Dr Bob ward For CRESH Pas 12820 Introduction Who Am I Ex GP Ex GPSI Ex Trainer Ex PD Ex PAD Current Appraiser Senior Appraiser Independent Educator COVID19 111 clinician Introduction ID: 913235
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Slide1
The Diagnosis and Management of Shoulder and Knee Problems in GP
Dr Bob ward
For CRESH Pa’s 12/8/20
Slide2Introduction
Who Am I?
Ex GP
Ex GPSI
Ex Trainer
Ex PD
Ex PAD
Current Appraiser
Senior Appraiser
Independent Educator
COVID19 111 clinician
Slide3Introduction
The challenges of Zoom teaching
Not a rehash of PA Student teaching ? A practical approach to MSK in GPWith one exception not tackling trauma
Slide4Introduction
PAs are Trained generically according to The medical Model (a secondary care model)
Is there a difference between the primary and secondary care approach?
Hypotheticodeductive consulting
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Slide5A Quick Visit to PA School!
PA MSK
Look FeelMoveSpecial Tests
Functional Tests (and be determined by taking a good history of ADLs)
Slide6Meeting Learning Needs
Send me a message with your most important learning need for this afternoon’s session and I’ll try and ensure that I cover all requests
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Slide7Generic MSK considerations
PP
Age
Gender
History
Acute (trauma)
Chronic
Site of pain
Localised
Diffuse
SH
Work
Leisure
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Slide8The Shoulder
My plan – is to start with the most common diagnoses in primary care and work backwards!
Consider the diagnostic features of each condition and then consider management
Slide9Frozen shoulder v OA GHJ
Key finding:
Global decreased ROM (active and passive)
The difference is:PP – Age40-60 frozen shoulder
60+ OA
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Slide10Rotator Cuff Tendinitis
What’s in a name?
Rotator Cuff tendinitisSupraspinatus tendinitisSubacromial bursitis
How many rotator cuff muscles are there?4What are they?Supraspinatus, infraspinatus, Subscapularis, Teres minor
Slide11Rotator Cuff Tendinitis 2
What are the actions of the rotator cuff muscles:
Subscapularis - IR
Teres minor and Infraspinatus - ER
Supraspinatus - Initiation of abduction
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Slide12Rotator Cuff Tendinitis 3
Useful diagnostic features
Painful Arc SyndromePositive impingementPain on IR
Slide13Biceps Tendinitis
Anatomy
How many heads?
Origin of long head?
Actions of biceps?
Diagnostic aids
SH – throwers, racket sports
Localised pain/tenderness
Slide14Acromio-clavicular joint OA
Diagnostic features
HistoryPain on sleeping on the affected side
ExaminationLocalisation of pain/tendernessScarf test
Slide15Important considerations in MSK consulting (CSA)
ALWAYS consider dominance in upper limb pathology
Patient Expectations
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Slide16Beware!
Referred pain
Neck
Pancoast
Tumour
Red flags
Unremitting Night pain
–
constant ‘nagging’ pain
h/o Ca
–
particularly Prostate/KidneyWeight lossNight sweatsChildren
Slide17Injections in Musculoskeletal Medicine
Slide18General Principles
Controversial due to the incidence of side-effects and concern regarding their effect on tissue healing
Injection maximises the concentration at the site of injury and minimises the risk of side-effects
Generally use considering this as a ‘bridge’
Particularly useful for ‘bursitis’
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Slide19AdvantagesOften a good response
Usually quite quickly effective cf oral Rx
Easy for patient – no issues of compliance, long wait and use of time for Physio
Slide20Disadvantages/Potential side-effects
Pain
Fat atrophy (skin dimpling)
Depigmentation
Weakening of soft tissues/accelerated deterioration
Steroid flare
Risk of infection (1:23000)
Cumulative steroid effects
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Slide21Adverse Effects
Inhibit collagen synthesis
Deleterious effects dose relatedPossible long-term damage to articular cartilageConcern re possible increase in tendon ruptureTendin’itis’
Slide22Contraindications/Cautions
CI
Active infection
h/o allergy
Cautions
Diabetes
Bleeding disorder/anticoagulation
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Slide23Other considerationsAre you dealing with an inflammatory condition?
What has caused the current symptomatology – has it resolved/should it be treated?
What is the evidence?
Slide24Indications
Inflammatory conditions such as
Arthritis
Bursitis
Paratendonitis
Synovitis
Tendinitis (cp non-inflammatory)
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Slide25Substance?
Variation in speed of onset and half-life
No convincing evidence that efficacy differsWhat alternatives?Oral/Iontophoresis
NSAIDNitric Oxide donorSclerosant injectionsDry needling/autologous blood
Slide26Practicalities
How many/how frequent in one site?
What steroid?
What dose?
With or without LA?
What sized needle?
What anatomical approach?
Image guided?
‘Aseptic’ technique?
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Slide27Site
How accurate must one be?
Slide28Summary
Generate questions and perform an examination that helps you to confirm/refute your hypothesis
You should now be able to confidently differentiate between most COMMON shoulder pathologies presenting in
primary care
You should have an awareness of the treatment options available
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