Why shoulders are tricky Mr Lee Van Rensburg

Why shoulders are tricky Mr Lee Van Rensburg December 2013

. www. cambridgeses. co. uk

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

www. 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

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

Impingement Patient 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

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

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

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

Examination