4- shoulder pathologies & compressive neuropathies & elbow

Question 1

what are the 4 common shoulder pathologies?

Answer 1

1. instability
2. cuff disease (impingement & cuff tears)
3. frozen shoulder
4. arthritis

Question 2

what ages are typical for which shoulder problem?

Answer 2

20s-30s = instability problem
30s-40s = impingement
40s-50s = frozen shoulder
50s-60s = cuff tear
over 60 = arthritis

*grey hair cuff tear

Question 3

what movements do the rotator cuffs cause?

Answer 3

• supraspinatus = initiate abduction
• infraspinatus & teres minor = external rotation
• subscapularis = internal rotation

*often they initiate movement but other muscles help the movement

Question 4

what is typical presentation of instability?

Answer 4

• younger sporty people
• mostly anterior dislocation in contact sport
• can be posterior dislocation (5%) sometimes caused by epileptic fits or electrocution due to muscle spasm
• mostly traumatic

on examination = lose roundness of shoulder, tenderness, muscle spasm

Question 5

what is management of instability shoulder injury?

Answer 5

anterior dislocation = in normal sling

posterior dislocation = different brace with external rotation position

• also have physio for rotator cuff & scapula strengthening, always try move early with shoulder injuries
• can do surgery too

Question 6

what investigations done for instability shoulder injuries?

Answer 6

• x-ray = 1st line
• and MRI angiogram to look for capsule fluid leaks etc

*remember there’s more associated injuries to look out for like rotator cuff injury, humerus fracture etc

Question 7

what is impingement syndrome?

Answer 7

• big like bucket disease that loads of things can be in

= when people have pain originating in subacromial space

• can be intrinsic (tendon or cuff problems) or extrinsic (acromion, coracoacromial ligament, osteophyte)

Question 8

what is typical presentation of impingement? (type of cuff disease)

Answer 8

= classically pain right over end of shoulder at arm

• painful arc, painful picking up something far away, neck pain & vague pins & needles

Question 9

what are different causes of impingement syndrome more typical for what age? i.e. 30s more likely X causing impingement

Answer 9

30s = tendonitis or bursitis
30-40s = calcific tendons
40-50s = tendinosis or partial tears
50-60s = cuff tears
70s = cuff arthropathy

Question 10

what are investigations for impingement?

Answer 10

x-ray for calcification around head
- can then progress to MRI or ultrasound

Question 11

what is treatment of impingement?

Answer 11

• mainly rest & activity modification,
• pain relief like NSAIDs
• physio
• couple steroid injections
• keyhole operation last resort - less done now, painful rehab & lots of physio

Question 12

what is typical presentation cuff tear?

Answer 12

“grey hair cuff tear” = 50-60s
- weakness & pain (sometimes other muscles compensate if tear which means won’t present until later)

*weakness important syndrome - test with rotator cuff resistance clin skills

Question 13

what is investigations done for cuff tear?

Answer 13

x-ray = see migrating head

• ultrasound if good movement, MRI if not good movement

Question 14

what is treatment for cuff tear?

Answer 14

rest, analgesia, sling

chronic = physio & steroid injection
acute = urgent investigation, early physio and if doesn’t settle then early intervention with surgery (good, long ish recovery but good)

Question 15

what is typical presentation of frozen shoulder?

Answer 15

• severe pain coming in short period of time, can’t move or lie on shoulder. feels like gripping pain deep inside. pain at night & rest
• lost more than 50% of external rotation
• stiffness
• more in females 40-50s
• associated with diseases such as dupuytren’s

Question 16

what is frozen shoulder?

Answer 16

= also called adhesive capsulitis. contracture & thickening of coracohumeral ligament (external rotation main issue)

= tightening & decreases joint volume. it’s basically the ligament in capsule getting thicker & firmer & less elastic = bad movement

Question 17

what are the phases of frozen shoulder?

