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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

Shoulder Assessment and Injection

Dr Ian Ryans

General Practitioner, Dundonald Medical Centre

Hospital Practitioner, Rheumatology Dept, Ulster Hospital, Dundonald

the painful shoulder
The Painful Shoulder
  • Clinical Assessment
  • Treatment Options
  • Injection Techniques
history
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.
clinical assessment
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
red flag indicators
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
yellow flags
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.
management options
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
capsulitis
Capsulitis
  • Posterior Glenohumeral Injection
  • Anterior Glenohumeral Injection
  • X-Ray guided hydro-dilatation
  • Supra-scapular Nerve Block
  • Arthroscopic Capsular Release
glenohumeral injection posterior
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
anterior glenohumeral injection
Anterior Glenohumeral Injection
  • Coracoid Process
  • 1cm inferior and 1cm lateral
  • Aim for joint line
rotator cuff impingement
Rotator Cuff Impingement
  • Subacromial Bursa Injection
  • USS Guided Subacromial Bursa Injection
  • Suprascapular nerve block
  • Arthroscopic Subacromial Decompression
subacromial injection
Subacromial Injection
  • Lateral border acromion posterior 1/3
  • 2cm Distal
  • Aim slightly superior under acromion
  • Kenalog 40mg + 5mls Lidocaine 1%
chronic rotator cuff tear arthropathy
Chronic Rotator Cuff Tear / Arthropathy
  • Supra-scapular Nerve Block
  • Arthroscopic repair
  • Copeland Shoulder Resurfacing
suprascapular nerve block
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
ac joint injection
AC joint Injection
  • Palpate joint line
  • Orange needle
  • Angle medially
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