Uh either with cryotherapy or, or radiofrequency to permanently take that nerve out. Ok. Obviously, that's OK. If you're, if you're thinking you're gonna do a reverse in the future because if you take out the supra scapula, now you're also taking out your supraspinatus. Ok. So you just got to remember, remember that. So I wouldn't necessarily rush you in a younger patient, but it's, it's an option that's there, particularly for elderly patients who are not, not fit enough for anything. Ok. All right. That's good. So that definitely has a role. Uh, it's something that you often forget about as a potential solution. Um, but it's certainly something that, that, that, that we do pretty commonly at the rest of that tend to be a thing that's becoming more popular, right? I remember I got. What about these, has anyone seen these before in space balloon? So, so, uh as we all arthroplasty things, there's many different types you can do. David. David's favorite thing, which is shoulder replacements, of course, or you can do an interpositioned arthroplasty. All right. So, essentially this balloon is an interposition arthroplasty. Ok. You're, you're shoving something in between, uh, the, um, the bone to try and try and minimize it. The theory being that this balloon would give you enough time to train your deltoid up to be sort of Olympic champion deltoid. That would do all the work and, and you'd never have any pain there at all. Ok. So what do you think? What do you think about these good idea? So, maybe just for, as you said, for the anterior deltoid. But I think if, after, I think six months or something, they just kind of have pass it or disappeared as well or something like that, patients used to feel when they, they popped as well because it's quite a good saline in there, but they used to feel that when they popped. So the answer is no, don't use them. Ok. Uh And there was a big trial so this might come up as a thing because it is a potential solution to a problem. All right, there was a, a large randomized controlled trial, um, which is published in the Lancet called Start Rea which, which finished early actually. Um, because there, there was overwhelming evidence that this was no better than doing a debridement. Ok. Um, so they were very popular again when they came out, they seemed like a good idea. Um, quite a few went in. But, er, again, there wasn't much, um, much evidence to suggest that they were any better. And as, again, as I said earlier, with, with those trials earlier that the, there's a health economic argument as well because these costs, I think they're about 1200 quid each. All right. So, if you think that over debridement, if there's no clinical benefit, then, then it's a bit of a waste of time. So those are no longer used or licensed for use. Ok. Can you repeat the name of the trial? It's called Start Reacts and it's in the Lancet 2022 and it's um Metcalf at al out of bow tray then. Ok. Good. All right. We're nearly there guys. OK. So effectively, we've talked about the causes of shoulder stiffness. All right, which we get to four. So dislocation, never forget about dislocation. All right, always have that in the back of your mind as a potential cause of stiffness, particularly in younger patients. And a lot of this is governed by history. OK? If it sounds a bit dodgy, you know, epileptics, things like that, think about dislocation and then miss dislocation from my knee. OK. That can be anterior, posterior. It tends to be more commonly posterior dislocations that get missed. OK. Adhesive capsulitis. So that is a very common um cause of, of shoulder stiffness. I saw that Charlie. Um That's a very, was it? Yeah. Um So uh adhesive capsulitis is probably the most common cause of shoulder stiffness uh that you'll see. Ok. Um Hopefully today, um I've given you a kind of way of, of thinking about that. Uh And a stepwise kind of progression of treatment. Um I think it's about really with that, it's about looking at where that patient is on that, that graph and trying to work out what intervention you think is going to be the most effective. All right. Um I think if you can demonstrate that when you ask a question about an exam, it shows you you've got an understanding of the pathophysiology of it, what treatments are available and then if you can chuck in any evidence that we've said there, which is effectively do whatever you like. Um, but if you just quote a couple of things and that hopefully will give you a good, good solid way of them answering that. And I put that across in a relatively simple way for you to understand. All right, there's a load of stuff you can go on it. But I think the stuff I put on there is essentially the, the nuts and buts what you need to know arthritis. So this is gonna be the, the, the main topic next time when we, when we have teaching next week, I'll, I'll go into a lot more detail, uh, about, um, uh, shoulder arthroplasty. Ok. So the focus of today's talk was not really to talk about, um, the, the ins and outs of shoulder arthroplasty. It is really just to, to restarting that process of, you've got a patient in clinic who's got a stiff shoulder. How do you go about assessing and evaluating them. Ok. So osteoarthritis again is probably the next most common cause of, of shoulder stiffness that you'll see a VN to a lesser extent is, is there. Um, but it's certainly something to, to think about because it does present in a slightly different way. The treatments essentially are, are, are, are very similar. Um, in that you, most of the really bad A VNS, you're going to end up replacing most of the osteoarthritis, inevitably you're going to end up replacing. But next time when we have teaching, I'll, I'll go into more detail about, um, about what shoulder, um, Arth plasty involves and, and then major failure associated with that and then how you manage a shoulder that's failing. Ok. So shoulder rare one, all right. But they love pulling out rare stuff and exams, don't they? All right. So just, just bear that in mind as another potential cause of the shoulder stiffness. It's not common, but it's some, it's an interesting kind of process. It's just quite a different way of, uh, uh, but you can see there's a clear difference