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<Provider Id="sundheddkcms"> <Item Id="{7E23BC09-5368-4F15-B86E-3F5DDC2AE850}" Name="subacromielt-smertesyndrom" Type="LHContentPage" ParentProviderId="sundheddkcms" ParentItemId="{FDA65AA3-F353-4E21-B080-898C4AA2532F}" SortOrder="900" PublishDate="2010-03-09T14:55:00" DeleteDate="2999-12-31T00:00:00" PotItemType=""> <Content> <HtmlField Name="PageContent"><![CDATA[<h2>Diagnose</h2> <h3>Diagnostiske kriterier</h3> <ul> <li>Debuterer både akut og med langsomt udviklende kronisk præsentation</li> <li>Smerterne kan i akutte tilfælde med calcifikation være betydelige, ellers er de kronificeret ofte mere moderate</li> <li>Ofte er der natlige smerter med lejringsproblemer</li> <li>Fundene kan være varierende, men oftest <ul> <li>Positiv smertebue</li> <li>Nedsat aktiv men ofte normal passiv bevægelighed, særligt efter smertelindring</li> <li>Oftest normal kraft, særligt efter smertelindring</li> <li>Palpationsømhed lateralt og fortil ved akromion</li> </ul> </li> </ul> <h3>Sygehistorie</h3> <ul> <li>Skuldersmerter ofte med udstråling, særligt nedover C5-dermatomet</li> <li>I akutte tilfælde ofte med svære smerter og betydelig nedsat funktion, hvorimod de kronificerede smerter oftest er mere moderate </li> <li>Akut udviklede smerter ses ofte i hvile og kronificerede er mere relateret til aktivitet</li> <li>Natlige smerter med opvågning og lejringsproblemer er karakteristiske</li> <li>Ofte beskrives sammenhæng med aktivitet, hvor armene er belastet over skulderhøjden</li> <li>Mange beskriver nedsat skulderfunktion</li> </ul> <h3>Kliniske fund</h3> <ul> <li>Systematisk skulderundersøgelse bør udføres</li> <li>Det anbefales at den kliniske test minimum indeholder Hawkin's test, Neer's test og test for smertefuld bue</li> <li>Ofte er der udslag ved flere tests, og fundene kan være vanskelige at tolke pga. nedsat specificitet og sensitivitet ved testene, der oftest kan være positive ved forskellige kliniske tilstande</li> <li>Det anses for god praksis at teste kraften over rotator cuffens sener for at udelukke skade, der evt. bør behandles/vurderes kirurgisk</li> <li>De fleste patienter har <ul> <li>En positiv smertebue, som er hoved kriteriet for diagnosen</li> <li>Oftest normal passiv bevægelighed, evt. efter smertelindring</li> <li>Normal kraft, særligt efter smertelindring</li> </ul> </li> <li>Lokal ømhed ved acromions forflade og lateralt</li> <li>Smerter i alle skulderens yderstillinger er almindeligt</li> <li>Ofte kan diagnostisk infiltration med <a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/225000#">lokal anæstesi</a> være nødvendig for at vurdere bevægelighed og kraft. For at undgå at flere strukturer bliver påvirket af anæstesien, anvendes et svagt lokalanæstetikum, f.eks. lidocain, xylocain eller tilsvarende.