Frozen shoulder Shoulder injections

Mr Lee Van RensburgNovember 2011

Rheumatology 2006;45:215–221

office@cambridgemedicalpractice.co.uk

www.nufffieldhealth.comwww.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 tearSpecial scanGetting 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

J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34

175175

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 years< 20 years 20 – 40 years20 – 40 years > 40 years> 40 years

InstabilityInstability TraumaTrauma

Labral pathologyLabral pathology Biceps Biceps pathologypathology InstabilityInstability TendonitisTendonitis

Frozen shoulderFrozen shoulder Rotator cuff dzRotator cuff dz OsteoarthritisOsteoarthritis TumorTumor

General Age, dominance,

occupation, hobbies General health

Specific Pain – sleep, night

pain Weakness Stiffness Rx so far

Instability

Rotator cuff and ACJ

Arthritis

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

60-69 =30% FTRCT

70-79 = 50% FTRCT

80-89 = 80% FTRCT

1961 - 50

1930 - 81

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 hemiPersistent painMade no better

Coming from shoulder Referred, neck

Instability Rotator cuff, ACJ

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 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

RCR Tendon healing times

Stabilisation Arthroscopic less stiffness

See separate presentation top of the list updated

www.cambridgeses.co.uk