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Welcome to me all primary care. Joining us today is Mr Christopher Dukes who is a shoulder and elbow clinical Fellow at Liverpool University Hospital's NHS Foundation Trust committed to advancing patient care and medical education within the healthcare system. Today, Mr Dukes will be teaching us how to master shoulder and pain management. Uh We have around 45 minutes for the presentation and there will be some time for questions. So do put your questions in the chat. As we go along at the end of the event, there will be a feedback form, emailed to you and once completed your attendance certificate will be on your Meadow account. That's all for me. I'll let Mr Dukes take it away. Thanks YJ. Um So yeah, so I'm one of the upper limb fellows up here at Liverpool, one of two of us and this teaching is aimed primarily at GPS. Um I appreciate we've got some people from overseas. So thank you everyone for joining this evening and also anyone from overseas who it's probably even later for now. Um So I'll just start sharing my screen. Hopefully everyone can see it maybe up then start there. So shoulder pain, well, shoulders, uh I think can be a bit uh, confusing and daunting. I think I remember when I was at med school and taught the shoulder exam, it seemed a little bit complicated and like there was a lot of stuff going on, especially when you're trying to remember different cuff muscles and things like that. So the aim of this is to try and simplify everything as much as possible. Give you some basic principles to follow. Um And throughout I'll try and include these QR codes which are linked to the British Elbow Shoulder Society and British Orthopedic Association guidelines for shoulder pain. And there's also nice guidelines as well just to give you a rough idea of things you can do. Um so broadly, you can, you can, there are three ages of the shoulder. So in young people, they tend to complain more of instability problems. So dislocations and then complications of dislocations. And then in middle age, uh you start getting a bit of a CJ arthritis, you start getting subacromial pain and all the conditions that can cause that. And then you can have a bit of frozen shoulder and then a bit of crossover. But as you get older, you start getting rotator cuff problems and then shoulder arthritis. So when a patient comes in and they've got shoulder pain and they're of a certain age, you can already start to try and categorize them into one of these domains uh just by looking at their age and they're coming through the door. Um So instability, I'll just touch on this lightly because most of these patients will probably present to an orthopedic department through the A&E route. Uh And this is called the Stanmore triangle, this in the middle and this is that instability of the shoulder is on a spectrum, er, at one end, you have the traumatic one. So these are your rugby players or people who have fallen down stairs and they've had a obvious injury with the shoulder that's out, that has to be put in uh in A&E and then they get referred to the orthopedic services through that way. So that normally doesn't darken your door uh as a GP, uh the ones that might be a bit more confusing and might give you a bit of a headache whilst you're trying to work out are the ones that are atraumatic. So you can have people who are atraumatic from a structural problem and these could be patients with S Danlos or hyper mobile. Uh and they just have ligamentous laxity, which can predispose them to having an unstable shoulder or shoulder that functions poorly and gives them pain. And then you have patients over here who if you were to scan their shoulder, everything would be completely normal and pristine, but they have a muscle problem, a muscle patterning problem. And if you look at this patient's scapul here, you can see that's winging. Um, so I'll talk on this later about when you're examining these people, you've got to get them down to skin, you get them in a vest at least, and then get them to move and then that's how you'll see asymmetry. Otherwise you might miss things like that. Uh, so it's this group at the bottom that might present in a more insidious way, er, and which might confuse you for a bit or can be difficult to treat. Um, if you're not quite sure what's going on. So again, the importance of getting patients to strip down to a vest before examining them and getting to move. If you look at this patient's right shoulder as they come down, you'll see their scapular, just lift up there and it's quite subtle if you're not looking for it. Um, and again, I'll just replay that there. So, uh, we've got some really good physios where I work and they look at this and they know exactly what's going on and they'll say that the, the pe is over fring or whatnot. I start to glaze over when they start talking about which muscles are imbalanced and how to treat it. I think all you need to appreciate is that these patients sort of shoulder pain and function. If you examine them and you see their scapular moving around like that, the muscles are trying to work in a, in an odd way. Um, similarly, this patient is one of the ones that would present to R A&E with the quote dislocated shoulder. Uh, and you can see how tens all the muscles are here and they're holding it in a sublux position. Um And that is just a pure, over fring of her muscles needed to X ray. It, it would look abnormal. It wouldn't be dislocated, but it wouldn't look normal. So they haven't get referred as dislocated shoulders and she's obviously in a crisis. Um If you were to give her an anesthetic, all her muscles would relax and the shoulder would just go straight back into joint without you having to pull on it or do anything. Um So the muscles around the shoulder are complicated and can give rise to all sorts of things going on and they can present in odd ways. Um But the more of the story is that there's no operation that can help these people. They just need a load of physio and specialist up physio and they retrain all their perula muscles, they work on their posture. Um Often they, after a few sessions start becoming psychiatrists to some extent as well. Sometimes a lot of people, especially young girls, this can affect to broadly categorize or generalize. Um Sometimes you can find that there's history of uh abuse. Uh So it might, they have a pretty traumatizing event in their life or they're in a bad situation and they will start manifesting that through their shoulder instability. Um, so, er, it can be quite a complex, er, thing to treat. Um, but the m story is, er, if it's atraumatic, er, lots of physiotherapy, that's the route one goal. If the physiotherapy isn't working or it can be very difficult. But like I mentioned, there's a lot of other things going on then, then you can refer them into secondary care and then when they're in our care and we're not being able to deal with them, we'll refer them on to an even more specialized unit of which we want here at Liverpool. Um, and, uh, you want to start getting them to an MDT clinic pretty sharpish if they're getting absent from school a lot. If it's keeping you off work, they frequent flies in A&E because their shoulder is dislocating. Um, or if like that lady in the video, their shoulder is persistently dislocated or subluxed, then they need specialist shoulder review. Um, and most important really, those specialists should physiotherapists. So that was a little bit of lip service just to young patients and instability. Um, now, whilst we're talking about instability, you can have, er, patients, er, who have dislocated their shoulder, er, and if they're not getting better afterwards, um, then consider a cuff tear, especially if they're getting older and they're over the age of 40. So if you have a patient over the age of 40 who's been to A&E for an injury or dislocated their shoulder and for whatever reason, every now and again, you get one that slips the neck and, er, doesn't come in through the, the fracture clinic pathway. They might present to you a couple of weeks or a few months later saying that their shoulder is weak and painful, um, and they hurt their shoulder a few months previously, uh, then be very suspicious of a cuff tear and, uh, refer them in quickly. Don't, um, try and send them down physiotherapy first, please. Uh, please try and refer them to a fracture clinic or the urgent up limb clinic if you have one. So that's, er, a bit of instability out of the way. Now. Now we're come on to what's, what's probably more commonly gonna come in through your door. So patients come to you and say that they've got pain in their shoulder. Um, so let's try and work out where it's coming from. So, first of all, where is the pain? So if you ask them where it is and if they rub the top of their shoulder there, generally, er, that's their A CJ. Er, so they put their hand on the top of the shoulder and they rub up and down their, think a CJ. First of all, if they rub the side of their shoulder, then that's normally