Below are some core facts about the most common shoulder conditions including treatment algorithms and advice on when to refer.

IMPINGEMENT

  • Most common shoulder problem
  • In under 40’s think instability
  • May represent Cuff degeneration or tear

Initial Treatment

Physiotherapy
– Rotator cuff strengthening
– Activity modification

Subacromial steroid + LA injection
– 40mg Kenalog + 10ml 0.25% rehab
– Diagnostic = Neer’s test (LA)
– Therapeutic

Review at ~ 6 weeks

Referral

Failure to improve or recurrent symptoms at review

CALCIFIC TENDONITIS

Cell mediated calcific process

STAGE PHASE HISTOLOGICAL PROCESS
Pre-calcific Fibrocartilage metaplasia
Calcific Formation Calcification fibrocartilage
Calcific Resting
Calcific Resorption Cell mediated SEVERE PAIN
Post-calcific Tendon restitution

Initial Treatment

Analgesia – NSAIDs
Physiotherapy
Subacromial steroid injection

Referral

As per impingement
No absolute indication
– Severity of pain
– Poor response to non-operative treatment

Some patients have several severe short periods of pain over 2 year period.

FROZEN SHOULDER / ADHESIVE CAPSULITIS

Typically passes through 3 stages

  1. Freezing phrase:
    Pain and loss ROM (approx 3 months)
  2. Frozen phase:
    Pain at extreme range of movement and marked stiffness (approx 3-9 months)
  3. Thawing phase:
    Painless and stiffness starts to gradually resolve (approx 9-18 months)

Key examination finding is restricted external rotation

Initial Treatment

Analgaesia
GHJ injection
(Physio – can be too painful)
Review at ~ 6 weeks

Referral

Symptoms 6-12 weeks not improving
– Pain
– Sleep disturbance
Limited ROM affecting ADL / occupation
Not responding to non-op treatment

Some patients have several severe short periods of pain over 2 year period.

INSTABILITY

Under 40’s

‘Bankart tear’ (Glenoid labral tear) universal after anterior dislocation

50% recurrent instability after 1st dislocation
Up to 80% recurrence after 2nd dislocation

Treatment

Evidence supports primary stabilisation for young active males.
Often trial physio after 1st dislocation
If recurrent instability – refer for surgery

ROTATOR CUFF TEAR

Usually in over 40’s

Acute – traumatic
Chronic – degenerate
Acute on chronic – minor trauma

Partial or Full thickness

Initial Treatment

6 week trial of physio
Inject x1
Review at 6 weeks

Acute weakness – traumatic tear in young – REFER

Referral

Persistent sx under 75yrs – refer
Over 75 – consider 2nd injection or refer

Acute weakness – traumatic tear in young
Poor function & strength

Some patients have several severe short periods of pain over 2 year period.