Shoulder Flashcards
Name 8 red flags in the shoulder
Non-traumatic acute pain
Trauma+acute pain+weakness = (possible cuff tear)
Visceral masqueraders
Avascular necrosis of humeral head
Systemic/local infection - (fever, malaise)
Systemic inflammatory disease
Malignancy - (sweats, night pain, unwell, weight loss, obvious mass/swelling)
Unreduced dislocation
What causes rotator cuff-related shoulder pain (RCRSP)?
Loading alterations;
- Dominance - occurs in the dominant arm
- Occupation and sports with high loading rate
- Unloading
What factors increase the risk of getting RCPSP?
Aging >50 increases risk of tears Genetics Vascular changes (limited blood flow) Metabolic syndrome/obesity/ smoking/alcohol
Name reasons why unloading causes RCRSP?
Poor muscle control
Weakness
Inhibition
Acromio-humeral space reduction - kyphotic
Describe the pathology of rotator cuff tendinopathy (RC).
- Inflammatory event
- Tendon swells
- Disrupted matrix with collagen breakdown
- Increased tenocyte death (apoptosis)
- Neovascularity & nerve ingrowth (these blood vessels are very permeable - its part of the
- May get calcification (of the tendon)
- Chondrometaplasia (fibrocartilage in matrix) (it should be a soft matrix)
- Can develop partial or full thickness tears
- Degradation of muscle fibres
What tendon is most commonly affected with RC tendinopathy?
Supraspinatus with or without subacromial bursa involvement
How would you test for RC tendinopathy (objective test)?
Neer Hawkins-Kennedy Pain with empty can/full can (Jobe test) Painful arc 70-120 degrees Painful resisted lateral rotation
What is the clinical presentation (history, MOI, subjective features) of RC tendinopathy?
MOI: Sudden onset after overhead activity
Subjective Features: Pain localised deep in shoulder and spreading over deltoid region
Pain on overhead activity
Night/constant pain – suspect bursa
What are common capacity and functional impairments of RC tendinopathy?
Weakness and painful abduction and lateral/external rotation
Unable to perform overhead activities/lie on shoulder
Outline the difference between an irritable and non-irritable RC tendinopathy?
Irritable - Night pain, Constant pain, even at rest, Ongoing, Bursa
Non-irritable - Catching (when reaching behind their head etc.), Full range but painful, Sleep ok, +/- sport (they may be able to play sport but not at their original frequency)
What imaging devices are used to diagnose RC tendinopathy?
Ultrasound (for viewing tendons), MRI
With partial RC tears how do they present and in what population are they most commonly seen in?
Present similar to tendinopathy and are managed similarly
Common in the older population
What are some symptoms of a full tendon tear?
Sudden loss of strength (which is confirmed with resisted testing) and inability to actively raise arm, pain free passive range
What is the aim in early stage irritable RC tendinopathy management? How would you manage early-stage irritable RC tendinopathy?
Aim= control tenocyte overactivity (there may also be inflammation of the bursa)
Management: ice/NSAIDs, taping to overload, reduce aggravating activities, identify movement faults such as poor control of scapula when in lateral rotation, isometric internal and external rotation while respecting the 24hr response of the tendon
How would you progress an isometric exercise programme in early stage of irritable RC tendinopathy?
Begin isometric exercises in supine and progress to a 45 degree angle and eventually to overhead isometrics. Its more likely that after 6 weeks patient will be able to move onto external rotation
How would you manage early-stage non-irritable RC tendinopathy?
Isotonic – 3x week or day on/off Low range to high range progression Short lever to long lever Progressive resistance and speed Focus on external rotation load -Supported/unsupported/prone/ side lying Add function - do not avoid provocative positions Monitor pain 3-4/10 and 24hr response
When should adjuncts be used with RC tendinopathy? What are these adjuncts?
If the tendon quality is low (in older people). However the surrounding tendons can be strengthed
Exercise for 12weeks+ has the same outcome as surgery.
Corticosteroid injections - for pain relief and to reduce chronic inflammation. Ice or heat before or after exercise. Nitroglycerine patches to improve collagen formation
Are chronic/partial tears irritable or non-irritable?
Non-irritable
What is the most important thing to remember about management of RCT?
Dyskinesia of the scapula exists in asymptomatic population so the most important thing is to focus on rotator cuff activation
What structures are damaged in a shoulder dislocation?
Capsule, labrum, glenohumeral ligaments (as extensions of the capsule), articular surface (head of the humerus), bone
Under what mechanisms can the shoulder dislocate?
Abduction/external rotation under force. Anterior dislocation (most common)
Posterior dislocations do not occur due to the protective nature of the shoulder
What are the different dislocation types in the shoulder?