a subacromial pathology. So that's the problem with their bursa or their cuff and if they've got pain in the front of their shoulder, so where this gentleman's thumb is, um, then that might be a problem with the long head of biceps or the subscap, the tendon at the front. Um, arthritis, pain might be more sort of within the armpit or they'll describe it as deep in the joints, um, uh, is, is. And so that, and they also generally tend to be older as well. So you can start again if you are trying to categorize where someone's pain might be, uh you can see just where they gesture, um where you're thinking that the pathology might be. Although as always, it's not as easy as that. Now, if patients say that pain is going below the elbow and radiating into their hand, that's usually not the shoulder. So shoulders will give you pain in those areas that I described previously. It shouldn't give you anything radiating down. Similarly, if you have pain between your shoulder blades, not normally shoulder, there are some muscles and things there that can be sore. But if they have bad thoracic or pain between the shoulder blades, then think about their neck. So it could be a so called a thoracic spine problem uh giving rise to radiculopathy down the arm or pain between your shoulder blades. So now coming to the examination, this is, as I said before, I think I found this confusing earlier on in my career, but it is easy to simplify and you know, try and focus. Now there are over 100 different tests and names for shoulder exams in existence. And II cannot remember all of them. And every now and again, you will get a letter from a very key physiotherapist who lists all these tests and you just don't know what they're talking about. Um, so you don't necessarily need to know the names of all of these. I think it's perfectly acceptable just to say, you know, I tested for impingement or I tested the bicep and there was pain or there was no pain and you, you can keep it as simple as that, so long as you tested for them. Um I think, er, once you start getting into these, it, it, I mean, you can be used to be specific but um so it doesn't really satisfy anyone, I don't think. Um so examination again, get them down to skin otherwise you'll miss things. So such as muscle wasting. So mu so this is supraspinatus and infraspinatus muscle wasting here, er, indicating that they've got, he's got either chronic cuff tear and the muscle wasted away, er, or he's had a neurological condition and again, the same here as some infraspinatus waiting. So uh get them down to the skin, have a good look and then at this stage, you can also get them to do their movement and you can look at those scapular movements as well. Uh when you're feeling the shoulder, there's not really many places to feel that sort of sort of give you a good idea of what's going on. Um, but the areas that I feel for are, I was always taught in med school to feel this S CJ. And I've done it for years and this year, finally, II did it on a man who'd been referred by A&E to the clinic who had a bit of vague shoulder pain. I didn't know what's going on and, and I always just start here and II pushed, pushed him on his CJ and he jumped off the table and, um, I found that he had a, a septic arthritis and, uh, actually became quite unwell after it. So I was, I was quite glad that I picked up on it on it and, uh, I send him home. So always start. That's where the shoulder starts. So have a quick feel of the joint there. Uh, but then come across to the outside of the joint and that's your A CJ. So if you've got any, a CJ arthritis, that'll be focally 10 very tender there, people feel it around the outside of the shoulder, but it's not usually too specific. Uh, it's got a bit of impingement or, or something there, then you might pick up on something but generally not what, what is more useful is feeding the front of the shoulder here where their bicep tendon is. So in the bicep groove, have a poke in there and if they jump and say, ah, they could very well have some bicep tendonitis. Er, and then often when people have shoulder pain it will radiate up into the neck as well. And that's because they're hunched, they're trying to protect their bad shoulder. So then there's a secondary effect that their neck muscles hurt and you might find that they're all tender up there. But that's again, a bit more nonspecific and, uh, uh, uh, yeah, just, uh, probably just a reflection of them trying to protect their shoulder. But while you are feeling up the neck, feel the neck itself and check their neck range of movement again at all, before about some pain can radiate into the shoulder from the neck. So I usually use this opportunity to feel their neck and then check their neck range of movement as well, ne moving their neck, gives them any of that pain that they've been experiencing shooting into their shoulder again, just think of the c spine as a potential pathology. Uh And it's good to do that at the start of the examination rather than leaving it to the end. Cos that's where when it usually gets forgotten. So shoulder movements really simple, you know, forward flexion and abduction and you can just measure the angles like that and you have external rotation and you have internal rotation and, and that's about 70 degrees of, of external rotation uti the er if the hand was pointing straight out to the front at zero, that's how you quantify that. Uh, an internal irritation. You can just say where they get their hand to. So can they get their hand to their pocket? Can they get to their buttock sacrum, thoracic spine, uh, et cetera. And another thing to check what people can do is can they get their hand to the head? Can they scratch their armpit and can they scratch their bum or wipe their bum? People can do those things. They're generally quite happy as soon as their shoulder pain or stiffness gets bad enough that they can't do those. Then that's probably when they start to darken your door. So, something they've been putting up for years suddenly they find they can't get their hands to their mouth to eat. And so that's when they come to you. Um, so it's nice to check that they can do those three things and that just gives you a basic idea of function. Uh, so Acular joint pain, um, is a, a kind of a young person's arthritis. It can happen from, er, sort of late twenties thirties onwards. Um, and it could be in people that played a bit of sport and took a lot of hits and, er, have aggravated that joint over the years. But it, it can be a gradual onset, er, worse with activity, er, and they'll find that they can't sleep on the point of that shoulder. Um, and working above shoulder height would be sore And uh if you were going to examine the patient, you can just push their arm across the shoulder like that. So it's the abduction or scarf test and they'll get pain on the top of the shoulder and an X ray will show that they've got narrowing of the joint space here, osteophytes. So, management for that, uh again, there will be a running theme here for shoulders and as you can start quite simple with almost everything. Um So you can start with activity modification. So avoiding the activities that aggravate it. Um analgesia and you just work up your, your, your ladder. So you can start with paracetamol. Um Nsaids if they're helpful and even topical nsaids, the good thing about the A CJ is that it's just sitting just under the skin and codeine and then physiotherapy can help. Uh And if those things aren't working, you can consider steroid injections. Um You can do these blind or in the clinic. Um It is a very small joint, the A CJ and the orientation isn't always straight up and down. Some people can have quite an angled 11 way or the other. Um So trying to scratch around and get a needle in the right place can be challenging. So I'm probably a bit spoiled in that we only ever see people when we were in a hospital and in a clinic. Um So we send the majority of our offer an ultrasound guided injection um, just so that we know it's got to the right place. Uh, and that we're not thinking or did, did it, did it, did an injection not work because we just missed, uh where we put it. Um So that's a CJ. If those things aren't working, then you've tried some physiotherapy, you've tried some injections and they've still got problems and they're referred to our services, then we'll perform an A CJ excision. Um And this can be either open or keyhole and here you can just see you've got the, we're looking at the joint from below, you've got the end of the clavicle here where it meets the acromium and then we just shave the end of the clavicle off and we release a bit of space there. You can see that increases that space and that offloads the joint and that takes that pain away the subacromial pain. Now, again, this is that pain that patients will feel on the side of their shoulder might radiate down the side of the arm, but it shouldn't radiate down below the elbow. Now, this is subacromial pain sort of covers a whole host of, of, of conditions that are, can