Shoulder Flashcards
Tendinitis/Bursitis/Subacromial impingement
Subacrominal impingement occurs when the rotator cuff becomes irritated underneath the acromion.
Causes:
- reasons why this happens is unclear
- some people thought to be born with ‘hooked’ acromions that will predispose them to impingement
- weakness of rotator cuff will allow it to ride up and impinge on the acromion
- this will result in inflammation of the bursa between the rotator cuff and the acromion
- typical patient presents with recent history of over-activity.
AG:
- 40+ more common
- can occur in active people due to over activity
CP:
- often complain of pain at the top and front of the shoulder. Pain is the most common symptom.
- localised tenderness, inflammation, oedema, and loss of function.
- weakness and stiffness to the shoulder may occur
- most symptoms chronic not acute
- sometimes, cracking or popping sensation may occur within the shoulder
prognosis:
- when pain is eliminated, weakened and stiffness generally resolve themselves
- if pain persists, pt should be evaluated for a tear of the rotator cuff or a neurologic etiology (cervical radiculopathy).
- if weakness persists, the pt may also have a frozen shoulder, inflammatory arthritis or calcific tendinitis
- most pt will recover and return to normal function within 6 months.
tests:
- Hawkins ken
- empty can
- painful arc
- passive nears
Calcific tendinitis
Develops when calcium deposits build up in your tendons or muscles.
These deposits can become inflamed and cause pain.
Most often affects the shoulder but can occur anywhere in the body
causes:
- age and wear and tear can lead to calcific tendinitis.
- however cause is generally unknown to why it occurs
CP:
- may have minimal or no symptoms
precalcific stage:
- pain-free
- fibrocartilaginous metaplasia of the tendon
- range of motion starts to decrease
calcific:
- formative phase:
– calcific deposits occur
– pain
- resorption phase:
– phagocytic resorption and vascular infiltration
– clinically most painful stage
postcalcific:
- deposits replaced by healthy tissues. Range of motion starts to improve
prognosis:
- non-operative treatment is successful in approx. 80% of patients.
- when surgery is needed, good results are achieved in 85% to 90% of pt after arthroscopic excision.
Acromioclavicular Joint Arthritis
Common source of shoulder pain.
Rare in GH joint but more common in AC joint.
causes:
- degeneration of the cartilage in the AC joint. General wear and tear over time.
AG:
- older people 50-60 years old.
RF:
- occupation can be related
- may have previous history of injury to the joint, this will make the joint weaker and can have already damaged cartilage.
CP:
- shoulder pain on top of the shoulder common symptom.
- all vectors of movement cause pain- horizontal adduction most painful
- complaint of inability to sleep on affected side
- morning stiffness lasting less than 30 minutes
prognosis:
- treatments limited
- will gradually become worse and worse: symptoms are usually intermittent and take decades for them to become very severe
- surgical alternatives are satisfactory but should be reserved for patients falling conservative therapy for a prolonged period of time and have significant structural changed within the joint
Rotator cuff tear
Rotator cuff injuries are common and increase with age.
Rotator cuff keeps the head of the upper arm bone within the shallow socket of the shoulder.
causes:
- younger people :
either a traumatic injury or the pt is demanding unusual use of the shoulder (professional baseball pitchers)
- older population:
muscle and tendon tissue of the rotator cuff loses some elasticity as you get older. So it becomes more susceptible to injuries, and is often damaged while performing everyday activities.
Often the reason why rotator cuff injuries are seen more in older pt.
AG:
- seen in both young and older pt. More common in the older population 45+.
RF:
- sports that require unusual action of the shoulder repetitively
CP:
- pain felt over the outside of the shoulder and upper arm in the deltoid region is the most common symptom.
- loss of motion, depending on severity
- crepitus, catching and stiffness may be felt
- pt will describe generalised discomfort which is exacerbated with specific movement
incomplete tear:
- pain most prominent, decreased strength might be present
complete tear:
- patient likely to be unable to move the shoulder through normal motions
prognosis:
- variable prognosis
depending on:
- age
- size of lesion
- duration of tear
- patient expectations
- persistence of symptoms
Shoulder Instability (multidirectional and unidirectional)
Shoulder instability represents instability within the joint. This can be from the ligaments that make up the capsule.
The shoulder sacrifices stability for more movement, meaning the shoulder isn’t the most stable joint in the body.
causes:
unidirectional instability:
- usually the result of significant trauma to the shoulder.
