Frozen shoulder Shoulder injections Mr Lee Van Rensburg November 2011

www.shoulderses.co.uk

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

www.nufffieldhealth.com

Overview Introduction Anatomy Clinical Injections

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

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

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

Frozen shoulder

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123 Tests

Supraspinatus - 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

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

Anatomy Rotator Cuff Muscles

Anatomy Glenoid Labrum

Anatomy Capsule/Glenohumeral Ligaments

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

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

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

Examination Look Feel Move Special Tests COMPARE SIDES

Neck Examination Referred pain Cervical Spine Thoracic Spine Cardiac Disease

Look Muscles Deformity Scapulohumeral rhythm Wasting Winging Malunion Scars ACJ Scapulohumeral rhythm

Scapulo-humeral rhythm Arm Elevation (Abduction) Glenohumeral & Scapulothoracic Jts Variable Contribution Compare sides EXPOSE AND EXAMINE FROM BEHIND

Feel Sternoclavicular joint Clavicle ACJ Trapezius/ parascapula Neck

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

External rotation

Forward flexion

Abduction

Internal rotation

Special tests Rotator Cuff Disease Instability

Rotator cuff disease Muscle Strength Impingement ACjt Pathology Biceps Pathology

Supraspinatus Jobe’s

Posterior cuff ER against resistance

Subscapularis Gerber’s

Subscapularis Napolean

Subscapularis Napolean

Impingement Neer’s Painful arc

Impingement Hawkin’s

AC Joint Scarfe’s

Biceps Speed’s

Biceps Yergason’s

Labrum O’Brien’s

Normal X rays

Arthritis

Calcific tendonitis

Normal x rays

…….. Perhaps this patient needs an MRI scan 1961 - 50 1930 - 81 60-69 =30% FTRCT 70-79 = 50% FTRCT 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

MRI Atypical Mechanical integrity Rarities Previously prior to surgery Although it hurts your coming to no harm Rarities Previously prior to surgery ALL rotator cuffs arthroscopically

59 YO male Coronal PDFS (T2)

29 YO Lymphoma Steroids Avascular necrosis

Right

36 YO male severe pain

72 YO Male Bilateral shoulder pain 4 Years post hemi Persistent pain Made no better

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

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

Rotator cuff - Impingement 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

Rotator cuff - tear Acute tear Degenerate tear Previously normal Fall or similar Now unable to elevate Passive good elevation ? Earlier surgery Degenerate tear Impingement weakness Orthotherapy Arthroscopic rotator cuff repair

Rotator cuff - calcific Acute pain Chew arm off in night Exclude infection Radiograph Orthotherapy Needle barbotage Arthroscopic decompression and needle barbotage

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

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

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

Frozen shoulder Treatment Physiotherapy Steroid injection Hydrodilatation Manipulation under anaesthetic Arthroscopic capsular release

Arthroscopic shoulder surgery 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

Injections about the shoulder See separate presentation top of the list updated www.cambridgeses.co.uk