be used fairly interchangeably and are probably all a bit of a spectrum of one another. Um So we would have talked about bursitis, er, and impingement and you can use those terms fairly interchangeably, impingement really is probably an element of cuff tendinopathy. So that is the rotator cuff is constantly getting squashed, uh, and becomes diseased and you'll get signal changes on the MRI, uh, and the tendon will start looking a bit frayed and, uh, and scuffed and you might start getting some partial tears, uh, just on the surface of the tendon or within the substance of the tendon itself. But there's not, um, it's not frankly torn in two so it's a bit like a rope scuffing. Um, well, it's been rubbing on something for a long time. Uh Calcitic tendonitis comes er, under this umbrella of subacromial pain as well. And then, of course, at the far end of the spectrum, if cuff tears were to progress or if it's very bad, they can get chronic cuff tears. So, uh MRI here showing rotator cuff here and then they've got their subacromial subdeltoid bursa and you can see that's got all this white fluid in. So they've got a significant amount of bursitis there which could be given their subacromial pain and then it's a different MRI of someone else who their cuff. You can see that there's some signal change here and they've got what you call cuff tendinopathy. So that is a, an unhappy uh rotator cuff, uh which again could be the cause of their pain and these can happen in isolation or in combination with one another. Um er, so that, that's why this is, you might find all these terms that all blend and mix into one to some extent. Uh So these usually have an insidious onset, they'll have difficulty raising their arms above shoulder height or lifting their arm away from their body. And to test this, you can, er, sort of abduct and internally rotate their arm and then you just give a sort of AAA sudden eleva a sudden elevation, internal rotation or gentle, sudden, internal rotation and then they'll jump and they won't like it. So, II often leave that examination till the very end cos if they do have true impingement, er, then this is probably the most sore thing you can do on as part of the examination. So II always try and leave that one until last. Now, this is the point of your examination. If someone's got subacromial pain uh and a problem on the side of their shoulder, this is where you're trying to decide is it just bursitis and impingement or have they got a cuff tear that you need to know about and deal with? So, er, once you've done your previous look, feel move, uh you know, come on to just testing the cuff. So first of all, supraspinatus, er, you have the arms out about 30 degrees to the side, er, internally rotate and then you just check their power and you can see there's a difference one side to the other. Um you probably don't have to have their arms quite as high as this, but that is your test for supraspinatus. And that's the ma test the back of the cuff, your external rotators. So, infraspinatus and Teres minor uh will allow you to externally rotate. So you can check if they can externally rotate or not. If they can, then you check it against resistance and you're looking for any weakness or pain, er, if they can't externally rotate it at all, then you can check and see if you can do it passively and if you can do it passively, er, then let go and if they have no rotator cuff, then the arm will flop back in. Er, and that's an external rotate, that's an external rotation, lag sign. And that, that's quite rare. They'd have to have AAA full thickness, uh, you know, big tear there for it to be completely laxer but you see it every now and again, but more likely what you'll get is some weakness and pain against resistant external rotation. Er, and then finally, subscap is the muscle at the front of the shoulder. Er, and that you can test, they always used to tell you to put the arm behind the back and see if they can do the lift off test and then check that against resistance. In reality, that's a really hard thing to do if you have a painful shoulder or if your subscap is bad, what is a lot easier is the belly press test? So you can just get them to put their hand on their tummy and then can they bring their elbow forward and you can just push on the front of their elbow and check if they can resist that. And if there's any pain, uh and again, if they have a diseased subscap or if is completely torn, then the arm will flop to their side, they won't be able to bring internally, rotate and bring their elbow forward. So they, that is a good subscap one that's working and it should stay there when you push against it, that's a diseased or absent subscap. So, subcranial pain, if you've tested and you're happy, they haven't got any sort of, you know, big cuff tears and that you're, you're dealing with a, a tendinopathy um or bursitis type picture. Er, then again, you can start simple, so simple, analgesia, physiotherapy and the physiotherapist will work on patients posture, they'll work on muscles around the scapula. For scapular stabilization, they'll work on core strength. There's a lot of things they can do sort of away from the shoulder that can get the patient into a better situation to better position, to then be able to use the shoulder in a more normal way. Um and offload their disease cuff. Yeah, activity modification, of course, avoid any activities that, that can predispose them into this will that make it worse? And if these aren't working, then you can perform crom injections. And I think the nice guidelines say that you can do this in the clinic. If you have the skills you're capable of doing it, then you can inject blind in the clinic. Um Again here where once you get to the, the orthopedic clinic, we tend to get all that done in ultrasound. Two reasons. One, you know, you've injected it in the right place and that you have an accident, you inject a load of steroid into the tendon of the cuff itself. Um But also the ultrasound allows us to have a look around the shoulder. Uh And the radiologist can tell us is there tendinopathy, is there a big cuff tear? Do they have significant bursitis? Is it actually their bicep tendon? And that hurts? Um So that's I appreciate you probably don't have access to that in the community, but it is a useful tool. Uh One to know what's going on in the shoulder and two to make sure the injections in the right place. Uh And the guidelines, they can give 1 to 2 injections, the maximum. If um if they're still having problems after that, then you can uh refer to secondary care things just to mention when you're consenting patients to steroids. So it's pretty safe and simple. Um You know, there's thousands of them being done in the country each day without too many problems. But, you know, in theory, there's a risk of infection um being inoculated into the joint. You can have skin depigmentation and thinning skin thinning around the shoulder is not as important. It's more relevant in places like around the elbow. Um uh but around the shoulder, it's uh less of an issue. But deep pigmentation always, if the patient's diabetic, then warn them that their blood sugars will be upset for a few days around the, the injection. And then really it's really upsetting. But patients actually get a steroid flare, which is where they get a, an exacerbation of pain and they almost present a bit like a septic joint and they get severe pain, limited movement and then they often end up coming back to the clinic or coming to A&E um, just to make sure that they, they haven't got a aseptic arthritis. But um, usually it's just for some reason, they've had a reaction to the steroids and uh it's always a bit upsetting when it's done the opposite thing that you were intending it to do. Um And lastly, the steroid injections for stromal pain, the, the downsides are that it, they don't always last for very long. They are pretty short acting might be 8 to 12 weeks in general before it starts wearing off. Um, but the useful thing about them is that they are, they are have good diagnostic value if, if you've got someone that's got a load of bursitis or signs of impingement on their skin and you've injected this other chro space and they've said, oh, that was a fantastic eight weeks, but it's worn off again. At least, you know, that's what the pathology is. Uh, you know, that, that injection work nicely. You, you know exactly what you're dealing with so that, you know what to do moving forward, if, if you've injected it and the pain didn't change whatsoever, um, then gives you the chance to reconsider your diagnosis. Uh People are always hesitant with sero injections, um, especially if there's already some partial tearing or frame of the cuff about the possible increased risk of it progressing to a full thickness, tear. The evidence for this is spurious. There are some papers that suggest it might, there are others that haven't necessarily replicated that it's not strong evidence. Um But I think if you've got a good reason to perform the injection or