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OMS Peripheral > Shoulder > Flashcards

Shoulder Flashcards

1
Q

What are the main bursae of the shoulder (2)

A

(1) Subscapular bursa

(2) Subacromial bursa

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2
Q

How deep is the subacromial space and what does it house?

A 
It is 7-14mm deep
It houses: 
- subacromial bursa
- supraspinatus tendon
- superior part of the shoulder capsule
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3
Q

What are the four articulations between the scapula, clavicle, humerus and sternum?

A

1- Glenohumeral joint
2- Acromioclavicular joint
3- Sternoclavicular joint
4- Scapulothoracic joint

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4
Q

How does the clavicle transmit the weight of the upper limb?

A

It transmits weight to the axial skeleton via the coracoclavicular and costoclavicular ligaments

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5
Q

Where does the inferior angle of the scapula lie?

A

It lies over the 7th rib

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6
Q

What crosses the inferior angle of the scapula?

A

Latissimus Dorsi

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7
Q

Where does the suprascapular notch lie?

A

Junction between the superior border of the scapula and the coracoid process. Landmarks: about half way along the scapular spine posteriorly

The superior transverse scapular ligament turns this into a foramen

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8
Q

What lies within the suprascapular notch?

A

The suprascapular nerve

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9
Q

What does the suprascapular nerve innervate?

A

Supraspinatus and Infraspinatus

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10
Q

Where is the spinoglenoid notch?

A

Laterally where both the supra and infraspinatus fossas communicate

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11
Q

What runs through the spinoglenoid notch?

A

Supraspinatus Nerve

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12
Q

What attaches to the supraglenoid tubercle?

A

The long head of the biceps

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13
Q

What attaches to the infraglenoid tubercle?

A

The long head of the triceps

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14
Q

What attaches onto the greater tubercle?

“SIT”

A

Supraspinatus
Infraspinatus
Terres Minor

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15
Q

What attaches to the intertubercular sulcus/bicipital groove?

A

Pectoralis Major

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16
Q

What inserts onto the lesser tuberosity?

A

Subscapularis

Terres Major -> on the medial lip of the bicipital groove

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17
Q

What provides the structural stability to the acromioclavicular joint?

A

Coracoclavcular ligament

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18
Q

What are the components and functions of the coracoclavicular ligament?

A

1- Trapezoid: more horizontal, acts as a hinge for scapular motion
2- Conoid: more vertical, acts as a longitudinal axis for scapular rotation

TOGETHER they prevent medial displacement of the acromion under the clavicle

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19
Q

What is the surface difference between the head of the humerus and the glenoid fossa?

A

The head of the humerus is 3-4x larger than the glenoid fossa

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20
Q

What is the volume of the shoulder’s joint capsule?

A

15-30mL

Large volume but thin and spacious

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21
Q

What are the shoulder’s capsular ligaments?

A

Superior, middle and inferior glenohumeral ligaments

They are only evident on the interior aspect

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22
Q

What is the capsular pattern of the shoulder?

A

Lateral rotation > Abduction > Medial rotation

“LAM”

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23
Q

What is the rotator interval?

A

It is a fibrous gap between the supraspinatus and subscapularis tendons and is therefore part of the rotator cuff

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24
Q

How does active elevation at the shoulder progress through range?

A

0-60 degrees - abduction at the glenhumeral joint
60-120 degrees - abduction at the scapulothorcic joint
120-180 degrees - abduction at the scapulothoracic and glenohumeral joint as well as side flexion of the trunk on the opposite side

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25
Q

What is the main nerve supply to the glenohumeral joint?

A

C5 segment

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26
Q

How do you palpate the supraspinatus tendon?

A

Seat the patient at a 45 degrees angle, medially rotate the arm (behind their back).

Palpate for the anterior edge of the acromion and locate the greater tuberosity.

The tendon runs directly (in line with a shoulder strap), it is 1 finger’s width.

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27
Q

How do you palpate the infraspinatus tendon?

A

Either have the patient side lying with their hand on their cheek or have the seated with the arm adducted and laterally rotated.

Palpate from the posterior aspect of the acromion and locate the greater tuberosity. The tendon runs horizontally and is 2-3 finger’s width.

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28
Q

How do you palpate the subscapularis tendon?

A

Have the patient’s arm in neutral and find the coracoid process and move slightly laterally and slightly downwards.

The tendon is 3 finger’s width.

