1. Why shoulders are tricky Mr Lee Van Rensburg December 2013

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3. . Rheumatology 2006;45:215–221 office@cambridgemedicalpractice.co.uk

4. www.nufffieldhealth.com

5.  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

7.  GP 1  Diffuse pain in upper arm, spontaneous onset  Hawkins impingement +ve  Painful arc  Subacromial impingement  Physio

8.  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

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

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

11.  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

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

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

15. …….. 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

16.  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

17. Arthroscopy: Vol 26, No 3 (March), 2010: pp 393-403

19. < 20 years 20 – 40 years > 40 years Instability Instability Trauma Trauma Labral pathology Labral pathology Biceps pathology Biceps pathology Instability Instability Tendonitis Tendonitis Frozen shoulder Frozen shoulder Rotator cuff dz Rotator cuff dz Osteoarthritis Osteoarthritis Tumor Tumor

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

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