you've at least thought about it and uh you've at least warned the patient about this. Um then, then it's, it's perfectly OK to do. You might get some patients asking about PRP injections, platelet rich plasma. And this is this is where you take a sample of their blood and you spin it on a essential view. There's a little machine that the company provides. And then you take this nice golden layer which is full of platelets and a load of allegedly loads of growth hormones and factors. And then you can inject that into a disease part of the body. And in theory, it brings a load of nutrients and cells to the area that should promote good healing. The reality is, is that there's certainly not any clear evidence that it helps. Certainly not anything above placebo. Um, so there's no sort of guidelines that recommend us using it. We don't really use it for shoulders unless we've really tried everything else and the patient is not fit for anything else or asking for it. Um, so you might find that a load of patients in, say, sports clinics might get a load of this. Um but it's, it's, there's no hard evidence that it works. Calcific tendonitis um er exists er in, in this family of subacromial conditions and, and it's, it's just another manifestation of a, a diseased cough. Um The difference with these is that they can present really acutely. So you can sometimes get patients waking up in the middle of the night with a suddenly severely painful shoulder, you know, coming to A&E at four in the morning. Um People thinking wondering if they're having a heart attack with shoulder pain or whether they've got a septic joint. Um but luckily you can take an X ray and see a big calcitic deposit and they, they're usually women in, in late forties to fifties. This is your classic patient that gets this. Um So usually in A&E you can get a reassuring X ray and a set of hopefully normal bloods to, to, to, you know, exclude any serious uh systemic infection. Um and these patients, rather than waiting a long time for physio and simple analgesia. Um If you've got someone who's got an acute uh cal tendonitis, then please refer them early to consider an ultrasound guided injection and barbotage. That's where the sonographer will put the probe over the calcium deposit and then they'll try and basically pierce it with a needle, try and release out all that calcium, which is sort of a chalky toothpaste like substance at that stage. And that one, the steroid helps with inflammation, but also two, the needle helps decompress that. It's a bit like popping a big spot. Um So when we, we sometimes sometimes these stay long enough that these patients get as far as surgery and it, it's, it's really satisfying. It's like a doctor pimple popper. Um but, but they certainly look really sore and a barbotage early on um is really helpful for these patients. So if you have a calcitic tendonitis, um yes, it's in the same family as those subacromial conditions, but uh send them early for an injection and barbotage and they'll be much happier for it. So who, who's to refer to the orthopedic clinic? So anyone who all those conservative measures haven't worked and if you're just not c certain of the diagnosis or if you think that they have got a cuff tear, um, you know, if you don't always have access to, to an ultrasound or any other imaging, for example, um this is a subacromial decompression, arthroscopic one. So this is a rotator cuff tear. This is the acromium above with a big spur coming down and then that's all shaved away and that creates a much bigger space. Not very neat one. This um but that, that's the theory of a a subacromial decompression. But what you can't see on these images is that before this, you get to this stage, this would have all been filled with red, angry bursa. Um And that is what has a lot of pain fibers in and actually clearing all of that out is the theory or the thought behind why a lot of patients, pain is taken away during this operation. Um So the um but uh yeah, the act of taking out all the bursa in these operations is is probably what's most useful. And uh and the benefit of doing arthroscopic is also that you can have a look around the rest of the shoulder as well. So you can check their bicep tendon. Um You can check the integrity of their cuff, uh You can sort out a few things at once. Um And there was a study in the lancet a few years ago that er compared arthroscopy, so simple diagnostic arthroscopy to subacromial decompression, er to no treatment. And there was a slight improved outcome or, or results with the surgery. Um but not much and not much difference between decompression alone and keyhole on its own. Um So they sort of threw into the air, the question of how much of it is placebo and, uh, how much of it truly works. Um, but I think, uh, it's, it's very rare now that we do, er, subacromial decompression just purely for impingement or bursitis. Um, er, nowadays we usually do it in the sort of the context of other things in the shoulder, like, er, um, in a, a chromar joint excision, um, and been sorting out bicep pathology. And it's more now, if they do have true cuff tendinopathy and early fraying or tears of their cuff, then it's certainly still a good, a good operation to decompress the cuff and stop any propagation of cuff tears. So, so yes, if you were to just to go and scope every single subacromial pain or impingement, um they might not help with everyone, but certainly if you've run the gamut of non operative treatments, um, and then you pick your patients while they're hoping there's a case for it. So, we're coming on to a frozen shoulder now. Um, this is a what you get at the front of the shoulder and frozen shoulders. It's all of this red, thick angry tissue which er, is contractile and you get my fibroblasts and it's a bit like uh Dres is the analogy. Um So you get all this tissue that then shrinks down and is one incredibly painful. So it can be slow onset and very painful and actually early on it can be quite hard to, to diagnose if they haven't got any stiffness yet. So you might sometimes see patients who have pain, you think, maybe it's, you know, something else. So you'll give them some analgesia, you'll try some physio. Uh, and it hasn't worked and then when they come back you go, oh, hang on your shoulder is not moving. Now, it was before and then you go, well, it's, it's frozen shoulder then. Um, but the key thing about frozen shoulder is that they will have a normal X ray and I'll touch on this again in a second. So, uh, er, with frozen shoulder, you've got an inability to externally irritate the shoulder even passively. Er, and they have a normal x-ray and that's what you'll see, they'll have zero degrees of external rotation, whereas the normal arm will be able to externally rotate out to there. So in patients who can't externally rotate and it's locked there, there's sort of three broad things it can be, is either a locked posterior dislocation, it's either frozen shoulder or it's osteoarthritis. So with a lot of posterior dislocation, they might describe an injury to you. Um However, you do get some patients who are neglectful, either they are um alcohol misuse or they've had epilepsy and a seizure in the night, not realized it. And for whatever reason, they don't access the services and they ignore their shoulder and they will have a shoulder that won't externally rotate um, and it, and you can be tricked into thinking it's a frozen shoulder, uh, frozen shoulder, like I mentioned, can be a sort of more slowly insidious onset symptoms. But so too can arthritis and arthritis can give you a stiff shoulder. Um, but the difference between all of these is that the post dislocation and osteoarthritis will have abnormal x-rays, frozen shoulder should have a normal x-ray. So you have a lot shoulder that can't exit or rotate in a normal X ray, it's frozen shoulder. So if you do think I have a patient with this, it is nice to get an X ray early doors just to make sure that is what you're dealing with. Uh And then you might have patients who also can't aone rotate because they have a massive cuff tear. However, if you were to take their arm gently, you would be able to exer rotate it passively. And that's what differentiates that from these conditions. So come back to frozen shoulder, they get pain which comes on and then they get stiffness, uh Their pain eventually goes away and then they have this residual stiffness here, which can carry on for a long time. Now, if you were to try and start giving them physiotherapy around here, it, they won't thank you for it. There will be an extreme agony and it can be a bit counterproductive. Um They, they won't wanna do it and they won't. Thank you. You've gotta try and wait until the pain's gone away. Bef and you're in this stiff phase. So you have your freezing phase of frozen shoulder and then your thawing phase. And it's here where you can start engaging with physio and trying to loosen things up. But what we can do if you've got a diagnosis, frozen shoulder, it's perform a glenohumeral joint