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<Provider Id="sundheddkcms"> <Item Id="{901DF7BA-0FBF-463B-867A-C7CCC2AC696F}" Name="skuldersmerter" Type="LHContentPage" ParentProviderId="sundheddkcms" ParentItemId="{0DC18AC1-8322-42DA-BF54-C4D06C1501CE}" SortOrder="1600" PublishDate="2010-02-10T13:18:00" DeleteDate="2999-12-31T00:00:00" PotItemType=""> <Content> <HtmlField Name="PageContent"><![CDATA[<h2>Basisoplysninger</h2> <h3>Definition</h3> <ul> <li>Med skuldersmerter menes smerter udgående fra strukturer i og omkring selve skulderleddet (glenohumeralleddet) eller acromioclavicularleddet (AC-leddet) </li> <li>Rotatorcuffen <ul> <li>Er betegnelsen på fire muskler (subscapularis, supraspinatus, infraspinatus, teres minor) som mødes under acromion lige over ledhovedet og fæstner proximalt på humerus </li> <li>De roterer, abducerer og stabiliserer skulderleddet</li> </ul> </li> <li>Betegnelserne rotatorcufftendinit, rotatorcuffsyndrom og tendinose i rotatorcuffen benyttes af og til. De er samlebetegnelser på tendinit samt kronisk tendinit i en af de fire sener. Samlet anvender man nu tendinopati som fælles betegnelse</li> <li>Kroniske skuldersmerter har per definition varet længere end 6 måneder</li> </ul> <h3>Forekomst</h3> <ul> <li>Prævalens generelt<a title="Raynor MB, Kuhn JE, Utility of features of the patient's history in the diagnosis of atraumatic shoulder pain: a systematic . J Shoulder Elbow Surg. 2016;25: 688-94" href=" " data-type="journal-reference" data-value="Raynor MB, Kuhn JE, Utility of features of the patient's history in the diagnosis of atraumatic shoulder pain: a systematic . J Shoulder Elbow Surg. 2016;25: 688-94" data-url="reference-link" data-value-piped="Raynor MB, Kuhn JE|Utility of features of the patient's history in the diagnosis of atraumatic shoulder pain: a systematic |J Shoulder Elbow Surg.|2016|25|688-94">1</a> <ul> <li>Skuldersmerter er hyppigt forekommende i den generelle befolkning. Hyppigheden stiger med alderen</li> </ul> </li> <li>I almen praksis <ul> <li>Skuldersmerter er efter rygsmerter den mest almindelige muskelskeletsygdom, som folk søger læge for<a title="Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J, Chronic shoulder pain: Part II. Treatmen. Am Fam Physician 2008;77: 493-7" href=" " data-type="journal-reference" data-value="Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J, Chronic shoulder pain: Part II. Treatmen. Am Fam Physician 2008;77: 493-7" data-url="reference-link" data-value-piped="Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J|Chronic shoulder pain: Part II. Treatmen|Am Fam Physician|2008|77|493-7">2</a> </li> <li>I en almen praksis ser lægen 6,6-25 per 1.000 patienter årligt med skulderlidelse</li> </ul> </li> <li>I idræt <ul> <li>Skulderskader er den dominerende skade med en forekomst fra 17-26 % i idrætter som svømning, tennis og idrætter med kast </li> </ul> </li> </ul> <h3>Diagnostisk tankegang</h3> <ul> <li>Skuldersmerter skyldes oftest tendinit og sjældnere en bursit eller kapsulit - men kan også være en kombination af tilstandene</li> <li>Kronisk tendinit og bursit <ul> <li>Har kun i ringe grad tendens til spontan helbredelse</li> </ul> </li> <li>Akut bursit <ul> <li>Helbredes spontant inden 6 uger</li> </ul> </li> <li>Kapsulit <ul> <li>Helbredes spontant først i løbet af 1-2 år</li> </ul> </li> <li>Hvis smerterne også er lokaliseret til nakke eller skulderbue, skal man primært tænke på cervical lidelse</li> </ul> <h4>Generelt</h4> <ul> <li>Skuldersmerter skyldes i de allerfleste tilfælde en inflammatorisk proces baseret på <ul> <li>relativ overbelastning eller fejlbelastning </li> <li>forandringer sekundære til skade </li> <li>degenerative forandringer</li> </ul> </li> </ul> <h3>Diagnostiske faldgruber</h3> <ul> <li><a href="~/link.aspx?