Shoulder Assessment and Injection

1
Shoulder Assessment and Injection

• Dr Ian Ryans
• General Practitioner, Dundonald Medical Centre
• Hospital Practitioner, Rheumatology Dept, Ulster
  Hospital, Dundonald

2
The Painful Shoulder

• Clinical Assessment
• Treatment Options
• Injection Techniques

3
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.

4
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 gt Impingement gt
  Bursitis gt Partial Tear gt Complete Tear gt
  Arthropathy

5
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

6
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.

7
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

8
Capsulitis

• Posterior Glenohumeral Injection
• Anterior Glenohumeral Injection
• X-Ray guided hydro-dilatation
• Supra-scapular Nerve Block
• Arthroscopic Capsular Release

9
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

10
Anterior Glenohumeral Injection

• Coracoid Process
• 1cm inferior and 1cm lateral
• Aim for joint line

11
Rotator Cuff Impingement

• Subacromial Bursa Injection
• USS Guided Subacromial Bursa Injection
• Suprascapular nerve block
• Arthroscopic Subacromial Decompression

12
Subacromial Injection

• Lateral border acromion posterior 1/3
• 2cm Distal
• Aim slightly superior under acromion
• Kenalog 40mg 5mls Lidocaine 1

13
Chronic Rotator Cuff Tear / Arthropathy

• Supra-scapular Nerve Block
• Arthroscopic repair
• Copeland Shoulder Resurfacing

14
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

15
AC joint Injection

• Palpate joint line
• Orange needle
• Angle medially