shoulder complaints based on the nhg- guideline shoulder complaints 2008 wim willems hovumc
TRANSCRIPT
Shoulder complaints
based on the NHG- guideline Shoulder complaints 2008
Wim Willems HOVUmc
www.gpsupport.nl
Shoulder complaints
1. Complaints / medical history
2. Physical examination
3. Treatment / Injection therapy
A case history
Man, 35 years
Construction worker
Pain in the shoulder and upper arm (right)
3-4 months
A case history
Questions?
Physical examination?
Additional examination?
(Blood tests / X-ray / Ultrasound / .. )
Treatment?
Purpose
What kind of shoulder pain has this patient?
• Limitation of passive movement (abduction or exorotation)
• No limitation of passive movement, however: painful abduction
• No limitation of passive movement and no painful abduction
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Medical interview
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Medical interview
Type of complaints• Where is the pain localized?• Radiation?• Painful movement(s) of the arm?• Pain during abduction?• Neck pain?• Feeling of instability ?• Known cause (work / sports / trauma)?
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Medical interview
Severity of complaints
• How long do the complaints exist?• Severity of the complaints• Limitations? Hindrance?• Complaints during the night?• Absence of work?
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Medical interview
Factors that influence course
• How long do the complaints exist?• Work relevant factors? • Psychosocial factors?• Effect of rest / movement / medication?• Complaints in the past?
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Physical examination
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Physical examination
• Neck (esp. extension / rotation)
• Active abduction shoulder (limited / painful / painful arc?)
• Passive abduction (limited / painful?)
• Passive exorotation (limited / painful?)
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Passive exorotation
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Passive abduction
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X-ray ? / ECHO ?
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X-ray ? / ECHO ?
Not helpful in this stage
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Beware of:
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Beware of:
• Pain ++, pins & needles, radiation (cervical radicular syndrome)
• Pain in several joints, history of rheumatic arthritis, signs of synovitis (rheumatic arthritis)
• Pain in both shoulders, pain / stiffness in pelvic girdle / malaise / elevated ESR (polymyalgia rheumatica)
• Severe / persistent pain, fever, malaise, weight loss, chest pain, shortness of breath (cardiac / pulmonary / abdominal / septic arthritis)
• Complaints not corresponding with age of patient
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Evaluation
1- With limitation of passive movement• Painful arc / abduction most prominently limited
movement/ pain at the end of the abduction
(subacromial syndrome)
• Painful and restricted exorotation / exorotation most prominently limited
(capsular syndrome / frozen shoulder)
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Evaluation
2- Without limitation of passive movement
• Painful arc / abduction
(subacromial syndrome)
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Evaluation
3- Without limitation of passive movement and without painful abduction
• Cervical spine, • glenohumeral instability • a.c. / s.c.
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Treatment
1 Paracetamol / NSAID2 weeks or longer when successful and necessary
when ineffective:
2 Injection corticosteroid10-40 mg triamcinolone acetonide (1 ml)(can be combined with lidocaine 20 mg/ml, 2 ml)
and / or
3 Activating physiotherapy
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Anatomy
1 Humerus
2 Acromion
3 Acromio-clavicular joint
4 Clavicula
5 Proc. Coracoideus
6 Glenohumeral joint
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Subacromial injection
• Needle 5 cm• 2 cm below the middle of
the lateral edge of the acromion
• Advance needle to well under the acromion
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Precautions
• Asepsis / iodine
• Single use ampoules
• Respect all resistance while inserting needle and injecting
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Side effects
• More pain temporarily
• Flushing
• Menstruation
• (higher glucose levels)
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Thank you
www.gpsupport.nl
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