CL1: The Frozen Shoulder

Question 1

What type of shoulder pain are older people likely to suffer from?

Answer 1

Rotator cuff disease

Question 2

What type of shoulder pain are younger people likely to suffer from?

Answer 2

Scapulothoracic rhythm

Question 3

Gives details of the glenohumeral joint.

Answer 3

Glenohumeral joint:

- True synovial joint 
- It is the least stable of the large joints due to it being multi-axal 
- Lax capsule allows rotation and elevation (The shoulder joint capsule is the ligament that surrounds the shoulder joint. It stabilizes the shoulder by keeping the head, or ball, of the upper arm bonecentred in the glenoid socket in your shoulder blade.)

The synovial tissue and the capsule go all the way down into the biceps.

The capsule is thickened anteriorly to prevent dislocation as the anterior aspect has no bony barrier. This is why most people have an anterior dislocation.

Question 4

Give details of the acromioclavicular joint.

Answer 4

Acromioclavicular joint

- Fibrous 
- Little movement - allows full abduction, adduction and flexion 
- Not usually the one that causes pain
- Interacts with subacromial space 
- The ligaments here include the acroclavicular ligament, coracoacromial ligamnet and the coracoclavicular ligament

Question 5

Give details of the sternoclavicular joint.

Answer 5

Sternoclavicular joint
- Attaches the shoulder to the thorax
The joint rotates as it elevates by 30-40 degrees

Question 6

What muscles allow for abduction?

Answer 6

• The supraspinatus externally rotates. It also causes the first 30 degrees of abduction
  
  • The deep muscles depress the humeral head preventing the now unopposed deltoid action (towards the acromion) - allowing the next 30-90 degrees of abduction
    The Trapezius causes the next 90-189 degrees of abduction

Question 7

What muscles allow for adduction?

Answer 7

Pectoralis major and latissimus dorsi

Question 8

What muscles allow for flexion?

Answer 8

Pectoralis major and anterior deltoid

Question 9

What muscles allow for extension?

Answer 9

Latissimus dorsi and teres major and posterior deltoid

Question 10

What muscles allow for lateral rotation?

Answer 10

Infraspinatus

Question 11

What muscles allow for medial rotation?

Answer 11

Pectoralis major, Latissimus dorsi and deltoid

Question 12

What is the subacromial bursa?

Answer 12

Subacromial bursa A bursa is a thin lubricated cushion located at points of friction. It helps to reduce friction between bones and tendons and muscles around a joint. The bursa separates the superior surface of the supraspinatus tendon and the acromion. It can become inflamed. There are many bursas.

Question 13

What is involved in the assessment of the shoulder?

Answer 13

Assessment: 
	- History 
	- Inspection 
	- Palpation 
Movement - active, incl. resisted, passive (doctor moves the arm) and tests

Question 14

What is involved in the history of shoulder pain?

Answer 14

History

- Age, sex - older people get more rotary cuff and younger people more instability with the  STJ (sterothoracic joint)
- Females are more affected by instability in any join by men 
- Repeated or multi-use are often female 
- Trauma/activities 

- Pain can be referred. It may be into the hand, back or front of the shoulder, deltoid insertion (very common). Adhesive capsulitis (deep seated shoulder pain). Pain at night is also common. Diabetes, inflammatory disease, occupation and CVS may increase your risk of certain conditions

Question 15

What is involved in inspection of the shoulder?

Answer 15

Inspection 
	- Undress and compare each side 
	- Anterior, posterior and lateral view
	- Swelling and deformity 
	- Neck position 
	- Muscle wasting 
	- Asymmetry of scapulohumeral rhythm 
	- Sign if scapula winging 
Tendon rupture-biceps  can be easily seen

Question 16

What is involved in palpation of the shoulder?

Answer 16

Palpation

- Bicipital groove, rotator cuff (compare) 
- Consider calcific tendonitis if tender
- Trigger and tender points 
- Osteophytes - Osteophytesare bony lumps (bone spurs) that grow on the bones of the spine or around the joints due to regeneration of damaged bone. They often form next to joints affected by osteoarthritis, a condition that causes joints to become painful and stiff.
- Crepitus - Crepitusis the abnormal popping or crackling sound in either a joint or the lungs
- GH vs SAB (subacromial bursitis) swelling

Question 17

What are the differential diagnoses in shoulder pain?

Answer 17

Differential diagnosis

- Joint/Capsule   - Arthritis                
		      - Capsulitis ‘frozen shoulder’

- Tendons        - Rotator cuff tendinopathy    
		  - Bicipital tendinopathy    

	- Calcific tendinopathy    
				§ SCJ, ACJ
	- Instability
	- Referred    - cervical, thorax, abdomen, brachial 
Regional pain syndrome

Question 18

What is frozen shoulder?

Answer 18

Adhesive capsulitis: Frozen shoulder happens when the tissue around your shoulder joint becomes inflamed. The tissue then gets tighter and shrinks, which causes pain. Frozen shoulder can happen because: you had an injury or surgery that keeps you from moving your arm normally.

“This is a condition of unknown aetiology in which there is a painful global restriction of GH movements in all planes, both active and passive, in the absence of joint degeneration sufficient to explain this restriction”

Question 19

Give details of frozen shoulder.

Answer 19

• It is rare in under 40s, usually found in 60s. There is a slight female preponderance. May be precipitated by trauma, MI or a cerebrovascular accident. Becomes contralateral in 6-15% in 5 years. Found in 2-3% of diabetics.
• Histology shows increase fibrous tissue and fibroblasts.
• Around 2/3rd have reduced range of motion. 10-15% have reduced function. There is no link between duration and outcome. Corticosteroids reduce symptoms but not the duration of the disease.
• Early phase more like neuropathic pain with allodynia (where pain is caused by a stimulus that does not normally elicit pain). There is evidence of a neurogenic mechanism. There has been evidence of sympathetic dysfunction (hyper reactivity) in the upper limbs of many with adhesive capsulitis (this may explain the link between hyperthyroidism and capsulitis).

Question 20

What is calcific tendinopathy?

Answer 20

1. Calcific tendinopathy - the presence ofcalcificdeposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons.
   Calcific tendinopathy is a self-limiting condition.Symptoms may last several days or become chronic; there is no clear prediction of disease course.Time required for symptoms to disappear is typically too long for patient’s QoL. The typical clinical manifestation is a sub-acute, low-grade shoulder pain that increases at night (50% of patients), with restricted range-of-motion.