</li> </ul> <h4>Supplerende undersøgelser</h4> <ul> <li>Røntgen er velindiceret både ved det akutte fulminante forløb og i de kronificerede forløb for at påvise evt. calcifikationer og afkræfte anden evt. malign patologi</li> <li>Ultralydsskanning har stor værdi i forhold til at udelukke strukturel seneskade</li> <li>Har der tidl. været givet injektion, bør man særligt ved akut udvikling overveje infektion og udrede for dette</li> </ul> <ul> </ul> <h3>Andre undersøgelser hos specialist</h3> <ul> <li>UL-vejledt steroid injektion benævnt Barbotage kan anvendes til at knuse subakromielle calcifikationer og kan være indiceret, når sådanne er til stede og ikke synes at svinde spontant som normalt</li> <li>MR-skanning af skulderen kan være gavnlig til at demonstrere både knogle og bløddele i skulderen, særligt når strukturel rotator cuff skade eller skulderkapsulit (frossen skulder) mistænkes</li> </ul> <h3>Differentialdiagnoser</h3> <ul> <li>Patologi i skulderleddet, artrose, artrit eller fraktur</li> <li><a href="~/link.aspx?_id=E1C1CBF791BF48D5A1C3DE526B0895D0&_z=z">Acromioklaviculærleds læsion</a> eller artrose</li> <li>Rotator cuff irritation (tendinitis)</li> <li>Rotator cuff læsion (traumatisk eller degenerativ)</li> <li>Bicepssenepatologi</li> <li>Skulderustabilitet</li> <li>Skulderledskapsulit (frossen skulder)</li> <li>Cervikal patologi særligt C4/C5 </li> <li>Andre (hjerte, lungetumor, lever/galde)</li> <li>Neoplasmer/metastaser</li> </ul> <h2>Behandling</h2> <h3>Behandlingsmål</h3> <ul> <li>Primært smertelindring</li> <li>Restitution til normal funktion</li> <li>Styrkelse af rotator-cuff musklerne og scapula stabilisering gennem skuldertræning</li> </ul> <h3>Generelt om behandlingen</h3> <ul> <li>Dokumentation af effekt af behandling er meget usikker, fordi der mangler konsensus vedrørende diagnostik af skulderlidelser, hvilket medfører en betydelig heterogenitet i de forskellige forskningsmaterialer og usikkerhed omkring deres effekt</li> <li><a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/213010">NSAID</a> kan anvendes til smertelindring</li> <li>Der er udgivet en <a href="https://www.sst.dk/da/Udgivelser/2021/NKR-subakromielt-smertesyndrom-i-skulderen">National Klinisk Retningslinje af SST i feb. 2021</a>. Her anbefales formaliseret superviseret øvelsesbehandling, <a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/171050">kortisoninjektioner</a>,<br> og kirurgi</li> </ul> <h3>Håndtering i almen praksis</h3> <ul> <li>Oftest behandles denne type patienter bedst i almen praksis</li> <li>De bør henvises til fysioterapeutisk træning, det kan enten være formaliseret superviseret holdtræning eller vejledt egen-træning</li> <li>Er patienten meget forpint, hvorfor træning ikke kan opstartes, kan kortisoninjektion, som beskrevet nedenfor, være indiceret </li> <li>Træning bør havde en varighed på minimum 3 måneder og gerne mere</li> <li>Kun i få tilfælde er henvisning til speciallæge nødvendig </li> <li>Overvej radiologisk udredning med røntgen og/eller UL, særligt ved tvivl om diagnosen eller ved kronificerede forløb</li> </ul> <h3>Råd til patienten</h3> <ul> <li>Patienten kan bruge armen frit indenfor smertegrænsen og bør forklares, hvordan indeklemning af bursaen ved løft af armen over skulderhøjde giver smerter og vedligeholder irritationen af slimsækken og evt. sener</li> <li>Se <a href="~/link.aspx?_id=53CEA00218DB44EEBD4E17E8E92AA51E&_z=z">film med øvelser til skulder</a></li> </ul> <h3></h3> <h3>Fysioterapeutisk træning</h3> <ul> <li> <p>Langvarig træningsterapi har lige så god effekt som operativ behandling - <a href="~/link.aspx?