Shoulder Flashcards
Rotator cuff syndrome
Compromises several conditions with distinct clinical features
Rotator cuff syndrome; degeneration
Age- micro tears- potential scarring, calcium deposits
Common site= ‘critical zone’ of supraspinatous near insertion
Rotator cuff syndrome: trauma/impingement
Supraspinatous= liability to injury
E.g., lifting weight, or stop yourself falling
Much more likely if cuff is already degenerate
Rotator cuff syndrome: vascular reaction
In attempt to repair torn tendon, new blood vessels grow in + calcium deposits are re absorbed
This reaction may cause congestion + P
Rotator cuff syndrome clinical presentation
Shoulder P, weakness
Onset may be sudden
P typically appears over front/lateral aspects of shoulder
Tenderness felt at ant edge of ado iron
Always compare to other shoulder
Subacute tendinitis
Pt develops ant shoulder P after vigorous or unaccustomed activity e.g., swimming
Shoulder looks normal but appears acutely tender along ant edge of acromion
Arm in ext- palpate this point- supraspinatous tendon exposed, arm into flex- no P
Chronic tendinitis
Most prevalent in 40-50
History of recurrent attacks of subacute tendinitis
P settles with rest, ant-inflam treatment
P reoccurs when more demanding activities are resumed
P usually worse at night, Pt can’t sleep on affected side
Crepitus or palpable over snapping over rotator cuff when shoulder rotated
Rotator cuff tears
Pt usually over 45
History of P with increasing stiffness/weakness
P can be eliminated by injection local an atheistic- if abduction is now possible only partial tear, still not possible= full tear
Rotator cuff tears cause/post tear- Hx
Prior trauma- lifting or throwing
Degeneration- elderly
Rotator cuff tear S+S
Weakness in specific rotator cuff movements
Abnormal scapulohumeral movement
Rotator cuff DDX
Supraspin rupture
Impingement syndrome
Congential ligament laxity
Conservative treatment of rotator cuff tears
Tendinitis when self-limiting + symptoms settle after aggravating activity is eliminated
Physiotherapist- strengthening
NSAIDs
If this doesn’t work, injection of corticosteroid into sub acromion space
Modification of activity for 6 months
Surgical treatment of rotator cuff tear
If Pt has useful ROM, strength + well-controlled P, no operative measure appropriate
If symptoms do not subside 3 months, consider operation
Indication more pressing if evidence of full tear in young person
Decompress rotator cuff by removing structures pressing on it
Procedure allows for early rehab
Repair of tears
Indicators for operative repair are chronic P weakness of shoulder, signs ant loss of function
Younger + more active= greater justification for surgery
Procedure either open or arthroscopy
Advantages of arthroscopy - no soft issue damage, faster rehab, better cosmetic appearance
Bicipital tendonitis
P over ant shoulder
Hx of repetitive elbow flexion
Bicipital tendonitis S+S
P with direct palpation of BLH tendon
P with resisted horizontal adduction
Torn long head of bicep
Degeneration + distraction of tendon is common, often associated with rotator cuff problems
Pt usually middle aged/elderly
While lifting heavy object, feel a snap, aching, brushing over front of arm
During elbow flexion, bicep contracts into prominent lump
Function usually so little no treatment required
SLAP lesion
Superior part of glenoid labrum anteriorly + posteriorly
SLAP lesion epidemiology
Fall on outstretched arm
HX of fall followed by P
SLAP lesion risk factor
Overhead and contact sport
Clinical presentation of SLAP lesion
As P settles, Pt continues to experience painful click whilst lifting arm above shoulder height
Non-specific shoulder P may describe deep P in association with weakness or stiffness
Prognosis of SLAP lesions
3-4 months
Chronic instability of shoulder
Glenoid socket is very shallow + Jt held by fibrocartilagenoous glenoid labrum + by surrounding muscles/ligaments
If these structures give way, shoulder will lack stability
Anterior dislocation
Most common
Usually follows acute injury whereby arm is forced into abd, ER + ext
Recurrent dislocation
Labrum + capsule often detached from anterior rim of glenoid
