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Why shoulders are tricky

Shoulder pain is prevalent, affecting 7% of the adult population and 26% of the elderly. Despite its common occurrence, only a small percentage seek primary care. This complexity arises from various potential diagnoses, including rotator cuff tears, impingement syndrome, and frozen shoulder. Accurate diagnosis often requires careful examination and sometimes imaging, such as MRI. Treatment typically involves physiotherapy and analgesia, yet many cases resolve independently. Understanding the range of shoulder pain causes and appropriate referral pathways is crucial for effective management.

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Why shoulders are tricky

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  1. Why shoulders are tricky Mr Lee Van Rensburg December 2013

  2. www.cambridgeses.co.uk

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

  4. www.nufffieldhealth.com

  5. 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

  6. Rheumatology 2006;45:215–221

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

  8. 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

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

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

  11. 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

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

  13. 123 Tests

  14. 175 J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34

  15. …….. 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

  16. 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

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

  18. Tricky

  19. Differential by age

  20. 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

  21. 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

  22. Examination

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