injection uh to try and take their pain away. Uh And here actually in Liverpool, we also do a hydro dilatation. So the, the sonographer, the radiologist will um inject a large volume of saline into the joint in a bit to break down some of those adhesions and scar tissue. And if you have a good working injection, then you can take that pain away where you can shorten the amount of time they're in pain for. And now suddenly you can get them engaged with physio much earlier on. So, if you have a frozen shoulder and they're very sore early injection and ation might be useful in order to, well, one help with their pain. Um but you might be able to slightly shorten the, the pain cycle and start on their video. Er, and the thing to tell patients is that it frozen shoulder does go away but it not quickly. So, uh when they've got it, that's the next year or two of their life, potentially trying to work at it with a stiff shoulder, er, before it gradually gets better. Uh something to mention is that it is more severe and more common in diabetic patients. So, um I think all the patients that have got as far as an operating theater this year to have their frozen shoulder released were, were all diabetic as, as far as I can recall. Um And the other thing to mention is that if you have a patient that's got a new diagnosis of frozen shoulder, um but with no history of diabetes, then consider it. So I think a conference recently someone presented their work and they, they tested every new frozen shoulder that was referred to their department and I think one in 10 of them had a raised bi HBA1C and a new diagnosis of diabetes. So, uh, if you get, uh, get any of these um, in your clinics, then, er, certainly consider diabetes if uh, they have not already been diagnosed with it. And yeah, so most of the time this condition does go away on its own, people who it might not go away diabetics if people have had it for a year or two and they have worked hard as anything with physio and it's still not moving. Um, then there might be sign to get fed up and might go in to be referred in and they might be eligible for manipulation or arthroscopic release. Um, and then of course, you have some people who have manual workers and just need to get going quicker. So, so Yes, it does go away on its own. But there are some patients who symptoms are particularly severe or persistent that they'll need to be referred to us. So, rotator cuff tears. Now, now this is, um, yeah, a, a wide ranging topic and, uh, you can see here there are so many different patterns of cuff tear. Um, that, that's why it's very difficult to sort of pigeonhole patients into one treatment path because you've got all these different types of way to tear your cuff in lots of different patients of lots of different ages with lots of different jobs and lots of different sports they like to do. So it can be very difficult to work out what to do with people, but you can just take it on a case by case basis and you can have a s you know, simple sensible discussion with patients and often they'll sort of guide you as to what they might wanna do. Um But when you're looking at cuff tears, you can look at the different types. So you can have fairly small ones. And you can imagine when you look at these, when we say that, you know, the majority of people over the 80 have some element of cuff tear, but a fairly normal shoulder. But of course, tears can get much and then you can even get to the point where the tendons retracting and then the muscles are wasting away and then it's in that sort of situation where it starts becoming irrepairable. You can also have just partial thickness tears, so articular sided tears of the cuff and this is what you might see in a lot of those impingement patients. When we talk about tendinopathy, you might see sort of partial uh tearing either in the articular surface or on the bursal surface. Um or you can have your classic full thickness tear and then this tendon can retract back in this way, the longer you leave it. So when it comes to, to managing cuff tears, the main take home message I'll say from today is that a patient has a, an acute tear. So they come to you and say I did something last week or I had an injury three weeks ago and I felt apart and my shoulder hurts and it's weak, refer them in straight away. Uh If you think it's genuinely a cuff tear once you've examined them, or if you have an ultrasound approving that, um, we'd like to see them, you know, as as soon as possible, really, either through through fracture clinic or if you have an urgent referral pathway because the longer you leave them, the more difficult they are to repair and the worse the patient's outcome can be. So I know here at Liverpool, uh once we've been referred to patient, we like to try and see if we can do their repair within the next two months or so. Um, so you're looking at a time frame within two or three months that we'd like to see them and treat them. No, chronic tears are where it can be a bit more different, uh difficult. But as we all know, chronic tears, their prevalence increases with age. So the older a patient is, the more likely they are just to have a cuff tear and not necessarily know about it. So the majority are asymptomatic, but unfortunately, they're not the ones that are gonna come through your door. You're gonna have patients presenting with pain similar to the subacromial pain we talked about, but then also with weakness and pain on certain activities. So, um using pots and pans on the kitchen counter, trying to lift a kettle, those little movements out at this range, what they find particularly difficult, uh when you're treating them, when you're deciding how to treat them, you can consider whether it is an acute one or chronic if it's chronic and it's been coming on for years. So you can obviously take your time a bit more the age of the patient. So they're young, high demand. You might have a lower threshold for sending them to orthopedics compared to an 1890 year old, uh who doesn't really do very much or has not much demand on their shoulder. Again, their job might affect whether you want to refer them early or not. And then finally, the size of the tear, if they just have partial or partial tears, um, er, or just some element of tendinopathy there. Um, then of course, you can take your time, but if it's full thickness, if it's retracted, if you think they've got muscle wasting developing, um, then, then feel free to send them in early. Again, if you think you have time in your hands and often you do, uh, of, of often, quite often you do. Um, then again, the principles are, are very similar to treating the subacromial pain. And that is you give them analgesia physiotherapy can help and the physiotherapist can work on recruiting deltoid. So that's another big muscle here that can help lift the arm up. And that's how patients who don't have a cuff are able to compensate. You can change your activities, you can perform more injections again, but again, warn of uh tear progression. And then finally, what we can do in our clinic or what the pain team can do as well is a suprascapular nerve block. So if you have someone with a big rotator cuff tear, that's not repairable, then actually you can inject the nerve here and switch off any pain coming back from the shoulder. And if that's successful, then the pain clinic can actually do a more permanent nerve ablation. So that's another another type of nerve blocker injection that we can do to try and help with the shoulder pain. Um This is just a paper saying that uh various different treatment regimes. So I think in the old days we used to even now we give people six or 12 sessions of physiotherapy over a course of weeks and months. But this paper shows that actually you can just see the patient once at the beginning of their treatment, but for a good hour and educate them. And that is just as useful as a multiple appointment physiotherapy regime. Um but in terms of referring people to user, then we wanna see acute traumatic tears. Anyone who you've tried, the conservative treatment has not worked. If someone has a larger thicker tear that's retracted, maybe send them in early cos the, the more it retracts and the longer it is, the harder it is for us to treat. And then of course, you'll have patients who are just younger and have higher functional demand who will, er, yeah, you again, you will just have a low threshold but, you know, the sort of patient, I mean, the ones that will get referred one way or another and that's fine. You know, we want to see these people, er, and so we can take them from having a cuff tear to a repair, er, and, er, the majority do improve. So the natural endpoint of cough, er, big cuff test is cuff arthropathy. So the role of the rotator cuff is to centralize the humeral head onto the glenoid. If you take that away, then you just have the action of deltoid working and you get the humeral head pistoning up and down in the glenoid. And so you get this high sitting humeral head within the joint, there's no space