Regional Peri-Articular Pain - Shoulder Flashcards
What are the common differentials for shoulder pain?
Acute (calcific) rotator cuff tendonitis Chronic rotator cuff tendonitis Rotator cuff tear Adhesive capsulitis Subacromial bursitis Cuff arthropathy Osteoarthritis Rheumatoid arthritis Polymyalgia rheumatica
How does articular pathology present?
Global sx affecting all movements
What are the two main types of articular pathology?
Inflammatory
-morning stiffness easing on movement
Degenerative
-worse after repeated use
What are the peri-articular causes of shoulder pain?
Acute (calcific) rotator cuff tendonitis Chronic rotator cuff tendonitis Rotator cuff tear Adhesive capsulitis Subacromial bursitis
What is Acute (calcific) Rotator Cuff Tendonitis?
Deposition of apatite in supraspinatus tendon, leading to intense inflammation/swelling
How does Acute (calcific) Rotator Cuff Tendonitis present?
Young patients Aching pain following overuse -pain increases to climax, then resolves over few days Arm held immobile -joint too tender to touch
What investigation may be appropriate in Acute (calcific) Rotator Cuff Tendonitis?
X-ray (calcification above greater tuberosity)
What is the management of Acute (calcific) Rotator Cuff Tendonitis?
Resting arm in sling
NSAIDs
Intra-capsular corticosteroid/lignocaine injections
How long does Acute (calcific) Rotator Cuff Tendonitis take to resolve?
1-3wks
What is Chronic Rotator Cuff Tendonitis?
Subacute/chronic vascular response causing pain/stiffness
What causes Chronic Rotator Cuff Tendonitis?
Overuse/minor tears of rotator cuff causing subacute/chronic vascular response
How does Chronic Rotator Cuff Tendonitis present?
Pain in shoulder -worse at night -worse when abducting/elevating arm Tenderness below anterior edge of acromion Painful arc (60-120o) present Power normal
What investigation may be appropriate in Chronic Rotator Cuff Tendonitis?
X-ray (calcification from former events)
USS/MRI (diagnostic)
What is the management of Chronic Rotator Cuff Tendonitis?
NSAIDs
Corticosteroid injection
Physiotherapy
Arthroscopic decompression of rotator cuff
-excision of coraco-acromial ligament & osteophytes
What causes Rotator Cuff Tears?
Trauma (younger pts)
Spontaneously (elderly pts)
What are the two main types of Rotator Cuff Tear?
Partial -frequently occur w/ (may precipitate) chronic tendonitis -can repair naturally Complete -will not repair naturally
How do Rotator Cuff Tears present?
‘Sprain’ of shoulder, limited abduction after event
What are the signs on examination of Rotator Cuff Tears?
Tenderness over ant acromium
Abduction paradox
What is the abduction paradox?
Once arm has been lifted above shoulder it can be held there by deltoid
When pt lowers arm it suddenly drops
How can partial/complete Rotator Cuff Tears be distinguished?
Intra-articular anaesthetic injection
-partial tears regain abduction movement when pain abolished
What investigations may be appropriate in Rotator Cuff Tears?
USS/MRI/arthroscopy (confirm diagnosis)
How is the acute phase of a Rotator Cuff Tear managed?
Heat
Exercises
Local anaesthetic injections
When can the extent of a Rotator Cuff Tear be assessed?
3 weeks
How are Complete Rotator Cuff Tears managed?
Surgically repaired in younger individuals
How are Partial Rotator Cuff Tears managed?
Conservatively treated to allow natural healing
What is Adhesive Capsulitis?
Also known as frozen shoulder, more common diabetes
How does Adhesive Capsulitis present?
Initial progressive 'deep' pain -stops pt sleeping on affected side -subsides after few mo Increasing stiffness -worsens as pain subsides -lasts 6-12 mo Resolves spontaneously after 18mo
What are the signs on examination of Adhesive Capsulitis?
Limited signs, joint cannot be moved due to pain
Limited external rotation
How is Adhesive Capsulitis managed?
Reassurance
NSAIDs
Intra-articular steroid injections
What is Subacromial Bursitis?
Inflammation of the bursa below the acromion
What causes Suabcromial Bursitis?
Repetitive overhead lifting/pulling
Trauma
How does Subacromial Bursitis present?
Burning pain
- worse when lifting above head
- stiffness when passively abducting arm
What investigations may be appropriate in Subacromial Bursitis?
USS/MRI (to distinguish from cuff pathology)
What is the management of Subacromial Bursitis?
NSAIDs
Avoid exacerbating movements
What is a Rotator Cuff Syndrome?
Any peri-atricular pathology until diagnosis has been confirmed radiologically
What are the potential complications of rotator cuff pathology?
Subluxation of humeral head
Cuff arthropathy
What is Painful Arc/Impingement Syndrome?
Painful arc from 80-120o
- due to swelling/oedema
- decreases space b/w humeral head & acromion
How can Impingement Syndrome due to articular/peri-articular pathology be distinguished?
Articular
-painful on both active/passive movements
Peri-articular
-less painful on passive movements
What is the classic presentation of ACJ OA?
Painful high arc
Crepitus
Global pain/stiffness
Scarf test +ve
What is the Scarf Test?
Passive adduction across body horizontally causing pain
