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Frozen shoulder Shoulder injections Mr Lee Van Rensburg November 2011.

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Presentation on theme: "Frozen shoulder Shoulder injections Mr Lee Van Rensburg November 2011."— Presentation transcript:

1 Frozen shoulder Shoulder injections Mr Lee Van Rensburg November 2011

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3 Rheumatology 2006;45:215–221

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5 Introduction Anatomy Clinical Injections

6 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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8 Common Most get better on own Time Analgesia - NSAID If not better by 3 months refer?

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

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

12 Impingement Tendonitis Problem biceps tendon – SLAP tear Rotator cuff tear Special scan Getting worse Cant sleep Chew arm off

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

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

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17 - 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 J Shoulder Elbow Surg Jul-Aug;18(4):

19 Rotator Cuff Muscles

20 Glenoid Labrum

21 Capsule/Glenohumeral Ligaments

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

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

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

25 Look Feel Move Special Tests COMPARE SIDES

26 Cervical Spine Thoracic Spine Neck Examination Cardiac Disease

27 Muscles Wasting Winging Deformity Malunion Scars ACJ Scapulohumeral rhythm

28 Arm Elevation (Abduction) Glenohumeral & Scapulothoracic Jts Variable Contribution Compare sides EXPOSE AND EXAMINE FROM BEHIND

29 Sternoclavicular joint Clavicle ACJ Trapezius/ parascapula Neck

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

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35 Rotator Cuff Disease Instability

36 Muscle Strength Impingement ACjt Pathology Biceps Pathology

37 Jobes

38 ER against resistance

39 Gerbers

40 Napolean

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42 Neers Painful arc

43 Hawkins

44 Scarfes

45 Speeds

46 Yergasons

47 OBriens

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53 …….. Perhaps this patient needs an MRI scan =30% FTRCT = 50% FTRCT = 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 Atypical Mechanical integrity Although it hurts your coming to no harm Rarities Previously prior to surgery ALL rotator cuffs arthroscopically

56 Coronal PDFS (T2)

57 Avascular necrosis

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60 4 Years post hemi Persistent pain Made no better

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

62 Pain top of shoulder Pain worst arm abducted 90° Unable to lie on it Point tender ACJ Scarfes crossed adduction Reassurance Analgesia Steroid injection Arthroscopic excision

63 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 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

65 Acute pain Chew arm off in night Exclude infection Radiograph Orthotherapy Needle barbotage Arthroscopic decompression and needle barbotage

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

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

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

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

70 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 See separate presentation top of the list updated


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