O&T SC057: A Painful Shoulder: Shoulder Problems

Question 1

History taking in Shoulder

Answer 1

HPI:
1. Pain
- Location (Genuine shoulder pain?)
—> Shoulder (anterior, diffuse, posterior etc.)
—> Neck (cervical spine problem)
—> Inter-scapular region (thoracic spine problem)
—> Chest
—> Head / Chin
—> Shoulder pain / Radiculopathy pain (e.g. C5 cervical radiculopathy) / Referred pain (e.g. cholecystitis)
—> ***“Can you lie on affected shoulder during sleeping?”

• ***Mechanical vs Rest
• **History of Trauma
  —> **Mechanism of injury (High / Low energy)
  —> ***Injury is significant?
  ——> Definite traumatic in High energy trauma in normal tissue
  ——> Degenerative / Overuse in Low energy trauma in “weakened” tissue

2. ***Age
   - Young: Traumatic / Overuse
   - Elderly: Degenerative
3. Duration, Progress, Severity, Provoking / Relieving factors, Response to treatment
4. Associated symptoms
   - **Stiffness (↓ passive ROM) —> ask **ADL
   - **Weakness (↓ active ROM) —> ask **ADL
   - Instability
   - Deformity
   - Swelling
   - “Hotness” / Discharge
   - Crepitation, Clunking, Snapping
5. ***ADL
   - Extent: Involvement of 1 plane / Global involvement of whole shoulder
   - Severity
6. Dominant shoulder
7. Systemic + Constitutional symptoms
8. Risk factors (including occupation, sport, past health, social history, etc.)

Question 2

Mechanical vs Rest pain

Answer 2

Mechanical pain:
1. Trauma
- Fracture
- Dislocation
- ***Rotator cuff tear
- Superior labral lesion anterior to posterior (SLAP)

2. Degenerative
   - Osteoarthritis
3. Overuse
   - ***Impingement syndrome
4. Others
   - Synoviochondromatosis

Rest pain:
1. Inflammatory
2. Infection
3. Neoplasm
4. Others
- ***Frozen shoulder
- Calcific tendinitis

Can be Combination!

Question 3

Rest pain:
- Neoplasm
- Inflammatory: Systemic inflammatory joint disease
- Infection

Answer 3

Neoplasm:
- **Painless swelling
- **Present with pain only when it is in a late stage
—> Rapidly growing tumor
—> Pending pathological fracture
—> Pressure effect on adjacent structure
- ***Painful in uncommon neoplastic condition (e.g. osteoid osteoma)

Inflammatory: Systemic inflammatory joint disease:
- e.g. RA
- ***Other joint involvement
- Deformity, Swelling, Morning stiffness, etc.

Infection:
Acute bacterial infection:
- ***Fever, chill, rigor
- Superficial vs deep

Chronic infection:
- Low grade fever
- Swelling, sinus discharge, etc.

Question 4

Significant injury vs Trivial injury

Answer 4

Significant:
- Injured tissue is normal before injury —> **Potential to heal —> Can do **early surgery to facilitate healing
- Tissue damage because force > ultimate failure strength of tissue
- e.g. fracture distal clavicle, shoulder dislocation
—> ***Definite traumatic problem
—> Young patients: High energy trauma
—> Elderly patients: Low energy trauma

Trivial:
- Injured tissue is weakened by pre-existing pathology
- Tissue is damaged even under physiological loading
- e.g. degenerative rotator cuff tear
—> **Degenerative (Elderly) / **Overuse (Young) instead of Traumatic
—> Probability of healing is **low though symptoms may improve with **non-operative treatment

No injury:
- Exacerbation of symptoms of a pre-existing pathology
- No new / recent damage
- e.g. osteoarthritis of shoulder
—> **Degenerative (Elderly) / **Overuse (Young) instead of Traumatic
—> Probability of healing is **low though symptoms may improve with **non-operative treatment

Question 5

Mechanical shoulder pain

Answer 5

**Traumatic conditions (after significant injury):
Young:
1. **Bankart lesion
2. **Dislocation
3. +/- **SLAP
Clinical features:
- Recurrent shoulder dislocation
- +/- Pain

Elderly:
1. **Rotator cuff tear
2. **Biceps tendon rupture
Clinical features:
- Shoulder pain
- Shoulder weakness +/- pseudoparalysis
- Popeye sign

**Degenerative / **Overuse conditions (Without history of significant injury):
1. **Impingement syndrome
2. **Rotator cuff tear
3. Biceps tendinitis
4. ACJ arthritis
5. GHJ Osteoarthritis
6. Synoviochondromatosis

Question 6

ADL of shoulder symptoms

Answer 6

1. Combing
2. Overhead activity
   —> Forward flexion + Abduction (e.g. Supraspinatus)
3. Dressing
   —> External rotation (patient may pull sleeve up if have problem with external rotation)
4. Button of bra / Scratching back
   —> Internal rotation

