MSK - Shoulder Pain Flashcards

1
Q

When taking a shoulder pain history - how might patients describe each aspect of SOCRATES?

A

Shoulder Pain:

  • Site:
    • Tip of shoulder / on the bone
    • Deep / muscular
  • Onset:
    • Sudden - trauma
    • Insidious
  • Character:
    • Aching, stabbing, burning
  • Radiation:
    • From chest - pericarditis
    • Into neck
    • Down arm
  • Associated symptoms:
    • Reduce range of movement
    • Stiffness
    • Swelling
  • Timeline:
    • Worsening progressively?
  • Exacerbating / make it better:
    • Worse in morning or evening?
    • Movement make it better or worse?
    • OTC analgesia helping
  • Severity:
    • Intensity x/10
    • Impat on daily living e.g. able to dress self, shopping, work
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2
Q

What special tests might you perform in a shouler exam?

A

Empty Can Test: - tests for supraspinatus muscle + tendon

  • Abduct arm to 90 degrees
  • Forward flex arm 30 degrees
  • Medially rotate arm and point thumb downwards
  • Apply downward pressure (pt resists) - if unable then supraspinatus issue

Lift Off Test: - tests for subscapularis + tendon

  • Stand or sit comfortably
  • Bring dorsum of hand to lumbar spine
  • Ask patient to lift hand backwards away from lumbar spine (involve medial rotation of shoulder)
  • Apply resistance (press hand towards spine)

Scarf Test / crossover test: - tests acromial-clavicular joint

  • Sit up on edge of couch
  • You pot one hand on non-test shoulder (to stabilise pt)
  • Use other hand to abduct test arm 90 degrees + straight and then move across patients trunk towards other shoulder
  • Pain at end of movement/earlier = abnormal

Hawkins-Kennedy Test: - test for impingement between coracoid + acromioclavicular joint (alternatively Neer’s impingement test)

  • Pt sits on edge of couch
  • Arm abducted 90 and flexed at elbow 90, plam down
  • Medial rotation (bend forearm at elbow 90 degrees towards midline)
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3
Q

What are the main presenting features of a Rotator Cuff injury?

A
  • Painful arc of abduction
  • Subacromial impingement - inflammation/irritation of rotator cuff tendons as they pass through subacromial space
    • Typically between 60 and 120 degrees
  • For rotator cuff tears pain may be in 1st 60 degrees
  • Tenderness over anterior acromion
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4
Q

What are the main features of Adhesive Capsulitis ‘Frozen Shoulder’?

A
  • Inflammed + stiff connective tissue surrounding glenohumeral joint
  • Features:
    • Tend to have pain, then stiffness + pain then long term stiffness alone
    • Pain elicited by direct pressure to coracoid process
    • Limited shoulder movement in all directions
    • Loss of external rotation and abduction (50% pts)
  • Risk factors:
    • F > M
    • Aged 40-70
    • Tonic seizures
    • Diabetes
    • Trauma
    • CTD
    • Thyroid disease
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5
Q

Which 4 muscle compose the rotator cuff?

What is the action and innervation of the rotator cuff muscles?

A
  • Supraspinatus:
    • Action: abduction (mainly first 15 degrees - then is deltoid) + maintining humeral head in glenoid cavity
    • Innervation: suprascapular nerve
  • Infraspinatus:
    • Action: external rotation
    • Innervation: suprascapular nerve
  • Teres minor:
    • Action: external rotation
    • Innervation: auxillary nerve
  • Subscapularis:
    • Action: internal rotation
    • Innervation: upper and lower subscapular nerves
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6
Q

There is a spectrum of rotator cuff injury, consisting of 4 stages - what are they?

A
  1. Subacromial impingement (impingement syndrome)
  2. Clalcific tendonitis
  3. Rotator cuff tears
  4. Rotator cuff arthropathy - composed of:
    • Rotator cuff tear (big) - causes insufficiency
    • Degenerative changes e.g. glenoid/humeral erosions, articular chondral loss, subchondral osteoporosis, humeral head collapse
    • Superior migration of humeral head - causes remodeling of acromion termed ‘acetabularisation’ - excavation + thinning
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7
Q

What are the demographics + risk factors for rotator cuff arthropathy?

