OUTLINES

• Common causes of pain in knee & shoulder

• Focused clinical assessment

• Investigations

• Options of treatment

• Role of joint injection / aspiration

COMMON CAUSES OF JOINT PAIN

By Structures By Age Groups By Systems

• Superficial • Adolescent • Trauma
• Extracapsular • Adult • Degenerative
• Intracapsular • Elderly • Inflammatory
• Infection
• Malignancy
• Referred pain
COMMON CAUSES OF JOINT PAIN
Which one relevant to intraarticular injection / aspiration?

Knee Shoulder
• Osteoarthritis • Subacromial impingement
• Septic arthritis • Frozen shoulder / stiff shoulder
• Acromioclavicular joint arthritis
OSTEOARTHRITIS
Definition
• Chronic, progressive joint disease due to failure in repair of joint damage

Pathophysiology
• Damage > Repair

• Involves
• Cartilage degradation
• Bone remodeling
• Osteophyte formation
• Synovial inflammation
OSTEOARTHRITIS
Classification
1. Primary (Idiopathic)
• Generalised, polyarticular
• High female preponderance & genetic influence

2. Secondary
• Traumatic
• Inflammatory e.g. RA / Gout
• Infection i.e. Septic arthritis
• Anatomical e.g. Malalignment
OSTEOARTHRITIS
Risk Factors
• Mainly aging & obesity
OSTEOARTHRITIS
2019 American College of Rheumatology (ACR) Guideline for the Management of
OA of the Hand, Hip, and Knee
2019 American College of Rheumatology (ACR) Guideline for the Management of
OA of the Hand, Hip, and Knee
A Malaysian Delphi Consensus on Managing Knee Osteoarthritis 2021
A Malaysian Delphi Consensus on Managing Knee Osteoarthritis 2021

Symptomatic slow-acting drugs for OA (SYSADOAs)

• Only Glucosamine Sulphate (GCS) effective
• Correct dose: 1500 mg daily
• GCS therapy regularly for over 3 years did not experience any significant joint
space narrowing (JSN) and reduce need for rescue NSAIDS

• Avocado Soybean Unsaponifiables (ASU), PIASCLIDINE improves pain & function

but does not delay JSN
SEPTIC ARTHRITIS
• Most commonly affecting the knee (>50%), hip, and shoulder
• Risk factors:
• Comorbidities
• DM
• Rheumatoid arthritis
• Gouty arthritis
• HIV
• Recent surgery / joint procedure
• IVDU
SEPTIC ARTHRITIS
• Staphylococcus aureus (accounts for >50% of cases)

• Clinical presentation:
• Fever only present in 60% of cases!!
SEPTIC ARTHRITIS
• Joint fluid analysis

• Treatment: IV antibiotic therapy + Irrigation & drainage

INFLAMMATORY ARTHRITIS
• Rheumatoid arthritis
• Gouty arthritis
SHOULDER IMPINGEMENT SYNDROME
Definition
• Painful condition of the upper extremity resulting from a structural narrowing of
the subacromial space
SHOULDER IMPINGEMENT SYNDROME
Subacromial Space
• Anterior border: Acromion & Coracoacromial ligament

• Superior border: Acromioclavicular (AC) joint

• Inferior border: Humeral head

SHOULDER IMPINGEMENT SYNDROME
Classification
• External vs Internal impingement (based on location)

• Primary vs Secondary impingement (based on cause of impingement)

SHOULDER IMPINGEMENT SYNDROME
Causes
• Inflamed Subacromial bursa

• Hook shaped acromion

• Osteophytes (AC joint)

• Swollen and thickened Supraspinatus tendon

• Weak supraspinatus causing superior
migration and narrowing of the subacromial
space
SHOULDER IMPINGEMENT SYNDROME
Clinical Presentation
• Insidious onset shoulder pain
• Exacerbated by overhead activities and
lifting objects away from body

• Neer’s sign

• Hawkin’s Kennedy Test

• Painful Arc 60-120°

• Jobe’s test
SHOULDER IMPINGEMENT SYNDROME
Management

NON OPERATIVE OPERATIVE

1. Analgesia 1. Subacromial decompression
2. Subacromial steroid injection 2. Bursectomy
3. Suprascapular nerve block 3. Acromioplasty
4. Aggressive rotator cuff 4. RC repair
strengthening and periscapular
stabilizing exercises
SHOULDER IMPINGEMENT SYNDROME
Subacromial Steroid Injection
FROZEN SHOULDER
 Stiff Shoulder

Primary
Secondary
(Frozen shoulder)
TERMINOLOGY
FROZEN SHOULDER
Pathophysiology
• Cytokine-mediated synovial inflammation with
fibroblastic proliferation
• Adhesions around the rotator interval caused by
increased collagen and nodular band formation
• Contraction of the coracohumeral ligament
limits shoulder ER
• In advanced stages, thickening and contraction
of the glenohumeral joint capsule develop,
further limiting the range of motion in all
directions
FROZEN SHOULDER
Clinical Diagnosis
• Based on the history of an insidious onset
• Global reduction of the ROM in 2 or more planes, and equal in passive and active
examination
• FF < 100
• ER < 10
• IR < L5
• Loss of ER is typical initial symptom
 FROZEN SHOULDER
Phases

