Frozen shoulder; Tennis & Gold elbow; Rotator cuff injury

Question 1

*

What are the four rotator cuff muscles? [4]
What movements do they cause? [4]

Answer 1

S – Supraspinatus – abducts the arm (first 20/30 degrees)
I– Infraspinatus – externally rotates the arm
T – Teres minor – externally rotates the arm
S – Subscapularis – internally rotates the arm

Question 2

Which nerves invervates the rotator cuff muscles and what are their nerve roots? [4]

Answer 2

Supraspinatous muscle:
- Suprascapular nerve
- C5-C6

Teres minor:
- axillary nerve
- C5-C6

Infraspinatous muscle:
- Suprascapular nerve
- C5-C6

Subscapularis muscle:
- Subscapularis nerve
- C5-7

Question 3

Describe the spectrum that rotator cuff injuries occur on [1]

Answer 3

Rotator cuff injury is a continuum ranging from impingement to partial and full thickness tears.

Question 4

Describe shoulder anatomy that prediposes impingement syndrome [3]

Answer 4

Impingement syndrome is caused by rotator cuff tendonitis as the tendons pass beneath the acromion. The supraspinatus muscle’s tendon is most commonly affected.

Patients with impingement syndrome often complain of pain when their arms are raised (this is particularly common in mechanics and manual labourers who work with their arms overhead).

When the arm is raised, the subacromial space narrows, which can result in impingement of the supraspinatus muscle tendon leading to an inflammatory response.

Question 5

Describe the difference between intrinsic tendon degeneration versus impingement syndrome in rotator cuff injuries

Answer 5

Intrinsic tendon degeneration
* Tendon hypo-perfusion of a watershed area
* Repetitive micro-trauma

Impingement syndrome can be classified as external, internal or secondary:

External
* Compression of rotator cuff tendons as they pass underneath the coracoacromial arch
* Narrowing of this space can occur due to osteophyte formation, bony spurs or malunion after fractures

Internal
* Associated with overhead and throwing sports activities causing small repetitive injuries
* Under surface fraying of infraspinatus tendon on the posterior glenoid
* Increased association with labral disorders

Secondary
* Glenohumeral instability leads to slight humeral head subluxation
* This narrows the acromiohumeral interval

Question 6

Typical findings on clinical examination in supraspinatus impingement syndrome include: [2]

Answer 6

• Pain experienced between 60-120° of shoulder abduction (known as a ‘painful arc’).
• Weakness and pain experienced when the supraspinatus muscle is isolated using the ‘Empty can/Jobe’s test

Question 7

The combination of extrinsic compression and intrinsic degeneration contributes to the spectrum of clinical findings associated with SIS (shoulder impingement syndrome)

As SIS represents a spectrum of pathology associated with damage to the rotator cuff tendons, it can progress with time. The progression of this spectrum can be thought of in 3 stages. Describe them [3]

Answer 7

Stage 1: haemorrhage and oedema surrounding the cuff tendons.

Stage 2: rotator cuff tendinopathy: fibrosis and inflammation of the tendons.

Stage 3: rotator cuff tears (varying degrees of severity). May have corresponding arthritic changes, or a coexistent long head of biceps tear.

Question 8

What movement would be impaired if the supraspinatus is injured?

External rotation
Internal rotation
Abduction
Adduction

Answer 8

What movement would be impaired if the supraspinatus is injured?

External rotation
Internal rotation
Abduction
Adduction

Question 9

What movement would be impaired if the teres minor is injured?

External rotation
Internal rotation
Abduction
Adduction

Answer 9

What movement would be impaired if the teres minor is injured?

External rotation
Internal rotation
Abduction
Adduction

Question 10

What movement would be impaired if the subscapularis is injured?

External rotation
Internal rotation
Abduction
Adduction

Answer 10

What movement would be impaired if the subscapularis is injured?

External rotation
Internal rotation
Abduction
Adduction

Question 11

What movement would be impaired if the infraspinatous is injured?

External rotation
Internal rotation
Abduction
Adduction

Answer 11

What movement would be impaired if the infraspinatous is injured?

External rotation
Internal rotation
Abduction
Adduction

Question 12

This tests which muscle?

External rotation
Internal rotation
Abduction
Adduction

Answer 12

Gerbers lift off test:
- subscapularis

Question 13

Individuals with rotator cuff injuries can be broadly divided into 2 groups according to their presenting clinical features:

What are these? [2]

Answer 13

Those with subacromial impingement symptoms (SAIS) or symptoms of a torn rotator cuff tendon

Question 14

Describe the symptoms of the following with subacromial impingement symptoms (SAIS) or symptoms of a torn rotator cuff tendon

Answer 14

subacromial impingement symptoms (SAIS):
- Pain (79%) typically localised to the anterior superior shoulder / deltoid region
- Worse at night and at rest; worse laying on it
- True shoulder weakness is typically NOT present in SIS unless the patient has progressed to having a significant rotator cuff tear. However, significant pain may cause symptoms similar to weakness.
- Painful arc of motion - during arm abduction, shoulder pain occurs between 60 to 120º; eases beyond 120

Torn rotator cuff tendon:
- Pain is the most commonly reported symptom (83%)
- Muscular weakness and atrophy (50-63%)
- Inability to abduct the arm above 90º

Question 15

In those with suspected SAIS, two common examination signs can be elicited

What are they? [2]

Answer 15

Neer’s impingement test
* Anterolateral shoulder pain reported during forward flexion with arm internally rotated

