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Shoulder Assessment and Injection. Dr Ian Ryans General Practitioner, Dundonald Medical Centre Hospital Practitioner, Rheumatology Dept, Ulster Hospital, Dundonald. The Painful Shoulder. Clinical Assessment Treatment Options Injection Techniques. History. Onset Site

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Shoulder Assessment and Injection

Dr Ian Ryans

General Practitioner, Dundonald Medical Centre

Hospital Practitioner, Rheumatology Dept, Ulster Hospital, Dundonald


The painful shoulder l.jpg
The Painful Shoulder

  • Clinical Assessment

  • Treatment Options

  • Injection Techniques


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History

  • Onset

  • Site

  • Neck or other joints

  • Injury

  • Impact on function work and sporting activities

  • Instability

  • Systemic symptoms

  • Past history

  • Co-morbidity, drug treatment, adverse drug reactions.


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Clinical Assessment

  • Cervical Spine

  • Instability Symptoms

  • Acromioclavicular Joint - localised

  • Passive External rotation - Capsulitis (OA in older patient)

    • Confirm with passive abduction

  • Pain on Active Abduction - Rotator Cuff Impingement

    • Resisted Movements - Exclude Tear

    • Rotator Cuff Tendonopathy > Impingement > Bursitis > Partial Tear > Complete Tear > Arthropathy


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Red flag indicators

  • Tumour:

    • history of cancer, symptoms and signs of cancer, unexplained deformity, mass or swelling, lymphadenopathy

  • Infection:

    • red skin, fever, systemically unwell

  • Unreduced dislocation:

    • trauma, epileptic fit, electric shock, abnormal shape

  • Acute rotator cuff tear:

    • recent trauma, acute disabling pain and significant weakness, positive drop arm test

  • Neurological lesion:

    • unexplained wasting, significant sensory or motor deficit


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Yellow Flags

  • Belief that pain and activity are harmful

  • Sickness behaviours e.g. extended rest

  • Social withdrawal, lack of support

  • Emotional - low/negative mood, depression, anxiety, stress

  • Problems/dissatisfaction at work

  • Claims for compensation/social benefits

  • Prolonged time off work (e.g. more than 6 weeks)

  • Overprotective family

  • Inappropriate expectations of treatment e.g. low expectations of active participation in treatment.


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Management Options

  • Analgesics

  • Keep active within limits of pain

  • Physical contributory factors

  • Physiotherapy - short-term outcomes -reduce GP consultations

  • Steroid injections - short-term effect

    • Consider repeat 6/52 if recurrs (Max 3)

    • Consider USS/XRay guided if unsccessful

  • Orthopaedic referral


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Capsulitis

  • Posterior Glenohumeral Injection

  • Anterior Glenohumeral Injection

  • X-Ray guided hydro-dilatation

  • Supra-scapular Nerve Block

  • Arthroscopic Capsular Release


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Glenohumeral Injection Posterior

  • Postero-lateral angle of acromion

  • 1-2 cm inferior 1-2 cm medial

  • Aim for coracoid process

  • Kenalog 40mg and Lidocaine 1% 5mls


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Anterior Glenohumeral Injection

  • Coracoid Process

  • 1cm inferior and 1cm lateral

  • Aim for joint line


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Rotator Cuff Impingement

  • Subacromial Bursa Injection

  • USS Guided Subacromial Bursa Injection

  • Suprascapular nerve block

  • Arthroscopic Subacromial Decompression


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Subacromial Injection

  • Lateral border acromion posterior 1/3

  • 2cm Distal

  • Aim slightly superior under acromion

  • Kenalog 40mg + 5mls Lidocaine 1%


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Chronic Rotator Cuff Tear / Arthropathy

  • Supra-scapular Nerve Block

  • Arthroscopic repair

  • Copeland Shoulder Resurfacing


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Suprascapular Nerve Block

  • Mid-point of spine of scapula

  • 2cm superior

  • Needle parallel to scapula

  • Inject suprascapular fossa

  • 5-10mls 0.5% Bupivicaine +/- 10mg Kenalog


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AC joint Injection

  • Palpate joint line

  • Orange needle

  • Angle medially


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