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29
Q

What is the main cause of impingement in the young patient?

A

Instability of the shoulder

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30
Q

What does the middle aged person present with most often?

A
  • Overuse rotator cuff lesions
  • Impingement
  • Chronic bursitis
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31
Q

What is the most common presentation in older patients?

A
  • Degenerative rotator cuff lesions or tears

+/- secondary or idiopathic adhesive capsulitis

32
Q

What is the most common acromioclavicular injury onset?

A

Trauma, usually with a hand outstretched

33
Q

What is the characteristic for an acute subacromial bursitis onset?

A

Sudden onset with no apparent cause

34
Q

What are the most common shoulder lesions with a gradual onset of pain due to overuse factors?

A
  • Tendinopathy
  • Bursitis
  • Capsulitis
35
Q

How do you differentiate nerve entrapment?

A

Non-specific shoulder pain, objective weakness but with no pain on shoulder movements

36
Q

What behaviour does an acute subacromial bursitis have?

A

Severe pain that is constant and often unrelenting, disturbing sleeping

37
Q

What is the behaviour of shoulder capsulitis?

A
  • Increasing worsening pain, referring further and further down the C5 dermatome
  • Inflammatory in nature and so patients complain of pain and stiffness on waking
  • Capsular pattern
38
Q

What is the behaviour of a shoulder impingement?

A
  • ‘Catching’ pain during activities such as reaching for a seat belt or into the back of the car, placing an arm into the coat of a sleeve
39
Q

What are the three main behaviour questions to ask for capsulitis to determine severity and irritability?

A

1- Does the pain spread below the elbow? (site and spread)
2- Can you lie on that side at night? (symptoms)
3- Is the pain constant? (behaviour)

40
Q

Special behaviours to the shoulder?

A
  • Clicking
  • Snapping
  • Feeling as though the shoulder is coming out
  • Crepitus or grating sounds
41
Q

What to look out for in the PMH?

A
  • RA/OA
  • Previous frozen shoulder
  • Previous acute subacromial bursitis
  • Serious illness
  • Surgeries
42
Q

Natural history of adhesive capsulitis?

A

1- Increasing signs and symptoms (freezing), short painful
2- Plateau stage (frozen), short recovery
3- Slow, spontaneous recovery of partial or complete function (thawing), longer period of pain with a longer recovery period

43
Q

What are the primary changes in the pathophysiology of frozen shoulder?

A
  • Volumes of less than 10 mL
  • Inflammatory changes, adhesion formation, erythematous fibrinous pannus over the synovium and loss of redundant axillary folds
  • Fibrosis, not inflammation
  • Retraction of the capsule away from the greater tuberosity
44
Q

Is Primary frozen shoulder sensitive to steroid injections?

A

Yes!

45
Q

What is the common development in Stage 1 of Secondary Frozen Shoulder?

A

This stage develops over several weeks (pain over deltoid initially then starts referring down C5 dermatome) and pain is the key feature, NOT the limited movement

46
Q

What are the specific points in the history and objective AX for Stage one Secondary Frozen Shoulder?

A

Hx:

  • Pain is above the elbow
  • Pain is not usually constant
  • Patient can sleep on that side at night

Objective:

  • Minor capsular pattern (even just loss of lat rotation)
  • End feel remains relatively elastic but is harder than the normal end feel
47
Q

What is the treatment for Stage 1 of Secondary Frozen Shoulder?

A
  • Grade B mobilisations (ONLY IF NOT IRRITABLE)

- Steroid injections

48
Q

What are the key features of Stage 2 of Secondary Frozen Shoulder?

A

Pain and loss of function and the capsular pattern has fully developed.

This affects function: doing up bra, combing hair

49
Q

What is secondary frozen shoulder?

A

Causes include trauma or any condition that causes immobilisation of the shoulder

50
Q

What are the specific points in the history and objective AX for Stage two Secondary Frozen Shoulder?

A

Hx:

  • Pain usually spreads beyond the elbow
  • Pain is usually constant
  • Patient cannot sleep on that side at night

Objective:

  • Full capsular pattern
  • Hard end feel due to muscle spasm and capsular contracture
51
Q

Treatment for Stage two Secondary Frozen Shoulder?

A
  • Steroid injection

- Grade A mobilisations to help restore accessory range

52
Q

Treatment for Stage three Secondary Frozen Shoulder

A

Similar to stage 1:

  • strengthening and stretching
  • Grade B
53
Q

Is acute subacromial bursitis self-limiting?

