Why shoulders are tricky

Mr Lee Van RensburgDecember 2013

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Rheumatology 2006;45:215–221

office@cambridgemedicalpractice.co.uk

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