—> Involvement of 1 plane / Global involvement of whole shoulder (e.g. Frozen shoulder, Osteoarthritis)

(Ranking shoulder symptoms:
- PROM: Patient report outcome measure
- Example: American shoulder and elbow surgeons score (ASES score))

Question 7

***P/E of shoulder

Answer 7

• Standing / Sitting position
• Normal side before abnormal
• Exposure:
  —> Man: Take over all clothing above waist level
  —> Lady: Expose both shoulders above breast

Inspection (Front + Side + **Back):
- Convenient to examine both shoulders at the same time
1. Swelling (uncommon ∵ muscular joint)
2. Deformity (e.g. scapula dyskinesia, popeye sign)
3. **Muscle wasting (common, esp. rotator cuff: supraspinatus, teres minor, infraspinatus)
4. Wound / Scar
5. Sign of inflammation, sinus tract

Palpation:
1. ***Localised tenderness
2. Effusion
- Initial position of shoulder:
—> “Hand-behind-back” (internal rotate shoulder, put rotator cuff out)
—> Extend and internally rotate the shoulder

• Joints:
  —> Sternoclavicular joint
  —> Clavicle
  —> Acromioclavicular joint (commonest site of tenderness)
  —> Acromion (anterior + lateral + posterior)
  —> Greater tuberosity (commonest site of tenderness) (insertion of rotator cuff: supraspinatus, infraspinatus, teres minor)
  —> Bicipital groove (long head of biceps)
  —> Lesser tuberosity (insertion of subscapularis)
• Muscles:
  —> Biceps, Triceps, Supraspinatus, Infraspinatus

ROM:
1. **Active
2. **Passive
- Convenient to examine both shoulders at the same time
- Active before Passive ROM

3 planes + 6 directions:
1. Sagittal: **Forward flexion + extension
2. Coronal: **Abduction + Adduction
3. Axial: External + **Internal rotation
(*: More functionally important)

Muscle power:
1. ***Rotator cuff
2. Deltoid
3. Biceps
etc.

Special tests:
1. **Impingement syndrome
- **Positive impingement signs (2 active + 3 passive)
—> Active signs: Painful arc, Jobe’s test
—> Passive signs: Neer impingement sign, Lateral impingement sign, Hawkins sign
2. Irritation of long head of biceps
3. Acromioclavicular joint arthritis
4. Instability
etc.

Question 8

Shoulder anatomy

Answer 8

Rotator cuff insertion:
Greater tuberosity:
- Supraspinatus
- Infraspinatus
- Teres minor
Lesser tuberosity:
- Subscapularis

Shoulder Girdle - Joint:
1. ***Glenohumeral joint (movable)
2. Acromioclavicular joint
3. Sternoclavicular joint

Shoulder Girdle - Movable part:
1. ***Scapulothoracic junction (movable)

ROM:
3 planes + 6 directions:
1. Sagittal: **Forward flexion + extension
2. Coronal: **Abduction + Adduction
3. Axial: External + **Internal rotation
(*: More functionally important)

Question 9

P/E: ROM: Forward flexion

Answer 9

Active ROM:
- Standing / Sitting
- Initial position:
—> 0-degree flexion
—> 0-degree abduction

Examiner:
- Ask patient to actively forward flex the shoulder
- Amount of flexion measured in the sagittal plane along an imaginary vertical line along the trunk

Normal:
1. Normal max range (**150 - 180 degree)
2. **Symmetrical
3. Symptoms free (look at patient’s face)

Abnormal:
- Proceed to ***Passive ROM

Passive ROM:
- Examiner forward flexes the shoulder of the patient
- Watch the patient’s face
- ***No need to immobilise scapula (∵ block scapulothoracic joint movement)

Question 10

P/E: ROM: Abduction

Answer 10

Active ROM:
- Standing / Sitting
- Initial position:
—> 0-degree flexion
—> 0-degree abduction

Examiner:
- Ask patient to actively abduct the shoulder
- Amount of abduction measured in the coronal plane along an imaginary vertical line along the side of the trunk

Normal:
1. Normal max range (**150 - 180 degree)
2. **Symmetrical
3. Symptoms free
4. ***Normal scapulothoracic rhythm

Abnormal:
- Proceed to Passive ROM

Passive ROM:
- Examiner abducts the shoulder of the patient
- Watch the patient’s face
- ***No need to immobilise scapula (∵ block scapulothoracic joint movement)

Question 11

Scapulothoracic rhythm

Answer 11

Shoulder Girdle - Joint:
1. ***Glenohumeral joint (movable) (GHJ)
2. Acromioclavicular joint
3. Sternoclavicular joint