_id=53CEA00218DB44EEBD4E17E8E92AA51E&_z=z">se træningsvideoer til patienter: Skulderøvelser</a></p> </li> <li> <p>Når konservativ behandling er uden effekt, kan operation være aktuel</p> </li> </ul> <h3>Medicinsk behandling</h3> <ul> <li><a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/213010">NSAID</a> kan forsøges, men giver sjældent mere end kortvarig lindring</li> <li><a href="https://pro.medicin.dk/Laegemiddelgrupper/Grupper/315123">Morfika</a> bør undgås, men kan være indiceret ved det akutte fulminante forløb med calcificering</li> </ul> <h4><a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/171050#">Kortisoninjektion</a></h4> <ul> <li><a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/171050#">Steroidinjektion</a> kombineret med <a href="http://pro.medicin.dk/Laegemiddelgrupper/Grupper/225000">lokalanæstesi </a>er ofte brugt som behandling, og kan være nødvendig før træningsopstart, hvis patienten har mange smerter</li> <li>Det er veldokumenteret, at ved undersøgelser efter 6 mdr. har steroidinjektion ingen effekt på udviklingen i tilstanden, måske endda negativ effekt</li> <li>Da træning er den bedst dokumenterede behandling, bør steroidinjektion kun udføres samtidig med træningsbehandling</li> <li>Injektioner af lokalanæstesi alene har kun diagnostisk værdi </li> <li>Det bedste indstikssted er lateralt lige under acromion med armen hængende afslappet og frit ned, alternativt kan man injicere posteriort eller forfra alt efter erfaring</li> <li>Manglende effekt kan skyldes, at blokaden ikke er lagt i bursa subacromialis, og blokaden kan så lægges ultralydsvejledt </li> <li>Se video om <a href="~/link.aspx?_id=5DBF022A79034A43991F662E455E7414&_z=z">blokade i bursa subacromialis</a></li> <li>Har patienten diabetes, bør man overveje effekten af steroid på blodsukkeret</li> <li>Har der været gavn af steroidinjektion i behandlingsforløbet med træning, kan man overveje gentagelse 2 - 3 gange med 4 - 8 ugers mellemrum </li> </ul> <ul> </ul> <h3>Kirurgi</h3> <ul> <li>Subacromiel dekompression kan overvejes hos patienter, der trods formaliseret træningsforløb har blivende symptomer i mere end 6 mdr. Da den kirurgiske effekt er svagt dokumenteret, og da der er beskrevet bivirkninger til behandlingen, bør behandlingen forudgås af nøje patientinformation om fordele og ulemper ved behandlingen</li> <li>Indgrebet foretages sædvanligvis arthroskopisk og omfatter fjernelse af bursa subacromialis, afløsning af det coracoacromielle ligament ved acromions forflade, efterfulgt af fjernelse af subacromielle osteofytter fra acromions underflade. Er der subacromielle forkalkninger, bør disse tilstræbes fjernet. Dette medfører bedre plads i det subacromielle rum</li> <li>Kirurgien bør efterfølges af relevant smertebehandling og formaliseret skuldertræning. Skuldertræningen har fokus på skuldermobilitet og scapulastabilisering for at bedre pladsen i det subacromielle rum</li> </ul> <h3>Forebyggende behandling</h3> <ul> <li>Undgå skulderimmobilisering</li> <li>Hav fokus på at undgå belastede arbejdsprocesser med ensidig kraftfuldt arbejde med skuldrene over skulderhøjde. Vekslende arbejdsfunktioner med forskellig skulderbelastning over og under skulderhøjde kan være gavnlig</li> <li>Styrkelse af skuldermuskulaturen kan være gavnlig for at undgå skuldersmerter</li> </ul> <h2>Henvisning</h2> <ul> <li>Hvis den praktiserende læge (evt. fysioterapeut) ikke kan stille diagnosen, hvis behandlingen med træning