Why shoulders are tricky Spire - BRidge Mr Lee Van Rensburg Mr Niel Kang March 2014

www.cambridgeses.co.uk

www.cambridgeorthopaedics.com office@cambridgemedicalpractice.co.uk Rheumatology 2006;45:215–221

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

Rheumatology 2006;45:215–221

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

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

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

Patient Impingement Tendonitis Problem biceps tendon – SLAP tear Rotator cuff tear Special scan Getting worse Can’t sleep Chew arm off

Specialist 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

123 Tests

175 J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34

…….. Perhaps this patient needs an MRI scan 1953 - 60 60-69 =30% FTRCT 1940 - 73 70-79 = 50% FTRCT 1930 - 83 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 296-299

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

Tricky

Shoulder pain Common Most get better on own Time Analgesia - NSAID If not better by 3 months refer? BMJ. 2005 Nov 12;331(7525):1124-8