Disorders of the Shoulder

Question 1

Shoulder Pain

Answer 1

3rd most common joint pain
When considering pain the shoulder extra-shoulder causes must be excluded and peri-articular and articular causes considered

Question 2

Causes of pain referred to the shoulder

Answer 2

Cervical Spondylosis
Mediastinal pathology
Cardiac ischaemia

Question 3

Non-shoulder pathologies to be excluded

Answer 3

Infection
Fracture
Tumours

Question 4

Shoulder disorders

Answer 4

Extracapsular - Rotator Cuff pathologies

Intracapsular - joint instability, adhesive capsulitis, OA/RA

Question 5

History of shoulder pain

Answer 5

Must identify - pain, stiffness/loss of movement, deformity, functional loss,

Question 6

Examining shoulder pain

Answer 6

Must look (skin changes, scars, swelling), feel (temperature, creptitus, tenderness) and move (actively and passively)

Question 7

Special tests for shoulder pain

Answer 7

Impingement tests (painful arc)
Instability/apprehension tests

Question 8

Shoulder problems in a young adult

Answer 8

Instability until proven otherwise - especially if they play lots of contact sports

Question 9

Shoulder problems in a middle aged person

Answer 9

Rotator Cuff - impingement (tendinosis/tendinitis)
- Partial or complete RC tears
Adhesive capsulitis/Frozen shoulder

Question 10

Shoulder problems in a old person

Answer 10

Rotator cuff disorders - impingement, tears or arthropathy

OA

Question 11

Rotator Cuff impingement

Answer 11

The tendons of the RC become inflamed as they pass under the acromion - or are squeezed by bony spurs or swollen subacromial bursa
This causes pain, weakness and loss of movement with a painful arc from 60-120 degrees

Question 12

Management of Rotator Cuff impingement

Answer 12

Conservative – analgesia/NSAIDs, LA, physiotherapy

Acromioplasty

Question 13

Causes of RC impingement (4)

Answer 13

Inflammation of the tendons of the RC
Bony spurs from the Acromion
Swollen subacromial bursa
RC weakness allowing the humeral head to move superiorly

Question 14

Investigations for shoulder disorders (5)

Answer 14

X-rays, USS, MRI, CT scans, Arthroscopy

Question 15

Calcific tendinitis

Answer 15

The deposition of calcium crystals in muscle tendons particularly in the shoulder causing pain and inflammation
This can cause a ‘frozen shoulder’

Question 16

Adhesive capsulitus (frozen shoulder)

Answer 16

A disorder of thickening, contracture & adhesion formation of the shoulder capsule causing pain and limited movement (external rotation most effected) - middle aged or women. initial severe pain with some stiffness, which then lessens and is replaced by more stiffness which eases over a number of years

Question 17

AC joint problems

Answer 17

Most commonly affects males in their 20s
Most commonly traumatic joint disruption from contact sports or OA related
Will be severe pain and if separated there will be a visible ‘step’

Question 18

Rotator Cuff Disorders

Answer 18

Present 35-75yrs, Tendon tears usually follows trauma in young people but can be atraumatic in the elderly
Partial tears are often hard to distinguish from tendonitis but complete tears may cause ‘shoulder drop’ when lowering past 90 degrees

Question 19

Causes of Shoulder Instability

Answer 19

Can be traumatic, atraumatic or due to muscular problems

Repeated trauma will produce instability as will Rotator cuff or labrial tears

Question 20

Treatments of Shoulder instability

Answer 20

Conservative if the problem is minor and the patient does not want to continue sports etc
Surgical - arthroscopic (Bankart repair) stabilization or if there is multidirectional instability can use a capsular shift

Question 21

Management of Shoulder OA/RA

Answer 21

Management should be conservative and medical at first to limit disease progression –> if there is significant pain then joint replacement should be considered

Question 22

Causes of adhesive capsulitis

Answer 22

Immobility or systemic diseases (diabetes)
Spontaneous or after shoulder surgery
Calcific tendinitis

Question 23

Rockwood classification of ACJ disruption

Answer 23

I - Sprain without tear II - AC ligaments torn but CC not
III - Both sets of ligaments torn with >5mm elevation-+#
IV - Lateral clavicle separated and displaced posteriorly
V - Complete separation of the scapula and clavicle
VI - As with V but with inferior detachment of the clavicle

Question 24

Management of ACJ dysfunction

Answer 24

Type I and II managed conservatively with sling for 1-3wks and physiotherapy - type III usually also managed like this
Type IV, V & VI should be treated with ORIF