Shoulder Girdle - Movable part:
1. ***Scapulothoracic junction (movable) (STJ)

Normal Scapulothoracic rhythm:
- **Sequence (GHJ —> STJ) + **Amount (2:1 ratio)
- from 0 - 180 degree abduction
- GHJ move first (120 degree)
—> followed by movement at scapulothoracic junction (60 degree)
—> overlapping in the middle

Pathology in GHJ (more common than STJ):
- Pain
- Stiffness
- Weakness
- GHJ cannot be moved, despite patient is asked actively abduct the shoulder
- Movement now begins at STJ
—> Rotation of scapula first
—> ***Reverse scapulothoracic rhythm

Reverse scapulothoracic rhythm:
- often first sign before pain, ↓ ROM

Question 12

P/E: ROM: External rotation

Answer 12

Active ROM:
- Standing / Sitting
- Initial position:
—> 0-degree flexion
—> 0-degree abduction
—> ***Medial aspect of elbow touching side of trunk (手肘掂腰)

Examiner:
- Ask patient to actively ER

Normal:
- Normal max range (**45 - 60 degree)
- **Symmetrical
- Symptoms free

Abnormal:
- Proceed to Passive ROM (usually larger than Active ROM even in normal person)

Question 13

P/E: ROM: Internal rotation

Answer 13

Active ROM:
- Standing / Sitting
- Initial position:
—> **“Hand-behind-back”
—> **Along midline in lumbar level
—> ***“Thumb up” position

Examiner:
- Ask patient to move the thumb along the **midline of spine as much as possible
- “Amount of internal rotation” measured as **highest level of vertebrae that the tip of thumb can reach

Normal:
- ***Symmetrical
- Symptoms free

Abnormal:
- Proceed to Passive ROM (very uncomfortable, avoid doing it)

Question 14

Discrepancy between Active and Passive ROM

Answer 14

Indicate NO stiffness in joint

Problem in ***neuro-motor unit:
1. Tendon problem
2. Muscle problem
3. Nerve problem (peripheral nerve / nerve root / CNS)

E.g.: ***Full-thickness full-width Rotator cuff tear

Question 15

P/E: Muscle power: Supraspinatus

Answer 15

• Standing / Sitting
• Initial position:
  —> **20-degree forward flexion (along plane of scapula)
  —> **60-degree abduction (put supraspinatus in maximum contraction)
  —> ***“Thumb down” / “Empty-can” position

Examiner:
- Ask patient to perform ***resisted abduction of shoulder

**Apley Drop Arm sign (Non-functional Supraspinatus i.e. < Grade 3):
- Standing position
- Passive maximum abduction
- Patient is asked to lower her arm
- **Arm drops when abducted to or less than 90-degree (突然間手臂跌)
—> Indicate Functional deltoid but ***Non-functional supraspinatus (e.g. Full-thickness full-width tear of supraspinatus tendon)

Supraspinatus:
- ***Initiation of abduction of shoulder joint (after that Deltoid take over)
- Active in range below 90-degree abduction
- Origin: supraspinous fossa of scapula
- Insertion: upper one third of greater tuberosity
- Innervation: suprascapular nerve

Question 16

P/E: Muscle power: Infraspinatus (+ Teres minor)

Answer 16

• Standing / Sitting
• Initial position:
  —> **0-degree forward flexion
  —> **0-degree abduction
  —> ***Maximum external rotation

Examiner:
- Ask patient to perform resisted ER of shoulder

**Neer Drop Arm sign (Non-functional Infraspinatus i.e. < Grade 3):
- Standing
- Passive maximum ER
- Patient is asked to maintain the ER
- **Arm swings back towards midline (手臂彈翻前面)

Infraspinatus:
- ***External rotation of shoulder joint
- Origin: Infraspinous fossa of scapula
- Insertion: middle one third of greater tuberosity
- Innervation: suprascapular nerve

Question 17

P/E: Muscle power: Subscapularis

Answer 17

• Standing / Sitting
• Initial position:
  —> ***“Hand-behind-back”
  —> Along the midline in lumbar level
  —> Hand rest on the back

Examiner:
- ***Gerber Lift Off test: Ask patient to lift the hand “OFF” the back
- If able to lift hand off the back, patient enjoy ”functional” power of subscapularis (MRC Grade 3 or above)
- Gerber Lift-off test is NEGATIVE

**Lag sign (Non-functional subscapularis i.e. < Grade 3):
- Standing
- Hand on back and is passively lifted off from back by examiner
- Patient is asked to maintain the “lift-off” position
- **Patient fails to maintain and hand drop

Subscapularis:
- ***Internal rotation of shoulder joint
- Origin: Subscapular fossa of scapula
- Insertion: lesser tuberosity of humerus
- Innervation: upper and lower subscapular nerve