1/3 Pt under age 30
1/5 over 50
Anterior subluxation
Jt feels as if it ‘pops out’, only partial dislocation
May describe ‘catching’ sensation, followed by numbness + weakness- dead arm syndrome
Posterior dislocation
Rare
Usually due to violent jerks in unusual positions (e.g., following an epileptic fit)
Instability Hx
Prior trauma
Pt may be able to demonstrate inc ROM
Pt may have impingement type symptoms due to excess GH movement
Instability S+S
Observation of sulcus sign
Frequent subluxation
Instability DDX
Rotator cuff strain
Impingement syndrome
Congenital ligament laxity
Ant instability- indications for operative treatment
Frequent dislocations
Fear of recurrent subluxation
Dislocation sufficient to prevent participation in everyday activities
Posterior instability
May persist after acute post dislocation
Usually takes form of subluxation rather than full dislocation
When arm is held in flex + IIR
Post instability treatment
Treatment usually conservative Muscle strengthening exercises + voluntary control of Jt
Operative reconstruction indicate only if disability is marked, no gross Jt laxity + structural abnormality found using CT/MRI
Atraumatic instability treatment
Usually treated by Pt to strengthen muscles + restore proprioception
Occasionally surgery needed to tighten capsule
Example of Atraumatic instability
Voluntarily subluxation or dislocate their shoulders
Can become involuntary
Treatment requires physiotherapist + sometimes psychological counselling
- surgery should avoided
Disorders of GH Jt- TB arthritis
Uncommon in shoulder
Usually starts as osteitis rarely diagnosed till arthritis has intervened
Pt usually adults
Constant ache + stiffness lasting many months
Striking features include muscle wasting around the shoulder
TB arthritis treatment
Anti-TB drugs
Rest until acute symptoms have settled
Movement encouraged
If repeated flares, or if articulate surfaces are destroyed, Jt should be arthrodesed
Disorders of GH- RA
AC, GH + synovial pouches commonly involved in RA
Chronic synovial leads to rupture of rotator cuff + Jt erosion
Pt usually has generalised arthritis, complaints of P + difficulty with tasks which involve lots of movement
Passive movements are painful + marked with crepitus
RA treatment
In general, measures do not control synovitis, corticosteroids may be injected
If synovitis persists, surgical options are available
Disorders of GH- OA
Usually secondary to other obvious disorders (local trauma, long standing rotator cuff lesion, rheumatoid disorders, a vascular neurosis of head of humerus)
Pt usually 50-60
History of previous shoulder problems
Most typical sign= progressive restriction
Analgesics, anti-inflam relieve P, exercise may improve mobility
Rapidly destructive shoulder arthropathy epidemiology
Crystal induced, rapidly progressive arthopathy
Sometimes associated with massive tears of rotator cuff
Clinical presentation of rapidly destructive arthopathy
Swelling
X-ray shows bizarrely destructive form of arthritis
Similar conditions encountered in other Jts
Prognosis of rapidly destructive arthropathy
No satisfactory treatment
Arthroplasty may relive P but will not improve function because Jt is unable
Congenital elevation of scapula
One remains higher than other- visible by 3 months of life
Smaller than usual + somewhat prominent
Abduction limited
Associated symptoms- Fuchs on of Csp, kyphosis or scoliosis likely
Mild cases left untreated
Marked limitation of abduction or severe deformity= operation
Klippel-Feil syndrome
Rare congenital disorder
Compromises bilateral failure of scapula descent + fusion of several Csp vertebrae
Neck usually short + may be webbed, Csp motion limited
Condition usually left untreated
Winged scapula
Scapula just under skin, like small wing
Due to weakness of serrated anterior (stabilises scapula on thoracic cage)
May cause asymmetry of shoulders, often not apparent until Pt contracts serrated ant against resistance
Can gradually improve
Even if it doesn’t, disability usually slight
Can be stabilised by tendon transfer
Weakness of serrated anterior may arse from..