_id=52A9071470B54BB7B64C4BAC0CCC9162&_z=z">Thorasic outlet syndrom</a></li> <li>Radiculopati </li> <li>Leukæmi </li> <li>Sarkom</li> <li>Lungetumor (Pancoast tumor)</li> </ul> <h3>ICPC-2</h3> <p>[ICPC]</p> <h3>ICD-10/SKS-koder</h3> <p>[ICD10]</p> <h2>Differentialdiagnoser</h2> <h3> Skuldertendinit </h3> <ul> <li>Forekomst <ul> <li>Tendinitter udgør størstedelen af alle skulderlidelser, og langt de fleste er lokaliseret til supraspinatus</li> </ul> </li> <li>Kliniske fund <ul> <li>Supraspinatustendinit er karakteriseret ved en positiv isometrisk abduktionstest og positiv impingementtest </li> <li>Infraspinatus tendinit er karakteriseret ved en positiv isometrisk udadrotation </li> <li>Subscapularis tendinit er karakteriseret af positiv isometrisk indadrotation </li> <li>Bicepstendinit er karakteriseret af smerter ved samtidig isometrisk fleksion og supination i albuen og er meget sjælden</li> </ul> </li> </ul> <h3>Skulderbursit</h3> <ul> <li>Forekomst <ul> <li>Langt de fleste er kroniske bursitter. Bursitter forekommer ofte sammen med tendinitter</li> </ul> </li> <li> Akut bursit <ul> <li>Giver stærke smerter både ved aktiv og passiv elevation, ved passiv abduktion og nogle gange også ved passiv indad- og udadrotation </li> <li>Akut bursit debuterer ofte med meget akut indsættende smerter, som hindrer patientens nattesøvn </li> <li>Ved bursitis calcarea er der kalkudfældning i bursa, - kan ses på røntgenbilleder</li> </ul> </li> <li> <a href="~/link.aspx?_id=7E23BC0953684F15B86E3F5DDC2AE850&_z=z">Kronisk bursit</a> <ul> <li>Har positiv smertebue og giver ofte smerter både ved isometrisk abduktion og udadrotation </li> <li>Der er positiv impingement test</li> </ul> </li> </ul> <h3> <a href="~/link.aspx?_id=5759722629464405B6A10446F779E350&_z=z">Kapsulitis, periarthrosis humeri, frozen shoulder</a> </h3> <ul> <li>Forekomst <ul> <li>Kapsulitter er sjældnere end både tendinitter og bursitter og ca halvdelen er posttraumatiske</li> </ul> </li> <li>Symptomer <ul> <li>Kapsulit er karakteriseret ved smerter og nedsat aktiv og passiv bevægelighed</li> </ul> </li> <li>Kliniske fund <ul> <li>Ved test af passiv bevægelighed er et typisk fund indskrænket passiv udadrotation (+++), passiv abduktion (++) og passiv indadrotation (+) </li> <li>Desuden er der smerter ved aktiv og passiv elevation </li> <li>Isometrisk test fører ikke til væsentlig smerteforværring</li> </ul> </li> </ul> <h3> <a href="~/link.aspx?_id=84BE3B57AC7E4581933ED096BC5B2316&_z=z">Acromioclavicularleddets symptomer, AC leds symptomer</a> </h3> <ul> <li>Årsag <ul> <li>Smerter er ofte udløst af et traume </li> <li>Artrit, artrose, affektion af ledbånd</li> </ul> </li> <li>Symptomer <ul> <li>AC-leds affektion er karakteriseret ved smerter over AC-leddet og smerter, som går op i nakke-skulderbuen (C4-området)</li> </ul> </li> <li>Kliniske fund <ul> <li>Smerterne forstærkes ved horisontal adduktion i skulderleddet </li> <li>Smerter i yderstilling ved flere passive skulderbevægelser</li> </ul> </li> </ul> <h3> <a href="~/link.aspx?_id=B59047E2EE83499287784356E3BF5D17&_z=z">Post-traumatisk skulder instabilitet</a> </h3> <ul> <li>Glenohumeral instabilitet </li> <li>Årsag <ul> <li>Opstår som følge af skulderluksation én eller flere gange. Der foreligger i over 80% af tilfældene en afrivning af labrum og de glenohumerale ligamenter fra forreste nederste del af cavitas glenoidalis</li> </ul> </li> <li>Forekomst <ul> <li>Ganske almindelig, særlig blandt yngre personer</li> </ul> </li> <li>Symptomer <ul> <li>Tidligere skulderluksation</li> </ul> </li> <li>Kliniske fund <ul> <li>Finder øget forreste skuffesymptom, positiv apprehension-test og positiv relokationstest (se funktionsundersøgelser)</li> </ul> </li> <li>Andre undersøgelser <ul> <li>Evt. røntgen kan vise ossøse skader og har betydning for valg af operationsmetode</li> </ul> </li> </ul> <h3> <a href="~/link.aspx?