Below are some core facts about the most common shoulder conditions including treatment algorithms and advice on when to refer.
- 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
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.
Typically passes through 3 stages
- Freezing phrase:
Pain and loss ROM (approx 3 months) - Frozen phase:
Pain at extreme range of movement and marked stiffness (approx 3-9 months) - 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.
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
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.
