why shoulders are tricky mr lee van rensburg december 2013
TRANSCRIPT
Why shoulders are tricky
Mr Lee Van RensburgDecember 2013
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www.nufffieldhealth.comwww.nufffieldhealth.com
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
Rheumatology 2006;45:215–221
GP 1 Diffuse pain in upper arm, spontaneous onset Hawkins impingement +ve Painful arc
Subacromial impingement Physio
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
GP 2 Unable to sleep Difficult to examine, slightly reduced ROM Weakness of shoulder ? Rotator cuff tear Refer specialist ? Needs MRI
Impingement
Tendonitis
Problem biceps tendon – SLAP tear
Rotator cuff tearSpecial scanGetting worse
Can’t sleep Chew arm off
Thank you for the referral Pain in shoulder last 4 - 6 months Limited ROM
No External rotation Normal x rays No need for scan
FROZEN SHOULDER
VOL. 85-B, No. 6, AUGUST 2003
J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34
175175
…….. Perhaps this patient needs an MRI scan
60-69 =30% FTRCT
70-79 = 50% FTRCT
80-89 = 80% FTRCT
1930 - 83
Age-related prevalence of rotator cuff tears in asymptomatic shoulders; Tempelhof et al; JSES July 1999 (Vol. 8, Issue 4, Pg 296-299
1940 - 73
1953 - 60
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;14:233-237
Arthroscopy: Vol 26, No 3 (March), 2010: pp 393-403
< 20 years< 20 years 20 – 40 years20 – 40 years > 40 years> 40 years
InstabilityInstability TraumaTrauma
Labral pathologyLabral pathology Biceps Biceps pathologypathology InstabilityInstability TendonitisTendonitis
Frozen shoulderFrozen shoulder Rotator cuff dzRotator cuff dz OsteoarthritisOsteoarthritis TumorTumor
Common Most get better on own
Time Analgesia - NSAID
If not better by 3 months refer?
BMJ. 2005 Nov 12;331(7525):1124-8
Coming from shoulder Referred, neck
Instability Rotator cuff, ACJ
Impingement Tear (degenerate) Tendonitis (calcific)
Glenohumeral Arthritis Frozen shoulder
BMJ 2005;331:1124–8