Question 18

1. Frozen shoulder (***Adhesive capsulitis)

Answer 18

Primary vs Secondary frozen shoulder

Diagnosis:
Reduction of passive ROM in **ALL directions, esp. **External rotation

Clinical features:
1. Initial phase of **rest pain
—> Followed by **mechanical pain + associated **stiffness of shoulder
2. **Progressive pain + stiffness of the shoulder
3. **Inflammatory changes of the entire rotator cuff and underlying capsule
4. Capsule stick to the humeral head and the intra-articular synovial gusset may be obliterated by **adhesion

Primary (Idiopathic) Frozen shoulder:
- Etiology not well understood
- Typically found in patient in **5th – 6th decade of life
- Risk factor: **DM

1. **“Freezing” stage
   - **Acute Inflammatory Phase (Rest Pain)
   - Component of **Night pain
   - **Diffuse tenderness over the whole shoulder
   - Global painful limitation of both active and passive ROM
   Treatment:
   - **NSAID
   - **Physiotherapy (assisted active mobilisation exercise to maintain ROM)
   - Intra-articular steroid injection
   - **Avoid passive stretching
   - **No surgical intervention at this stage
2. **“Frozen” stage
   - **Stiffness Phase (Mech Pain + Stiffness)
   - Night pain gradually subside
   - **Global stiffness in all direction
   - Pain on end-range of motion
   - PE: Loss of **both active and passive range of motion in all direction (forward flexion, abduction, ER and IR)
   Treatment:
   - Analgesics
   - Physiotherapy
   - ***Start passive stretching
3. **“Thawing” stage
   - **Residual Impairment (Stiffness)
   - Inflammatory phase subside
   - **Stiffness gradually improve
   - **Significant residual stiffness after adequate physiotherapy of 12 - 24 months
   Treatment:
   - Surgery if persistent stiffness:
   —> Manipulation under anaesthesia
   —> Arthroscopic release

Question 19

2. Rotator cuff tear

Answer 19

Rotator cuff tear is a common radiological
finding >=60 yo (>50%!!!), even if there is no symptom —> do NOT overdiagnose / overtreat asymptomatic people!!

Pathogenesis:
1. Intrinsic factor
- **Degenerative
- **Overuse
2. Extrinsic factor
- Repeated mechanical ***impingement by overlying coracoacromial arch (acromion + coracoacromial ligament)

Types:
1. Partial / Full thickness tear
2. Unilateral / Bilateral cuff tear

Natural history:
- Spontaneous healing is unlikely
- Size of tear will progress with tear (at variable rate)
- Chronic complete tear will lead to muscle atrophy + fatty infiltration, which are ***irreversible
- Cuff tear arthropathy (Secondary osteoarthritis) (but uncommon)

Question 20

S/S of Rotator cuff tear

Answer 20

Symptoms:
1. Pain
- **Mechanical pain
- Pain on lying on the affected shoulder
2. **Weakness
- Difficulty in performing overhead activity
3. Stiffness
- Onset of secondary frozen shoulder

Signs:
1. Localised tenderness at the rupture site
2. **Discrepancy between active and passive ROM
3. **Weakness + Wasting of involved muscle group
4. +/- ***Impingement signs
- “Drop Arm” / “Lag” sign (if full thickness, full width tear of the involved tendon)
5. Swelling of shoulder
6. Cuff rupture
(7. Upward migration of humeral head in supraspinatus tendon tear)

Small tear:
- **Pain (mainly)
- Weakness
- Single tendon involvement, usually **supraspinatus
- Impingement sign usually ***positive

Massive Tear:
– Pain / **Pain-free
– **Weakness mainly
– **Lag sign may be present
– **Concomitant involvement of supraspinatus + infraspinatus
– Impingement sign usually ***negative (∵ 已經斷左)

Question 21

Treatment for Rotator cuff tear

Answer 21

Conservative:
- Tendinitis / Small partial thickness tear
- Elderly patient with known chronic massive tear
- Aim: Pain control + Maximise residual cuff function
1. NSAID
2. Physiotherapy (ROM exercise + Cuff muscle strengthening exercise)
3. Subacromial corticosteroid injection

Surgery:
- Symptomatic tear in young patient (<60 yo)
- Small / Medium sized tear
- Acute tear within 3 months

Question 22

3. Impingement syndrome

Answer 22

Painful disorder of shoulder due to **impingement of Rotator cuff **tendons under the ***Corocoacromial arch (during forward flexion / abduction)

2 parts of Corocoacromial arch:
1. **Anterolateral corner of acromion
2. **Coracoacromial ligament

(Causes (from Dex Wu):
1. Supraspinatus Tendonitis
2. Reactive Subacromial Bursitis
3. Acromion Osteophytes
4. Degenerative Coracoacromial Ligament Hypertrophy
5. Osteoarthritis of Acromioclavicular Joint
6. Dialysis-related Amyloidosis (according to McRae)
7. Biceps Tendonitis)

