1. Frozen shoulder Shoulder injections
Mr Lee Van Rensburg
November 2011

3. www.cambridgeorthopaedics.com office@cambridgemedicalpractice.co.uk
Rheumatology 2006;45:215–221

5. Overview
Introduction
Anatomy
Clinical
Injections

6. Prevalence 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

7. Rheumatology 2006;45:215–221

8. Shoulder pain Common Most get better on own
Time
Analgesia - NSAID
If not better by 3 months refer?

9. Referral GP 1 Diffuse pain in upper arm, spontaneous onset
Hawkins impingement +ve
Painful arc
Subacromial impingement
Physio

10. Physiotherapy 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

11. Referral GP 2 Unable to sleep
Difficult to examine, slightly reduced ROM
Weakness of shoulder
? Rotator cuff tear
Refer specialist ? Needs MRI

12. Patient Impingement Tendonitis Problem biceps tendon – SLAP tear
Rotator cuff tear
Special scan
Getting worse
Can’t sleep
Chew arm off

13. ? Specialist Thank you for the referral
Pain in shoulder last months
Limited ROM
No External rotation
Normal x rays
No need for scan
FROZEN SHOULDER

14. Frozen shoulder

15. VOL. 85-B, No. 6, AUGUST 2003

16. 123 Tests

17. Supraspinatus
- 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

18. 175
J Shoulder Elbow Surg Jul-Aug;18(4):529-34

19. Anatomy
Rotator Cuff Muscles

20. Anatomy
Glenoid Labrum

21. Anatomy
Capsule/Glenohumeral Ligaments

22. Overview Differential Shoulder Assessment Primary care shoulder pain
Acromioclavicular disorders
Rotator cuff disorders
Glenohumeral disorders
Frozen shoulder
Arthritis
Instability
Injections

23. Differential by age < 20 years 20 – 40 years > 40 years
Instability
Trauma
Labral pathology
Biceps pathology
Tendonitis
Frozen shoulder
Rotator cuff dz
Osteoarthritis
Tumor

24. Shoulder history General Specific Instability Rotator cuff and ACJ
Age, dominance, occupation, hobbies
General health
Specific
Pain – sleep, night pain
Weakness
Stiffness
Rx so far
Instability
Rotator cuff and ACJ
Arthritis

25. Examination
Look
Feel
Move
Special Tests
COMPARE SIDES

26. Neck Examination Referred pain Cervical Spine Thoracic Spine
Cardiac Disease

27. Look Muscles Deformity Scapulohumeral rhythm Wasting Winging Malunion
Scars
ACJ
Scapulohumeral rhythm

28. Scapulo-humeral rhythm
Arm Elevation (Abduction)
Glenohumeral & Scapulothoracic Jts
Variable Contribution
Compare sides
EXPOSE AND EXAMINE FROM BEHIND

29. Feel
Sternoclavicular joint
Clavicle
ACJ
Trapezius/ parascapula
Neck

30. Move Compare sides (great variation) Passive v Active Loss of Motion
- Mechanical
- Muscular
- Pain Inhibition
- Neurological

31. External rotation

32. Forward flexion

33. Abduction

34. Internal rotation

35. Special tests
Rotator Cuff Disease
Instability

36. Rotator cuff disease Muscle Strength Impingement ACjt Pathology
Biceps Pathology

37. Supraspinatus
Jobe’s

38. Posterior cuff
ER against resistance

39. Subscapularis
Gerber’s

40. Subscapularis
Napolean

41. Subscapularis
Napolean

42. Impingement
Neer’s
Painful arc

43. Impingement
Hawkin’s

44. AC Joint
Scarfe’s

45. Biceps
Speed’s

46. Biceps
Yergason’s

47. Labrum
O’Brien’s

48. Normal X rays

49. Arthritis

50. Calcific tendonitis

51. Normal x rays

53. …….. Perhaps this patient needs an MRI scan
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

54. 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:

55. MRI Atypical Mechanical integrity Rarities Previously prior to surgery
Although it hurts your coming to no harm
Rarities
Previously prior to surgery
ALL rotator cuffs arthroscopically

56. 59 YO male
Coronal PDFS (T2)

57. 29 YO Lymphoma Steroids
Avascular necrosis

58. Right

59. 36 YO male severe pain

60. 72 YO Male Bilateral shoulder pain
4 Years post hemi
Persistent pain
Made no better

61. SHOULDER PAIN Coming from shoulder Instability Rotator cuff, ACJ
Referred, neck
Instability
Rotator cuff, ACJ
Impingement
Tear (degenerate)
Tendonitis (calcific)
Glenohumeral
Arthritis
Frozen shoulder
BMJ 2005;331:1124–8

62. ACJ 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

63. Rotator cuff - Impingement
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

64. Rotator cuff - tear Acute tear Degenerate tear Previously normal
Fall or similar
Now unable to elevate
Passive good elevation
? Earlier surgery
Degenerate tear
Impingement weakness
Orthotherapy
Arthroscopic rotator cuff repair

65. Rotator cuff - calcific
Acute pain
Chew arm off in night
Exclude infection
Radiograph
Orthotherapy
Needle barbotage
Arthroscopic decompression and needle barbotage

66. Glenohumeral Stiff painful shoulder Reduced ROM
Similar active and passive
No ER
Scapulothoracic movement
Radiograph
Frozen shoulder
Arthritis

67. Frozen shoulder Three phases Symptoms and signs depend on phase
Inflammatory phase
Frozen phase
Thawing phase
Symptoms and signs depend on phase
Diabetic
2 years

68. VOL. 85-B, No. 6, AUGUST 2003

69. Frozen shoulder Treatment Physiotherapy Steroid injection
Hydrodilatation
Manipulation under anaesthetic
Arthroscopic capsular release

70. Arthroscopic shoulder surgery
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

71. Injections about the shoulder
See separate presentation top of the list updated