here, the cuffs all gone. And it's now articulating under the chromium. And that's what cuff arthropathy is. So that's kind of the natural endpoint of uh rotator cuff disease. Uh Finally, I'll touch on long hair, a bicep pain. So we have two bicep tendons at the top of our shoulder. The short head is the good reliable one. You'll never have to talk about that and it will never give you a problem. The long head unfortunately, winds around the shoulder here uh and can cause a lot of trouble. Uh This is a very diseased and shabby one within the shoulder. You can see that doesn't look healthy, should be nice and shiny and smooth and sometimes the tendon itself can be ok. But the labrum where it attaches is diseased and you get degenerative changes there. And so the pull of the tendon can actually pull on the labrum and give you pain at that location. Testing for the bicep pain at the front of the shoulder where this man's thumb is palpate there, see if they're tender pain will radiate down the arm. It can coexist with several other things. So it's not always easy to pick up. Um But the way to test it is to try and resist supination while feeding in the front, they might get pain or a much easier. One is just to get them to extend their arm with the palm up, push down and then they might get pain here. So that's a bicep provocation test management. It's a theme developing analgesia physio and a steroid injection. Uh, and these are much more successful of some guided than doing it blind because you want to try and inject into the sheath or around the tendon. They don't want to inject the tendon itself. If all those measures don't work, then they'll, they'll get to the orthopedic surgeon and we can just perform a simple toomy where we just cut the tendon at its, at its origin, it goes pin down the arm and that takes their pain away and they feel great. They will get this po deformity and the which some skinny patients don't like is more pronounced in some people than others. Um And you can get some bicep cramping with this. So it's, most patients are absolutely fine with this because they're usually a lot older, sometimes in younger patients who are high demand. So a very active job, you might want to do a Tenodesis where we reattach it onto the front of the shoulder and that avoids you getting the bicep Popeye sign here and um stops with the cramping. It doesn't affect their strength whatsoever. So, the strength outcomes are pretty comparable between the two. but it might help with their cramping. Uh, you might get the odd patient who has spontaneously ruptured their bicep tendon and they'll have a pop, they'll have pain in their shoulder, it'll be bruised. They might get some cramping and they'll get this appearance which, uh, alarms them. But I've just told you that, uh, you know, sometimes we cut this tendon on purpose but the majority of the time when we're treating it, we do so you can just give them reassurance. They can have some physio, just make sure they keep working. When they arrange move, you can consider an ultrasound just to confirm the diagnosis and just to reassure them, that is what the problem is. But if the pain persists, then you can consider whether they have a cuff tear off and this goes hand in hand with having um uh cuff pathology. So, uh if once the Popeye sign has developed, the pain isn't subsiding, then go back to assessing for cuff problems. And finally, arthritis, um pain stiffness range of movement is a problem. And uh crepitus, when you move the shoulder, you'll feel a lot of crunching going on. Um And they'll put up with this for years and you'll be treating this gradually with analgesia activity modification, physio, you can do injections directly into the joint. Uh but eventually these measures will fail as you know, from treating all sorts of other arthritis and it will either be that their pain isn't being managed or they get stiff enough that they then can't do the things that they need to do such as wash their hair, get their hands to their mouth. Um, so sometimes it might not be pain. That's the pain might not seem so bad, but actually the stiffness is so much that, you know, their shoulder isn't working very well. And you would have heard us talk about anatomic versus reverse replacements. So, in an anatomic, we simply replace the ball in the socket socket exactly where they were. Er, and this is fine. If you have an intact cuff, if you don't have an intact rotator cuff, er, then this will work. I'll show you a slide in a minute where this works in an abnormal way and it will fail. So, with a reverse shoulder, we've simply swapped the ball and socket around and this gives you a more constrained shoulder that doesn't loosen and doesn't wobble around, it's more stable. And if you have an absent cuff, then the mechanics of this work in such a way that your deltoid muscle can take over and move your shoulder, you don't need a cuff here. So again, I talked before that if you don't have a cuff, your humeral head sits high and if you have a shoulder replacement, that's what it would look like and it will rock back and forward on your glenoid and you'll get a glenoid component loosening and that's how the shoulder will fail, er, and this person will need to be changed to reverse shoulder replacement anyway. So that's the main difference between an anatomic and a reverse shoulder replacement. So, in summary, you can simplify the shoulder examination quite well, make sure you just get them down to skin. Look at the scapular movements, feel their stocli joint, their ac joint and their bicep tendon. They're sort of the main ones, everything else, not as useful to feel for, for tenderness or less useful, move their neck up and down, left and right, check forward flexion abduction, external internal rotation, whilst you're then doing their movements, just quickly check their cuff and all you need to do is empty, can test resistance to external rotation, resistance to internal rotation. That's the belly press. And then depending on their other symptoms, more focused tests just test their bicep test their A CJ, do that impingement time. And that is that you can probably do all that within a minute. And I'd say I do that for most of my examinations and not much else and that and that gets you through 90 95% of your pathology, er er depending on what patients you got coming through your door. So you, so you can simplify things and you can get a method going uh that can see you through. But uh just to just be reassured, most conditions are self limiting and can be managed pragmatically and on a patient. Uh you know, case by case basis. So go back to your principles of analgesia physio and and targeted injections. As long as you've thought about what might be going on and please refer early if they've got an acute tear, we don't want to wait around for those. So as soon as possible for those and then uh uh think about not as urgent early referral for people with large tears. They're younger, high demand. and just remember that calcitic tendonitis patients um might benefit from a much earlier injection uh as as well as uh adhesive capsulitis patients as well. So, thank you very much. I'll pass you back to, to Ying Ying and we'll see if there's any questions. Uh I haven't been able to look at the questions whilst on this. So I hope there isn't 100s of them. I'm sure there is. But uh let's see, fab thank you very much, Mister Dukes. There's quite a few questions in the Q and A. So I'm just gonna start it and answer them as you're ready. Uh So can everyone see that? So, so the pain between scapula and the spine can be due to the shoulder, um it can be so you can sometimes get um pain beneath the scapula. So, subscapular pain um and you might get crepitus er and discomfort under the scapula or you might get pain from the rhomboids. Um Often it's a it's a muscular pain or might be, you know, due to, to, to posture. So that would be, um, something a physiotherapist can assess and, and work on, uh, initially. Um, but if you have someone who, that it's not getting better or there's something not quite right about it, if they're much older, for instance, um, then consider whether their neck or thoracic spine is a problem. So, er, this question, if you can see that. So when doing your special tests, uh, is it a good indicator of which specific cuff is partially torn? So, um, or can you do it to rule in or out a full thickness test? So, the reality is, it's, it can be quite difficult and, uh, none of these, when you look at sort of sensitivity and specificity of a lot of these shoulder exams, they're, they're not always 100%. Um, but, so what you're looking for is, I suppose, pain, er, or weakness and it, and it, it, whenever you're testing all of those, as long as you're trying to test it symmetrically with the other shoulder that might give you an idea of being able to pick up an imbalance there. So you can sometimes do it and people have, you know, really good shoulder exam and then you scan them and there's nothing in there. So, um, it, you