D R 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

HIP AND SHOULDER PAIN GP ASSESSMENT TIPS AND INJECTION TECHNIQUES

DISCLAIMER

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

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 2009-2010)

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

HIP PAIN

LATERAL HIP PAIN (ADULTS)

GREATER TROCHANTERIC PAIN SYNDROME

Spectrum of conditions including trochanteric bursitis

and gluteal enthesiopathy and tendinitis, tendinosis

and tears of gluteus minimus and medius.

ANATOMY

HISTORY

• 40 - 60 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

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*

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)

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

NO

YES

GTPS ALGORITHM

Exclude red flags if traumatic

bony injury (X-Ray)

analgesia +/- NSAIDs, stretching

exercises, ice application

IMPROVED

Stretching ITB and gluteal strengthening

exercises,

Dry needling or trigger point injection,

Physical therapy referral

IMPROVED

NO

Local steroid injection and

repeat if required

IMPROVED

NO

Review clinical examination

Consider further investigation

(X-ray, U/S, MRI)

DIAGNOSIS ALTERED

Treat accordingly YES

Prolotherapy to enthesis and

bursal regions or

Topical glyceryl trinitrate

IMPROVED

SURGICAL OPINION NO

NO

NO

ACUTE ONSET

INJECTION TECHNIQUES

Office based lateral hip injection techniques

• Dry needling

• Local Anaesthetic injection

• Steroid injection

DRY NEEDLING

DRY NEEDLING / TRIGGER POINT INJECTION

POSITIONING

STEROID INJECTION

TECHNIQUE

EXERCISE PRESCRIPTION

EXERCISES

SLEEP POSITION

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

SHOULDER PAIN

ANATOMY

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

ROTATOR CUFF SYNDROME

ROTATOR CUFF SYNDROME

Spectrum of conditions including subacromial

bursitis, rotator cuff enthesiopathy and

tendinitis, tendinosis and tears in the rotator

cuff muscles

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’

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

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

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)

INJECTION TECHNIQUES

SUBACROMIAL INJECTION

POST STEROID TRIGGER POINT INJECTION

2

ACROMIOCLAVICULAR JOINT INJECTION

BICEPS TENDON SHEATH INJECTION

EXERCISE PRESCRIPTION

1 2 3

4 5

MY CHOICE

SCAPULA EXERCISES

POSTERIOR SHOULDER CAPSULE STRETCH

ROTATOR EXERCISES

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

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)

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; 108:1662-1670

• Shbeeb MI, Matteson EL. Trochanteric bursitis (

greater trochanter pain syndrome) Mayo Clin

Proc.1996;71:565-569

• Collee G. Greter trochanteric pain syndrome

(trochanteric bursitis) in low back pain.

Scandinavian Journal of Rheumatology

1991;20:262-266

• 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): 199-204

• 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: 115-131

• Brinks A et al. Corticosteroid Injections for greater

trochanteric pain syndrome: A randomised

controlled trial in primary care. Ann Fam Med

2011;9:226-234

• 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, 159-170

• Silva L et al. Accuracy of physical examination in

subacromial impingement syndrome.

Rheumatology 2008; 47: 679-683

• Kuijpers T et al. Clinical prediction rules for the

prognosis of shoulder pain in general practice.

Pain120(2006) 276-285

• 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) 407-446

• 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); 473-488