11b. shoulder Flashcards
differentials shoulder pain?
Conditions which affect several joints
Osteoarthritis of shoulder
Inflammatory arthritis
Polymyalgia rheumatica
Fracture
Conditions which affect the shoulder specifically
Referred neck pain
Rotator cuff injury
Frozen shoulder
Shoulder dislocation
joints in the shoulder
AC joint - acromioclavicualr
glenohumeral joint
when may a shoulder xray be useful
anterior dislocation
posterior dislocation
acromioclavilar joint dislocation
clavicualr fracture
humeral head fracture
what joints in shoulder may be affected by osteoarthritis? presentation?
Can affect :
Acromioclavicualr joint
Glenohumeral joint
Osteoarthritis
Painful stiffness
Tenderness over AC joint
Limitation of active and passive movement, worse on raising arm overhead or across the body
Crepitus
presentation polymyalgia rheuamtica
PC: over 50 with 2 weeks of: bilateral shoulder and/or pelvic girdle pain AND stiffness lasting for at least 45 mins after waking
HoPC: may be accompanied by: low grade fever, fatigue, anorexia, weight loss, depression, upper arm tenderness, ask about features of temporal arteritis including visual disturbance
Red flags: muscle strength should be normal, visual change
what is polymyalgia rheumatica
inflammatory vasculitis that causes pain and stiffness in the shoulders, pelvic girdle and neck. There is a strong association to giant cell arteritis and the two conditions often occur together.
examination polymyalgia rheumatica
Examination
MSK and neuro exam of UL and LL
Cranial nerve exam assessing vision
Examine temporal artery for tenderness
investiagations PMR
Investigations for PMR
1. Bloods: ESR and CRP
Investigations to exclude other things and before medication:
2. Do these before starting steroids: full blood count, urea and electrolytes, liver function tests, calcium, alkaline phosphatase, protein electrophoresis, thyroid stimulating hormone, creatine kinase, rheumatoid factor, and dipstick urinalysis.
- Consider : urine bence-jones protein, blood tests for ANA and anti-cyclic citrullinated peptide antibody, CXR,
management PMR
- Trial of oral prednisolone 15 mg daily and follow up after 1 week
- After 3-4 weeks consider reducing dose and assess response to treatment
what is the rotator cuff?
a group of four shoulder muscles (supraspinatus, infraspinatus, teres minor, subscapularis) and their tendons originating from the scapula attaching to the humeral head, which provides the glenohumeral joint additional stability.
what are the rotator cuff muscles
SITS
vowels AEEI correspond to actions
Supraspinatus - A - abduction
Infraspinatus - E - external rotation
Teres minor - E - external rotation and adduction
Subscapularis - I - internal rotation and adduction
What are the two groups of rotator cuff injury? what examination findings support rotator cuff injury?
impingement
- painful arc between 60-120 degrees
tears = pain/weakness during:
- ‘empty can jobe test’ resisted active abduction - supraspinatus
- “posterior cuff test” resisted active external rotation - infraspinatus
- “gerbers lift off” resisted active internal rotation - subscapularis
plan ?rotator cuff injury in primary care
Rest in the acute phase
Offer paracetamol as 1st line analgesia. If no benefit consider oral NSAID
Referral for a course (usually 6 weeks) of physiotherapy
Consider subacromial corticosteroid injection
- Only one should be administered due to risk of tendon damage
- A second injection can be administered if a good response to the 1st course and to facilitate physio exercises
The following are indications for referral to secondary care for consideration of surgery:
- Pain and loss of function despite appropriate non-operative treatment
- Sudden loss of ability to actively raise the arm (with or without trauma) on an urgent 2-week pathway
Suggestive of acute cuff tear
when should you refer someone with ?rotator cuff tear
for x-ray for other things such as fracture/dislocation/arthritis if:
a history of trauma, is not improving with conservative treatment, symptoms persisting for more than 4 weeks, restriction of movement or severe pain, then plain film radiographs (true AP and lateral or scapular Y views) can be considered in a primary care setting
If patients continue to have symptoms after 6 weeks of non-surgical care they can be referred to secondary care for further investigation:
MRI is often the 1st line investigation in hospital, with sensitivities close to 100% for full-thickness rotator cuff tears.
Ultrasound has been shown to have comparable sensitivity to MRI
first line invetsigation rotatr cuff injury
MRI
what surgical options are there for rotator cuff injury
Acromioplasty
Mainly indicated in SAIS
Aims to increase the volume of the subacromial space, preventing mechanical irritation of the rotator cuff tendons
Rotator cuff repair
Indicated in rotator cuff tears
Acute (traumatic or chronic degenerative) tear
Persistent subacromial pain and weakness with radiologically proven full-thickness tear despite appropriate conservative treatment
associations adhesive capsulitis
diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder
name for frozen shoulder?
adhesive capsulitis
clinical features adhesive capsulitis
Features typically develop over days
external rotation is affected more than internal rotation or abduction
both active and passive movement are affected
patients typically have a painful freezing phase, an adhesive phase and a recovery phase
bilateral in up to 20% of patients
the episode typically lasts between 6 months and 2 years
management adhesive capsulitis
no single intervention has been shown to improve outcome in the long-term
treatment
options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids
most common type of shoulder dislocation
Anterior shoulder dislocations account for > 95% of cases.
management shoulder dislocation
If the dislocation is recent then reduction may be attempted without any analgesia/sedation.
However, other patients may require analgesia +/- sedation to ensure the rotator cuff muscles are relaxed.
What causes winging of the scapula
damage of the long thoracic nerve (innervates the serratus anterior)
The long thoracic nerve can be damaged by trauma to the shoulder, repetitive movements and by structures becoming inflamed.
define tendinopathy
Tendinopathy is a broad term used to encompass a variety of pathological changes that occur in tendons, typically due to overuse. This results in a painful, swollen, and structurally weaker tendon that is at risk of rupture*.
biceps tendons and their attachments
long head - distally to common distal tendon attached to radial tuberosity. proximally to glenoid
short head- distally to common distal tendon attached to radial tuberosity. proximally to coracoid process
2 types of tendon rupture? epidemiology?
proximal long tendon rupture - in pts over 60. accounts for 90% of tendon rupture
distal biceps tendon - mean age 40, only 10% of cases (distal - dh that take anabolic steroids)
symptoms and signs biceps tendon rupture
sudden pop or tear at shoulder or antecubital fossa, followed by pain, brusing and swelling
popeye deformity - with proximal tendon rupture (PP)
weakness in shoulder and elbow and difficulty with supination
biceps squeeze test - no supination
Plan ?biceps tendon rupture
- USS
long head (proximal) more likely to be conservative management
distal rupture - urgent MRI, more likely surgical management
risk factors biceps tendon rupture
Heavy overhead activities
Shoulder overuse or underlying shoulder injuries which may stress the biceps tendon
Smoking
Corticosteroids; these weaken tendons
