1. Shoulder complaints based on the NHG- guideline Shoulder complaints 2008 Wim Willems HOVUmc www.gpsupport.nl

2. Shoulder complaints 1.Complaints / medical history 2.Physical examination 3.Treatment / Injection therapy

3. A case history Man, 35 years Construction worker Pain in the shoulder and upper arm (right) 3-4 months

4. A case history Questions? Physical examination? Additional examination? (Blood tests / X-ray / Ultrasound /.. ) Treatment?

5. 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 5

6. Medical interview 6

7. 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)? 7

8. Medical interview Severity of complaints How long do the complaints exist? Severity of the complaints Limitations? Hindrance? Complaints during the night? Absence of work? 8

9. 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? 9

10. Physical examination 10

11. Physical examination Neck (esp. extension / rotation) Active abduction shoulder (limited / painful / painful arc?) Passive abduction (limited / painful?) Passive exorotation (limited / painful?) 11

12. Passive exorotation 12

13. Passive abduction 13

14. X-ray ? / ECHO ? 14

15. X-ray ? / ECHO ? Not helpful in this stage 15

16. Beware of: 16

17. 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 17

18. 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) 18

19. Evaluation 2- Without limitation of passive movement Painful arc / abduction (subacromial syndrome) 19

20. Evaluation 3- Without limitation of passive movement and without painful abduction Cervical spine, glenohumeral instability a.c. / s.c. 20

21. Treatment 1Paracetamol / NSAID 2 weeks or longer when successful and necessary when ineffective: 2Injection corticosteroid 10-40 mg triamcinolone acetonide (1 ml) (can be combined with lidocaine 20 mg/ml, 2 ml) and / or 3 Activating physiotherapy 21

22. Anatomy 1Humerus 2Acromion 3Acromio-clavicular joint 4Clavicula 5Proc. Coracoideus 6Glenohumeral joint 22

23. Subacromial injection Needle 5 cm 2 cm below the middle of the lateral edge of the acromion Advance needle to well under the acromion 23

24. Precautions Asepsis / iodine Single use ampoules Respect all resistance while inserting needle and injecting 24

25. Side effects More pain temporarily Flushing Menstruation (higher glucose levels) 25

26. Thank you www.gpsupport.nl 26