HIP AND SHOULDER PAIN GP ASSESSMENT TIPS AND INJECTION TECHNIQUES M. B., B. S. D I P R A C O G D I P M U S C M E D G C H P E

Size: px

Start display at page:

Download "HIP AND SHOULDER PAIN GP ASSESSMENT TIPS AND INJECTION TECHNIQUES M. B., B. S. D I P R A C O G D I P M U S C M E D G C H P E"

Randall Rich
7 years ago
Views:

1 HIP AND SHOULDER PAIN GP ASSESSMENT TIPS AND INJECTION TECHNIQUES DR D E N N I S O C O N N O R M. B., B. S. D I P R A C O G D I P M U S C M E D G C H P E

2 DISCLAIMER

3 LEARNING OBJECTIVES Review hip and shoulder assessment in a general practice setting Apply a focused algorithmic approach to hip and shoulder pain Explore evidence based medicine principles in management Revise office based injection techniques for common hip and shoulder problems

4 HOW COMMON? MSK conditions second most common presentation to Australian GPs (10%) Shoulder symptoms 0.7% of consultations (third most common MSK problem behind back and knee complaints) Shoulder ultrasound 11.2 % of all ultrasound exams and 4.2% of all imaging Hip symptoms < 0.6%* of consultations Hip ultrasound 2% of all ultrasounds (BEACH Data )

5 SIMILARITIES Lateral hip pain is termed the rotator cuff of the hip Anatomical similarities of short muscles inserting onto a tuberosity or trochanter Overlying large strong muscles which attach distally Bursa intimately related to muscle/tendon/bone interface Process of tendon degeneration and traction forces and compression likely to be responsible for injury Propensity to chronic symptoms

6 HIP PAIN

7 LATERAL HIP PAIN (ADULTS)

8 GREATER TROCHANTERIC PAIN SYNDROME Spectrum of conditions including trochanteric bursitis and gluteal enthesiopathy and tendinitis, tendinosis and tears of gluteus minimus and medius.

9 ANATOMY

10 HISTORY y.o woman Pain in the lateral hip region Insidious onset Worse lying on that side at night Radiation of pain down lateral thigh (Pseudosciatica) Symptoms with prolonged standing Worse sitting with affected leg crossed Pain lying on contralateral side

11 CLINICAL TESTS Painless hip flexion and internal rotation Then Point tenderness over the greater trochanter And possibly Positive single leg stance for 30 seconds Painful resisted external derotation Positive FABER (Patrick s) Test Positive Trendelenberg s Test WITH Symptom relief from trigger point injection*

12 DIFFERENTIAL DIAGNOSIS Atypical hip joint pain L4/5 facet referred pain Meralgia paraesthetica Lumbar radiculopathy Iliotibial band syndrome Stress fracture femoral neck (Snapping Hip - Coxa Sultans)

13 GTPS ALGORITHM Lateral hip and thigh or buttock pain with focal tenderness over the region of the greater trochanter. Examination negative for hip joint and lumbar spine origin Clinical diagnosis of GTPS ACUTE ONSET NO YES Stretching ITB and gluteal strengthening exercises, Dry needling or trigger point injection, Physical therapy referral IMPROVED Exclude red flags if traumatic bony injury (X-Ray) analgesia +/- NSAIDs, stretching exercises, ice application NO IMPROVED NO Local steroid injection and repeat if required IMPROVED NO Review clinical examination Consider further investigation (X-ray, U/S, MRI) DIAGNOSIS ALTERED NO Prolotherapy to enthesis and bursal regions or Topical glyceryl trinitrate IMPROVED YES NO Treat accordingly SURGICAL OPINION

14 INJECTION TECHNIQUES Office based lateral hip injection techniques Dry needling Local Anaesthetic injection Steroid injection

15 DRY NEEDLING

16 DRY NEEDLING / TRIGGER POINT INJECTION

17 POSITIONING

18 STEROID INJECTION

19 TECHNIQUE

20 EXERCISE PRESCRIPTION

26 EXERCISES

27 SLEEP POSITION

28 GP TIPS This tends to be a chronic condition Often patients present late, having tried other remedies A focused history and directed examination is time efficient for GPs Local anaesthetic injection can assist in diagnosis Steroid injections give good short term benefit Prescribe, describe and scribe a range of simple exercises Modify activities and postures which worsen the problem Sleep with a pillow between legs

29 SHOULDER PAIN

30 ANATOMY

31 NON TRAUMATIC SHOULDER PAIN IN ADULTS Acromioclavicular joint Osteoarthritis Capsule / ligament injury Glenohumeral joint Osteoarthritis Frozen shoulder Instability / subluxation / dislocation Labral injury Rotator cuff syndrome Subacromial (subdeltoid) bursitis Tendinosis Partial/complete tears Calcific tendonitis Bicipital tendonitis Hooked acromion

