Recent Management in Shoulder Pain Syndrome

RECENT MANAGEMENT IN
SHOULDER PAIN SYNDROME
Teddy H Wardhana
Hand & Upperlimb Division
Orthopaedic & Traumatology Dept.
Airlangga University – Soetomo Hospital Surabaya
Orthopaedic Knowledge Update 3

Surabaya 10th November2018
Consideration
• The most mobile joint in the human body.
• It has heavy reliance on the muscles to act as dynamic
stabilizers.
• Shoulder pain is responsible for 16% of all
musculoskeletal complaints.
• Prevalence in General Population
 70 -260 per 1000
• Common in Female
• Common in > 40 y
• Risk increases on activities that need
raising the arms or working with hand tools
Surabaya Surgical Update S-ANTEM
Surabaya 11 March 2017
Prevalence
• Prevalence of shoulder pain - adults

• 7% overall
• 26% in elderly
• Only 20-50% present to primary care
• 1% of primary care consultations
– 20% referred to secondary care
– Over 50% only 1 consultation
Rheumatology 2006;45:215–221
Surabaya 10th November2018Rheumatology
2006;45:215–221
Epidemiology
• Shoulder pain is responsible for 16% of all
musculoskeletal complaints.
• Prevalence in General Population
 70 -260 per 1000
• Common in Female
• Common in > 40 y
• Risk increases on activities that need
raising the arms or working with hand tools
Most Common Cause
• Impingement Syndrome > 70%
• Adhesive Capsulitis (Frozen Shoulder) 12%
• Bicipital Tendonitis 4%
• ACJ Osteoarthritis 7%
• Others (Instability, Infection etc) 7%

Impingement Syndrome
• The supraspinatus tendon
connects the humerus with
the scapula (shoulder blade)
and helps raise and rotate
the arm.
• As the arm is raised, the
supraspinatus tendon also
keeps the humerus tightly in
the socket (glenoid) of the
scapula.

Impingement Syndrome
• If any condition decreases
the amount of space
between the acromion and
the supraspinatus
tendon, the impingement
process may get worse.
– Swelling
– Bone spurs
– Anatomical structure

• 75% of cases of shoulder pain due to
supraspinatus
• Weakest point of tendon 1cm form insertion
into humerus
• Can have tendinopathy, partial or complete
tears
• Symptoms: impingement

Testing/Provocation
Impingement: Empty Can
Resist Forward Flexion &

Internal Rotation
Test of Supraspinatus
Impingement

Impingement: Neer
• Neer Impingement
Test
– Passive forward
flexion of the
forearm resulting in
pain

Impingement: Hawkins’ Test
Hawkins, Am J Sports Med 1980

Surabaya 11 March 2017 Woodward, Am Fam Phys 2000
Diagnostic Tools
• Ultrasound Scan
– One stop clinic
– Accurate, dynamic and cost
effective
– However, operator
dependant
• MRI Scan
– Expensive and less
accessible,
– Quality of the muscles and
fatty infiltration
– Other intra-articular
pathology
Surabaya th November2018
20th National10Congress of IOA 2016
…….. 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
Surabaya 296-299
Surgical Update S-ANTEM
• 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
– 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
Treatment Option
• Conservative
– Physical Therapy & Rehab Program
– NSAID
– ESWT
– Injection
• Surgery / Arthroscopic

Conservative Treatment
• This generally consists of a period of immobilization,
a supervised rehabilitation program, and restriction
from return to vigorous activity for a limited time
period.
• Conservative care should focus on endurance and
strength training of the rotator cuff and scapular
stabilizer muscles
• The aim of this treatment is to allow soft-tissue
healing, maximize strength of the dynamic stabilizers
of the shoulder, and minimize recurrence.

Conservative Treatment
• Principally, conservative methods are used in the
treatment of this syndrome.
• Resting, activity regulation,
• Non-steroid antiinflammatory (NSAID) medicines,
• Superficial hot and cold applications,
• Deep heaters such as ultrasound and short wave,
therapeutic exercises,
• Laser and electromagnetic field treatments,
• Subacromial steroid injection
• Suprascapular nerve blocks.
Rotator Cuff Exercises
External Rotation
Internal Rotation
Internal Rotation Orthopaedic Knowledge Update 3

Rotator Cuff Exercises
External Rotation
Internal Rotation
External Rotation
Surabaya Surgical
Abduction
Update S-ANTEM
(to work the supraspinatus)
th
Surabaya 10 November2018
ESWT (Extracorporal shock wave therapy)
• High energy extracorporeal shock-wave
therapy (ESWT) may be recommended as it
has shown strong evidence with tissue
regeneration and calcium deposit resorption
for rotator cuff damage due to calcific
tendinosis,
• Low energy ESWT has shown some evidence
for short term pain relief in noncalcific
tendinosis
Role of PRP in Cuff Tear
• PRP contains various growth factors such as :