Hawkin’s test
Forced internal rotation of an arm held at shoulder height and elbow bent at 90º causes anterolateral shoulder pain

Question 16

In those with suspected rotator cuff tendon tears, three common examination signs can be elicited

What are they? [3]

Answer 16

‘Empty can test’
* Evaluates supraspinatus
* Patient’s raise their arm to 90º in the scapular plane
* The arm is internally rotated (thumbs down)
* Downward pressure is applied to their arm
* Presence of weakness or pain indicates a tear

Posterior cuff test
* Evaluates infraspinatus
* Weakness or pain on resisted external rotation suggests a tear

Gerber’s lift-off test
* Evaluates subscapularis
* Patient attempts to lift a hand from small of the back, while resistance is applied
* Weakness or pain suggests a subscapularis tear

Question 17

The [] tendon is commonly implicated in the pathology of SIS as it runs directly beneath the overhanging acromion, and so is especially predisposed to damage.

Answer 17

The supraspinatus tendon is commonly implicated in the pathology of SIS as it runs directly beneath the overhanging acromion, and so is especially predisposed to damage.

Question 18

If patients continue to have symptoms after 6 weeks of non-surgical care for rotator cuff injuries, they can be referred to secondary care for further investigation.

Which type of imaging? [2]

Answer 18

MRI is often the 1st line investigation in hospital

Ultrasound has been shown to have comparable sensitivity to MRI for detecting full-thickness tears and can be performed alongside/instead of MRI

Question 19

Describe the managment plan for rotator cuff injuries

Answer 19

Non-operative:
* 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

Operative:
Acromioplasty:
- Aims to increase the volume of the subacromial space, preventing mechanical irritation of the rotator cuff tendons

Rotator cuff repair:
- Aims to reattach the cuff tendons to the bone

Question 20

Frozen should aka? [1]

Answer 20

Adhesive capsulitis

Question 21

Describe the pathophysiology of frozen shoulder [1]

Answer 21

The glenohumeral joint is the ball and socket joint in the shoulder. The glenohumeral joint is surrounded by connective tissue that forms the joint capsule.

In adhesive capsulitis, inflammation and fibrosis in the joint capsule lead to adhesions (scar tissue). The adhesions bind the capsule and cause it to tighten around the joint, restrict movement in the joint.

Get three stages (probs dont need to know)
1. Freezing Phase: synovitis leads to increased vascular permeability, resulting in capsular oedema, pain, and reduced range of motion (ROM). Progressive fibrosis and angiogenesis and nerve growth occur
2. Frozen Phase: Characterised by the progressive loss of glenohumeral movements due to a stiffened capsule.
3. Thawing Phase: This phase involves the gradual resolution of symptoms

Question 22

Describe the clinical presentation of adhesive capsulitis [4]

Answer 22

Course of symptoms:
Painful phase
– shoulder pain is often the first symptom and often worse at night

Stiff phase
– shoulder stiffness develops and affects both active and passive movement (external rotation is the most affected) – the pain settles during this phase

Thawing phase
– there is a gradual improvement in stiffness and a return to normal

Symptoms
* external rotation is affected more than internal rotation or abduction
* both active and passive movement are affected
* the episode typically lasts between 6 months and 2 years

Question 23

The main differentials in a patient presenting with shoulder pain not preceded by trauma or an acute injury are [3]

Shoulder pain preceded by trauma or an acute injury may be due to [3]

Answer 23

Pain with no trauma:
* Supraspinatus tendinopathy
* Acromioclavicular joint arthritis
* Glenohumeral joint arthritis

Pain preceded by trauma:
* Shoulder dislocation
* Fractures (e.g., proximal humerus, clavicle or rarely the scapula)
* Rotator cuff tear

Question 24

Acromioclavicular (AC) joint arthritis can be demonstrated on examination by which positive test? [1]

Answer 24

Positive scarf test – pain caused by wrapping the arm across the chest and opposite shoulder

Tenderness to palpation of the AC joint

Question 25

Investigations for frozen shoulder? [3]

Answer 25

Clinical diagnosis based on the patient’s history and physical examination

First-Line Investigations
- Xray - rule out other pathologies like OA

Further Investigations
- MRI
- US
- Contrast-enhanced MRI Arthrography

Question 26

Describe the managment for frozen shoulder?

Answer 26

1. Physiotherapy
2. Analgesics
3. Intra-articular corticosteroid injections
4. Surgical intervention:
   - MUA (Manipulation under Anaesthesia): This procedure involves forcibly moving the shoulder joint under general anaesthesia.
   - Capsular release surgery: This is a more invasive procedure where the tight portions of the joint capsule are cut to allow for greater movement.

Question 27

Medial epicondyle act to [] the wrist
Lateral epicondyle act to [] the wrist

Answer 27

Medial epicondyle act to flex the wrist
Lateral epicondyle act to extend the wrist

Question 28

Which of the following clinical findings is most consistent with a diagnosis of frozen shoulder (adhesive capsulitis)?

Only active movement limited + internal rotation most affected
Active and passive movement limited + abduction most affected
Active and passive movement limited + external rotation most affected
Active and passive movement limited + internal rotation most affected
Only active movement limited + external rotation most affected

Answer 28

Active and passive movement limited + external rotation most affected

Question 29

QuesMed

Which two symptoms are most associated with frozen shoulder? [2]

Answer 29

Pain and stiffness