_id=F6754D6ADB5B4D3BB9653E3F76A74647&_z=z">Rotator-cuff ruptur</a> </h3> <ul> <li>Årsag <ul> <li>Regulær ruptur i normalt senevæv kræver et relevant traume som eksempelvis fald på skulderen ved et styrt på cykel </li> <li>Ved gentagne traumer i supraspinatussenen kan der opstå mikrorupturer og degeneration i senevævet, der ender i regulær ruptur </li> <li>Rupturen begynder oftest fortil i supraspinatussenen i området, hvor bicepssenen går gennem sulcus. Den kan efterhånden brede sig bagover og ned i infraspinatussenen </li> <li>Ved massiv ruptur vil også bicepssenen være afficeret</li> </ul> </li> <li>Symptomer <ul> <li>Patienten er ofte over 40 år og kan berette om gentagne traumer eller belastninger </li> <li>Ofte gentagne inflammationer og behandlinger med lokale kortisoninjektioner</li> </ul> </li> <li>Kliniske fund <ul> <li>Positive isometriske tests, ofte med impingement </li> <li>Evt. nedsat kraft</li> </ul> </li> <li>Andre undersøgelser <ul> <li>Det anbefales at anvende MR- eller UL-skanning i diagnostikken</li> <li>MR- og UL-skanning er fundet at være ligeværdige metoder i diagnostikken </li> <li>Det anses for god praksis at anvende MR, medmindre den sundhedsprofessionelle har særlig rutine i udførelsen af muskuloskeletal UL-diagnostik<a title="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" href="https://cms.sundhed.dk/%20" data-type="book-reference" data-value="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" data-url="reference-link" data-value-piped="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U|National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser|Sundhedsstyrelsen|Sundhedsstyrelsen|2013">3</a></li> </ul> </li> <li>Behandlingen <ul> <li>Ved akut ruptur og relevant traume overvejes primær operation</li> <li>Ved ældre og ruptur uden relevant traume er rupturen på basis af degeneration i senevævet, og her er behandlingen primært konservativ som ved tendinitter. Ved manglende respons overvejes operation</li> </ul> </li> </ul> <h3>Nerveindklemning</h3> <ul> <li>Årsag <ul> <li>N. suprascapularis kan komprimeres, idet den passerer gennem incisura scapulae og den spinoglenoidale notch</li> </ul> </li> <li>Forekomst <ul> <li>Kan forekomme hos idrætsudøvere, f.eks. volleyballspillere, svømmere, kastere, tennisspillere</li> </ul> </li> <li>Symptomer <ul> <li>Nedsat kraft i m. infraspinatus, evt. også supraspinatus og smerter bagtil i skulderen</li> </ul> </li> <li>Kliniske fund <ul> <li>Afhænger af hvor indeklemningen er </li> <li>Hvis denne ligger før afgangen af motorisk gren til m. supraspinatus, kommer der atrofi og svaghed ved testning af både m. supraspinatus og m.infraspinatus og smerter ved forceret udadrotation og abduktion </li> <li>Ved mere distal affektion er kun m. infraspinatus svækket</li> </ul> </li> <li>Andre undersøgelser <ul> <li>Diagnosen kan verificeres med EMG </li> <li>MR bør gøres for at udelukke ganglioncyste</li> </ul> </li> <li>Behandling <ul> <li>Konservativ med undtagelse af ganglioncyste, som bør opereres </li> <li>Ingen effekt efter 6-12 måneder indicerer operation</li> </ul> </li> </ul> <h3>Brud eller seneruptur</h3> <ul> <li>Kan opstå efter kraftig traume eller overbelastning </li> <li>Se efter bevægelsesindskrænkning, fejlstilling, hævelse, misfarvning eller betydelig kraftnedsættelse med kun lette til moderate smerter ved isometrisk muskeltestning</li> </ul> <h3>Andre tilstande</h3> <ul> <li>Infektion </li> <li>Svulst </li> <li>Leukæmi</li> </ul> <h2>Sygehistorie</h2> <h3>Centrale elementer</h3> <h4>Generelt</h4> <ul> <li>Sygehistorien har en begrænset værdi for at stille en præcis diagnose </li> <li>Alder under 40 år <ul> <li>Foreligger oftere tendinopatier </li> <li>Traume giver oftere skulderdislokation</li> </ul> </li> <li>Alder over 40 år <ul> <li>Foreligger oftere sværere degeneration med rifter i rotatorcuffen, kapsulit, artrose </li> <li>Traume giver oftere rifter i rotatorcuffen</li> </ul> </li> </ul> <h4>Skade?