between the, between the presentations on x-ray of those things. Ok. We've already said that we'd get an x-ray regardless of, of person's age or presenting kind of features for shoulder stiffness because it can be a number of things as you, as you see today. All right. Ok. Good. Little bit early. But I didn't think I could string out stiff shoulders for two hours. It's quite difficult to do that because you can talk about all sorts. But hopefully that's, that's covered what we need to. So, is there any questions at all that they want to ask? Um, I was just wondering with that suprascapular block. Um, so what patients would you suggest it for the younger patients who aren't quite ready for, um, for anything more surgical? Yes, you can use them in that setting. Um, keen on avoiding an operation to start with. Ok. Um, it depends on, if they've got cuff, it's more for the cuff faily type ones if you know what I mean? Um, but the, the predominant ones that I'd be using that in are the, um, multiply comorbid, you know, elderly who would not be likely to survive an anesthetic for a shoulder replacement. So those are the ones that, because you've got to offer them something, um, whether it works or not is a different matter, but there's not really the resource there for them all to be guided injections. So that's, that's why it's a bit tricky sometimes. So you never, but I, my feeling is if you put a large volume of local in there, in the right place, you know, hopefully, hopefully you'll hit the nerve, but the age group that I'll be looking at on where I'm, I'm not planning any surgical intervention. Ok. But you wouldn't use it as a stop gap. Or like a, you know, pain relief, temporary. I think if you were going for a stop gap option for someone I would do hum joint inject. All right with, with the caveat that, that if they've had multiple ones, it's less likely to, to be effective. And if we're looking to replace, I wouldn't want one within, you know, minimum of three months prior to operation. Ok. Thanks Mr De Hun. One question. Um, for patients who have, for example, a massive rotator cuff injury, irreparable cuffs or we have done an MRI scan and the MRI scan shows retracted cough, possibly with fat infiltration. But on the actual MRI scan, there is no significant signs of glenohumeral osteoarthritis. Can these patients benefit from superior capsule reconstruction? For example, just very good question. Uh So uh superior caption reconstruction for those who don't know what that is essentially is your, you're uh fastening a superior restraint uh for the hum or head using normal, normally something like dermal allograft. Um uh And you, you essentially debride the top of the glenoid and you, you're, you're pulling you, you anchor it into the top of the glenoid, pull it across to cover what, what was where the rotator cuff was and then putting that onto the humerus. Ok. So you're effectively recreating a AAA superior restraint. Um Is there a role for it? That's a good question. Uh They, I've done them. Uh and I've been in units where they are done. Um, they're quite technically challenging. So, uh, they're not commonly done and I think as a consequence of that, the evidence for it is a bit difficult because from what I understand, but only about a third of patients who have it done, er, demonstrate any, I, I know measurable improvement. Ok. Um, so it's like all things to do with massive rotator cuff tears. We've looked at, um, you know, balloons, as we said, no evidence that that makes any difference. We've looked at people looked at tendon transfers less popular in the UK, but certainly big on the continent and big in America. Um If you look at it as a whole tendon transfers again, not a massive improvement good in certain people's hands, you do lots of them, but in the generality, it's not, it's not, not probably as successful as people may count. Um I think in terms of sc yeah, the only about a third of people I think benefit um significantly. So it's really about patient choice and shared decision making. Isn't it reliable thing? Still? I think there's the acceptance that the most reliable solution to a massive cuff tear if you're looking for pain relief and functional improvement is a reverse shoulder replacement. And 11 last question I wanted to ask you in, in case, for example, you mentioned one example when we had a 55 year old gentleman fit and well active, but the only concern was he's too young to go ahead with a reverse shoulder. Yeah. Yeah. So, so some, sometimes when I was discussing with some of my previous operate consultants we had some discussion about, is it a possibility of giving them an early hemiarthroplasty and then possibly keep the option for reverse later on? So, it depends if it's a massive cuff, if it's a massive cuff issue. Mhm. He arts is not gonna be you effectively. Correct. Yes, you can put there are types of, I'll show I'll show you an example next week one where there are heads that are called cu to arthropathy heads. He just headed hemi essentially. So that is an option. Um but the issues about stability then isn't it really if you, if you can make things worse by that by essentially exchanging someone's normal anatomy for, for a large chunk of metal, effectively unstable within their shoulder. OK. Actually things a bit worse. Interestingly, when I was at a conference, there was a lot of talk actually about um the fact that perhaps reverses are not as bad as we think they are. Um And with modern, you know, uh reverse total shoulder. A lot of the early evidence is based on the original gram uh where there were issues and the lymph node failure with, with a shoulder replacement was just the glenoid side. OK. Essentially free forces, you know, forces being transmitted that cause the glenoid to loosen. But I think now that, that, that you've got better technology there that actually the rate of failure on the Glenn side is not as high as it used to be. So there's a, a feeling really now that reverses perhaps aren't as bad as we thought they were. Um And maybe that it's not, not quite as bad. I understand what you're saying in terms of the, um, in terms of that, once you've done a reverse, it's much more difficult to revise