ikke har effekt, trods regelret forløb evt. forudgået af blokade, kan patienten henvises til reumatolog eller ortopædkirurg. Her vil der typisk foranstaltes yderligere udredning og behandling, der oftest vil havde fokus på initiel ikke-operativ behandling, som specificeret ovenfor</li> <li>Ved mistanke om skulder-sene-læsion, særligt hos midaldrende eller yngre personer</li> <li>Ved smerter der ikke kan behandles</li> <li>Ved mistanke om smerter udløst af anden patologi </li> </ul> <h2>Opfølgning</h2> <h3>Plan</h3> <ul> <li>Patienten bør følges af egen læge over lang tid, henvisning er som regel ikke nødvendig</li> <li>Erhvervsaktive patienter med let arbejde kan havde behov for sygemelding i en kortere periode, så længe hvile- og natlige smerter er væsentlige</li> <li>De, der har tungere og specielt manuelt arbejde, kan havde behov for længere sygemeldinger, indtil det meste af funktionen i skulderleddet er remitteret</li> <li>Sygemelding bør aldrig stå alene og er kontraindiceret uden samtidig formaliseret behandlingsforløb </li> <li>Overførsel til andet erhverv er sjældent nødvendigt</li> </ul> <h2>Sygdomsforløb, komplikationer og prognose</h2> <h3>Sygdomsforløb</h3> <ul> <li>Lidelsen kan udvikle sig akut og mere snigende, tilstanden kan havde varierende varighed</li> </ul> <h3>Komplikationer</h3> <ul> <li>Ruptur af rotator cuff sene eller ruptur af bicepssene</li> <li>Skulderstivhed </li> <li>Kronificerede smerter</li> </ul> <h3>Prognose</h3> <ul> <li>Varierende forløbsvarighed men kendetegnet ved spontan lindring over tid, ikke sjældent er forløbet langvarigt</li> </ul> <h2>Baggrundsoplysninger</h2> <h3>Definition</h3> <ul> <li>Der er uenighed om afgrænsningen til tendinit. De fleste mener, at tendinit og bursit samt evt. partielle degenerative rotatorcuff læsioner er udtryk for den samme patologi. Tilstandene lader sig ikke adskille fra hinanden og behandles derfor her samlet</li> <li>Tilstanden kan debutere både akut og mere snigende med kronificeret præg</li> <li>Bursa subdeltoideus har en dyb del, som er lokaliseret under acromion, og en overfladisk del af varierende størrelse lokaliseret under m. deltoideus </li> </ul> <h3>Forekomst</h3> <ul> <li>Lidelsen er hyppig og udgør 3/4 af alle de skulderlidelser, der ses i almen praksis</li> <li>Incidensen er stærkt stigende</li> <li>Prævalensen er størst blandt midaldrende 45 - 60 år</li> <li>Kønsfordelingen er lige</li> </ul> <h3>Ætiologi og patogenese</h3> <ul> <li>Tilstanden skyldes afklemning af den subacromielle bursa, biceps senen og supraspinatussenen</li> <li>Årsagen er oftest ukendt, men ses ikke sjældent efter overbelastning og traume</li> </ul> <h3>Disponerende faktorer</h3> <ul> <li>Kraftfuldt arbejde med armene over skulderhøjde, f.eks. elektrikere, malere, anlægsarbejdere osv. </li> <li>Brug af vibrationsudstyr</li> <li>Skulderbelastede sportsgrene som svømning, ketchersport, kastesport og fitness træning </li> </ul> <h3>ICPC-2</h3> <p>[ICPC]</p> <h3>ICD-10/SKS-koder</h3> <p>[ICD10]</p> <h2>Patientinformation</h2> <h3>Hvad du bør informere patienten om</h3> <ul> <li>Patienten bør informeres om årsagen til smerterne, undgå immobilisering af skulderen og vigtigheden af træning</li> <li>Periodisk aflastning fra tung skulderbelastning kan havde en plads i behandlingen, men bør ikke stå alene</li> </ul> <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> <h3>Hvad findes af skriftlig patientinformation</h3> <ul> <li><a href="~/link.aspx?