</h4> <ul> <li>Fald på hånd, arm eller skulder? <ul> <li>Traumemekanisme og kraft? </li> <li>Var skulderen ude af led?</li> </ul> </li> <li>Tungt løft? <ul> <li>Kan give seneskade i degenereret senevæv, særlig hos ældre personer</li> </ul> </li> <li>Kraftigt stræk i skulderen? </li> <li>Deltagelse i kontaktidræt og vægtløftning? <ul> <li>Disponerer for ustabilt AC-led</li> </ul> </li> <li>Idræt og arbejde som foregår over hovedet? <ul> <li>Øger risikoen for tendinopatier</li> </ul> </li> </ul> <h4>Har skulderen været ude af led?</h4> <ul> <li>Hvor mange gange og i hvilke situationer har patienten måttet på sygehus for reposition? </li> <li>Holdes skulderen eleveret? Opstår der klik i visse positioner? Tænk labrumpatologi</li> </ul> <h4>Lokalisering og udstråling?</h4> <ul> <li>Smerter fra skulderleddets strukturer giver udstråling til dele af eller hele C5-dermatomet, dvs. lateralsiden af skulder og overarm samt radialsiden af underarm til tommelfingerens grundled </li> <li>Smerterne fra AC-leddet refererer i hovedsagen til C4-dermatomet, dvs. skulderbuen </li> <li>Nakkesmerter med udstråling bør udredes for cervical patologi</li> </ul> <h4>Hvad fremprovokerer smerter?</h4> <ul> <li>Udløses smerterne af bestemte bevægelser eller aktiviteter? </li> <li>Smerter som opstår, når armen føres ind foran kroppen, tyder på AC-led-lidelse </li> <li>Smerter ved løft af armen forekommer hyppig ved supraspinatuslidelser, men også ved andre lidelser</li> </ul> <h4>Nedsat kraft?</h4> <ul> <li>Skal give mistanke om seneskade, men skyldes oftere smerter og i sjældne tilfælde neuropati </li> <li>Ved neuropati er der ofte paræstesier i nervens udbredelsesområde</li> </ul> <h4>Varighed og forløb?</h4> <ul> <li>Skuldersmerter over 6 måneder tyder på kapsulit (periartrose) eller kronisk tendinit (tendinose) eller kronisk bursit</li> </ul> <h4>Debut?</h4> <ul> <li>Spontant - tyder på bursit eller tidlig kapsulit </li> <li>Efter overbelastning - tyder på tendinit eller tendinose </li> <li>Efter traume - kan være traumatisk kapsulit</li> </ul> <h4>Hvilesmerter og natlige smerter?</h4> <ul> <li>Typisk for akutte bursitter og kapsulitter, specielt når patienten vender sig i sengen, men også når han ligger på den afficerede skulder </li> <li>Kapsulit kan give natlige smerter </li> <li>Ved tendinit kun når patienten ligger på den aktuelle skulder</li> </ul> <h4>Konsekvenser?</h4> <ul> <li>I forhold til arbejde og andre aktiviteter </li> <li>Visse arbejder og aktiviteter disponerer til skulderproblemer. Generelt gælder dette arbejde med armen over skulderhøjde - f.eks. snedkere, malere, vinduespudsere, elektrikere og musikere </li> <li>Svømmere og de som dyrker kasteidræt, har øget risiko for at få skulderproblemer og bør undersøges for tegn på instabilitet</li> </ul> <h2>Klinisk undersøgelse </h2> <h3>Generelt</h3> <ul> <li>Skulderen består af kontraktile strukturer (muskler med sener) og ikke-kontraktile strukturer (kapsel, bursa, ligamenter) <ul> <li>Kontraktile strukturer testes ved isometrisk test </li> <li>Ikke-kontraktile strukturer testes via maksimale passive bevægelsesudslag</li> </ul> </li> <li>Den nationale klinisk retningslinje om skuldersmerter anbefaler, at kliniske undersøgelse som minimum indeholder <a href="https://www.youtube.com/watch?v=q9P8zDYsERs" target="_blank">Hawkins’ test</a> , <a href="https://www.youtube.com/watch?v=nq6x7f31tZ0" target="_blank">Neer’s kliniske test</a> og test for positiv smertebue<a title="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" href="%20" data-type="book-reference" data-value="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" data-url="reference-link" data-value-piped="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U|National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser|Sundhedsstyrelsen|Sundhedsstyrelsen|2013">3</a> </li> <li> Palpationsømhed <ul> <li>Er ofte refereret fra andre strukturer og har som regel lille diagnostisk værdi ved tendinitter (hvor man behandler i forhold til funktionel test) </li> <li>Har dog værdi ved infiltrationsbehandling af akut eller kronisk subdeltoid bursit</li> </ul> </li> <li>Diagnostisk blokade med <a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/225000">lokalanestetika</a> <ul> <li>Kan bidrage til at differentiere mellem forskellige tendinitter og kronisk bursit</li> <li>Det anses for god praksis at anvende subakromiel injektion af <a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/225000">lokalanalgetika</a> diagnostisk ved den præoperative udredning<a title="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" href="%20" data-type="book-reference" data-value="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" data-url="reference-link" data-value-piped="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U|National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser|Sundhedsstyrelsen|Sundhedsstyrelsen|2013">3</a></li> </ul> </li> </ul> <h4>Funktionsundersøgelser</h4> <ul> <li>Eksempler på skuldertest <a href="~/link.aspx?_id=676F33773034430D87C0F134731744E2&_z=z">(video)</a> </li> </ul> <h4>Abduktionstest</h4> <ol> <li>Aktiv abduktion af begge arme (se på sideforskel bagfra) </li> <li>Passiv elevation </li> <li>Test for smertebue (aktiv elevation)</li> </ol> <ul> <li>Testrespons giver indtryk af problemets omfang <ul> <li>"Painful arc", smertebue, beskriver smerter i et område af bevægebanen ved aktiv elevation </li> <li>Ved elevation af armen vil patienten ofte rapportere smerter i et område af bevægebanen, almindeligvis mellem 70 og 150 graders elevation, med smertefri elevation både under og over smertebuen </li> <li>Positivt fund gøres ved tendinit eller bursit på grund af kompression af en inflammeret struktur under acromion ("impingement") </li> <li>Testen kan understøttes ved positiv indeklemningstest</li> </ul> </li> </ul> <h4>Bevægelighedstest - passive bevægelser</h4> <ol> <li>Passiv abduktion (180°) - med fikseret scapula </li> <li>Passiv udadrotation (60°) </li> <li>Passiv indadrotation (70°)</li> </ol> <ul> <li>Testrespons vil være <ul> <li>Kapsulært mønster vises ved nedsat udadrotation, abduktion og indadrotation og tyder på inflammation i ledkapslen (kapsulit) </li> <li>Nedsat passiv bevægelighed i et ikke-kapsulært mønster tyder på inflammation i bursa (typisk ved akut bursit)</li> </ul> </li> <li>Fejlkilder <ul> <li>Hvis scapula ikke fikseres ved abduktionstesten, vil man kunne overse en betydelig reduceret bevægelighed, fordi scapula roterer </li> <li>Det er let at overdiagnosticere en kapsulit </li> <li>Nedsat aktiv bevægelighed er ofte betinget i smerter </li> <li>For at finde den reelle bevægelighed i et led kan det være nødvendigt at gå over smertegrænsen</li> </ul> </li> </ul> <h4>Isometriske tests</h4> <ul> <li>Testene udføres med maksimal kraft uden bevægelse. Fikser armen og lade patienten presse imod undersøgeren <ol> <li>Isometrisk abduktion - tester supraspinatus </li> <li>Isometrisk adduktion - tester teres minor/major, pectoralis major, latissimus dorsi </li> <li>Isometrisk udadrotation - tester infraspinatus </li> <li>Isometrisk indadrotation - tester subscapularis, foruden pectoralis major og caput longum biceps </li> <li>Isometrisk albuefleksion - tester biceps </li> <li>Isometrisk albueekstension - tester triceps</li> </ol> </li> </ul> <ul> <li>Testrespons <ul> <li>Smerter alene tyder på tendinit </li> <li>Nedsat kraft alene tyder på totalruptur af muskel eller sene eller på parese </li> <li>Smerter og nedsat kraft skyldes oftest inflammation, hvor patienten ikke bruger fuld kraft pga. smerter</li> </ul> </li> </ul> <h4>AC-ledtest</h4> <ol> <li>Horisontal adduktion</li> </ol> <ul> <li>Udføres ved at lægge den afficerede sides hånd på den modsatte skulder, så skubber man albuen ind mod kroppen - eller ved at presse hænderne sammen i horisontalt niveau </li> <li>Er aktuel at udføre ved mistanke om AC-artrit, medens der ved <a href="~/link.aspx?