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Shoulder complaints

Shoulder complaints. based on the NHG- guideline Shoulder complaints 2008 Wim Willems HOVUmc www.gpsupport.nl. Shoulder complaints. Complaints / medical history Physical examination Treatment / Injection therapy. A case history. Man, 35 years Construction worker

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Shoulder complaints

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  1. Shoulder complaints based on the NHG- guideline Shoulder complaints 2008 Wim Willems HOVUmc www.gpsupport.nl

  2. Shoulder complaints Complaints / medical history Physical examination Treatment / Injection therapy

  3. A case history Man, 35 years Construction worker Pain in the shoulder and upper arm (right) 3-4 months

  4. A case history Questions? Physical examination? Additional examination? (Blood tests / X-ray / Ultrasound / .. ) Treatment?

  5. Purpose What kind of shoulder pain has this patient? • Limitation of passive movement (abduction or exorotation) • No limitation of passive movement, however: painful abduction • No limitation of passive movement and no painful abduction

  6. Medical interview

  7. Medical interview Type of complaints • Where is the pain localized? • Radiation? • Painful movement(s) of the arm? • Pain during abduction? • Neck pain? • Feeling of instability ? • Known cause (work / sports / trauma)?

  8. Medical interview Severity of complaints • How long do the complaints exist? • Severity of the complaints • Limitations? Hindrance? • Complaints during the night? • Absence of work?

  9. Medical interview Factors that influence course • How long do the complaints exist? • Work relevant factors? • Psychosocial factors? • Effect of rest / movement / medication? • Complaints in the past?

  10. Physical examination

  11. Physical examination • Neck (esp. extension / rotation) • Active abduction shoulder (limited / painful / painful arc?) • Passive abduction (limited / painful?) • Passive exorotation (limited / painful?)

  12. Passive exorotation

  13. Passive abduction

  14. X-ray ? / ECHO ?

  15. X-ray ? / ECHO ? Not helpful in this stage

  16. Beware of:

  17. Beware of: • Pain ++, pins & needles, radiation (cervical radicular syndrome) • Pain in several joints, history of rheumatic arthritis, signs of synovitis (rheumatic arthritis) • Pain in both shoulders, pain / stiffness in pelvic girdle / malaise / elevated ESR (polymyalgia rheumatica) • Severe / persistent pain, fever, malaise, weight loss, chest pain, shortness of breath (cardiac / pulmonary / abdominal / septic arthritis) • Complaints not corresponding with age of patient

  18. Evaluation 1- With limitation of passive movement • Painful arc / abduction most prominently limited movement/ pain at the end of the abduction (subacromial syndrome) • Painful and restricted exorotation / exorotation most prominently limited (capsular syndrome / frozen shoulder)

  19. Evaluation 2- Without limitation of passive movement • Painful arc / abduction (subacromial syndrome)

  20. Evaluation 3- Without limitation of passive movement and without painful abduction • Cervical spine, • glenohumeral instability • a.c. / s.c.

  21. Treatment 1 Paracetamol / NSAID 2 weeks or longer when successful and necessary when ineffective: 2 Injection corticosteroid 10-40 mg triamcinolone acetonide (1 ml) (can be combined with lidocaine 20 mg/ml, 2 ml) and / or 3 Activating physiotherapy

  22. Anatomy • Humerus • Acromion • Acromio-clavicular joint • Clavicula • Proc. Coracoideus • Glenohumeral joint

  23. Subacromial injection • Needle 5 cm • 2 cm below the middle of the lateral edge of the acromion • Advance needle to well under the acromion

  24. Precautions • Asepsis / iodine • Single use ampoules • Respect all resistance while inserting needle and injecting

  25. Side effects • More pain temporarily • Flushing • Menstruation • (higher glucose levels)

  26. Thank you www.gpsupport.nl

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