A

Demographics:

  • F > M
  • 7th decade most common

Risk factors:

  • Rotator cuff tear
  • RA
  • Crystalline-induced arthropathy (gout / pseudogout)
  • Haemorrhagic shoulder (hemophiliacs and elderly on anticoagulants)
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8
Q

How does rotator cuff arthropathy present?

A
  • Symptoms:
    • Pain, night-pain
    • Weakness
    • Stiffness
  • Examination:
    • Supraspinatous / infraspinatous atrophy
    • Prominence of humeral head anteriorly with elevation of arm
    • Limited ROM both active + passive
    • Inability to abduct shoulder
    • External rotation lag sign - inability to maintain passively externally rotated shoulder with elbow at 90 degrees (when +ve shoulder will medially rotate)
      • Supraspinatous tear
    • Hornblower sign - can’t externally rotate or maintain passive external rotation of a shoulder placed in 90 degrees of elbow flexion and 90 degrees of shoulder abduction
      • Teres minor dysfunction
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9
Q

What does conservation + non-surgical treatment for rotator cuff arthropathy involve?

A

Conservative:

  • Simple analgesia
  • Physiotherapy - to recruit deltoid for abduction

Non-surgical:

  • Subacromial steroid injection + local anaesthetic
    • Check pt isn’t on anticoagulation or diabetic (steroids can induce hyperglycaemia + ↑ risk of infection)
    • Steroid injection precludes surgical intervention with prosthesis or bone anchors for 3 months minimum (↑ infection risk)
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10
Q

What surgical interventions may be used in treatment of rotator cuff arthropathy?

A
  • Tendon repair - sutures + bone anchors
  • Subacromial decompression - remove inflammed tissue, creating space for normal cuff movement
  • Remove osteophytes from under surface of acromion
  • Arthroplasty - often aim is to alleviate pain, with ROM remaining restricted e.g. abduction + forward flexion to 90 degrees is good outcome
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11
Q

What are the 3 phases of tendon healing?

A
  1. Inflammation
  2. Proliferation
    • Type III collagen produced
  3. Remodelling
    • Replacement of type III collagen with type I
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12
Q

How many ligmanets of the shoulder joint are there and what are they?

A

5

  • Transverse humeral ligament - between greater + lesser tubercles of humerus
  • Coracohumeral ligament - coracoids to greater tubercle
  • Glenohumeral ligaments: - margin of glenoid fossa to lesser tubercle + anatomical neck of humerus
    • Superior
    • Middle
    • Inferior
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13
Q

What movement is commonly restricted in both osteoarthritis and a frozen shoulder?

  • Abduction
  • Internal rotation
  • Extension
  • External rotation
  • Flexion
A

External Rotation

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14
Q

A past medical history of Diabetes or Thyroid disease predisposes to which pathology of the shoulder?

  • Biceps tendinopathy
  • Frozen shoulder / adhesive capsulitis
  • Impingement syndrome
  • Osteoarthritis
  • Rotator cuff pathology
A

Frozen shoulder / adhesive capsulitis

  • Patients with diabetes or thyroid disease are at higher risk of frozen shoulder
  • 10-20% of patients with diabetes will develop frozen shoulder
  • Concurrent bilateral frozen shoulder is rare but sequential of the contralateral side is common in these patient groups
  • It is unusual to have recurrence of frozen shoulder on the same side
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15
Q

What is the most commonly injured nerve in shoulder dislocation?

  • Axillary nerve
  • Median nerve
  • Musculo-cutaneous nerve
  • Mutliple plexus injury
  • Radial nerve
A

Axillary nerve

  • he axillary nerve wraps posteriorly around the humerus and is the most commonly injured nerve in dislocation of the shoulder
  • This can be tested with sensation in the regimental badge area and through deltoid contraction
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16
Q

What is the most common direction for dislocation of the shoulder?

A

Anteriorly

  • Note: Commonality of posterior dislocation increases in electrocution and seizures … but anterior dislocation is still more common