Answer 17

basically frozen shoulder comes on and lasts for like 3-4 years, easy to think of in 3 phases

1. freezing = very very sore, reduced movement
2. frozen = acute pain settles, very stiff & barely movement
3. thawing = pain reduces and more movement comes back

Question 18

what is the treatment of frozen shoulder?

Answer 18

• gentle movements
• analgesia
• physio
• steroid injections
• fluoroscopic distension →air or saline forcefully pumped in to expand joint until pops, not painful for patient but they can feel something changes. helps movement

Question 19

what are the only 3 differential diagnosis if lack of passive external rotation?

Answer 19

1. locked posterior dislocation
2. severe glenohumeral arthritis
3. frozen shoulder
   →these all seen on plain x-ray so xray important

Question 20

what is presentation of glenohumeral osteoarthritis?

Answer 20

• over 60s
• uncommon location
• gradual location
• intermittent exacerbations
• pain at rest & night
• stiffness
• functional difficulties

can see radiographic features of arthritis = joint space narrowing, subchondral sclerosis, subchondral cysts, osteophyte formation

Question 21

what is risk factors of carpal tunnel syndrome?

Answer 21

• female, often pregnancy or hormonal fluctuations
• hypothyroidism
• obesity
• diabetes
• rheumatoid arthritis

Question 22

what is common presentation of carpal tunnel syndrome?

Answer 22

• under 30
• pins & needles
• pain (very varied)
• clumsiness
• early morning awake = shake & relieves
• driving, reading & phone use pain
• thenar atrophy, altered sensation, weakness APB

Question 23

what is cause of carpal tunnel syndrome?

Answer 23

→due to relative reduction of blood supply (intrinsic or extrinsic) causing compression of tunnel, the nerve easily squished (9 tendons & median nerve)

median nerve muscles = LOAF (lumbricals, opponens, abductor pollicis brevis, flexor pollicis brevis)

Question 24

what are tests for carpal tunnel syndrome?

Answer 24

test abductor pollicis brevis best by thumb up to sky against resistance

= durkins test (compression), tinels test )tapping), phalens (flex wrist for long time and they’ll feel tingling)

Question 25

what is presentation of cubital tunnel syndrome?

Answer 25

• ulnar pins & needles
• lean on elbow or flex elbow for long time = pins & needles
• pain
• clumsiness = especially fine motor skills
• numbness & weakness

Question 26

what are risk factors for cubital tunnel syndrome/what causes?

Answer 26

• under 30
• males
• post traumatic
• direct pressure from cysts & tumours
• arthritis around elbow
• heavy lifting

= causes compression of ulnar nerve

Question 27

what are signs of cubital tunnel syndrome?

Answer 27

• hypothenar & interosseous atrophy
• clawing of ring finger & small finger
• altered sensation
• weakness of abducens digiti minimi

Question 28

what are tests for cubital tunnel syndrome?

Answer 28

tinels test (tapping). modified phalan’s test (elbow flexion test), froment’s test (thumb flexion during holding like peice of paper)

Question 29

what is treatment for compressive neuropathies?

Answer 29

• elbow splint for cubital & splint for carpal
• physio
• NSAIDs
• if severe ulnar or median nerve decompression. day surgery. quick rehab, successful. recurrence rate low. high success rate

Question 30

what is golfers elbow? where is pain?

Answer 30

chronic overuse of flexors of hand (twisting & swinging)

pain = felt at medial epicondyle (where flexor muscles attach)
- pain on flexion and pronation

Question 31

what is clinical test for golfers elbow?

Answer 31

flex elbow in supination, pain on resisted wrist flexion

Question 32

what is tennis elbow? where is pain felt?

Answer 32

= overuse injury of wrist and hand extensors

pain = felt at lateral epicondyle, on wrist extension and pronation

Question 33

what is clinical test for tennis elbow?

Answer 33

flex elbow in pronation, pain on resisted middle finger & wrist felt at lateral epicondyle