Shoulder 1 Flashcards
Remind yourself of the bony anatomy of the shoulder
State the 4 rotator cuff muscles
State the origins and insertions of each of the muscles of the rotator cuff
- Subscapularis:
- O: subscapular fosssa of scapula
- I: lesser tubercle of humerus
- Supraspinatous:
- O: supraspinous fossa of scapula
- I: greater tubercle of humerus
- Infraspinatous:
- O: infraspinatous fossa of scapula
- I: greater tubercle of humerus
- Teres minor:
- O: posterior aspect of superior half of lateral border of scapula
- I: greater tubercle of humerus
Remind yourself of the ligaments of the shoulder
Extra notes:
- Glenohumeral ligament has 3 parts: superior, middle, inferior
- Transverse humeral ligmanet: between greater and lesser tubercle of humerus- long tendon of biceps brachii passes under it
- Coracoclavicular ligament: composed of trapezoid and deltoid ligament. Conoid more medial
State some common shoulder conditions you need to be aware of
- Impingement syndrome
- ACJ arthritis
- Frozen shoulder
- Rotator cuff tears
- Biceps tendinopathy
- Dislocation
- Fractures
- Clavicular
- Humeral shaft
- Scapula & glenoid fractures
State some common shoulder problems in the following age groups:
- Young adult <30yrs
- Middle age 40-60yrs
- Elderly >65yrs
- Pain and weakness at any age
- Young adult <30yrs- more likely to have instability
- Middle age 40-60yrs- impingement/ACJ arthritis, frozen shoulder
- Elderly >65yrs- arthritis, frozen shoulder
- Pain and weakness at any age- any age, rule out rotator cuff tear
State some differentials for shoulder shoulder symptoms
- Cervical spine pathology
- Brachial plexus injury
- Infection
- Tumourss
- Thoracic outlet/inlet syndrome
State some key aspects of a history for someone presenting with shoulder problems
- Age
- Sex
- Pain (SQITARS)**
- Stiffness (timing?)
- Instability
- History of trauma
- How it is affecting activities of daily living
- Hand dominance
- Occupation
- Sports/hobbies
- PMH
If someone describes their pain as the following, suggest what the diagnosis could be:
- Pain at ACJ joint
- Severe
- Pain at night
- Aggravated by overhead activities
- Assoicated weakness
- Lack of active & passive movement
- Pain at ACJ joint- ACJ OA
- Severe- rule out septic arthritis, acute calcific tendinitis
- Pain at night- arthritis, rotator cuff tear
- Aggravated by overhead activities- impingement syndrome, ACJ arthritis
- Assoicated weakness- rotator cuff trear
- Lack of active & passive movement- frozen shoudler or arthritis
If a young person presents with shoulder instability and has had previous significant injury in the joint, what might be going on?
If a young person presents with shoulder instability but has never injured the joint, what might be going on?
- Recurrent dislocation or they can’t trust the joint
- Muscle coordination problems
What is impingement syndrome/subacromial impingement syndrome?
Who is it common in?
How does it present?
- Inflammation and irritation of the structures passing through the subacromial space. Structures: supraspinatus ligament, long head of biceps and subacromial bursa
- Middle age (40-60yrs) but may also see in young pts who are active or in manual professions
- Presents wtih:
- Progressive pain in anterior superior shoulder
- Pain exacerbated by abduction
- Pain releived by rest
- Weakness
- Stiffness
- Reduced range of motion
State some risk factors for developing impingement syndrome
- Repetitive use of shoulder (repetitive microtrauma can cause inflammation of tendons)
- Weakness in rotator cuff muscles (muscular imbalances may shift humerus proximally and decrease SA space)
- Congential or acquired anatomical variations in shape and gradient of acromion (decrease SA space)
- Instability of glenohumeral joint (superior subluxation of humerous decreasing SA space)
*All of above can decrease subacromail space
The underlying cause of impingement syndrome can be divided into intrinsic & extrinsic mechanisms; state some intrinsic mechanism and some extrinsic mechanisms
Intrinsic (pathology of rotator cuff tendons due to tension)
- Weakness rotator cuff
- Overuse of shoulder leading to repetitive microtrauma
- Degenerative tendinopathy (degenerative cahnges of acromion can lead to tearing of rotator cuff which allows proximal migration of humeral head)
Extrinsic (pathology of rotator cuff tendons due to external compression)
- Anatomical varaitions in shape and/or gradient of acromion
- Reduction in function of scapular muscles may reduce size of SA space
- Abnormalty of glenohumeral joint can lead to superior subluxation of humerus and reduce SA space
What may you find on clinical examination of someone with impingement syndrome?