_id=84BE3B57AC7E4581933ED096BC5B2316&_z=z">AC-leds artrose kan være yderligere objektive fund</a> </li> <li>Testrespons <ul> <li>Ved positiv AC-test udløses smerter fra AC-leddet</li> </ul> </li> </ul> <h4>Indeklemningstest, impingement test</h4> <ol> <li>Indeklemningstest er positiv, når patienten angiver smerte ved passiv fleksion, mens armen bliver indadroteret, så tuberculum majus kommer under acromion </li> </ol> <h4>Test efter injektion af lokal anæstesi</h4> <ul> <li>Hvis funktionsundersøgelsen ikke giver en sikker diagnose, kan infiltration med lokalanæstesi i den mistænkte struktur, efterfulgt af retest, måske afklare diagnosen</li> </ul> <h4>Undersøgelser af stabilitet i skulderleddet</h4> <ul> <li>Skuffetest <ul> <li>Udføres med armen hængende ned langs siden </li> <li>Caput humeri kan normalt kun skubbes nogle få millimeter fremad og bagud, øget translation tyder på øget kapselløshed</li> </ul> </li> <li>Sulcustegn <ul> <li>Forskydning nedad ved at trække i albuen distalt </li> <li>Fremkommer der en fordybning under acromion, tyder det på øget løshed</li> </ul> </li> <li>Apprehension-test (se testen på <a href="https://www.youtube.com/watch?v=_JA-qvXcUdQ">youtube</a>) <ul> <li>Testen udføres med patienten i rygleje eller siddende med armen i 90° abduktion og 90° fleksion i albuen, samt udadrotation </li> <li>Forceres udadrotationen yderligere og det udløser smerte, ubehag og angst for at skulderen skal gå ud af led, er testen positiv for forreste instabilitet </li> <li>Klager patienten over smerter bagtil i skulderen, er det tegn på bageste instabilitet</li> </ul> </li> <li>Relokationstest (se testen på <a href="https://www.youtube.com/watch?v=_JA-qvXcUdQ">youtube</a>) <ul> <li>Udfører apprehension-test, men humerus presses forfra. Hvis lindring, styrker det mistanken om forreste instabilitet </li> <li>Patienten sidder eller står med en foroverbøjet holdning. Armen bøjes til ca. 45° og indadroteres, samtidig som caput humeri trykkes bagover i humerus længderetning <ul> <li>Ved positiv test opstår bageste subluksation eller luksation af caput humeri</li> </ul> </li> </ul> </li> </ul> <h2>Supplerende undersøgelser</h2> <h3>I almen praksis</h3> <ul> <li>Blodprøver og røntgen giver normalt kun en lille tillægsinformation ved skuldersmerter i almen praksis</li> <li>Ved mistanke om reumatisk lidelse tages rheumaprøver</li> </ul> <h3>Andre undersøgelser</h3> <h4>Billeddiagnostik</h4> <ul> <li>Er almindeligvis ikke indiceret initialt </li> <li>Røntgen <ul> <li>Kan vise artrose/artrit i glenohumeralleddet, evt. artrose i AC-leddet, eller kalkudfældning i bursa eller senefæste </li> <li>Fund af kalk vil som regel være af begrænset praktisk betydning, hvis kalkudfældningen ikke er specielt stor (> 16 mm) og lokaliseret til klinisk diagnosticeret bløddelsvæv</li> <li>Det anses for god praksis, at der foretages konventionel røntgenoptagelse ved klinisk mistanke om rotator cuff-ruptur, ved traume samt ved vedvarende skuldersmerter, som ikke responderer på ikke-kirurgisk behandling<a title="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" href="%20" data-type="book-reference" data-value="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" data-url="reference-link" data-value-piped="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U|National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser|Sundhedsstyrelsen|Sundhedsstyrelsen|2013">3</a> </li> </ul> </li> <li>Ultralyd og MR <ul> <li>Det