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