that. Ok. Uh But again, there's a lot more bone preserving types of uh implant that that are available. All right, it's the same with any arthroplasty concept, really, isn't it? You've always got to think beyond the operation you're doing. If you see what I mean, I don't think that I would be against putting a reverse in someone of 55 in that context if that was the best treatment for them. But again, it's a discussion with the patient explaining that there is a real risk of, of revision date. Of course. Thank you so much. Thank you. Any other questions at all? Uh Mr Dunn, there's a couple of questions from the chat box um from uh Doctor Addy, one of our visiting people. Um The question is, uh, do you want me to read it all? Um I, I can read it there actually quite nice injections better than sub injections for impingement syndrome. Interesting. Um So if it's impingement by subacromial inflammation, uh then a subacromial injections better, especially in the context of an intact rotator cuff because you're not, the steroid is not going to get to the right place. So I think if it is, if it's truly impingement by subacromial bursitis, then then a, a subacromial injection is better than the G A hum joint injection. OK. It, it depends what you're talking about if you're, if you're, if you're asking in the context of a, of a, of a rotator cuff kind of related pain syndrome, turning into a frozen shoulder, then you've got to treat what you think the underlying problem is really? So, it's about, again, examination and history there trying to tease out what the actual issue is. Um, but I, for me, I inject where the pain where I think the pain's coming from. So, like Charlie said, if it's a massive rotator cuff tear, it doesn't really matter. But if you've got, if you want an intact cuff and, and you think it's bursitis and get the bursitis, not the joint, um, the Cons Morley score, man, you're gonna have to look that one up. No one uses it anymore. So, um, so yeah, it's not commonly done. It, it's massive. It's a really, I ever have to do one but it is, I think it's about two pages long. It involves all sorts of things. So, constant scores, it's the most quoted, er, thing I think in shoulders, um, because it was used for everything as a, as a measure. But yeah, you, you'd have to look that one up and oral nsaids. Uh What do we co prescribe gastric protection? Um It depends how long you're using them for. Ok. If they're short term, obviously not providing the patient doesn't have any history of any gastroesophageal problems. Um If they're long term, then yes, of course, the gastro protection would be that, but in the context of um of us working within secondary care, uh most long term prescriptions would be managed by the GP. So, so I would say that the, the GP should probably make that call on that. Any other questions? Um Hi, it's Luke. Sorry. I've got a really quick question but I do apologize. It's slightly off um as in, it's not actually to do with the a stiff shoulder, but it is at least shoulders. Um In our trauma meeting this morning, we didn't have a shoulder surgeon and we were just debating, there was a guy in his early forties that had clinically a long head of biceps rupture and we were just discussing, would you if you're committed that you're not going to operate on the long head of biceps? Is there any merit in imaging the shoulder? Is it going to change your management? And I just didn't know whether in your experience if that comes up in a trauma meeting when you're on call, do you get any imaging of the shoulder or do you just say, let's just leave if he's and tell him about that, he's gonna have a Popeye sign. Yeah. So, so if it's just that, if it is just that the history fits, you know, like it was, if you say they went ping and they got some bruising proximately, then no, I wouldn't image it. Um Just see how they get on in terms of rehabbing with physi a. Um the main kind of consequence of that, that they tend to get apart from a Popeye sign, which you can't really do much about is is they can sometimes get cramping that tends to be the most sort of annoying symptom that they can subsequently get. If they get persistent kind of cramping, then then sometimes going back in and doing a subpectoral biceps tenodesis is, is worthwhile in them or, or before you get to that stage, a steroid injection uh around where, where, where it's getting tends to get caught just above peck. So you can inject steroid there to try and help with that inflammation, but I wouldn't routinely get imaging. Um If they're struggling that, you know, after there's you can have an association with, with long headed biceps rupture or subluxation, it can be, there can be an associate of subscap injury as well. But I think it's, it depends on the context. If it was a big traumatic injury, you might want to consider imaging the cuff. But if it's just that he was there and it just pinned er, without any significant force. Then probably not. I don't know if that answers your question or. No, probably not. No, in a nutshell. Ok. Any questions too. No, doesn't look like it. Ok. Um, so, oh, there's another message exciting. Oh, there he goes s down right there. That's fine. No worries. Um, ok, so next week we'll be talking more about, um, arthroplasty. Ok. So a bit more detail about that. Um And then obviously today signed up for the 26th, isn't it? Um uh The format day is basically gonna be, I've got um the A X bus coming. Um So there'll be some chance to have a play around with um some uh cuff anchors and things like that. Um And then there's also uh exact tech uh are coming with some Saw Bains so we can do some glenoid implantation uh and have a play with that. And also we'll have the um navigate GPS navigation uh for people to have a play on as well. All right. So, and then we'll do some viva stuff in the afternoon if that all sounds ok. If anyone's got any suggestions or things they want covering, um Please just drop me a line. I'm happy for any additional questions that might come up from this today. If you've got any other questions, just just drop me an email. Ok. All right. Are you finished, guys? Enjoy the rest of your afternoons. Ok. Thank you very much. Thanks a lot. Bye bye.