_id=3A210B2BEAD24C89BF4A7C7DEC4C3F3F&_z=z">Kortisonindsprøjtning</a></li> </ul> <ul> </ul> <h2>Link til vejledninger</h2> <ul> <li><a href="https://www.sst.dk/da/Udgivelser/2021/NKR-subakromielt-smertesyndrom-i-skulderen">Behandling af patienter med subakromielt smertesyndrom i skulderen, Sundhedsstyrelsen, 2021</a></li> <li>NKR Diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen. 2013</li> </ul> <ul> </ul> <h2>Illustrationer</h2> <h3>Træningsvideoer</h3> <ul> <li><a href="~/link.aspx?_id=53CEA00218DB44EEBD4E17E8E92AA51E&_z=z">Skuldertræning, øvelsesprogram til hjemmebrug</a></li> </ul> <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=51053E53317A494396870CFE7B7A01CF&_z=z">Subacromial bursa, tegning</a> </li> <li> <a href="~/link.aspx?_id=742F588B090A496FBE7F5C94E30F92F9&_z=z">Skulderled skelet, tegning</a> </li> <li> <a href="~/link.aspx?_id=0F1E0D23FF4749E48BA47F7162581BAE&_z=z">Skulderbursae, tegning</a></li> </ul>]]></HtmlField> <HtmlField Name="PageReferences"><![CDATA[<ol style="margin-top: 0cm;"> <li>Witten A, Barfod KW, Thorborg K, Foverskov M, Clausen MB. Subacromial impingement syndrome. Ugeskr Laeger. 2019 Apr 1;181(14):V03180215</li> <li>Balaji Umamahesvaran, Senthil Nathan Sambandam, Varatharaj Mounasamy, Ponnusami Pillai Gokulakrishnan and Munis Ashrafa. Calcifying Tendinitis of the Shoulder: A Concise Review. J Orthop. 2018; 15(3): 776–782. doi: 10.1016/j.jor.2018.05.040</li> <li>Ottenheijm RP, Jansen MJ, Staal JB, van den Bruel A, Weijers RE, de Bie RA, Dinant GJ., Accuracy of diagnostic ultrasound in patients with suspected subacromial disorders: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2010;91: 1616-25</li> <li>NKR Diagnostik og behandling af patienter med udvalgte skulderlidelser. Sundhedsstyrelsen. 2013</li> <li>Guideline National Klinisk Retningslinje for behandling af patienter med subacromielt smertesyndrom i skulderleddet. Sundhedsstyrelsen 2021.ISBN elektronisk udgave: 978-87-7014-232-8</li> <li>Faglig visitationsretningslinje. Impingementsyndrom/rotator-cuff syndrom og traumatisk rotator cuff-ruptur. Sundhedsstyrelsen 2011</li> </ol>]]></HtmlField> <HtmlField Name="Resume"><![CDATA[<strong>Diagnose</strong> <ul> <li>Skuldersmerter evt. med udstråling til C5 dermatomet</li> <li>Smertefuldt buesyndrom</li> <li>Fri skulderbevægelighed og normal kraft evt. efter smertelindring </li> </ul> <strong>Behandling</strong> <ul> <li>Smertelindring</li> <li>Formaliseret træningsterapi evt. forudgået af blokade</li> <li>Sjældent kirurgi og kun efter formaliseret træningsterapi uden effekt</li> </ul> <strong>Henvisning</strong> <ul> <li>Ved manglende behandlingseffekt af træning</li> <li>Ved usikkerhed om diagnosen</li> </ul>]]></HtmlField> <LinkListField Name="Spot2"> <LinkField linktype="internal">{99A85AFD-2F7A-4B5D-A1C9-C2701D5E7D30}</LinkField> </LinkListField> <TextField Name="DoctorsHandbookID">1224</TextField> <TextField Name="PageTitle">Subacromielt smertesyndrom, afklemning skulder, impingement</TextField> <TextField Name="NavigationTitle">Subacromielt smertesyndrom, afklemning skulder, 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