Effect:
1. Tendinitis
2. ***Cuff tear (∵ repeated impingement)
3. Secondary cuff tear arthropathy (i.e. Osteoarthritis of shoulder due to rotator cuff deficiency)

Clinical features:
- **Overhead activity mechanical pain
- Point tenderness over anterior edge of acromion and greater tuberosity
- **Positive Provocative signs (MUST HAVE):

Active signs:
1. ***Painful arc
2. Jobe’s test

Passive signs:
1. Neer impingement sign
2. Lateral impingement sign
3. Hawkins sign

Diagnosis:
- ***>=1 of 5 provocative signs to be positive
- Impingement test is useful in confirming diagnosis + temporarily relief of symptoms

**Impingement test:
- Pre-requisite: Positive Impingement signs before the test
- Inject 2 -10 ml local anaesthetic agent +/- steroid into **subacromial space
- Positive: Alleviation of previous positive impingement signs

Question 23

Treatment for Impingement syndrome

Answer 23

Conservative (success rate 25-75%):
1. **NSAID
2. **Physiotherapy
- Ice therapy
- Mobilisation exercise
- Strengthening exercise to rotator cuff, periscapular muscles + core trunk stabilisers
3. ***Subacromial steroid injection

Surgery:
1. Subacromial decompression

Question 24

P/E: Impingement sign:
1. Painful arc

Answer 24

• Standing / Sitting
• Initial position:
  —> 0-degree flexion
  —> 0-degree abduction

Examiner:
- Ask patient to **actively abduct shoulder
- Observe patient’s face for painful expression
- Repeat the test by asking patient to **lower shoulder down

Positive:
- Pain at the painful arc between ***60 - 120 degrees abduction

Question 25

P/E: Impingement sign:
2. Jobe’s test

Answer 25

• Standing / Sitting
• Initial position:
  —> 20-degree forward flexion
  —> 60-degree abduction
  —> ***“Thumb down” / “Empty-can” position

Examiner:
- Ask patient to perform **resisted abduction of shoulder
- Observe patient’s face for **painful expression

Positive:
- Patient reports **pain during the test and examiner detects **weakness of supraspinatus

Question 26

P/E: Impingement sign:
3. Neer impingement sign

Answer 26

• Standing / Sitting
• Initial position:
  —> 0-degree flexion
  —> 0-degree abduction

Examiner:
- **Stabilises patient’s scapula with one hand (eliminate scapulothoracic motion)
- **Passively forward flexes the shoulder with the other hand up to ***90o (∵ GHJ only responsible for initial 120o)
- Watch patient’s face for painful expression

Positive:
- Pain when shoulder is passively forward flexed to ***70 - 90 degrees of flexion

Question 27

P/E: Impingement sign:
4. Lateral impingement sign

Answer 27

• Standing / Sitting
• Initial position:
  —> 0-degree flexion
  —> 0-degree abduction

Examiner:
- **Stabilises patient’s scapula with one hand (eliminate scapulothoracic motion)
- **Passively abduct the shoulder with the other hand
- Watch patient’s face for painful expression

Positive:
- Pain when shoulder is passively abducted to ***70 - 90 degrees of abduction

Helpful to predict need for acromioplasty

Question 28

P/E: Impingement sign:
5. Hawkins sign

Answer 28

• Standing / Sitting
• Initial position:
  —> 90-degree forward flexion
  —> Slight adduction

Examiner:
- **Warn the patient that it can be painful
- **Internal rotate the shoulder suddenly
- Watch patient’s face for painful expression

Positive:
- Pain on sudden internal rotation of shoulder

(Too sensitive, positive in many pathologies, not useful)

Question 29

***Summary of lecture

Answer 29

1. Frozen shoulder
   - **Rest pain initially
   - Decreased in **Passive ROM of **ALL directions of shoulder motion esp. **External rotation
2. Rotator cuff tear
   - **Mechanical pain
   - **Discrepancy between Active and Passive ROM
   - ***Weakness of cuff muscle
   —> Supraspinatus: Apley Drop Arm sign
   —> Infraspinatus (+ Teres minor): Neer Drop Arm sign
   —> Subscapularis: Lag sign
3. Impingement syndrome
   - **Mechanical pain
   - **Positive impingement signs (2 active + 3 passive)
   —> Active signs: Painful arc, Jobe’s test
   —> Passive signs: Neer impingement sign, Lateral impingement sign, Hawkins sign
   - Impingement test (Injection of LA to alleviate previously positive impingement signs)
   - Usually no weakness unless no cuff tear