Sub-coracoid - hyper-lateral rotation in abduction
Subclavicular - falling backward onto hand
Subglenoid - hyperabduction
Intrathoracic
What are the subjective symptoms of dislocation?
Feeling of popping out, pain, paraesthesia into arm due to compromise to neural structures
What are the objective symptoms of dislocation?
A visible gap lateral to the acromion
Inability to move the arm
X-ray confirmation
Name and describe 2 complications of a shoulder dislocation
Bankart lesion - an injury to the anterior or inferior aspect of the glenoid labrum
Hill-Sachs lesion - defect/ hole on head of humerus. When head of humerus pops out it gets jammed by the bony counter of the labrum/glenoid which digs in the softer articular surface of the hyaline cartilage of the head of the humerus
Name 7 other complications of shoulder fractures.
- Rotator Cuff/ Biceps tendon injuries (the cuff blends with the capsule - if capsule is damaged the cuff will be damaged)
- Capsular/Labrum tears
- Fractures (++ greater tuberosity)
- Axillary nerve lesions- common and often missed
- Brachial Plexus injury - brachial nerve travels behind head of humerus before giving off musculotaneous branch etc
- Fibrosis/ “frozen shoulder”
- Recurrence - shoulder dislocation is likely to reoccur
How would you build capacity in a patient recovering from shoulder dislocation?
Isometrics for scapulothoracic muscles
Develop strength and power
Improve range
How would you manage the early stage of recovery post- shoulder dislocation?
Protect- sling in internal rotation for 3-6/52
Isometric exercises (in pain-free positions, away from abduction and ext. rotation)
Progress to increasing range and resisted exercises if pain allows.
Aim is stability not range
Pain control- ice/painkillers
NSAIDs
How would you manage the later stages of recovery post- shoulder dislocation?
Overall rotator cuff synergy
Ensure good strength of all rotator cuff muscles
Good scapulothoracic activation
Weight bearing exercises - push up
Begin functional related rehab e.g. acceleration/deacceleration of the cuff for cuff synergy
How is recurrent dislocation managed?
Surgically. Loose bony fragment are re-attached if there is a Bankart lesion. Or filling in a gap in the case of a Hills-Sach lesion
What is the aims of surgery for recurrent dislocation
To prevent excessive anterior translation and lateral rotation
What are the Stanmore Instability Classifications for the shoulder?
- Traumatic structural - due to significant trauma. Acute, persistent and recurrent. Unilateral. No abnormal muscle patterning. Often a Bankart’s defect
- Atraumatic structural - no trauma. Is recurrent. Not commonly bilateral. No abnormal muscle patterning. Due to capsular dysfunction. There is structural damage to the articular surfaces
- Habitual non-structural - n o trauma. Persistent, recurrent. Often bilateral. Due to abnormal muscle patterning. There is no structural damage to the articular surfaces
How does atraumatic shoulder instability occur? (7)
- Excessive translation of the humeral head
- Can be Unidirectional or Multi-directional
- Overuse/microtrauma
- Hereditary/genetic Factors
- Hypermobility (in other joints as well as the humerus)
- Loss of rotator cuff control
- Poor scapula control
What are the symptoms (subjective) of atraumatic shoulder instability?
- Clicking
- Slipping
- Locking (getting stuck and they fell like they cant move the joint)
- Apprehension
- Episodes of subluxation (the shoulder popping in and out of place)
- Pain/ Impingement
What are the symptoms (objective) of atraumatic shoulder instability?
- Apprehension
- End of range limitation/fear (particularly in ext. rot.)
- Poor muscle control
- Weakness
- Joint laxity on testing (often in both shoulders)
How would you manage atraumatic shoulder instability?
Muscle control Good activation/co-contraction of RC Weight bearing exercises Propioceptive rehabilitation Surgery sometimes required –capsule shrinkage
What is the Derby shoulder instability programme?
Progression based on achieving good tolerance of 100 reps of each exercise.
Drop/catch N (progress to int/ext rot. - below)
Drop/catch with rotation (int/ext)
Falling press-ups- upright towards horizontal
Plyometric
Weight bearing – ball rolling- upright/horizontal, double/single arm
How is the acromioclavicular joint (ACJ) injured?
Fall on outstretched arm/shoulder
The acromion is forced under the clavicle
What is/are subjective features of an ACJ injury?
Pain localised to ACJ
What are objective features of an ACJ injury?
high arm of pain
positive (pain reproduction) cross arm test - horizontal flexion (this test forces the humerus under the clavicle, raising it which aggravates the injury)
What are the types of ACJ injury?