- Reduced range of motion
- Painful arc 60-120 degrees
- Hawkins test positive
- Neers impingement test positive
Explain how to do each of the following:
- Neers Impingement test
- Hawkins test
Neers Impingement test
Arm placed by pts side, fully internally rotated then passively flexed. If pain in anterolateral aspect of shoulder= positive
Hawkins test
Shoulder and elbow flexed to 90 degrees. Examiner stablises humerus and passively internally rottes the arm. If pain in anterolateral aspect of shoulder= positive
Diagnosis of impingement syndrome is mainly a clinical one however it is often confirmed with imaging; what imaging is used to confirm SAIS and what might you see?
MRI
- Narrowing of subacromial space
- Subacromial osteophytes and scleroisis
- Subacromial bursitis
- Humeral cystic changes
Discuss the management of impingement syndrome
1. Conservative
- Analgesia e.g. paracetamol, NSAIDs
- Physiotherapy
- Activity modification
2. Corticosteroid injections in subacromial space
3. Athroscopic subacromial decompression surgery (if persists beyond 6 months without response to previous treatment). Options include:
- Surgical repair of muscle tairs
- Surgical removal of subacromial bursa (bursectomy)
- Surgical removal of section of acromion (acriomioplasty)
State some potential complications of SAIS
- Rotator cuff degeneration and tear
- Adhesive capsulitis
- Cuff tear athropathy
- Complex regional pain syndrome
What is ACJ arthritis?
What age range does it commonly affect?
How does it present?
- Osteoarthritis affecting the acromioclavicular joint
- Middle aged (40-60yrs)
- Presentation:
- Pain in anterior, superior shoulder
- Pain worse with overhead activities
- Pain worse when bring arm across chest
- Difficulty sleeping on affected side
State some risk factors for developing ACJ arthritis
- Repetitive overhead activity
- Previous injury (e.g. AC joint separation)
- Age
What may you find on clinical examination of someone with ACJ arthritis?
- Tender over ACJ
- May be bigger bump over affected joint if there has been previous injury
- Scarf test positive
Explain how to do the scarf test
- Shoulder flexed at 90 degrees
- Elbow flexed at 90 degrees
- Support elbow with your hand
- Place other hand on pts scapula (you don’t want their scapula to move too much as this will interfere with results of test)
- Push pts arm further into horizontal adduction/across chest
Positive result is pain in ACJ region
Diagnosis of ACJ arthritis is mainly clinical however imaging may be done to rule out other pathologies e.g. USS, MRI, x-ray. What might you see on USS of pt with ACJ arthritis?
Partial tears of rotator cuff- no treatment required
Discuss the management of ACJ arthritis
1. Conservative
- Analgesia e.g. paracetamol, NSAIDs
- Physiotherapy
- Activity modification
2. Corticosteroid injections into ACJ
3. ACJ excision athroplasty
***PPT seems to suggest that x-ray required before intrarticular steroid injection
What is adhesive capsulitis also known as?
What is adhesive capsulitis?
Who does it commonly affect?