Question 30

4. Calcific tendinitis

Answer 30

• **Sudden onset of **severe rest pain
• Female
• 30 - 50 yo
• ***Cell-mediated calcification in a tendon and is usually followed by spontaneous resorption

3 stages:
1. Pre-calcific stage (no pain)
- Fibrocartilaginous metaplasia of tenocytes into chondrocytes

2. **Calcific stage
   - **Formative phase (+/- pain)
   —> **Calcium crystals deposition occurs within the tendon
   —> Seldom symptomatic
   —> Treatment: **Observation

• **Resting period (+/- pain)
  —> Macrophages + multinucleated giant cells surround the calcium deposits and start to initiate resorption through inflammatory process
  —> **Severe, acute onset pain (∵ edema + sudden increase in intratendinous pressure)
• Resorptive phase (Painful)
  —> Spontaneous resolution is likely
  —> ***Pain control (NSAID)
  —> Maintain ROM
  —> Needle aspiration + lavage (relieve
  intratendinous pressure)

3. ***Post-calcific stage
   - Reconstitution back to normal tendon

Chronic Calcific Tendinitis:
- Spontaneous resorption of calcium deposit fails
- Progressive pain due to **impingement
- Mechanical pain
Treatment:
- **Extracorporeal Shock Wave Therapy
- ***Arthroscopic Excision

Question 31

5. Fracture

Answer 31

Young patients:
- Higher energy trauma
- **Fracture clavicle
- **Fracture shaft of humerus

Elderly patients:
- Low energy trauma (e.g. fall on outstretched hand)
- Osteoporosis
- ***Proximal humerus

Question 32

6. Dislocation

Answer 32

Classification:
- Anterior / Posterior
- Acute / Chronic (>3-6 weeks) / Recurrent (normal shoulder in-between repeated dislocation) / Habitual (voluntary dislocation)

Glenohumeral joint:
- Anterior (98%) vs Posterior (2%)
- Young + Elderly —> Different mechanism + prognosis
- Young: **Bankart lesion + Prone to recurrence
- Elderly: Concomitant **Rotator cuff tear + Less chance of recurrence

Acromioclavicular joint:
- Higher energy trauma
- Young / Middle aged patient

Question 33

Anterior shoulder dislocation

Answer 33

History:
- **Direct hit, fall on outstretched hand
- **“Dead-arm” syndrome
- Reducible on-site in 50% of cases
- Easiest to displace in abduction + external rotation + extension (Posterior dislocation: flexion + adduction + internal rotation)
- Frank dislocation / Symptomatic subluxation
- Younger the patient —> Higher the chance of re-dislocation (∵ higher activity level + more lax ligaments)

Association:
- Always associated with **Bankart lesion (detachment of the labrum and capsule from anterior rim of glenoid)
- Can be associated with **Hill-Sach lesion (indentation on posterolateral aspect of the humeral head)

P/E:
- **Deformity, including loss of deltoid contour + **squaring of shoulder (∵ prominence of acromion)
- Shoulder **adducted, **externally rotated + slightly flexed position
- Complications of dislocation: **Fracture, **Nerve injury, ***Rotator cuff injury

Investigation:
- X-ray (**AP + **Transcapular (Y view))
—> Medially displaced humerus
—> More prominent greater tuberosity (posterior dislocation: cannot see greater tuberosity ∵ internal rotation —> light bulb sign)

Management:
Young + 1st time: Conservative / Operative
Elderly + 1st time: Conservative

1. Look for complication of dislocation
   - **Fracture
   —> Fracture greater tuberosity (posterior dislocation: lesser tuberosity fracture)
   —> Fracture anterior glenoid rim
   —> Fracture surgical neck or head
   - **Nerve injury
   —> Axillary nerve (can be due to dislocation / iatrogenic during reduction procedure) (motor loss in deltoid, teres minor, sensory loss in shoulder)
   —> Brachial plexus injury
   - ***Rotator cuff injury
2. Closed reduction ASAP: **Modified Hippocrates Method
   - Minimise secondary damage (e.g. neurovascular damage, articular surface damage (e.g. Hill-Sachs lesion), minimise soft tissue damage / pain)
   - Adequate muscle relaxation (sedation (BDZ) + analgesia (**opioid), may require ***GA)
   - Traction force along direction of deformity
   - Avoid excessive traction and rotation on humerus —> Iatrogenic spiral fracture shaft of humerus with rotational maneuver
   - Counter traction along side of chest instead of under axilla —> avoid iatrogenic brachial plexus injury

Post-reduction:
1. Shoulder **immobiliser to keep shoulder in **neutral abduction and ***internally rotated position (totally opposite to at risk position of anterior dislocation)
- Young patient: 3 weeks
- Elderly patient: 1 week

