Shoulder update - Cambridge Orthopaedics
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Transcript Shoulder update - Cambridge Orthopaedics
Frozen shoulder
Shoulder injections
Mr Lee Van Rensburg
November 2011
[email protected]
Rheumatology 2006;45:215–221
www.nufffieldhealth.com
Introduction
Anatomy
Clinical
Injections
Prevalence of shoulder pain - adults
7% overall
26% in elderly
Only 20-50% present to primary care
1% of primary care consultations
20% referred to secondary care
Over 50% only 1 consultation
Rheumatology 2006;45:215–221
Rheumatology 2006;45:215–221
Common
Most get better on own
Time
Analgesia - NSAID
If not better by 3 months refer?
GP 1
Diffuse pain in upper arm, spontaneous onset
Hawkins impingement +ve
Painful arc
Subacromial impingement
Physio
Sees physio - 2 weeks later
Physio examines patient - “tendonitis”
Starts treatment, pain gets worse
Refers back to GP some biceps signs
Biceps tendonitis ? Slap tear
GP 2
Unable to sleep
Difficult to examine, slightly reduced ROM
Weakness of shoulder
? Rotator cuff tear
Refer specialist ? Needs MRI
Impingement
Tendonitis
Problem biceps tendon – SLAP tear
Rotator cuff tear
Special scan
Getting worse
Can’t sleep
Chew arm off
Thank you for the referral
Pain in shoulder last 4 - 6 months
Limited ROM
No External rotation
Normal x rays
No need for scan
FROZEN SHOULDER
VOL. 85-B, No. 6, AUGUST 2003
- Apley's Scratch Test
- Jobes Supraspinatus test
- Dawburn's sign
- Sherry Party sign
- Codman's Sign (Drop Arm Sign)
- Rent Test
- Zero Degree Abduction Test
- Burkhead's Thumbs down & Burkhead's Thumbs
up
175
J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34
Rotator Cuff Muscles
Glenoid Labrum
Capsule/Glenohumeral Ligaments
Differential
Shoulder Assessment
Primary care shoulder pain
Acromioclavicular disorders
Rotator cuff disorders
Glenohumeral disorders
Frozen shoulder
Arthritis
Instability
Injections
20 – 40 years
< 20 years
Instability
Trauma
Labral pathology
Biceps
pathology
Instability
Tendonitis
> 40 years
Frozen shoulder
Rotator cuff dz
Osteoarthritis
Tumor
General
Age, dominance,
occupation, hobbies
General health
Instability
Rotator cuff and ACJ
Arthritis
Specific
Pain – sleep, night
pain
Weakness
Stiffness
Rx so far
Look
Feel
Move
Special Tests
COMPARE SIDES
Cervical Spine
Thoracic Spine
Neck Examination
Cardiac Disease
Muscles
Wasting
Winging
Deformity
Malunion
Scars
ACJ
Scapulohumeral rhythm
Arm Elevation (Abduction)
Glenohumeral & Scapulothoracic Jts
Variable Contribution
Compare sides
EXPOSE AND EXAMINE FROM
BEHIND
Sternoclavicular joint
Clavicle
ACJ
Trapezius/ parascapula
Neck
Compare sides (great variation)
Passive v Active
Loss of Motion
- Mechanical
- Muscular
- Pain Inhibition
- Neurological
Rotator Cuff Disease
Instability
Muscle Strength
Impingement
ACjt Pathology
Biceps Pathology
Jobe’s
ER against resistance
Gerber’s
Napolean
Napolean
Neer’s
Painful arc
Hawkin’s
Scarfe’s
Speed’s
Yergason’s
O’Brien’s
…….. Perhaps this patient needs an MRI scan
1961 - 50
1930 - 81
60-69 =30% FTRCT
70-79 = 50% FTRCT
80-89 = 80% FTRCT
Age-related prevalence of rotator cuff tears in asymptomatic shoulders;
Tempelhof et al; JSES July 1999 (Vol. 8, Issue 4, Pg 296-299
104 shoulders chronic, atraumatic shoulder pain
History, physical examination, radiographs
41% had pre evaluation MRI scans
Majority of pre-evaluation MRI scans had no
impact on the outcome
90% no value
Routine pre-evaluation with MRI does not
appear to have a significant effect on the
treatment or outcome
JSES 2005;14:233-237
Atypical
Mechanical integrity
Although it hurts your coming to no harm
Rarities
Previously prior to surgery
ALL rotator cuffs arthroscopically
Coronal PDFS (T2)
Avascular necrosis
4 Years post hemi
Persistent pain
Made no better
Coming from shoulder
Instability
Rotator cuff, ACJ
Referred, neck
Impingement
Tear (degenerate)
Tendonitis (calcific)
Glenohumeral
Arthritis
Frozen shoulder
BMJ 2005;331:1124–8
Pain top of shoulder
Pain worst arm abducted 90°
Unable to lie on it
Point tender ACJ
Scarfe’s crossed adduction
Reassurance
Analgesia
Steroid injection
Arthroscopic excision
Pain deltoid tuberosity
Reaching back, coat, bra
Painful arc
Impingement
No real weakness of cuff
Orthotherapy
Relative rest
NSAID
Physiotherapy
Steroid injection
Arthroscopic Subacromial decompression
Acute tear
Previously normal
Fall or similar
Now unable to elevate
Passive good elevation
? Earlier surgery
Degenerate tear
Impingement weakness
Orthotherapy
Arthroscopic rotator cuff repair
Acute pain
Chew arm off in night
Exclude infection
Radiograph
Orthotherapy
Needle barbotage
Arthroscopic decompression and needle
barbotage
Stiff painful shoulder
Reduced ROM
Similar active and passive
No ER
Scapulothoracic movement
Radiograph
Frozen shoulder
Arthritis
Three phases
Inflammatory phase
Frozen phase
Thawing phase
Symptoms and signs depend on
phase
Diabetic
2 years
VOL. 85-B, No. 6, AUGUST 2003
Treatment
Physiotherapy
Steroid injection
Hydrodilatation
Manipulation under anaesthetic
Arthroscopic capsular release
ASD & ACJ
RCR
Day case overnight stay
60-80% better
ASD sling 2-3 weeks
Drive 4-6 weeks
Desk top 4-6 weeks
Manual work 3 months
Tendon healing times
Stabilisation
Arthroscopic less stiffness
See separate presentation top of the
list updated
www.cambridgeses.co.uk