Frozen shoulder Shoulder injections Mr Lee Van Rensburg November 2011.
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Transcript of Frozen shoulder Shoulder injections Mr Lee Van Rensburg November 2011.
Frozen shoulder Shoulder injections
Mr Lee Van RensburgNovember 2011
Rheumatology 2006;45:215–221
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