6/5/2018. The Management of Shoulder Conditions in Primary Care. Mr Rupen Dattani (FRCS (Tr & Orth) Consultant Shoulder & Elbow Surgeon
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1 The Management of Shoulder Conditions in Primary Care Mr Rupen Dattani (FRCS (Tr & Orth) Consultant Shoulder & Elbow Surgeon Highgate Private Hospital (Chelsea & Westminster Hospital NHS Foundation Trust) E: Introduction: Shoulder Pain 20% lifetime incidence Third most common MSK condition 3% primary care consultations 80% resolve within 18 months Red Flag Symptoms What requires an urgent referral? Trauma, pain & weakness?acute cuff tear Any mass or swelling?tumour Red skin, fever or systemically unwell?infection Is it Neck or Shoulder? Ask patient to move the neck and then move shoulder Which reproduces the pain? Trauma/epileptic fit/electric shock?unreduced dislocation leading to loss of rotation Dislocation If neck: If shoulder: Follow local spinal service guidelines Determine cause of symptoms Patient Age & Presentation of Shoulder Conditions 10-35yrs >30yrs Calcific Tendinopathy of acute traumatic dislocation Recurrent instability Atraumatic with failed physiotherapy >60yrs Rotator cuff tear 1
2 What can be done? Investigation MR Arthrogram Arthroscopic stabilisation Open bone block procedure Non traumatic instability Associated with laxity Able to self relocate May be voluntary Dislocation REFER TO PHYSIO (subacromial impingement, rotator cuff tendinosis/tendinitis) Most common painful shoulder condition Pain usually localised around deltoid muscle Pain and weakness with overhead activity Difficulty sleeping on affected side (night pain) Painful arc Pain on abduction with Hawkins Test thumb down worse against resistance N.B. USS/MRI can be of value but some people >65 may have asymptomatic rotator cuff tears ACJ Arthritis Transient or no response to injection & physio Localised Pain Previous ACJ injury What can be done? USS guided injection Arthroscopic subacromial decompression ACJ Tenderness High Arc Pain Scarf Test 2
3 ACJ Arthritis Rest/NSAIDs/ analgesics Physiotherapy Steroid Injection X-ray if no improvement Transient or no response to injection & physio F>M Associations (DM, IHD, High cholestrol, Hypothyroidism) Pain Constant, severe, affects sleep Toothache pain at rest; pains with sudden movements Stiffness Reduced passive external rotation (global restriction of movements) Investigations Must get XR to rule out arthritis Rest, NSAIDs/analgesics, reassurance steroid injection Severe functional limitation Atypical symptoms (XR shows arthritis) Hydrodistension Arthroscopic capsular release +- MUA Thawing The : Cost Analysis Physiotherapy: Unguided steroid injection: USS guided steroid injection: Hydrodilatation: MUA: 1446 Arthroscopic capsular release 2204 Calcific Tendinopathy Sudden onset Comparable to renal stone/ childbirth Global pain Investigation X-ray USS guided barbotage Arthroscopic debridement 3
4 Increasing incidence with age Age: 50-60: 13% Age: 60-70: 20% Age: 70+: >30% Similar to rotator cuff tendinopathy Weakness Supraspinatus Infraspinatus Subscapularis Osteoarthritis Transient or no response to injection & physio USS guided injection Arthroscopic/open rotator cuff repair Arthroscopic subacromial decompression Pain, stiffness (weakness) Reduced passive external rotation (global restriction of movements) Investigations X-ray Same as Frozen Shoulder Osteoarthritis Cuff Tear Arthropathy Irreparable rotator cuff tear Arthritis confirmed on XR and poor response to analgesics and injection REVERSE SHOULDER REPLACEMENT What can be done? USS guided injection Total Shoulder Replacement 4
5 Patient Age & Presentation of Shoulder Conditions When to Inject? 10-35yrs >30yrs Calcific Tendinopathy >60yrs Rotator cuff tear Frozen shoulder Rotator cuff tendinopathy Chronic calcific tendinopathy Chronic rotator cuff tear What Investigations Shall I Get? XR (if possible at least 2 views) Confirms ACJ arthritis Differentiates between frozen shoulder & arthritis USS/MRI False positives May delay treatment Summary Thank You Any Questions? 5
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