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Why shoulders are tricky

Why shoulders are tricky. Dr Jumbo Jenner Dr Andrew Ostor Miss Natasha Woodbine Mr Lee Van Rensburg February 2014. www.cambridgeses.co.uk. Prevalence. Prevalence of shoulder pain - adults 7% overall 26% in elderly Only 20-50% present to primary care 1% of primary care consultations

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Why shoulders are tricky

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  1. Why shoulders are tricky Dr Jumbo Jenner Dr Andrew Ostor Miss Natasha Woodbine Mr Lee Van Rensburg February 2014

  2. www.cambridgeses.co.uk

  3. Prevalence • 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

  4. Rheumatology 2006;45:215–221

  5. Referral • GP 1 • Diffuse pain in upper arm, spontaneous onset • Hawkins impingement +ve • Painful arc • Subacromial impingement • Physio

  6. 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

  7. Referral • GP 2 • Unable to sleep • Difficult to examine, slightly reduced ROM • Weakness of shoulder • ? Rotator cuff tear • Refer specialist ? Needs MRI

  8. Patient Impingement Tendonitis Problem biceps tendon – SLAP tear Rotator cuff tear • Special scan • Getting worse • Can’t sleep • Chew arm off

  9. Specialist • Thank you for the referral • Pain in shoulder last 4 - 6 months • Physiotherapy made it worse • Limited ROM • No External rotation • Normal x rays • No need for scan • FROZEN SHOULDER

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

  11. 123 Tests

  12. 175 J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34

  13. …….. Perhaps this patient needs an MRI scan 1953 - 60 1940 - 73 60-69 =30% FTRCT 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

  14. 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

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

  16. Tricky

  17. 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

  18. 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

  19. Differential by age

  20. Examination

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