Frozen shoulder; Tennis & Gold elbow; Rotator cuff injury Flashcards
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What are the four rotator cuff muscles? [4]
What movements do they cause? [4]
S – Supraspinatus – abducts the arm
I– Infraspinatus – externally rotates the arm
T – Teres minor – externally rotates the arm
S – Subscapularis – internally rotates the arm
Describe the spectrum that rotator cuff injuries occur on [1]
Rotator cuff injury is a continuum ranging from impingement to partial and full thickness tears.
Describe the difference between intrinsic tendon degeneration versus impingement syndrome in rotator cuff injuries
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
The combination of extrinsic compression and intrinsic degeneration contributes to the spectrum of clinical findings associated with SIS.
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]
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.
What movement would be impaired if the supraspinatus is injured?
External rotation
Internal rotation
Abduction
Adduction
What movement would be impaired if the supraspinatus is injured?
External rotation
Internal rotation
Abduction
Adduction
What movement would be impaired if the teres minor is injured?
External rotation
Internal rotation
Abduction
Adduction
What movement would be impaired if the teres minor is injured?
External rotation
Internal rotation
Abduction
Adduction
What movement would be impaired if the subscapularis is injured?
External rotation
Internal rotation
Abduction
Adduction
What movement would be impaired if the subscapularis is injured?
External rotation
Internal rotation
Abduction
Adduction
What movement would be impaired if the infraspinatous is injured?
External rotation
Internal rotation
Abduction
Adduction
What movement would be impaired if the infraspinatous is injured?
External rotation
Internal rotation
Abduction
Adduction
This tests which muscle?
External rotation
Internal rotation
Abduction
Adduction
Gerbers lift off test:
- subscapularis
Individuals with rotator cuff injuries can be broadly divided into 2 groups according to their presenting clinical features:
What are these? [2]
Those with subacromial impingement symptoms (SAIS) or symptoms of a torn rotator cuff tendon
Describe the symptoms of the following with subacromial impingement symptoms (SAIS) or symptoms of a torn rotator cuff tendon
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
In those with suspected SAIS, two common examination signs can be elicited
What are they? [2]
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
In those with suspected rotator cuff tendon tears, three common examination signs can be elicited
What are they? [3]
‘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
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.
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.
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]
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