Pain is a common presenting symptom of patients with shoulder conditions, yet there has been little work done to accurately describe its distribution and nature.

We studied all patients attending the Royal Devon and Exeter Hospital shoulder clinic from August 2012 – 2013. Patients completed a questionnaire detailing their Oxford Shoulder Score and a validated neuropathic pain questionnaire. Patients were given diagrams to draw on their perceived location of pain or abnormal sensation.

We analysed all patients with frozen shoulder (48), osteoarthritis (37) and rotator cuff arthropathy (17).

We found that neuropathic pain is common in patients with shoulder conditions identified in 39% of OA patients, 42% with rotator cuff arthropathy and 57% with frozen shoulder. Pain outside the shoulder was reported in over 50% of patients, commonly the forearm, hand, neck and chest. Frozen shoulder was especially associated with pain outside of the shoulder with 39% describing symptoms in the neck or chest, 21% into the forearm and 18% into the hand. Interestingly, neuropathic pain radiating down the arm was not described in the rotator cuff arthropathy group.

The high prevalence of neuropathic symptoms and pain felt outside the shoulder aids diagnosis and more accurately identifies these conditions.

The Delto-pectoral approach is the workhorse of the shoulder surgeon, but surprisingly the common variants of the cephalic vein and deltoid artery have not been documented. The vascular anatomy encountered during one hundred primary elective delto-pectoral approaches was documented and common variants described.

Two common variants are described. A type I (71%), whereby the deltoid artery crosses the interval and inserts directly in to the deltoid musculature. In this variant the surgeon is unlikely to encounter any vessels crossing the interval apart from the deltoid artery itself. In a type II pattern (21%) the deltoid artery runs parallel to the cephalic vein on the deltoid surface and is highly likely to give off medial branches (95%) that cross the interval, as well as medial tributaries to the cephalic vein (38%).

Knowledge of the two common variants will aid the surgeon when dissecting the delto-pectoral approach and highlights that these vessels crossing the interval are likely to be arterial, rather than venous. This study allows the surgeon to recognize these variations and reproduce bloodless, safe and efficient surgery.

There are longstanding debates regarding surgical versus conservative management of Achilles tendon ruptures, however there is limited focus on rehabilitation. A specific rehabilitation programme was initiated in 2008 to unify management and improve patient outcomes. We present the results at three and a half years.

In October 2008 management was streamlined under the foot and ankle surgeons and a dedicated physiotherapy service. Operative management used mainly the Achillon device (Integra) and VACOped boot with a specific rehabilitation protocol.

We prospectively collected data on all patients with Achilles tendon ruptures from October 2008 to March 2012. There were 246 patients in total with four lost to follow up. 80 were treated with the Achillon system, 18 had an open repair and 144 were treated conservatively (of which 56 were partial or musculocutaneous junction tears).

Three patients sustained re-rupture (1.2%), all initially treated conservatively. There were two operative complications (2%), both wound breakdowns. Two patients suffered PE's (0.8%), confirmed on VQ scan or CTPA (one operative, one conservative). One non-compliant patient healed functionally long and required a shortening procedure.

The authors experience has been that using the VACOped boot with our custom rehabilitation programme in dedicated physiotherapy clinics has produced excellent results.