have to take it with a pinch of salt and there's an element of practice. Um, but in some people, if, if they're positive then they're really good tests, um, when they're not, not positive, uh, you know, or you're finding it difficult, it, it's less helpful. And so obviously then you're probably forced down the ultrasound or MRI route some of the time. But, um, when they are positive it's, uh, it, it, you know, it is good. It's a nice hard test to, to, to go on. Um, so in terms of using slings to offload the shoulder for periods of rest, I think generally injuries, it's nice to sort of rest the shoulder. But we, we do try and wanna keep people using their shoulder as normally as possible. Um I think if you, if you start treating the shoulder abnormally, the patient is gonna then use it in an abnormal way and the shoulder can become you might defunction it and uh you know, you might then cause more problems than you're trying to say. So I think most physios would um move away from this and certainly I've never sort of prescribed it for significant rest. Um Yeah, so what you want to do is try and train the patient to work on posture, scapular movements to try and get the shoulder into a much better and healthier, healthier position cause a weaning scapula. Whoa. Yeah. So there's quite a few. So um it's a neurological or, or muscular problem I think is what to think of here. So, um uh you wanna look at what direction it wings in. Um and So if the scapular wings towards you, then that's a serous anterior problem. Um if it wings away, then that's a problem or weakness with the rhomboids. Um I think being able to. So, yeah, so a neurological problem. So they could have a brachial neuritis or parsonage turner, um you know, or a tumor somewhere causing, you know, nerve compression. So weird and wonderful things. So, consider a neurology referral if you're thinking there's a more neurological cause or sometimes just muscle imbalance. So, so those cases will show you right at the beginning. Um you might have patients that are just susceptible to shoulder instability, um have never had a problem, but then they might take up a new sport or they might have a new job that gives them a slight imbalance in their muscles and then suddenly they start working in abnormal ways and you see winging. So it is, yeah, either a hard neurological problem or it's just a, a coordination problem. I think the important thing is just looking for it and picking up on it and if they have it, um physios are very helpful um to know whether it's something they can help with or whether something more fishy going on. So in terms of the freezing thawing phases. So yeah, I always say to them, you know, they've already a bit further down the line when they come to see me. So it's hard to know what to tell them on day one. So the whole process can take a year to two years. Uh, and generally the pain is at the start and then the, the freezing is at the start. So the freezing will take up to six months, maybe even a year. Um, yeah, generally six months or less for the freezing and then anything up to 18 months for the thawing. So, uh, I think it's just reassuring them, it does go away eventually. Unfortunately, you can't tell how long it's gonna be for that particular patient. But what you can try and do is help them with their pain, uh with injections. Um, and then usually once their pain is gone, that's much more manageable. Well, you know, obviously they, they still don't like the uh stiffness. But uh as long as you're not in constant pain, people tend to be able to, to cope a bit better and then having a conversation that it might take a while to go away isn't quite as catastrophic when they're sitting there in agony. So, septic arthritis and calcitic tendonitis are differentials with lack of fever help tell apart. So, yeah, so, so it, it can be difficult cos the patients are, can be in quite extreme pain and it, uh it can be difficult to examine them. Um, they, they usually, you know, and because it's difficult, they usually end up coming to A&E so you can do a set of bloods, you can do the X ray. Um You can tell that they don't have a fever. Uh And you get the opportunity to watch them for a few hours. It's a, it's a bit better than a 10 minute consultation, which a lot of you guys have. Um So, so you, you just have a little bit more time and a few more tests and you can take a, uh you know, sort of a, a, an educated guess that, that the cancer of tendonitis, not a septic joint. Um, we, we, we also have our clinics where we can follow them up and in that week or the next week, for instance. Um, so, you know, we can always follow them up and make sure that there's no problems, interferential therapy. I'm not entirely sure what you mean by that, I'm afraid. Um, I don't know if you mean interfere on injections or something. So, um, ii apologize if I misinterpreted that. I'm not entirely sure what you mean by that. So, feel, feel free to rephrase that and I can come back to that. Oh, yeah. So, um, so a CJ injections obviously into the A CJ joint, er, if it's a subacromial problem then an injection into the subacromial bursa. Um, er, so a targeted injection there is usually good glenohumeral joint, injections are good for shoulder arthritis. So, glenohumeral joint arthritis and for frozen shoulder, er, and then an injection into the long head or bicep is, is, is good for well, the sheath of long head of bicep is good for that. So, uh, so that's why it's good to sort of examine patients, try and think about what might be going on and then try and tailor your injection to one, maybe two of those things because then if it works nicely, you know, that's what the problem is or it might take away 50% of their pain and, you know, you've been looking somewhere else in the shoulder to try and work out what the rest of the pain might be coming from because a lot of these conditions do do exist in combination. So, um, so, uh, you know, I II try and inject just sort of one part of the shoulder, maybe two, there's clearly two different things going on to see if that can help them. Um, but yeah, it's, it's why it's good to just have a sort of a think about it and see what you think might be going on. So, uh, the guidelines say that you can, um, you don't have to get further imaging if you think if you've examined them and you think they have got subacromial pain. Um, again, I'm biased or my practice is slightly different cos I'm sitting in a clinic where I have it. Um, and they've already sort of run the gamut of having other things done. Uh, you know, they've, they've tried lots of conservative measures before they've got to me. So, Um So, so my process is we, we do get an ultrasound cos it's just useful in terms of seeing what else is there and they can inject them at the same time. So, uh we, we're very lucky here that we just happen to have them in our clinic. Um But the guidelines are, you don't have to do this. Uh If you're confident that they've got that, then you can. So for instance, if they've got subacromial pain and you've tested their cuff and their cuff is nice and strong, then you've probably got a good argument that you can perform at least one injection and see how they get on. Um, if there's any doubt about the diagnosis, if you're not sure. Um Then, then yeah, do get uh an ultrasound or, or MRI um you know, or, or refer them to us. So it, it certainly says in, in the guidelines, if there's any equivocity, if you're not sure, um, you can refer you cuff, tear and fs and tendinopathy. I'm not sure about FS, please. Uh jump and let me know if I'm not sure. So, tendinopathy is when the cuff is just diseased. So, um, er, it's been um, so if you have impingement, so the tendon has been squashed and compressed, uh you will see some, there will be some intrasubstance tearing of, of the tendon and normally tendons and tissues have a, have a natural turnover where they're healing. But in tendinopathy is just not able to do it quick enough or there's a disruption to that and you get this failed healing response. Uh So what you need to do is, is try and either get the patient's posture in a better position that it offloads the tendon or physically offloading with the decompression and then you get the, the, the, the chance to offload it and how to heal. Um and it really is, is probably like the early stages of a cuff tear. Er, if you were to leave it for long enough or it's happening quick enough, you might then progress to a cuff tear. So a tendinopathy, you can think of that. The, the tendon is there but it's all scuffed and shabby. Um you know, like a rope that's gradually fraying and then in a cuff tear, the rope has finally broken and, and torn and uh normally there shouldn't be any sort of escape of joint fluid from within the joint out into the subacromial space. But when you have a cuff tear, you have a hole in that tendon and there's a communication between those two spaces. So normally they're separate from one another, but when you have a cuff tear, there is a full thickness element to it. Um