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
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Introduction
Anatomy
Clinical
Injections
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Prevalence of shoulder pain - adults
 7% overall
 26% in elderly
 Only 20-50% present to primary care
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1% of primary care consultations
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20% referred to secondary care
Over 50% only 1 consultation
Rheumatology 2006;45:215–221
Rheumatology 2006;45:215–221
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Common
Most get better on own
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Time
Analgesia - NSAID
If not better by 3 months refer?
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GP 1
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Diffuse pain in upper arm, spontaneous onset
Hawkins impingement +ve
Painful arc
Subacromial impingement
Physio
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Sees physio - 2 weeks later
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Physio examines patient - “tendonitis”
Starts treatment, pain gets worse
Refers back to GP some biceps signs
Biceps tendonitis ? Slap tear
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GP 2
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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
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Can’t sleep
Chew arm off
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Thank you for the referral
Pain in shoulder last 4 - 6 months
Limited ROM
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No External rotation
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Normal x rays
No need for scan
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FROZEN SHOULDER
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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
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Differential
Shoulder Assessment
Primary care shoulder pain
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Acromioclavicular disorders
Rotator cuff disorders
Glenohumeral disorders
 Frozen shoulder
 Arthritis
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Instability
Injections
20 – 40 years
< 20 years
Instability
 Trauma
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Labral pathology
 Biceps
pathology
 Instability
 Tendonitis
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> 40 years
Frozen shoulder
 Rotator cuff dz
 Osteoarthritis
 Tumor
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General
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Age, dominance,
occupation, hobbies
General health
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Instability
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Rotator cuff and ACJ
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Arthritis
Specific
Pain – sleep, night
pain
 Weakness
 Stiffness
 Rx so far
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Look
Feel
Move
Special Tests
COMPARE SIDES
Cervical Spine
 Thoracic Spine
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Neck Examination
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Cardiac Disease
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Muscles
 Wasting
 Winging
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Deformity
 Malunion
 Scars
 ACJ
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Scapulohumeral rhythm
Arm Elevation (Abduction)
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Glenohumeral & Scapulothoracic Jts
Variable Contribution
Compare sides
EXPOSE AND EXAMINE FROM
BEHIND
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Sternoclavicular joint
Clavicle
ACJ
Trapezius/ parascapula
Neck
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Compare sides (great variation)
Passive v Active
Loss of Motion
- Mechanical
- Muscular
- Pain Inhibition
- Neurological
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Rotator Cuff Disease
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Instability
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Muscle Strength
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Impingement
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ACjt Pathology
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Biceps Pathology
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Jobe’s
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ER against resistance
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Gerber’s
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Napolean
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Napolean
Neer’s
 Painful arc
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Hawkin’s
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Scarfe’s
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Speed’s
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Yergason’s
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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
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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
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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
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Atypical
Mechanical integrity
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Although it hurts your coming to no harm
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Rarities
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Previously prior to surgery
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ALL rotator cuffs arthroscopically
Coronal PDFS (T2)
Avascular necrosis
4 Years post hemi
Persistent pain
Made no better
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Coming from shoulder
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Instability
Rotator cuff, ACJ
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Referred, neck
Impingement
Tear (degenerate)
Tendonitis (calcific)
Glenohumeral
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Arthritis
Frozen shoulder
BMJ 2005;331:1124–8
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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
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Pain deltoid tuberosity
Reaching back, coat, bra
Painful arc
Impingement
No real weakness of cuff
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Orthotherapy
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Relative rest
 NSAID
 Physiotherapy
 Steroid injection
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Arthroscopic Subacromial decompression
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Acute tear
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Previously normal
Fall or similar
Now unable to elevate
Passive good elevation
? Earlier surgery
Degenerate tear
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Impingement weakness
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Orthotherapy
Arthroscopic rotator cuff repair
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Acute pain
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Chew arm off in night
Exclude infection
Radiograph
Orthotherapy
Needle barbotage
Arthroscopic decompression and needle
barbotage
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Stiff painful shoulder
Reduced ROM
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Similar active and passive
No ER
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Scapulothoracic movement
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Radiograph
Frozen shoulder
Arthritis
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Three phases
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Inflammatory phase
Frozen phase
Thawing phase
Symptoms and signs depend on
phase
Diabetic
2 years
VOL. 85-B, No. 6, AUGUST 2003
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Treatment
Physiotherapy
 Steroid injection
 Hydrodilatation
 Manipulation under anaesthetic
 Arthroscopic capsular release
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ASD & ACJ
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RCR
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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
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Arthroscopic less stiffness
See separate presentation top of the
list updated
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