Why shoulders are
tricky
Mr Lee Van Rensburg
December 2013
.
.
office@cambridgemedicalpractice.co.uk
Rheumatology 2006;45:215–221
www.nufffieldhealth.com
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Prevalence of shoulder pain - adults
 7% overall
 26% in elderly
 Only 20-50% present to primary care
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1% of primary care consultations
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20% referred to secondary care
Over 50% only 1 consultation
Rheumatology 2006;45:215–221
Rheumatology 2006;45:215–221
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GP 1
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Diffuse pain in upper arm, spontaneous onset
Hawkins impingement +ve
Painful arc
Subacromial impingement
Physio
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Sees physio - 2 weeks later
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Physio examines patient - “tendonitis”
Starts treatment, pain gets worse
Refers back to GP some biceps signs
Biceps tendonitis ? Slap tear
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GP 2
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Unable to sleep
Difficult to examine, slightly reduced ROM
Weakness of shoulder
? Rotator cuff tear
Refer specialist ? Needs MRI
Impingement
Tendonitis
Problem biceps tendon – SLAP tear
Rotator cuff tear
 Special scan
 Getting worse
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Can’t sleep
Chew arm off
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Thank you for the referral
Pain in shoulder last 4 - 6 months
Limited ROM
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No External rotation
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Normal x rays
No need for scan
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FROZEN SHOULDER
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VOL. 85-B, No. 6, AUGUST 2003
175
J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):529-34
…….. Perhaps this patient needs an MRI scan
1953 - 60
60-69 =30% FTRCT
1940 - 73
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
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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
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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
Arthroscopy: Vol 26, No 3 (March), 2010: pp 393-403
20 – 40 years
< 20 years
Instability
 Trauma

Labral pathology
 Biceps
pathology
 Instability
 Tendonitis
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> 40 years
Frozen shoulder
 Rotator cuff dz
 Osteoarthritis
 Tumor
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Common
Most get better on own
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Time
Analgesia - NSAID
If not better by 3 months refer?
BMJ. 2005 Nov 12;331(7525):1124-8
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Coming from shoulder
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Instability
Rotator cuff, ACJ
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Referred, neck
Impingement
Tear (degenerate)
Tendonitis (calcific)
Glenohumeral
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Arthritis
Frozen shoulder
BMJ 2005;331:1124–8