shoulder complaints based on the nhg- guideline shoulder complaints 2008 wim willems hovumc

Shoulder complaints

based on the NHG- guideline Shoulder complaints 2008

Wim Willems HOVUmc

www.gpsupport.nl

Shoulder complaints

1. Complaints / medical history

2. Physical examination

3. Treatment / Injection therapy

A case history

Man, 35 years

Construction worker

Pain in the shoulder and upper arm (right)

3-4 months

A case history

Questions?

Physical examination?

Additional examination?

(Blood tests / X-ray / Ultrasound / .. )

Treatment?

Purpose

What kind of shoulder pain has this patient?

• Limitation of passive movement (abduction or exorotation)

• No limitation of passive movement, however: painful abduction

• No limitation of passive movement and no painful abduction

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Medical interview

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Medical interview

Type of complaints• Where is the pain localized?• Radiation?• Painful movement(s) of the arm?• Pain during abduction?• Neck pain?• Feeling of instability ?• Known cause (work / sports / trauma)?

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Medical interview

Severity of complaints

• How long do the complaints exist?• Severity of the complaints• Limitations? Hindrance?• Complaints during the night?• Absence of work?

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Medical interview

Factors that influence course

• How long do the complaints exist?• Work relevant factors? • Psychosocial factors?• Effect of rest / movement / medication?• Complaints in the past?

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Physical examination

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Physical examination

• Neck (esp. extension / rotation)

• Active abduction shoulder (limited / painful / painful arc?)

• Passive abduction (limited / painful?)

• Passive exorotation (limited / painful?)

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Passive exorotation

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Passive abduction

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X-ray ? / ECHO ?

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X-ray ? / ECHO ?

Not helpful in this stage

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Beware of:

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Beware of:

• Pain ++, pins & needles, radiation (cervical radicular syndrome)

• Pain in several joints, history of rheumatic arthritis, signs of synovitis (rheumatic arthritis)

• Pain in both shoulders, pain / stiffness in pelvic girdle / malaise / elevated ESR (polymyalgia rheumatica)

• Severe / persistent pain, fever, malaise, weight loss, chest pain, shortness of breath (cardiac / pulmonary / abdominal / septic arthritis)

• Complaints not corresponding with age of patient

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Evaluation

1- With limitation of passive movement• Painful arc / abduction most prominently limited

movement/ pain at the end of the abduction

(subacromial syndrome)

• Painful and restricted exorotation / exorotation most prominently limited

(capsular syndrome / frozen shoulder)

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Evaluation

2- Without limitation of passive movement

• Painful arc / abduction

(subacromial syndrome)

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Evaluation

3- Without limitation of passive movement and without painful abduction

• Cervical spine, • glenohumeral instability • a.c. / s.c.

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Treatment

1 Paracetamol / NSAID2 weeks or longer when successful and necessary

when ineffective:

2 Injection corticosteroid10-40 mg triamcinolone acetonide (1 ml)(can be combined with lidocaine 20 mg/ml, 2 ml)

and / or

3 Activating physiotherapy

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Anatomy

1 Humerus

2 Acromion

3 Acromio-clavicular joint

4 Clavicula

5 Proc. Coracoideus

6 Glenohumeral joint

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Subacromial injection

• Needle 5 cm• 2 cm below the middle of

the lateral edge of the acromion

• Advance needle to well under the acromion

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Precautions

• Asepsis / iodine

• Single use ampoules

• Respect all resistance while inserting needle and injecting

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Side effects

• More pain temporarily

• Flushing

• Menstruation

• (higher glucose levels)

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Thank you

www.gpsupport.nl

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