anbefales at anvende MR- eller UL-skanning i diagnostikken. MR- og UL-skanning er fundet at være ligeværdige metoder i diagnostikken<a title="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" href="%20" data-type="book-reference" data-value="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" data-url="reference-link" data-value-piped="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U|National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser|Sundhedsstyrelsen|Sundhedsstyrelsen|2013">3</a></li> <li>Det anses for god praksis at anvende MR i udredningen, medmindre den sundhedsprofessionelle har særlig rutine i udførelsen af muskuloskeletal UL-diagnostik<a title="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" href="%20" data-type="book-reference" data-value="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" data-url="reference-link" data-value-piped="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U|National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser|Sundhedsstyrelsen|Sundhedsstyrelsen|2013">3</a> </li> <li>For påvisning af totale rupturer af rotatormanchetten har både ultralyd og MR høj sensitivitet </li> <li>Ultralyd er mindre tidskrævende end MR og koster ca. en tredjedel af en MR-undersøgelse</li> </ul> </li> </ul> <h2>Tiltag og råd</h2> <h3>Henvisninger</h3> <ul> <li>Henvisning til specialist i reumatologi eller ortopædi er aktuel i vanskelige og kroniske tilfælde, både for at stille en mere sikker diagnose og for at vurdere behandlingsmuligheder inklusive operation</li> </ul> <h3>Råd</h3> <ul> <li>Det er vigtigt at informere patienten om, at langt de fleste skulderlidelser initialt behandles konservativt i almen praksis uden henvisning til ortopædkirurg</li> </ul> <h4>Steroidinjektioner </h4> <ul> <li>Ved impingementsyndrom eller rotator cuff-syndrom<a title="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" href="%20" data-type="book-reference" data-value="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" data-url="reference-link" data-value-piped="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U|National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser|Sundhedsstyrelsen|Sundhedsstyrelsen|2013">3</a> anses det for god praksis at anvende subakromiel <a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/171050">glukokortikoid injektion</a> som hjælp forud for igangsætning af træning, men behandlingen bør ledsages af et tilbud om træning</li> <li>Det kan overvejes at bruge subakromiel <a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/171050">glukokortikoid injektion</a> terapeutisk, dog sjældent mere end 2-3 gange</li> <li>Disse patienter bør få råd om aflastning for at undgå smertefuld aktivitet </li> <li>Om nødvendig skal patienten sygemeldes</li> </ul> <h4>Antiflogistika og analgetika</h4> <ul> <li>Anvendelsen af smertestillende behandling må afpasses efter det konkrete behov<a title="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" href="%20" data-type="book-reference" data-value="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" data-url="reference-link" data-value-piped="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U|National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser|Sundhedsstyrelsen|Sundhedsstyrelsen|2013">3</a></li> <li><a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/213010">NSAID</a> kan overvejes som smertelindring, men bør gives i lavest mulige dosis og kortest mulig tid<a title="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" href="%20" data-type="book-reference" data-value="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U. National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen: Sundhedsstyrelsen; 2013" data-url="reference-link" data-value-piped="Frandsen P, Juul-Kristensen B, Olsen BS, Jensen CM, Jensen CM, Frich