PDGF, VEGF, TGF-β , EGF, FGF
• American Academy of Orthopaedic Surgeons
summarizing that available data suggest PRP
valuable in enhancing soft-tissue repair and
wound healing. Orthopaedic Knowledge Update 3
Radiofrequency Tx
• The first known use of
radiofrequency ablation (RFA) was in
1931 when Krischner treated
trigeminal neuralgia with
thermocoagulation of the gassaerian
ganglion
• Lumbar facet nerve ablation is
perhaps the most common
application of RFA
• Suprascapular nerve block will give
pain relieve and time for physical
therapy

Shoulder Injection

Shoulder Injection
• Subacromial space (bursa)
• ACJ – Acromioclavicular joint
• Bicipital groove (biceps tendon)
• Intra articular

Corticosteroid Injection:They do work! Graeme Mackenzie
bmj.com, 17 Aug 2001 [Full text] Re: Corticosteroid Injection:They do work! Patrick
J Edwards
bmj.com, 18 Aug 2001 [Full text] Suggestions should include change the needle
after drawing up. Steve Searle
bmj.com, 19 Aug 2001 [Full text] Shoulder tendon lesions and injections Andrew
Bamji
bmj.com, 22 Aug 2001 [Full text] Are Rotator Cuff tedinopathy diagnoses right?
Bruce Gray
bmj.com, 22 Aug 2001 [Full text] A Timely But Flawed Review Steve Longworth
bmj.com, 24 Aug 2001 [Full text] Steroids relieve pain in rotator cuff tendinopathy
Simon Mellor
bmj.com, 12 Sep 2001 [Full text] Steroids and trigger finger,. The correct site for
injection. M Murnaghan, et al.Orthopaedic Knowledge Update 3
Cochrane review (2003)
• Corticosteroid injections for shoulder pain may
be of limited short-term benefit
• Supports the use of subacromial steroid injection
for rotator cuff disease
• effect may be small and short-lived, and may be
no better than NSAID’s
• Intra-articular steroid injection
• may be of limited, short-term benefit for
adhesive capsulitis.
Buchbinder et al. Corticosteroid injections for shoulder pain.
Cochrane
Orthopaedic Knowledge Database
Update 3
of Systematic Reviews 2003
Cochrane review (2003)
• Important issues that need clarification
– Accuracy of needle placement
– Anatomical site
– Frequency
– Dose
– Type of steroid

Fact
• Despite overwhelming evidence that accuracy in
injections is quite low & US significantly improves
this accuracy, many Do Not Believe
• Many Physicians will fell that they are excellent at
injections & never miss
• 30% of injection miss subacromial bursa - Experts

Sub Acromial Injection
Double edged sword
• Reducing inflammation
• Not good for tendon healing posterolate
• Diagnostic ?
• 1 Maybe 2 anterior
anterolateral
Do No Harm
• 2.5 ml syringe
• Lignocaine
• 40-80mg Depo medrone
(Methyl prednisolone)
• No touch
• Nail mark
• Ache 24 hrs
• 6-8 weeks
AC Joint Injection

Glenohumeral Joint Injection
• Identify posterior angle
acromion with thumb, and
coracoid process with index
finger
• Insert needle below angle of
acromion and push obliquely
anterior toward coracoid
process
• Inject as bolus. No resistance to
delivering solution should be
felt
• 40 mg (up to 80) Kenalog, 5 ml
Lidocaine / 10 ml (up to 20 ml)
Chirocaine into GH joint
Arthroscopic Debridement &
Decompression
141% increase 1996-2006
– Arthroscopic increased 600% open 34%
– Repairs done ASCs quadrupled
Colvin et al, JBJS Am, Feb. 2012
Acromioplasties decreased 10% 2004-09

– Mauro et al, JBJS Am, Aug. 2012

Conclusion
• Shoulder pain is one of the most common
musculoskeletal problems in community
• Building a Team (Surgeon, Rehab, Radiologist)
is mandatory for optimizing result of
conservative the treatment

Thank You


Recent Management in Shoulder Pain Syndrome

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RECENT MANAGEMENT IN

SHOULDER PAIN SYNDROME

Orthopaedic Knowledge Update 3

• Prevalence of shoulder pain - adults

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

Resist Forward Flexion &

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

Hawkins, Am J Sports Med 1980

60-69 =30% FTRCT 1940 - 73

70-79 = 50% FTRCT 1930 - 83

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

Internal Rotation Orthopaedic Knowledge Update 3

• PRP contains various growth factors such as :

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

Acromioplasties decreased 10% 2004-09

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

Orthopaedic Knowledge Update 3

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