2. Look for complications of reduction
   - Nerve injury (Axillary nerve + Brachial plexus)
   - Fracture
3. ***Post-reduction X-ray
   - Confirm reduction
   - Look for possible fractures
   —> Missed during initial injury film (e.g. anterior glenoid fracture)
   —> Result of iatrogenic injury (e.g. fracture shaft of humerus)
4. ***Surgery for recurrent shoulder dislocation

Question 34

Test for Anterior shoulder instability

Answer 34

***Apprehension test:
- Sitting / Supine
1. Shoulder in 90o abduction and maximum ER
2. Axial loading
3. Anterior translation

Positive:
- Apprehension

***Relocation test:
- Reduction of feeling of apprehension (feeling of stabilisation) after giving posterior force to shoulder (i.e. relocate shoulder into good position) in Apprehension test

Question 35

Associated pathologic changes to Anterior shoulder dislocation

Answer 35

Lesions of **Anterior band of IGHL (Inferior glenohumeral ligament):
1. **IGHL lesion (100%)
2. ***Bankart lesion (97%)
- Complete detachment of Anterior band of Inferior glenohumerual capsulolabral complex from the glenoid rim and scapular neck
3. HAGL (1%) (Humeral avulsion of glenohumeral ligament)
- Avulsion of IGHL from the neck of humerus
4. Interstitial capsular tear adjacent to the intact glenoid labrum (1%)

Bone:
1. **Hill-Sachs lesion (90%) (cortical depression in posterolateral head of humerus caused by impaction of humerus against glenoid —> prone to recurrent dislocation)
2. **Glenoid rim fracture (22%) (aka Bony Bankart: less support in inferior glenoid (inverted pear shape) causing recurrent dislocation)

Tendon:
1. ***SLAP (9%) and Detachment of biceps tendon (3%)
2. Rotator cuff tear (0%)

Question 36

Management of Shoulder dislocation in ***Elderly patients

Answer 36

At the time of Injury:
1. Confirmation of diagnosis + direction of dislocation
- History
- Deformity, including loss of deltoid contour + squaring of shoulder
- Shoulder in adducted, externally rotated and slightly flexed position
- Radiological confirmation (AP + Transcapular)

2. Look for complications of dislocation
   - Fracture
   - Nerve injury (Axillary nerve + Brachial plexus)
   - Rotator cuff injury
3. Look for complications of reduction
   - Nerve injury (Axillary nerve + Brachial plexus)
   - Fracture

6 weeks post-injury:
1. Whether the shoulder is reduced or not?
- Chronic dislocation
- Recurrent dislocation

2. Whether there is complication occurring at the time of dislocation?
   - Axillary nerve / Brachial plexus palsy
   - Rotator cuff tear
3. Whether there is complication following the initial treatment of the dislocation?
   - Neurological injury during the reduction procedure
   - Frozen shoulder

Treatment:
1. Shoulder dislocation (6 weeks post-injury)
- Start ***mobilisation to prevent secondary frozen shoulder

2. Axillary nerve palsy / Brachial plexus injury
   - Mainly **neurapraxia
   - Await **spontaneous recovery
   - Electrophysiological study to determine the prognosis
   - 95% spontaneous recovery by waiting 6 months
3. Massive rotator cuff tear
   - For early ***surgical repair
   - Early MRI shoulder
4. Frozen shoulder
   - Physiotherapy for mobilisation exercises

Question 37

Recurrent Shoulder Instability

Answer 37

• Failure to maintain the humeral head centered within the glenoid and coracoacromial arch during use of shoulder
• Laxity ***NOT equal to Instability

Incidence of Recurrent Dislocation:
- <20 yo: 83%
- 20-40 yo: 63%
- >40 yo: 16%

Natural history:
- 100% recurrent dislocation

Treatment:
- Always surgical stabilisation —> ***Bankart repair (repairing the torn labrum and capsule back to the anterior-inferior glenoid rim)

Question 38

Posterior shoulder instability

Answer 38

1. Posterior ***dislocation
   - Associated with trauma
   - Impression defect of humeral head
   - Acute vs Chronic (old, missed, locked or fixed)
2. Recurrent posterior **subluxation
   - **NOT associated with acute trauma
   - Part of MDI vs result of repetitive microtrauma
   - Pain and instability feeling when the shoulder is put in a provocative position of combined forward flexion, adduction and internal rotation

Question 39

Posterior shoulder dislocation

Answer 39

Acute vs Chronic (missed acute posterior dislocation which has been unrecognised for >3 weeks)
- History of trauma
—> Epileptic fit
—> Electric shock
—> Trauma such as fall on outstretched hand