So yeah, they're kind of on a spectrum of the same disease. The authors just clarified uh FSS for frozen shoulder. Oh OK. So er I can't go back. So, yeah, so frozen shoulder um, is different. So that's the capsule of the joint, er, and particularly at the front of the joint, um, that gets thickened and inflamed and it shrinks down and in doing so it brings their arm in and they can't ex rotate it cos this tissue, the capsule is all thickened and, and contract it down. So you think it a bit like dres of the shoulder? But the difference here is that it does burn itself out and things can release again unlike Durans. But it's, it's, it's a similar sort of myofiber plastic uh process that happens. Um But it's, yeah, separate to the cuff. Um So it's, it's very rarely that we have patients with a frozen shoulder and a cuff tear at the same time. How long did we try analgesia before referring for impingement or a CJ? Um So I think the guidelines say for impingement 6 to 8 weeks before secondary referral. Um, if you've been trying conservative measures and I think really that means probably physio as well. Um, often you think you need to take painkillers to physically be able to do the physio and then it's the act of the physio working on various elements that are then able to get their shoulders. Oh, I think I said 6 to 8 weeks. That doesn't feel very long to me, it might do if you're the patient. Um But, but that's technically what it says. But, uh, yeah, a couple of months. Um, and, er, yeah, if you're not winning and they've had physio and they've been good with their pain relief. Um, yeah, put them on 100 dilatation. I don't know which hospitals do. It, it depends entirely on the radiology department and who in there can do it. So, that's probably more of the personnel and, um, uh, eagerness, individual, eagerness to do it. We've got really good radiologists who are really keen on sort of building up their interventional side of the work probably because the A I is coming along. Um So they're really keen on hydro dilatation where I am at the moment. Um And again, it's, it's one of these conditions where there's lots of different treatments you can do at lots of different times and all the patients are different. So, um it's, it looks like it is a good treatment and it does work, I think uh it just hasn't come in as being like the first go to guideline yet, but if they do have it, um yeah, it's definitely we, we find it's useful here. So determining which investigations to get. Um So whether you think ultrasound or X ray. Um Yeah, is a good question. So most people who darken our door as from when they get to the orthopedic clinic, we do x-ray, most people, uh I'd say almost everyone. Um So x-ray is useful for, for instance, for a CJ arthritis, glo humeral joint, arthritis or frozen shoulder to make sure that there's no locked dislocation or arthritis there that you just haven't picked up on yet. Um, an X ray, even if you think someone has a cuff tear is useful because actually if they have got a cuff tear on ultrasound, but then their X ray shows they've got some arthritis developing as well. Um, or actually their cuff tear is so bad. They've got that rotator cuff arthropathy. Um Then there's no point doing a rotator cuff repair. Uh, cos it's doomed to fail. You have very bad outcomes in people who have preexisting arthritis. So, so it, it is a good question and uh I suppose it depends what you want to do. So, um I'd say subacromial problems um are more used, they're probably giving themselves more to ultrasound because there's a lot of things in a very small area that can mimic each other or be hard to pick apart. So, I'd say for subacromial pain, uh an ultrasound uh is probably useful in terms of diagnosis, but also tailoring your injection if you were lucky enough to have someone who would offer both. Um, so by the time they get to my clinic, everyone's got a bit of both. Um, and you can be a bit, er, er, pragmatic and you can choose but an X ray, er, can tell you a lot of what's going on, even if you think there is a soft tissue problem because sometimes it can confer what your next management will be. Certainly it would be, uh, when they come to our clinic. Oh, ok. Um, so, I don't know, uh, I haven't seen if that's useful for, I can't remember what condition it was. Now. I'm so sorry, we're gonna keep going back to this. Um, so electrotherapy. So, I don't know, er, what I do know is that I had tennis elbow and, er, the current guidelines say that everything is, er, placebo pretty much up to a point. Um, and you can offer patients that we have to tell them placebo. I had tennis elbow for six months, didn't go away with stretching and I, uh, had some electroacupuncture and it went away after two sessions and I was really annoyed at myself because I know it's placebo or, you know, not much better and it, but it worked. So, um, I don't know about the shoulder itself. Uh, certainly they can't come to any harm and I'm, I'm very happy with patients for people to try, try other things, but I haven't seen anything to say that's a, a definite treatment or, or better than others. Uh, oh, let's finish Q and A I think. Right. Yeah, thank you very much. Perfect. Thank you. Thank you. Thank you very much, Mr Dukes. Um, oh, we've got one question left in the chat symptom wise. What is the difference between the above conditions? Uh, regarding frozen shoulder impingement and rotator tear, say that again. So between, what, uh, what are the differences between frozen shoulder impingement and rotator cuff tear in terms of symptoms? So, frozen shoulder, you'll get, uh, pain, uh, fairly generalized pain, um, which can be quite bad, it can mimic the other things. So, if you see them early doors, it can be hard to work out what's going on. But then what will come in later is the stiffness and then they go, my shoulder doesn't move. So, so stiffness is uh the main one for frozen shoulder, er, for rotator cuff tear, rotator cuff tear and impingement can exist on the same spectrum. So, and because it's in the same part of the shoulder, they might complain of the same things. But then what differentiates the two in uh in your examination is testing the cuff output. Um, so strength, er, and if there's any weakness and if there's any pain against resistance, um, but that can be difficult and sometimes you don't necessarily know until you've had, had an ultrasound scan. Um, so I think you might have knocked your microphone. We can't quite hear you. Oh, sorry. Is that better? Yes. Yes. Oh yeah. Um, someone can have a cuff tear but no impingement. So if, if they've got a cuff tear and they can't actively lift their shoulder up, but you can pick it up for them, get them to relax and lift it up here quite happily, then it's just a cuff tear. Whereas if you were, if I was to do this in someone who had a lot of burs ice and impingement, they, they would not like that at all. Um, now it's not a hard and fast rule. There's probably lots of people with cuff tears who might not like that either. But, um, uh, yeah, it, it can be difficult and there is just an element of practice. Um, but, uh, yeah, certainly just examine the cuff. If there's any weakness or, or pain against resistance of the cuff, then they consider it fab there's one question on any benefit of dry needles in muscle pain. I'm not sure if that's acupuncture they're referring to. Oh, I see. Um Yeah, it probably comes under the umbrella of you probably tried everything else. So, muscle pain. Yeah, patients do get a lot of pain radiating up into the neck can go along the back of the shoulder as well. Um I think my priority in the shoulder clinic is trying to work out as a, a joint problem. Once, once I've established, there's nothing there that's going on or that this is maybe a secondary effect. Then you're looking at physiotherapy to work on posture and muscle stretching. Um And then that is does get into the zone where I might refer to my pain team colleagues who might be better about talking about acupuncture or um pressure point injections and things like that. So uh I think if I've, if I've established there's nothing within the shoulder that's causing that pain. If it is something radiating up into the neck here or down the back of the shoulder there, um, then that is something that I have uh done is uh spoken to the pain team and um about how they might be able to help if, if we've tried everything, it hasn't worked great. So I don't know if acupuncture comes under the umbrella. I'm afraid Fab Fab. Um Thank you so much, Mr Dukes. That was a really informative and interesting talk and a really helpful Q and A. I don't believe there's any more questions. There's lots and lots of. Thank you. Someone has said uh yours was the best session all year and we're in October now and we've run a lot of sessions. So that's, that's a yeah. Uh We really appreciate you taking the time to teach and thank you to everyone who joined. Uh You will all be sent a feedback form shortly. 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