- affects males more commonly than women
- these pt have had dislocations in the past that required treatment in the form of an emergent closed reduction by medical personnel.
multidirectional instability:
- usually female and involved in athletic activities that repetitively cycle the glenohumeral joint (swimming, volleyball, etc).
CP:
- pain is main presenting symptom; varying degree of instability or the sensation of joint subluxation; and occasionally, transient neurologic symptoms.
unidirectional anterior instability:
- pt localises pain to position of shoulder abduction and external rotation
- can often remember a specific event that may have brought on symptoms
multidirectional instability:
- pain
- pt may experience symptoms during daily activities with seemingly insignificant provocation
prognosis:
- 90% of patients can expect a satisfactory result with therapy alone in the setting of multidirectional instability.
- pt who still experience symptoms after 6 months of therapy may be candidates for surgical intervention
Shoulder Arthritis
Occurs in up to 20% of adults, much less common than knee or hip arthritis.
causes:
- different forms of arthritis
- most common OA:
– degenerative disorder
- degeneration of articular cartilage within the shoulder
- occurs chronically over time. Known as wear and tear
- when treating, its important to charecterise the onset and duration of symptoms, as well as the degree of functional limitation and the patients activity levels.
- RA may occur as well
CP:
- pain in the shoulder most common
- shoulder stiffness
- creptius
- stiffness in morning- OA (30-), RA (30+)
- symptoms usually begin gradually and are chronic and progressive
- symptoms worsened with activity, and pt awaken at night from pain, particularly if they sleep on the affected side
- functional limitations may be evident
prognosis:
- arthritis will become more and more severe, no cure. Management can make the disorder slightly easier, losing weight or maintaining weight.
Frozen Shoulder (Adhesive Capsulitis)
Common condition charecterized by pain and loss of ROM in the shoulder.
Diagnosis:
- diagnosis shouldnt be made until other intrinsic causes of shoulder pain and stiffness have been ruled out.
- other disorders also present with pain and stiffness:
– impingement syndrome
– rotator cuff tears
– GH arthritis
causes:
- occurs when capsule thickens and tightens around the shoulder joint, restricting its movement.
seperated into primary and secondary:
- primary-
– idiopathic (no known cause)
- secondary-
- associated with other medical conditions (secondary to these):
– cervical disc disease
– CNS disorders
– ischemic cardiac disease
– pulmonary disease
– diabetes mellitus
AG:
- rare in patients under 40
RF:
- recurrence after resolution is rare
CP:
- trademark feature is loss of both and passive shoulder motion.
- night pain
- stiffness reflected in gradual loss of function and insidious onset of pain.
3 stages of development:
- freezing phase:
pain increases with movement and is often worse at night. Progressive loss of motion with increasing pain. Lasts 2-9 months
- frozen phase:
pain begins to diminish, however the ROM is much more limited, about 50% less than the other arm. May last 4-12 months. - thawing phase:
condition may begin to resolve. most pt experience a gradual restoration of movement over next 12-42 months.
prognosis:
- difficult course to return to normal function- takes 6-12 months and is associated with episodes of pain.
- most pt will regain shoulder ROM and function when treated with a structured exercise program and appropriate analgesia.
Disorders of the rotator cuff
Commonest cause of pain around shoulder is disorders of the rotator cuff.
Rotator cuff made up of- SUBSCAPULARIS (in front), SUPRASPINATUS (above), INFRASPINATUS and TERES MINOR (behind).
Stabilises the head of the humerus by pulling it firmly into the glenoid whenever the deltoid lifts the arm forwards or sideways.
Rotator cuff syndrome:
causes:
- degeneration:
– cuff degenerates with advancing age, may be scarring
– commonest site is the ‘critical zone’ of the supraspinatus
- trauma and impingement:
– may occur with lifting weight
– much more likely if the cuff is already degenerate - vascular reaction:
– in an attempt to repair a torn tendon or to revascularize a degenerate area, new blood vessels grow in and calcium deposits are resorbed. This vascular reaction may cause congestion and pain.
CP:
- pain over the front and lateral aspect of the shoulder.
- tenderness is felt at the anterior edge of the acromion.
Subacute tendinitis
Chronic tendinitis
Rotator cuff tears:
- sudden pain and the patient is unable to abduct the arm.
Lesions of the biceps tendon
Tendinitis:
- tendon of long head of the biceps adjacent to the rotator cuff may be involved in impingement syndrome.