Clinical features:
1. **Loss of movement of involved shoulder, particularly external rotation
2. Difficulty in combing the hair and washing the face
3. For chronic posterior shoulder dislocation, often referred to the orthopaedic surgeon with the **diagnosis of “frozen shoulder” / “post-traumatic
stiff shoulder”
4. Patient holds his / her arm in adducted, internal rotated position
5. Arm is “locked” in internal rotated position with no active nor passive external rotation
6. Decreased forward flexion and abduction to <90 degrees

Investigation:
1. X-ray features
- **Light bulb sign (humeral head facing back) + **Vacant glenoid sign (anterior glenoid looks empty)
- ***Rim sign (widening of glenohumeral space)
- Trough line sign
2. CT

Treatment:
Acute:
1. Attempted closed reduction under GA (***DePalma method)

Chronic:
1. Supervised neglect: Elderly patient with a pain free shoulder and acceptable ROM
2. OR +/- Reconstruction

Post-reduction:
1. Stable after reduction (CR / OR)
- Immobilise shoulder in neutral rotation / external rotation for 3 weeks
2. Unstable after reduction
- Surgical reconstruction
- Related to size of reversed Hill Sachs lesion

Surgery:
- Shoulder joint arthroplasty
—> >50% of articular surface of humeral head
—> Glenoid healthy: Hemiarthroplasty
—> Glenoid eroded but intact rotator
cuff: Total shoulder arthroplasty
—> Cuff deficient: Reverse total shoulder arthroplasty

Question 40

7. Superior Labral Lesion from anterior to posterior (SLAP)

Answer 40

Superior labrum is in close proximity with long head of biceps

Mechanism of injury:
1. **Biceps traction overload
2. Acceleration of the arm during throwing in overhead sport (e.g. pitcher in a baseball game)
3. Sudden forced abduction and external rotation of shoulder (e.g. concomitant pathology in the time **anterior dislocation of shoulder)
4. Fall on outstretched hand

Clinical features:
1. Mechanical Anterior shoulder pain
2. “Clicking” / “Popping” sensation of affected shoulder
3. Symptoms on throwing and swimming with ↓ speed and function on such movement

P/E:
1. O’Brien Test
2. Anterior Slide Test
3. Crank test
4. Biceps load test
5. Speeds test
6. Yergason test
7. Apprehension Test
8. Relocation Test

Treatment:
Non-surgical:
1. Activity modification
2. NSAID
3. Muscle strengthening exercise

Surgical:
1. Repair
2. Resection +/- Biceps tenodesis

Question 41

8. Biceps tendinitis / rupture

Answer 41

Biceps tendinitis:
1. Pain over anterior aspect of shoulder
2. Subjective weakness of elbow flexion
3. Localised tenderness at the site of bicipital groove
4. Positive Provocative test (**Speeds test (forward flex shoulder in supination against force) + **Yergason test (supinate arm against force))
5. May have concomitant symptoms and signs of rotator cuff tear
Treatment:
1. Conservative
2. Surgery
- Biceps tenotomy
- Biceps tenodesis

Rupture of Long head of biceps:
1. Popeye sign
Treatment:
1. Conservative
2. Surgery

Question 42

9. Acromioclavicular joint arthritis

Answer 42

• ***Overhead throwing athletes
• ***Weight lifters

Clinical features:
1. Pain over anterior-superior aspect of shoulder
2. Mechanical pain (esp. by cross-body adduction, forward flexion + internal rotation of shoulder)
3. Localised tenderness over ACJ
4. Pain on **Terminal abduction
5. **Cross Arm Test (90o shoulder flexion + maximum horizontal adduction: +ve if pain in AC joint)

Treatment:
1. Conservative
- NSAID
- Lifestyle modification
- Physiotherapy
- ACJ injection of LA + Corticosteroid

2. Surgery
   - ACJ resection

Question 43

10. Glenohumeral joint arthritis

Answer 43

Osteoarthritis of GHJ:
1. **Primary OA shoulder
2. **Secondary OA shoulder
- Post-traumatic
- Cuff Tear Arthropathy
- RA
- Post-infection

Clinical features:
1. Insidious onset of dull pain in shoulder
2. Progressive stiffness of shoulder joint
3. Rest pain if inflammatory in nature
4. Decease in PROM of shoulder joint in all directions
4. Painful Crepitation of joint
5. OA: rotator cuff function is usually intact
6. RA: rotator cuff attenuation +/- rupture is common

Treatment:
1. Conservative
- Analgesic
- Physiotherapy (ROM exercise + Cuff muscle strengthening exercise)

2. Medical treatment (for inflammatory arthritis)
3. Surgery
   - Joint replacement surgery (target is pain control)

Question 44

11. Synoviochondromatosis

Answer 44

Benign disorder:
- Development of foci of cartilage in synovial membrane of joint
- Become loose body, some may even ossify

Clinical features (due to multiple loose bodies):
1. Mechanical pain
2. Locking
3. Prone to develop secondary OA

Treatment:
1. Surgery