ANDY TAMPUBOLON

EPIDEMIOLOGi

• Usia di atas 40 tahun

• Wanita > Pria

FAKTOR PREDISPOSISI

• Diabetes melitus

• Stress fisik

• Stress psikis

ANATOMI

ANATOMI

SYMPTOMS• Nyeri yang timbul setelah berkurangnya

ROM sendi bahu

• Nyeri yang terlokalisasi pada rongga rotatorik bahu

• Radiasi nyeri di bawah deltoid dan lengan anterior

• Nyeri saat berbaring bertumpu pada bahu yang sakit

SIGNS

• Penderita memfiksasi lengan pada sisi tubuh

• Atrofi deltoid dan supraspinatus

• Nyeri pada daerah rotatorik bahu dan tendo biseps

• ROM terbatas

• Distrofi simpatetik relfleks : edema tangan, dingin, perubahan warna kulit.

DIAGNOSIS

• Gejala klinis

• Gambaran radiologi (X-Ray)

MANAGEMENT

• Preventif• Pengobatan nyeri • Fisioterapi• Psikoterapi

Shoulder Injection

I. Frequency of injections A. Older patients: May repeat 2-3 times per year B. Younger patients: Consider surgery if no improvement

1. Repeat injection risks Rotator Cuff Rupture II. Precautions

A. Risk of Rotator Cuff Rupture 1. Use with caution especially in young patients

Glenohumeral Joint Injection

I. Preparation A. Needle: 25-27 gauge 1.5 inch B. Intraarticular Corticosteroid

1. Methylprednisolone: 1 ml of 40 mg/ml or 2. Betamethasone (Celestone Soluspan): 1 ml

C. Lidocaine 1%: 5-7 ml II. Indications

A. Shoulder Osteoarthritis B. Adhesive Capsulitis C. Rheumatoid Arthritis affecting the shoulder

III. Patient positioning A. Patient sits with arm resting at side B. Shoulder externally rotated

IV. Posterior Approach A. Images

1. (Followed) B. Landmarks

1. Find sulcus between head of humerus and acromion 2. Posterolateral corner of acromion (2-3 cm inferior)

C. Injected with sterile technique 1. Direct needle anteriorly toward coracoid process 2. Insert needle to full length 3. Fluid should flow easily

V. Anterior Approach A. Landmarks

1. Medial to head of humerus 2. Lateral to coracoid process by 1 cm

B. Injected with sterile technique 1. Direct needle posteriorly 2. Angle slightly superior and lateral

Pull-back and redirect needle if hits bone

Acromioclavicular Joint Injection

I. Indications A. Osteolysis of distal clavicle B. Osteoarthritis

II. Preparation A. Needle: 25-27 gauge, 1 to 1.5 inch B. Intraarticular Corticosteroid

1. Methylprednisolone: 0.25 - 0.50 ml of 40 mg/ml or 2. Betamethasone (Celestone Soluspan): 0.25 to 0.50 ml

C. Lidocaine 1%: 0.5 ml III. Patient positioning

A. Patient sits with arm resting at side B. Shoulder externally rotated

IV. Approach A. Images

1. B. Landmarks: Identify AC joint

1. Palpate clavicle to distal aspect 2. Slight depression where clavicle meets acromion

C. Injected with sterile technique 1. Insert needle from anterior and superior approach

Direct needle inferiorly

Subacromial Space Injection

I. Indications A. Subacromial bursitis (Subdeltoid Bursitis) B. Rotator Cuff Impingement or tendinosis C. Adhesive Capsulitis

II. Efficacy A. Study of n=40, DBRT, with mean age of 57 years B. After 30 weeks: Assessment moderate to severe pain

1. Subacromial Corticosteroid Injection: 16% had pain 2. Subacromial Lidocaine injection: 71% had pain

III. Preparation A. Needle: 25-27 gauge 1.5 inch B. Intraarticular Corticosteroid

1. Methylprednisolone: 1 ml of 40 mg/ml or 2. Betamethasone (Celestone Soluspan): 1 ml

C. Lidocaine 1%: 5-7 ml IV. Approach (Lateral shoulder)

A. Images 1.

B. Landmarks 1. Posterior and lateral aspect of shoulder 2. Inferior to lower edge of posterolateral acromion

C. Injected with sterile technique 1. Insert inferior to acromion at lateral shoulder 2. Direct needle toward opposite nipple 3. Insert needle to full length

Fluid should flow easily

Biceps Tendon Injection

I. Indications A. Bicipital Tendonitis

II. Preparation A. Needle: 25-27 gauge, 1 to 1.5 inch B. Intraarticular Corticosteroid

1. Methylprednisolone: 0.25 ml of 40 mg/ml or 2. Betamethasone (Celestone Soluspan): 0.25 ml

C. Lidocaine 1%: 0.5 ml III. Patient positioning

A. Patient sits with arm resting at side IV. Approach

A. Images 1.

B. Landmarks 1. Identify bicipital tendon in bicipital groove 2. Mark point of maximal tenderness over groove

C. Injected with sterile technique 1. Direct needle parallel to bicipital groove 2. Needle enters skin at 30 degrees 3. Do not inject bicipital tendon 4. Infiltrate area around groove, but not into tendon

a. Flow resisted when needle is inside tendon b. Withdraw needle slightly and retry c. Continue to withdraw until not in tendon