- Frozen shoulder
- Fibrosis of the glenohumeral joint capsule in which the glenohumeral joint capsule becomes contracted and adherent to the humeral head
- Women> men, 40-70yrs
Adhesive capsulitis can be categorised as primary or secondary; expalin the difference and state some conditions which can result in secondary adhesive capsulitis
- Primary= idiopathic
- Secondary= associated with a cause e.g. rotator cuff tendinopathy, SAIS, biceps tendinopathy, previous surgery or trauma, known joint athropathy
Adhesive capsulitis is associated with inflammatory diseases and current theory suggests it may have an autoimmune element; true or false?
True, can be associated with thyroid disease, diabetes.
If a person has had adhesive capsulitis in their left shoulder there is no increased risk of adhesive capsulitis in their right shoulder; true or false?
False- if previosuly been affected by adhesive capsulitis more susceptible to developing condition in the contralateral shoulder
State some risk factors for adhesive capsulitis
- Female
- Age
- Thyroid disease
- Diabetes
- Shoulder joint athropathy
- SAIS
- Rotator cuff tendinopathy
- Previous surgery or trauma
- Biceps tendinopathy
- Previous adhesive capsulitis in other shoulder
State symptoms of adhesive capsulitis
- Deep, constant pain of shoulder that may radiate to bicep
- Pain often distrubs sleep
- Joint stiffness
- Reduced movement
- Limited range of motion (primarily affecting external rotation and flexion of shoulder)
What might you find on clinical examination of someone with adhesive capsulitis?
- Loss of arm swing when walking
- Atrophy of deltoid muscle
- Tenderness on palpation
- Reduced range of motion
- Reduced external rotation
- Reduced flexion of shoulder
What movement in particular is reduced in pts with adhesive capsulitis?
- External rotation
- Flexion of shoulder
Diagnosis of adhesive capsulitis is largely clinical however you may do some investigations; state what investigations you may do and why
- X-ray: rule out other pathology. In adhesive capsulitis x-rays often unremarkable
- MRI: rule out other conditions affecting shoulder e.g. SIAS. But may see thickening of glenohumeral joint capsule in adhesive capsulitis
- HbA1c and plasma glucose: more common in diabetic pts therefore may screen for diabetes
Discuss the management of adhesive capsulitis
1. Conservative
- Education (importnace of keeping active)
- Reassurance (usually self-limiting)
- Physiotherapy
- Analgesia (e.g. paracetamol, NSAIDs)
2. Corticosteroid injection in glenohumeral joint
3. Surgery
- Manipulate joint under general anaesthetic
- Athoscopic release
- Arthrographic distension
How long can it take for adhesive capsulitis to get better?
When would we offer surgery?
- Can take up to 2 yrs
- Consider surgery if no improvement after 4-6 months of initial measures
*NOTE: a proportion of pts never recover full range of movement
State some potential complications of adhesive capsulitis
- Small proportion never regain full range of motion
- Reoccurence in contralateral shoulder
Adhesive capsulitis progresses in 3 stages; state the name of stage and what happens in each stage
- Freezing: 0-3 months, quite painful, insidious onset of pain & global loss of movement
- Frozen: 4-6 months, pain starts to get better but continued stiffness
- Thawing: 6+ months, symptoms & ROM improve
Degenerative joint disease can present similarly to all conditions discusses in this deck; present with progressive pain and restricted ROM. State some causes of degnerative joint disease
- OA
- General wear & tear
- Post-traumatic
- Large cuff tear
- RA
It may be difficult to distinguish between degenerative joint disease and other pathology; what imaging could we do to try and rule out degenerative joint disease?
X-ray of joint
Remind yourself of the role of each of the following ligaments:
- Glenohumeral
- Coracoacromial
- Coracoclavicular
- Glenohumeral: main source of stability for shoulder, prevent anterior dislocation
- Coracoacromial: prevents superior dislocation
- Coracoclavicular: maintain the alignment of the clavicle in relation to the scapula
- Coracohumeral: prevents superior dislocation
