frozen shoulder shoulder injections mr lee van rensburg november 2011
TRANSCRIPT
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Frozen shoulder Shoulder injections
Mr Lee Van RensburgNovember 2011
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www.nufffieldhealth.comwww.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
1% of primary care consultations 20% referred to secondary care Over 50% only 1 consultation
Rheumatology 2006;45:215–221
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Rheumatology 2006;45:215–221
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Common Most get better on own
Time Analgesia - NSAID
If not better by 3 months refer?
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GP 1 Diffuse pain in upper arm, spontaneous onset Hawkins impingement +ve Painful arc
Subacromial impingement Physio
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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
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GP 2 Unable to sleep Difficult to examine, slightly reduced ROM Weakness of shoulder ? Rotator cuff tear Refer specialist ? Needs MRI
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Impingement
Tendonitis
Problem biceps tendon – SLAP tear
Rotator cuff tearSpecial scanGetting worse
Can’t sleep Chew arm off
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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
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VOL. 85-B, No. 6, AUGUST 2003
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- 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
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J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34
175175
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Rotator Cuff Muscles
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Glenoid Labrum
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Capsule/Glenohumeral Ligaments
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Differential Shoulder Assessment Primary care shoulder pain
Acromioclavicular disorders Rotator cuff disorders Glenohumeral disorders
Frozen shoulder Arthritis
Instability Injections
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< 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
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General Age, dominance,
occupation, hobbies General health
Specific Pain – sleep, night
pain Weakness Stiffness Rx so far
Instability
Rotator cuff and ACJ
Arthritis
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Look Feel Move Special Tests
COMPARE SIDES
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Cervical Spine Thoracic Spine
Neck Examination
Cardiac Disease
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Muscles Wasting Winging
Deformity Malunion Scars ACJ
Scapulohumeral rhythm
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Arm Elevation (Abduction)
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
Instability
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Muscle Strength
Impingement
ACjt Pathology
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
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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
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…….. 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
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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 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
Although it hurts your coming to no harm Rarities
Previously prior to surgery ALL rotator cuffs arthroscopically
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Coronal PDFS (T2)
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Avascular necrosis
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4 Years post hemiPersistent painMade no better
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Coming from shoulder Referred, neck
Instability Rotator cuff, ACJ
Impingement Tear (degenerate) Tendonitis (calcific)
Glenohumeral 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
Orthotherapy Relative rest NSAID Physiotherapy Steroid injection
Arthroscopic Subacromial decompression
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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
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Acute pain 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
Similar active and passive No ER
Scapulothoracic movement
Radiograph
Frozen shoulder
Arthritis
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Three phases Inflammatory phase Frozen phase Thawing phase
Symptoms and signs depend on phase
Diabetic 2 years
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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 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
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See separate presentation top of the list updated
www.cambridgeses.co.uk