V. Complications A. Bicipital tendon rupture

1. Associated with intratendinous injection

Do not inject bicipital tendon

Scapulothoracic Injection

I. Indications A. Scapulothoracic articulation inflammation

1. Bursitis at inferior medial scapular border 2. Injured with pushing, pulling, and throwing 3. May be associated with popping or catching sensation

II. Preparation A. Needle: 25-27 gauge 1.5 inch B. Intraarticular Corticosteroid

1. Methylprednisolone: 1 ml of 40 mg/ml or 2. Betamethasone (Celestone Soluspan): 1 ml

C. Lidocaine 1%: 1-2 ml III. Approach

A. Images 1.

B. Patient position 1. Lying prone 2. Place hand of affected side on buttock

C. Landmarks 1. Inferior and medial border of scapula

D. Injected with sterile technique 1. Needle directed laterally in plane of scapula

Needle inserted deep to infero-medial scapula corner

Shoulder Range of Motion

I. Technique: Active and Passive Range of Motion A. Compare both sides B. Measure angles (goniometer)

II. Movement Directions (normal in parentheses) A. Abduction (150 degrees) B. Forward flexion (180 degrees) C. Extension (45 degrees) D. External Rotation (90 degrees), elbow at 90 degrees

1. With arm comfortably at side 2. With arm at 90 degrees abduction

E. Internal rotation (90) III. Specific Tests

A. Apley's Scratch Test

Shoulder Range of Motion Exercises

I. Pendulum A. While bending to 60-90 degrees at waist B. Swing bucket or weight anteriorly and posteriorly

II. Wall-climbing A. Walk fingers up wall and overhead

III. Rope and pulley from ceiling A. Hands see-saw back and forth B. Rope handles moved up and down via pulley C. Normal arm assists in elevation of stiff arm

IV. Internal rotation A. Clasp hands behind back B. Raise hands toward head

V. External rotation A. Hands behind neck B. Rotate elbows back and then forward C. Repeat motion

Apley's Scratch Test

I. Abduction and External Rotation Test Technique A. Compare both sides B. Reach over shoulders to "scratch" between scapulae

1. Measure to which vertebrae thumb can reach C. Actively resist moving scratching hand away from back

1. Tests Subscapularis strength II. Adduction and Internal Rotation Test Technique

A. Compare both sides B. Reach behind back as if to scratch low back

1. Measure to which vertebrae thumb can reach

Injectable Corticosteroid

Short-Acting Injectable Corticosteroids

A. Cortisone 1. Relative Potency: 0.8 (25 mg) 2. Dosing

a. Tendon Sheath and bursas: 20-50 mg b. Small Joints: 10-25 mg c. Large Joints: 50-125 mg

B. Hydrocortisone 1. Relative Potency: 1.0 (20 mg) 2. Supplied: 25 mg/ml, 50 mg/ml 3. Dosing

a. Tendon Sheath and bursas: 8-40 mg b. Small Joints: 8-20 mg c. Large Joints: 40-100 mg

Intermediate-Acting Injectable Corticosteroids

A. Prednisone 1. Relative Potency: 3.5 (5 mg)

B. Prednisolone tebutate (Hydeltra) 1. Supplied: 20 mg/ml 2. Relative Potency: 4 (5 mg) 3. Dosing

a. Tendon Sheath and bursas: 4-10 mg b. Small Joints: 2-5 mg c. Large Joints: 10-25 mg

C. Triamcinolone and Methylprednisolone 1. Preparations

a. Triamcinolone (Aristocort, Aristospan, Kenalog) b. Methylprednisolone acetate (Depo-Medrol)

2. Relative Potency: 5 (4 mg) 3. Supplied: 20 mg/ml, 40 mg/ml 4. Dosing

a. Tendon Sheath and bursas: 4-10 mg b. Small Joints: 2-5 mg

Large Joints: 10-25 mg

Long-Acting: Dexamethasone and Betamethasone

A. Preparations 1. Dexamethasone sodium phosphate (Decadron) 2. Betamethasone (Celestone Soluspan)

B. Relative Potency: 25 (0.6 mg) C. Supplied: 4 mg/ml, 6 mg/ml, 8 mg/ml D. Dosing

1. Tendon Sheath and bursas: 1.5-3.0 mg 2. Small Joints: 0.8-1.0 mg

Large Joints: 2-4 mg

Typical doses of corticosteroid used for injection Structure Dose (mg)* Volume ofinjection (mL)

Large joint    Knee 40-60 1-4Shoulder 30 1-4Elbow 20-30 1-4

Medium joint    Ankle 20-30 0.5-1Wrist 20 0.5-1

Small joint    Interphalangeal 5-10 0.25-0.5Metacarpophalangeal 5-10 0.25-0.5Metatarsophalangeal 5-10 0.25-0.5

Small soft-tissue structure    Bursa 20 0.5-1.5Tendon sheath 5-20 0.25-1

*Doses shown are for triamcinolone hexacetonide for joint injection and methylprednisolone acetate for soft-tissue injection.