frozen shoulder
TRANSCRIPT
ANDY TAMPUBOLON
EPIDEMIOLOGi
• Usia di atas 40 tahun
• Wanita > Pria
FAKTOR PREDISPOSISI
• Diabetes melitus
• Stress fisik
• Stress psikis
ANATOMI
ANATOMI
SYMPTOMS• Nyeri yang timbul setelah berkurangnya
ROM sendi bahu
• Nyeri yang terlokalisasi pada rongga rotatorik bahu
• Radiasi nyeri di bawah deltoid dan lengan anterior
• Nyeri saat berbaring bertumpu pada bahu yang sakit
SIGNS
• Penderita memfiksasi lengan pada sisi tubuh
• Atrofi deltoid dan supraspinatus
• Nyeri pada daerah rotatorik bahu dan tendo biseps
• ROM terbatas
• Distrofi simpatetik relfleks : edema tangan, dingin, perubahan warna kulit.
DIAGNOSIS
• Gejala klinis
• Gambaran radiologi (X-Ray)
MANAGEMENT
• Preventif• Pengobatan nyeri • Fisioterapi• Psikoterapi
Shoulder Injection
I. Frequency of injections A. Older patients: May repeat 2-3 times per year B. Younger patients: Consider surgery if no improvement
1. Repeat injection risks Rotator Cuff Rupture II. Precautions
A. Risk of Rotator Cuff Rupture 1. Use with caution especially in young patients
Glenohumeral Joint Injection
I. Preparation A. Needle: 25-27 gauge 1.5 inch B. Intraarticular Corticosteroid
1. Methylprednisolone: 1 ml of 40 mg/ml or 2. Betamethasone (Celestone Soluspan): 1 ml
C. Lidocaine 1%: 5-7 ml II. Indications
A. Shoulder Osteoarthritis B. Adhesive Capsulitis C. Rheumatoid Arthritis affecting the shoulder
III. Patient positioning A. Patient sits with arm resting at side B. Shoulder externally rotated
IV. Posterior Approach A. Images
1. (Followed) B. Landmarks
1. Find sulcus between head of humerus and acromion 2. Posterolateral corner of acromion (2-3 cm inferior)
C. Injected with sterile technique 1. Direct needle anteriorly toward coracoid process 2. Insert needle to full length 3. Fluid should flow easily
V. Anterior Approach A. Landmarks
1. Medial to head of humerus 2. Lateral to coracoid process by 1 cm
B. Injected with sterile technique 1. Direct needle posteriorly 2. Angle slightly superior and lateral
Pull-back and redirect needle if hits bone
Acromioclavicular Joint Injection
I. Indications A. Osteolysis of distal clavicle B. Osteoarthritis
II. Preparation A. Needle: 25-27 gauge, 1 to 1.5 inch B. Intraarticular Corticosteroid
1. Methylprednisolone: 0.25 - 0.50 ml of 40 mg/ml or 2. Betamethasone (Celestone Soluspan): 0.25 to 0.50 ml
C. Lidocaine 1%: 0.5 ml III. Patient positioning
A. Patient sits with arm resting at side B. Shoulder externally rotated
IV. Approach A. Images
1. B. Landmarks: Identify AC joint
1. Palpate clavicle to distal aspect 2. Slight depression where clavicle meets acromion
C. Injected with sterile technique 1. Insert needle from anterior and superior approach
Direct needle inferiorly
Subacromial Space Injection
I. Indications A. Subacromial bursitis (Subdeltoid Bursitis) B. Rotator Cuff Impingement or tendinosis C. Adhesive Capsulitis
II. Efficacy A. Study of n=40, DBRT, with mean age of 57 years B. After 30 weeks: Assessment moderate to severe pain
1. Subacromial Corticosteroid Injection: 16% had pain 2. Subacromial Lidocaine injection: 71% had pain
III. Preparation A. Needle: 25-27 gauge 1.5 inch B. Intraarticular Corticosteroid
1. Methylprednisolone: 1 ml of 40 mg/ml or 2. Betamethasone (Celestone Soluspan): 1 ml
C. Lidocaine 1%: 5-7 ml IV. Approach (Lateral shoulder)
A. Images 1.
B. Landmarks 1. Posterior and lateral aspect of shoulder 2. Inferior to lower edge of posterolateral acromion
C. Injected with sterile technique 1. Insert inferior to acromion at lateral shoulder 2. Direct needle toward opposite nipple 3. Insert needle to full length