- pain and tenderness are sharply localized to the bicipital groove
- mild swelling
- rest, local heat, and deep transverse frictions usually bring relief
Torn head of biceps:
- degeneration and disruption of the tendon of the long head of the biceps is fairly common and is often associated with rotator cuff problems.
- pt usually middle aged or elderly
- feel something snap, the shoulder will ache. Bruising appears over the front of the arm.
- soon ache will subside, and good function will return, but when the elbow is flexed actively, the belly of the muscle contracts into a prominent lump.
SLAP lesions
A fall on the outside arm can sometimes damage the ‘superior part of the glenoid labrum anteriorly and posteriorly (SLAP).
Bankhart lesion (less common)- tear of lower half of labrum and inferior glenohumeral ligament- seen with shoulder dislocations
Bennett lesion (least common)- posterior labral tear associated with posterior rotator cuff damage.
- usually a history of fall followed by pain in the shoulder.
- pt feels click lifting arm above the shoulder height, together with loss of power when using the arm in that position.
- may have inability to throw with arm
- sense of instability within the shoulder
- may have a prior history to dislocation or subluxation
Chronic Instability of the Shoulder
Shoulder less stable at cost for more movement.
Glenoid socket is very shallow, the joint is held secure by the glenoid labrum and ligaments and muscles.
If these structures give way the shoulder becomes ustable and prone to recurrent dislocation or subluxation.
Anterior instability:
– 95% of cases
– usually follows anterior dislocation, with detachment or stretching of the glenoid labrum and capsule
– typically young pt, with complaints of shoulder coming out of place recurrently.
posterior instability:
- follows a posterior dislocation
– usually recurrent subluxation rather than full dislocation
- treatment:
– conservative (muscle strengthening)
– voluntary control of joint
Atraumatic instability:
- pt complains of shoulder coming out with ease
- can occur in athletes like swimmer and throwers who overload and fatigue the stabilizing muscles around the shoulder, leading to pain and subluxation in various directions.
Disorders of the GH joint
Tuberculosis arthritis:
- blood-bourn, will travel to joint via the bloodstream
- uncommon
- usually starts as osteitis but is rarely diagnosed until arthritis has supervened. May proceed to abcess and sinus formation; in some cases fubrous ankylosis develops.
- destructive changes can occur in the joint
- pt usually adults
- warmth and tenderness of joint
- stiffness
- pt may have low-grade fever
- axillary lymph nodes are enlarged
RA:
- autoimmune, immune system mistakenly attacks own tissues.
- 4 stages:
- preclinical
- synovitis
- destruction
- deformity
- this leads to break down of cartilage and maybe deformity of joint RA is affecting.
CP:
- swelling
- pain and stiffness
- morning stiffness lasting longer than 30 minutes
- active movements limited
OA:
- degenerative disorder
- wear and tear of articular cartilage within a joint over time.
- can lead to formation of osteophytes and can cause pain and stiffness within the joint
CP:
- pain
- stiffness
- morning stiffness (lasting less than 30 mins)
- decreased ROM
- deformity may occur
- crepitus
- swelling
Rapidly destructive shoulder arthropathy
Occassionally pt with swelling of the shoulder x-rays show a bizarrely destructive form of arthritis.
It has been suggested that this is a crystal-induced, rapidly progressive arthropathy; it is sometimes associated with massive tears of the rotator cuff
Disorders of the scapula and clavicle
Congenital elevation of the scapula (Sprengel’s shoulder):
- where one scapula stays high close to the neck.
- shoulder on affected side is elevated
- scapula looks and feels abnormally high, smaller than usual and somewhat prominent
- movements are limited but abduction is limited
Klippel-Feil syndrome:
- rare congenital disorder
- comprises bilateral failure of scapular descent and fusion of several cervical vertebrae
- neck is usually short and may be webbed; cervical mobility is restricted
- condition usually left untreated
Winged-Scapula:
- scapula juts out under the skin, like a small wing
- due to weakness in serratus anterior, as this is the muscle which stabilizes the scapula on the thoracic cage
- may cause asymmetry of shoulders
Grating scapula:
- found in 1/3 of people
- cause is usually unknown
AC instability:
- results from dislocation of AC joint and rupture of the ligaments which tether the outer end of the clavicle.
- pt may have discomfort or weakness during strenuous activities with the arm above shoulder height.
- fairly obvious bump over the AC joint can be seen
OA of AC joint:
- common in older people due to wear and tear
- tenderness and swelling localised to the AC joint