Damage to long thoracic nerve
Injury to brachial plexus of 5-7 nerve roots
Viral infection of nerve roots
Certain types of muscular dystrophy
Grating scapula
Found in about 1/3 of normal people
Cause usually not found but occasionally an X-ray will show osteochondroma
Involves popping, grating, grinding or snapping of bones + tissue in the shoulder blade area when lifting or moving the arm
AC instability
Common, resulting from dislocation of AC + rupture of ligaments which surround end of clavicle
Pt may complain of discomfort + weakness during strenuous with arm above shoulder
On exam, fairly obvious bump over AC+ Direct pressure may be painful
If diagnosis not obvious on x-ray, re-exam with Pt standing + holding heavy object will drag shoulder down + show displacement
Condition causes little disability during non-strenuous activity + treatment unnecessary
OA of AC
Common in elders
Develops spontaneously
When it occurs in younger individuals it may be due to previous injury or repetitive stress
Pt complains of P over top of shoulder, particularly whilst using arm above shoulder height
Tenderness + localised swelling to AC
If analgesics + corticosteroid injections are ineffective, P may be relived by excision of lateral end o clavicle
Tendinitis/bursitis/sub acromial impingement
Subacromial impingement= rotator cuff tendinitis or bursitis
Subacromial impingement epidemiology
Irritation of rotator cuff underneath acromion
Exact cause unclear
Born with ‘hooked acromion’ will predispose impingement
Intrinsic rotator cuff weakness
Age groups affected by subacromial impingement
> 40
Risk factors of subacromial impingement
Sport
Work related activities (overhead motion)
Clinical presentation of subacromial impingement
Inflam of bursa between rotator cuff + acromion
Recent Hx of over activity
P on top of shoulder
Localised tenderness, inflam, oedema, loss of function
Most symptoms begin gradually, have chronic component that progresses over several months
Bursitis can cause crepitus
Assess Csp for radiculopathy
Prognosis of subacromial impingement
Best initial intervention= activity modification, NSAIDs, subacromial injections, PT program
Arthroscopy for failure of conservative treatment- 3-6 months- + impingement
Calcification tendinitis
Multi focal, cell-mediated calcification of tendon usually followed by spontaneous resorption
Epidemiology go calcification tendinitis
Build up on calcium in tendon
Genetic predisposition
Abnormal cell growth
Bodily production of anti-inflam agents
Metabolic diseases, such as diabetes
Age groups affected by calcification tendinitis
40-60
Women more likely to be affected
Risk factors of calcification tendinitis
Perform lots of overhead motions
More common in people who play sports routinely
Can affect anyone
Clinical presentation of calcific tendinitis
May have minimal/no symptoms during formative phase
Acute symptoms common in restorative phase, P related to increased intratendinus pressure from influx of inflam cells, oedema, swelling, etc
Increased tendon vol= increased restriction of subacromial space
Examine Csp
Acute phase of calcific tendinitis
Painful catching caused by localised impingement of calcified mass of coracoacromial arch, can easily be confused with acute infection
Chronic phase of calcific tendinitis
Supra/infraspinatous atrophy, severe P due to guarding against motion
During this provocative tests such as impingement can be nearly impossible due to significant loss of motion
Prognosis of calcific tendinitis
PT, NSAIDs, steroid injections
Calcific deposits remain, symptoms will resolve
Daily exercise program to avoid mobility loss
Surgery suggested when- symptoms progress despite treatment (3-6 months refer), when P interferes with daily activity
Clinical presentation of calcific tendinitis
Should P on top
Movement aggravates (specifically horizontal direction)
Typical complaints include inability to sleep on affected side
Overall should have nearly full but painful ROM
Prognosis of calcific tendinitis
NSAIDs
Intra-articulate injection of cortisone
Surgical excision of JT if P persists
Refer at 3-6 months
Frozen shoulder/adhesive capsulitis epidemiology
Capsule thickens + tightens around Jt, restricting movement
Primary is idiopathic
Secondary associated with other medical condition
Diabetes has high association, incidence= 2-4 x more likely
Could be result of other conditions such as cervical disc degen, or CNS disorders
Age groups affected by arthritis
Pt 40-60
Usually females
Weeks of shoulder P + Rx
Risk factors of arthritis
Having to keep shoulder still for long period (e.g., after surgery)
Diabetes, CCD, CNS disorder
Hx of trauma
Clinical presentation of frozen shoulder
P, limited ROM
Loss of both activity + passive shoulder motion
Diagnosis of exclusion
DDX Ad Cap
Cervical patho
Impingement syndrome
Rotator cuff tear
Arthritis
Disuse syndrome
Inflam stage of ad cap
Few weeks- 9 months- insidious onset of P + stiffness around shoulder
Adhesive stage of ad cap
4-12 months- P gradually subsides but stiffness persist
Resolution of ad cap
5-24 months- spontaneous but gradual improvement in ROM
Prognosis of arthritis
NSAIDs, analgesics
ROM activities to tolerance
Should be gradual return takes 6-12 months
Subacromial bursitis Hx
P over superior or lateral GH Jt at night, difficulty sleeping
Subacromial bursitis S+S
Tender palpation over acomion/deltoid
Reduced shoulder ROM in abduction + flexion
P may be relieved by GH inferior distraction
Supraspinatous tendonitis Hx
P with overhead movements or hand placed behind back
Supraspinatous tendonitis S+S
Exquisite P with resisted supraspinatous movements
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