Type 1 - disruption to acromioclavicular ligaments, no disruption to coracoclavicular ligaments (which stabilises the ACJ)
Type 2 - full disruption to AC ligaments, some overstretch to coroclavicular (CC) ligaments, deformity/bump visible
Type 3 - full disruption to ACJ and CC ligaments, clavicle sites away from acromion
How would you manage an ACJ injury?
Surgery Non-surgical - Manage inflammation: Ice/painkillers/NSAIDs/tape/bracing Ensure maintenance of strength Shoulder girdle and GH muscles Isometric to isotonic as able
Define SLAP. What is a SLAP injury?
Superior Labrum Anterior-Posterior
A site of injury at the labrum attachment to the glenoid.
The tear will occur in an AP direction
It usually occurs due to overuse (overhead-type movements)
When should you avoid anti-inflammatory medication?
In the early stages of healing as it slows down healing of soft tissues
How many types of SLAP injuries exist?
- Type 1 - fraying. Due to recurrent overload overhead
Type 2 - biceps + labrum. Biceps pulls on labrum. Labrum begins to detach from joint
Type 3 - folding of labrum into joint, biceps + rim intact. Causes clunking, pain. Would need surgery.
Type 4 - complete tear and displacement
How does a labral pathology/SLAP injury occur?
Constant subluxation of humeral head on labrum due to throwing activities
Or due to biceps pulling on labrum
Occurs over many months
What are symptoms of SLAP pathology?
Clicking/clunking, deep pain in shoulder
What 3 test/devices are used to diagnose SLAP?
O’Brien’s - horizontal flex. + thumb down
MRI - gives an image of fibrocartilage
How do you manage SLAP conservatively?
Strength of rotator cuff
Return to functional activities
Neuromuscular control i.e. rotator cuff exercises
What is the prognosis of SLAP?
Younger person (<50) will have a better prognosis as tissue is more viable and they are able to build more strength
When would surgery for SLAP be performed?
If there is a stage 2 or 3 tear
What is another name for frozen shoulder?
Adhesive capsulitis
What is the common pain mechanism of adhesive capsulitis?
Nociceptive but if severe it can be nociplastic
When would frozen shoulder occur as a secondary complication?
Following shoulder dislocation
What red flag must you be aware of if you suspect a patient has frozen shoulder? How is this red flag treated?
Avascular necrosis of the humeral head
With a shoulder replacement
What kind of populations is adhesive capsulitis most commonly seen in and what causes it?
Females>males Middle aged >40 years Diabetic Contralateral recurrence in 20-30% of people Genetic component - Idiopathetic, HLAB27 antigen
What is adhesive capsulitis?
Systematic inflammatory in the synovium causing periarticular adhesions (adhesions in ligaments) and pericapsular adhesions
Neoangiogenesis occurs in the capsule. It is fibrosis of the joint capsule
The presence of what antigen occurs in frozen shoulder?
HLA B27
What inflammatory mediators cause frozen shoulder?
PDGF, TGF, TNF alpha which are all cytokines
What are the 3 phases associated with frozen shoulder?
Freezing - severe pain which is worse at night
Frozen - pain has subsided but there is still loss of ROM
Thawing - gradual return of ROM
What are the subjective features of frozen shoulder?
Worsening pain with a loss of ROM. Night pain
What are the objective features of frozen shoulder?
Loss of ROM in abduction and external rotation (and in all movements)
How would you differentiate adhesive capsulitis from rotator cuff tendinopathy?
Passive movement of the shoulder would be more pain-provocative in adhesive capsulitis. Active/resisted movement of shoulder would aggravate RC tendonpathy more
How would you manage adhesive capsulitis?
- Advice and education: Slow progression/ painful/encouragement/continued mobility
Need for compliance in exercising, Symptom control with analgesia mostly – NSAIDs, codeine based meds. Avoid supports and immobilisation - Build capacity: Regain range – stretching, manual therapy. Add strengthening as range increases. Isotonic if possible, small range, gradually increasing
- Return to function - Specific to individual, Final acceptable outcome may be individualised
What is prognosis for adhesive capsulitis?
6-months of conservative treatment before a review if surgery is needed
What are the subjective features of OA shoulder?
The pain can be present at rest
Progressive, activity-related pain that is deep in the joint and often localized posteriorly.
Progressive night pain
Age
What are the objective features of OA shoulder?
Progressive stiffness creates significant functional limitations (dressing, reaching)
Crepitus on ROM
Joint effusion
Weakness and visible muscle atrophy
Outline the a) surgical and b) non-surgical treatment for OA shoulder?
a) shoulder replacement
b) Non-surgical
Pain relief/advice – heat/
ice/NSAIDs/taping/bracing
Range of motion
Maintenance and prevention of loss of strength
Corticosteroid injections
