Presentation is loading. Please wait.

Presentation is loading. Please wait.

Frozen shoulder Shoulder injections

Similar presentations

Presentation on theme: "Frozen shoulder Shoulder injections"— Presentation transcript:

1 Frozen shoulder Shoulder injections
Mr Lee Van Rensburg November 2011


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

Download ppt "Frozen shoulder Shoulder injections"

Similar presentations

Ads by Google