FREEZING PHASE FROZEN PHASE THAWING PHASE

• Worsening pain (night) • Pain is less severe • Function is gradually

• Gradually increasing • Stiffness is substantial • Restored and pain is

stiffness resolved
2 to 9 months 4 to 12 months 5-26 months
FROZEN SHOULDER
Treatment options
• Most studies with good end results include physical therapy as an
adjunctive intervention together with mobilization, glenohumeral
joint distension, steroid injection, or capsular release

Itoi E, Arce G, Bain GI, Diercks RL, Guttmann D, Imhoff AB, Mazzocca AD, Sugaya H, Yoo YS. Shoulder Stiffness: Current Concepts and Concerns.
Arthroscopy. 2016 Jul;32(7):1402-14. doi: 10.1016/j.arthro.2016.03.024. Epub 2016 May 12. PMID: 27180923.
FROZEN SHOULDER
Intraarticular Steroid Injection
• Intra-articular corticosteroid injection may be beneficial in the short term for
frozen shoulder. Multiple injections are beneficial until 16 weeks from the date of
the first injection. There is no evidence supporting more than 6 injections.
• There is no difference in the outcome between lower and higher doses of
corticosteroids.
FROZEN SHOULDER
Intraarticular Steroid Injection vs Subacromial Steroid Injection
• Intra-articular corticosteroid injections compared with subacromial injections
result in greater improvements in terms of pain and passive range of motion in
the short term but did not result in better outcomes in the long term.
FROZEN SHOULDER
Hydrodilatation / Capsular Distension Procedure
• In late freezing or early frozen stage, hydrodilatation of the glenohumeral joint
using saline, steroid, local anaesthetic agent is supposed to distend the capsule
by breaking the ‘early intracapsular fibrosis’ and accelerate the gain in ROM.
• No proven superiority of joint distension over other therapeutic options.
• Similar ROM improvement were noted after 6 months when comparing
between hydrodilatation & manipulation under anesthesia.
FROZEN SHOULDER
ACROMIOCLAVICULAR JOINT ARTHRITIS
Risk Factor
• Common in weight lifters and overhead
throwing athlete

Clinical Presentation
• Shoulder pain, esp. with pressing activities like
bench press or push ups
• Lateral clavicle or AC joint tenderness
• Cross arm adduction test, Scarf sign
ACROMIOCLAVICULAR JOINT ARTHRITIS
Investigation
• Shoulder x-ray
• Osteophytes and joint space narrowing

Treatments
• Strengthening and stretching of shoulder girdle
• ACJ steroid injection
REFERENCES
• 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip,
and Knee
• Jin, X., Gibson, A.A., Gale, J. et al. Does weight loss reduce the incidence of total knee and hip replacement for osteoarthritis?—A
prospective cohort study among middle-aged and older adults with overweight or obesity. Int J Obes 45, 1696–1704 (2021).
• Yeap SS, Abu Amin SR, Baharuddin H, Koh KC, Lee JK, Lee VKM, Mohamad Yahaya NH, Tai CC, Tan MP. A Malaysian Delphi
consensus on managing knee osteoarthritis. BMC Musculoskelet Disord. 2021 Jun 4;22(1):514. doi: 10.1186/s12891-021-04381-8.
PMID: 34088302; PMCID: PMC8178929.
• Chauhan K, Jandu JS, Goyal A, et al. Rheumatoid Arthritis. [Updated 2022 Jun 4]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441999/
• Khanna PP, Gladue HS, Singh MK, FitzGerald JD, Bae S, Prakash S, Kaldas M, Gogia M, Berrocal V, Townsend W, Terkeltaub R,
Khanna D. Treatment of acute gout: a systematic review. Semin Arthritis Rheum. 2014 Aug;44(1):31-8. doi:
10.1016/j.semarthrit.2014.02.003. Epub 2014 Feb 13. PMID: 24650777.
• Itoi E, Arce G, Bain GI, Diercks RL, Guttmann D, Imhoff AB, Mazzocca AD, Sugaya H, Yoo YS. Shoulder Stiffness: Current Concepts
and Concerns. Arthroscopy. 2016 Jul;32(7):1402-14. doi: 10.1016/j.arthro.2016.03.024. Epub 2016 May 12. PMID: 27180923.
• Pandey V, Madi S. Clinical Guidelines in the Management of Frozen Shoulder: An Update! Indian J Orthop. 2021 Feb
1;55(2):299-309. doi: 10.1007/s43465-021-00351-3. PMID: 33912325; PMCID: PMC8046676.
• Sumanont S, Boonard M, Peradhammanon E, Arirachakaran A, Suwankomonkul P, Oungbumrungpan W, Kongtharvonskul J.
Comparative outcomes of combined corticosteroid with low volume compared to high volume of local anesthetic in subacromial
injection for impingement syndrome: systematic review and meta-analysis of RCTs. Eur J Orthop Surg Traumatol. 2018
Apr;28(3):397-407. doi: 10.1007/s00590-017-2056-z. Epub 2017 Oct 12. PMID: 29027006.
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