Fluid should flow easily
Biceps Tendon Injection
I. Indications A. Bicipital Tendonitis
II. Preparation A. Needle: 25-27 gauge, 1 to 1.5 inch B. Intraarticular Corticosteroid
1. Methylprednisolone: 0.25 ml of 40 mg/ml or 2. Betamethasone (Celestone Soluspan): 0.25 ml
C. Lidocaine 1%: 0.5 ml III. Patient positioning
A. Patient sits with arm resting at side IV. Approach
A. Images 1.
B. Landmarks 1. Identify bicipital tendon in bicipital groove 2. Mark point of maximal tenderness over groove
C. Injected with sterile technique 1. Direct needle parallel to bicipital groove 2. Needle enters skin at 30 degrees 3. Do not inject bicipital tendon 4. Infiltrate area around groove, but not into tendon
a. Flow resisted when needle is inside tendon b. Withdraw needle slightly and retry c. Continue to withdraw until not in tendon
V. Complications A. Bicipital tendon rupture
1. Associated with intratendinous injection
Do not inject bicipital tendon
Scapulothoracic Injection
I. Indications A. Scapulothoracic articulation inflammation
1. Bursitis at inferior medial scapular border 2. Injured with pushing, pulling, and throwing 3. May be associated with popping or catching sensation
II. Preparation A. Needle: 25-27 gauge 1.5 inch B. Intraarticular Corticosteroid
1. Methylprednisolone: 1 ml of 40 mg/ml or 2. Betamethasone (Celestone Soluspan): 1 ml
C. Lidocaine 1%: 1-2 ml III. Approach
A. Images 1.
B. Patient position 1. Lying prone 2. Place hand of affected side on buttock
C. Landmarks 1. Inferior and medial border of scapula
D. Injected with sterile technique 1. Needle directed laterally in plane of scapula
Needle inserted deep to infero-medial scapula corner
Shoulder Range of Motion
I. Technique: Active and Passive Range of Motion A. Compare both sides B. Measure angles (goniometer)
II. Movement Directions (normal in parentheses) A. Abduction (150 degrees) B. Forward flexion (180 degrees) C. Extension (45 degrees) D. External Rotation (90 degrees), elbow at 90 degrees
1. With arm comfortably at side 2. With arm at 90 degrees abduction
E. Internal rotation (90) III. Specific Tests
A. Apley's Scratch Test
Shoulder Range of Motion Exercises
I. Pendulum A. While bending to 60-90 degrees at waist B. Swing bucket or weight anteriorly and posteriorly
II. Wall-climbing A. Walk fingers up wall and overhead
III. Rope and pulley from ceiling A. Hands see-saw back and forth B. Rope handles moved up and down via pulley C. Normal arm assists in elevation of stiff arm
IV. Internal rotation A. Clasp hands behind back B. Raise hands toward head
V. External rotation A. Hands behind neck B. Rotate elbows back and then forward C. Repeat motion
Apley's Scratch Test
I. Abduction and External Rotation Test Technique A. Compare both sides B. Reach over shoulders to "scratch" between scapulae
1. Measure to which vertebrae thumb can reach C. Actively resist moving scratching hand away from back
1. Tests Subscapularis strength II. Adduction and Internal Rotation Test Technique
A. Compare both sides B. Reach behind back as if to scratch low back
1. Measure to which vertebrae thumb can reach
Injectable Corticosteroid
Short-Acting Injectable Corticosteroids
A. Cortisone 1. Relative Potency: 0.8 (25 mg) 2. Dosing
a. Tendon Sheath and bursas: 20-50 mg b. Small Joints: 10-25 mg c. Large Joints: 50-125 mg
B. Hydrocortisone 1. Relative Potency: 1.0 (20 mg) 2. Supplied: 25 mg/ml, 50 mg/ml 3. Dosing
a. Tendon Sheath and bursas: 8-40 mg b. Small Joints: 8-20 mg c. Large Joints: 40-100 mg
Intermediate-Acting Injectable Corticosteroids
A. Prednisone 1. Relative Potency: 3.5 (5 mg)
B. Prednisolone tebutate (Hydeltra) 1. Supplied: 20 mg/ml 2. Relative Potency: 4 (5 mg) 3. Dosing
a. Tendon Sheath and bursas: 4-10 mg b. Small Joints: 2-5 mg c. Large Joints: 10-25 mg
C. Triamcinolone and Methylprednisolone 1. Preparations
a. Triamcinolone (Aristocort, Aristospan, Kenalog) b. Methylprednisolone acetate (Depo-Medrol)
2. Relative Potency: 5 (4 mg) 3. Supplied: 20 mg/ml, 40 mg/ml 4. Dosing
a. Tendon Sheath and bursas: 4-10 mg b. Small Joints: 2-5 mg
Large Joints: 10-25 mg
Long-Acting: Dexamethasone and Betamethasone
A. Preparations 1. Dexamethasone sodium phosphate (Decadron) 2. Betamethasone (Celestone Soluspan)
B. Relative Potency: 25 (0.6 mg) C. Supplied: 4 mg/ml, 6 mg/ml, 8 mg/ml D. Dosing
1. Tendon Sheath and bursas: 1.5-3.0 mg 2. Small Joints: 0.8-1.0 mg
Large Joints: 2-4 mg
Typical doses of corticosteroid used for injection Structure Dose (mg)* Volume ofinjection (mL)
Large joint Knee 40-60 1-4Shoulder 30 1-4Elbow 20-30 1-4
Medium joint Ankle 20-30 0.5-1Wrist 20 0.5-1
Small joint Interphalangeal 5-10 0.25-0.5Metacarpophalangeal 5-10 0.25-0.5Metatarsophalangeal 5-10 0.25-0.5
Small soft-tissue structure Bursa 20 0.5-1.5Tendon sheath 5-20 0.25-1
*Doses shown are for triamcinolone hexacetonide for joint injection and methylprednisolone acetate for soft-tissue injection.