33 ROTATOR CUFF SYNDROME

34 ROTATOR CUFF SYNDROME Spectrum of conditions including subacromial bursitis, rotator cuff enthesiopathy and tendinitis, tendinosis and tears in the rotator cuff muscles

35 HISTORY >35 y.o Pain in lateral upper arm region Worse with abduction and/or rotation Often catching pain with certain movements Aching pain at night Repetitive overhead activities or heavy lifting Maybe history of prior minor injury Absence of red flags

36 CLINICAL TESTS 105 documented tests for shoulder region! Most tests for rotator cuff pathology are inaccurate and cannot be recommended for clinical use Combination of physical tests at best raise the clinical suspicion of impingement

37 PREDICTORS OF PERSISTENT SHOULDER PAIN Duration of complaint before presentation Gradual (insidious) onset Psychological complaints Repetitive movements Intensity of pain at presentation Degree of disability at presentation

38 MANAGEMENT Evidence is lacking for benefit of one mode of treatment over another This includes conservative, injection therapy and surgical treatment Subacromial steroid injection reduces pain and improves function early (common theme)

39 INJECTION TECHNIQUES

40 SUBACROMIAL INJECTION

41 POST STEROID TRIGGER POINT INJECTION 2

42 ACROMIOCLAVICULAR JOINT INJECTION

43 BICEPS TENDON SHEATH INJECTION

44 EXERCISE PRESCRIPTION

52 MY CHOICE

53 SCAPULA EXERCISES

54 POSTERIOR SHOULDER CAPSULE STRETCH

55 ROTATOR EXERCISES

56 GP SHOULDER TIPS Calcific tendonitis presents as acute severe non traumatic pain and responds best to steroid injection Treat shoulder impingement early to reduce pain and allow exercise rehabilitation Give advice to improve posture Avoid overhead activities and precipitating activities Prescribe, describe and scribe exercises to stretch the GH capsule and strengthen the small shoulder muscle stabilisers Future techniques to treat tendinosis likely to emerge

57 SUMMARY Exclude red flags A focused algorithmic approach can be useful Treat early and aggressively to reduce chronicity An injection doesn t cure the problem but helps reduce pain at least initially. Prescribe, describe and scribe stretch and strengthening exercises in order to improve function. Rehabilitation exercises need to be ongoing. Investigate if it will alter your management. Allow yourself time ( both for assessment and management)

58 REFERENCES Strauss, E.J et al.greater Trocahnteric Pain Syndrome. Sports Med Arthrosc Rev. Vol 18, No 2, June 2010 Williams BS and Cohen SP. Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment. Anesth Analg. 2009; 108: Shbeeb MI, Matteson EL. Trochanteric bursitis ( greater trochanter pain syndrome) Mayo Clin Proc.1996;71: Collee G. Greter trochanteric pain syndrome (trochanteric bursitis) in low back pain. Scandinavian Journal of Rheumatology 1991;20: Lievense a, Bierma-Zeinstra S, SchoutenB, Bohnen A, Verhaar J, Koes B. Prognosis of trochanteric pain in primary care. British Journalof General Practice 2005; 55(512): Del Buono A, PapaliaR, Khanduja V, Denaro V and Maffuli N. Management of the greater trochanteric pain syndrome: a systematic review. British Medical Bulletin 2012: 102: Brinks A et al. Corticosteroid Injections for greater trochanteric pain syndrome: A randomised controlled trial in primary care. Ann Fam Med 2011;9: Hughes P, Taylor N, Green R. Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Aust Journal of Physio 2008 Vol 54, Silva L et al. Accuracy of physical examination in subacromial impingement syndrome. Rheumatology 2008; 47: Kuijpers T et al. Clinical prediction rules for the prognosis of shoulder pain in general practice. Pain120(2006) Masters S, O Doherty L, Mitchell G, Yelland M. Acute shoulder pain in primary care. An observational study. AFP Vol36,No6,June 2007 Crawshaw DP et al. Exercise therapy after corticosteroid injection for moderate to severe shoulder pain: large pragmatic randomised trial. BMJ 2010;340:c3037 Stitik TP, Foye PM, Fossati J. Shoulder injections for osteoarthritis and other disorders. Phys Med Rehab Clin N Am;15 (2004) Holmgren T, Hallgren HB, oberg B, Adolfsson Land Johanssen K. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ 2012;344:e787 Codsi M. The painful shoulder: when to inject and when to refer. Cleveland Clinic Journal of Medicine. Vol 74:7; (2007);

Musculoskeletal: Acute Lower Back Pain

Musculoskeletal: Acute Lower Back Pain Acute Lower Back Pain Back Pain only Sciatica / Radiculopathy Possible Cord or Cauda Equina Compression Possible Spinal Canal Stenosis Red Flags Initial conservative