LH, Sørensen PT, Schydlowsky P, Nielsen SN, Svendsen SW, Torfing T,Fredberg U|National klinisk retningslinje for diagnostik og behandling af patienter med udvalgte skulderlidelser|Sundhedsstyrelsen|Sundhedsstyrelsen|2013">3</a> </li> <li>Nogle patienter har så store smerter, f.eks. natlige smerter, som ødelægger søvnen, at det er rigtigt at give <a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/226500">analgetika</a> </li> <li>Hvis patienten ikke bliver bedre, bør han komme til kontrol og ny undersøgelse efter 1-2 uger</li> </ul> <h4>Fysioterapi</h4> <ul> <li>Det anbefales at anvende træning som led i behandlingen af patienten med impingementsyndrom/rotator cuffsyndrom og at behandlingen varer mindst 3 måneder </li> <li>Effekten på andre skulderlidelser er dårligere dokumenteret</li> <li>Se <a href="~/link.aspx?_id=53CEA00218DB44EEBD4E17E8E92AA51E&_z=z">film med øvelser til skulder</a></li> </ul> <h4>Aflastende og forebyggende tiltag</h4> <ul> <li>Sekundære profylaktiske tiltag på arbejdspladsen er aktuelle: <ul> <li>Undgå ensidigt arbejde, prøv at finde en bedre arbejdsstilling </li> <li>Tag pauser </li> <li>Udføre øvelser efter instruktion fra læge eller fysioterapeut</li> <li>Undgå skulderbelastende fritidsaktiviteter, der forværrer symptomerne</li> </ul> </li> </ul> <h2>Patientinformation</h2> <h3>Træningsfilm for skulderen </h3> <ul> <li><a href="~/link.aspx?_id=CC188691765C40D1A150CDA2CC2056BF&_z=z">Øvelsesprogram, 3 øvelser</a><br> <br> <a href="~/link.aspx?_id=53CEA00218DB44EEBD4E17E8E92AA51E&_z=z"><img alt="" height="84" width="135" src="F29C024F18294B948DCBD5C5BE19CD28-135-84" style="height: 84px; width: 135px;"></a></li> </ul> <ul> <li><a href="~/link.aspx?_id=9F6E392D800F48B18D827DF35EF95F3C&_z=z">Øvelsesprogram, 3 øvelser med arabisk tale - فيديوهات تمارين رياضية باللغة العربية</a><br> <br> <a href="~/link.aspx?_id=8425CFC13C1647309B1A14D3B31AF98D&_z=z"><img alt="" height="84" width="135" src="ECD34BA7D13E4B0BA41E5E9B16E3E3D7-0-0"></a></li> </ul> <h2>Illustrationer</h2> <h3>Billeder</h3> <ul> <li> <a href="~/link.aspx?_id=4B7F4CD09C574AA0BFB8D0BF1B252597&_z=z">Skulder, rtg. normalbillede</a> </li> </ul> <h3>Plancher eller tegninger</h3> <ul> <li> <a href="~/link.aspx?_id=742F588B090A496FBE7F5C94E30F92F9&_z=z">Skulderled skelet, tegning</a> </li> <li> <a href="~/link.aspx?_id=5E8E8E938B4C492DBCE90B5810D686D3&_z=z">Supraspinatussene, tegning</a> </li> <li> <a href="~/link.aspx?_id=EC12674325344D97B1706BB49F7EF664&_z=z">Injektion i supraspinatus, tegning</a> </li> <li> <a href="~/link.aspx?_id=5BE1DF8D5E0A4BACA46711D3801AE1C3&_z=z">Arm-position ved inj. i supraspinatussene</a> </li> <li> <a href="~/link.aspx?_id=925DEA3815A64E3F8E8CC2A98F714DF1&_z=z">Muskler i ryg og nakke, tegning</a> </li> </ul> <h3>Video</h3> <ul> <li> <a href="~/link.aspx?_id=676F33773034430D87C0F134731744E2&_z=z">Hele skulderundersøgelse, 13 tests</a></li> <li><a href="~/link.aspx?_id=5DBF022A79034A43991F662E455E7414&_z=z">Blokade i bursa subacromiale</a></li> </ul>]]></HtmlField> <HtmlField Name="PageReferences"><![CDATA[<p>Benyttes ej</p>]]></HtmlField> <LinkListField Name="Spot2"> <LinkField linktype="internal">{99A85AFD-2F7A-4B5D-A1C9-C2701D5E7D30}</LinkField> </LinkListField> <TextField Name="DoctorsHandbookID">1218</TextField> <TextField Name="PageTitle">Skuldersmerter</TextField> <TextField Name="NavigationTitle">Skuldersmerter</TextField> <CheckBoxField Name="ShowInMenu">true</CheckBoxField> <CheckBoxField Name="ShowInContentField">true</CheckBoxField> <DateTimeField Name="RevisedDate">2019-08-09T15:03:00</DateTimeField> <LinkListField Name="Authors"> <LinkField linktype="internal">{CFEF3DF6-6DE3-47EB-9967-10BC908CC816}</LinkField> <LinkField linktype="internal">{26E8FF8A-82A3-4E33-AEC4-889C9763B0DA}</LinkField> <LinkField 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