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The Diagnosis and Management of Shoulder and Knee Problems in GP The Diagnosis and Management of Shoulder and Knee Problems in GP

The Diagnosis and Management of Shoulder and Knee Problems in GP - PowerPoint Presentation

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The Diagnosis and Management of Shoulder and Knee Problems in GP - PPT Presentation

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

unknown photo licensed author photo unknown author licensed pain effects cuff rotator shoulder tendinitis msk diagnostic site side care

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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

Slide2

Introduction

Who Am I?

Ex GP

Ex GPSI

Ex Trainer

Ex PD

Ex PAD

Current Appraiser

Senior Appraiser

Independent Educator

COVID19 111 clinician

Slide3

Introduction

The challenges of Zoom teaching

Not a rehash of PA Student teaching ? A practical approach to MSK in GPWith one exception not tackling trauma

Slide4

Introduction

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

This Photo

by Unknown Author is licensed under

CC BY-SA-NC

Slide5

A Quick Visit to PA School!

PA MSK

Look FeelMoveSpecial Tests

Functional Tests (and be determined by taking a good history of ADLs)

Slide6

Meeting 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

This Photo

by Unknown Author is licensed under

CC BY-SA-NC

Slide7

Generic MSK considerations

PP

Age

Gender

History

Acute (trauma)

Chronic

Site of pain

Localised

Diffuse

SH

Work

Leisure

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by Unknown Author is licensed under

CC BY-NC-ND

Slide8

The 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

Slide9

Frozen shoulder v OA GHJ

Key finding:

Global decreased ROM (active and passive)

The difference is:PP – Age40-60 frozen shoulder

60+ OA

This Photo by Unknown Author is licensed under CC BY-SA

Slide10

Rotator 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

Slide11

Rotator 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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by Unknown Author is licensed under

CC BY-ND

Slide12

Rotator Cuff Tendinitis 3

Useful diagnostic features

Painful Arc SyndromePositive impingementPain on IR

Slide13

Biceps Tendinitis

Anatomy

How many heads?

Origin of long head?

Actions of biceps?

Diagnostic aids

SH – throwers, racket sports

Localised pain/tenderness

Slide14

Acromio-clavicular joint OA

Diagnostic features

HistoryPain on sleeping on the affected side

ExaminationLocalisation of pain/tendernessScarf test

Slide15

Important considerations in MSK consulting (CSA)

ALWAYS consider dominance in upper limb pathology

Patient Expectations

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by Unknown Author is licensed under

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Slide16

Beware!

Referred pain

Neck

Pancoast

Tumour

Red flags

Unremitting Night pain

constant ‘nagging’ pain

h/o Ca

particularly Prostate/KidneyWeight lossNight sweatsChildren

Slide17

Injections in Musculoskeletal Medicine

Slide18

General 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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by Unknown Author is licensed under

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Slide19

AdvantagesOften 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

Slide20

Disadvantages/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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by Unknown Author is licensed under

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Slide21

Adverse Effects

Inhibit collagen synthesis

Deleterious effects dose relatedPossible long-term damage to articular cartilageConcern re possible increase in tendon ruptureTendin’itis’

Slide22

Contraindications/Cautions

CI

Active infection

h/o allergy

Cautions

Diabetes

Bleeding disorder/anticoagulation

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by Unknown Author is licensed under

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Slide23

Other considerationsAre you dealing with an inflammatory condition?

What has caused the current symptomatology – has it resolved/should it be treated?

What is the evidence?

Slide24

Indications

Inflammatory conditions such as

Arthritis

Bursitis

Paratendonitis

Synovitis

Tendinitis (cp non-inflammatory)

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by Unknown Author is licensed under

CC BY

Slide25

Substance?

Variation in speed of onset and half-life

No convincing evidence that efficacy differsWhat alternatives?Oral/Iontophoresis

NSAIDNitric Oxide donorSclerosant injectionsDry needling/autologous blood

Slide26

Practicalities

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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by Unknown Author is licensed under

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Slide27

Site

How accurate must one be?

Slide28

Summary

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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by Unknown Author is licensed under

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