A

Yes, usually better within 7-10 days. Clearing completely within 6 weeks.

It is prone to reoccurrence.

54
Q

Objective findings for acute subacromial bursitis?

A
  • Empty end feels due to muscle spam and pain
  • Non-capsular pattern
  • Usually lateral rotation can be achieved +/- distraction
  • Abduction most limited and painful
55
Q

Treatment for acute subacromial capsulitis?

A 
- Advice:
sleeping position with pillow and tight t-shirt for support
collar and cuff
pain meds
- Steroid injection
56
Q

Where is the pain felt in issues of the acromioclavicular joint?

A

Epaulette region

57
Q

What is the onset for acromioclavicular joint pain?

A
  • Trauma (outstretched hand or direct heavy blow)
58
Q

Objective findings for acromioclavicular joint pain?

A
  • Non-capsular pattern
  • Pain at end of range for flexion, lateral and medial rotation
  • Positive Scarf test
59
Q

What are the three categories of acromioclavicular joint injuries?

A

1- Type 1: sprain or partial tearing of the capsuloligamentous fibres with local pain and tenderness. No joint instability

2- Type 2: tearing of capsuloligamentous fibres and minor subluxation, the coracoclavicular ligament is still intact, no instability

3- Type 3: dislocation of the acromioclavicular joint with disruption of the capsule and the coracoclavicular ligament –> SURGERY

60
Q

When are steroid injections useful for the acromioclavicular joint?

A

In Chronic cases

61
Q

Treatment for Type 1 and 2 acromioclavicular joint pain?

A
  • Friction to the superior acromioclavicular capsule ligament
  • Strapping/taping the joint
62
Q

What does impingement syndrome encompass? (9)

A

1- All rotator cuff lesions
2- Subacromial bursa
3- Subacromial space stenosis
4- Inflammation and/or fibrosis of the contents of the space
5- Shoulder instability
6- Degenerative changes in the acromioclavicular joint
7- Osteophyte formation
8- Degenerative spur formation under the acromion
9- Thickening of the coracoclavicular ligament

63
Q

Most common persons to get subacromial impingements?

A
  • Patients under 35 years: particularly athletes using the arm in overhead positions
  • Patients over 35 years: degenerative changes and ageing process
64
Q

What are the three main stages of subacromial impingement and treatment?

A

1- Inflammation and oedema in the subacromial bursa, mainly young people, conservative treatment

2- Secondary thickening and fibrosis, older persons, conservative management and surgery only if condition fails to respond after 18 months

3- Partial or full tears of the rotator cuff, over 40s, surgical opinion

65
Q

Objective findings for subacromial impingement?

A
  • Painful or weak resisted abduction/external rotation/internal rotation
  • Painful arc
  • +/- subacromial bursa involvement
66
Q

Best special tests for subacromial impingement?

A
  • Hawkins-Kennedy
  • Neer
  • Horizontal Adduction test
  • Drop arm Yergason
  • Painful Arc Test
67
Q

Can the supraspinatus and subacromial bursa be differentiated?

A

No, the inner synovial aspect of the bursa is also the outer aspect of the rotator cuff, the supraspinatus in particular. The lesion of one will affect the other.

68
Q

What is the behaviour for chronic subacromial bursitis?

A
  • Gradual onset of pain
  • Low grade ache over the insertion of the deltoid
  • May not be able to sleep on that side
69
Q

Objective findings for chronic subacromial bursitis?

A
  • Non-capsular pattern
  • Pain felt at the end of range
  • Painful arc MAY be present and various resisted tests MAY also produce pain
70
Q

Treatment of chronic subacromial bursitis?

A

Steroid injection

71
Q

What are the aims for treatment of rotator cuff tendinopathy?

A

1- Relieve pain

2- Restore full functional movement to the shoulder

72
Q

Objective findings for rotator cuff impingements?

A
  • Painful resisted: supraspinatus-abduction, infraspinatus and teres minor-lateral rotation, subscapularis-medial rotation
  • +/- Weakness
  • MAY have a painful arc
73
Q

How to use a painful arc to localise where the rotator cuff tendon is injured before palpating?

A

Distal end of tendon/tenoosseous junction = If there is a painful arc or pain at end of range on passive elevation

Musculotendinous junction = If pain is produced on resisted abduction but no painful arc

74
Q

Treatment for rotator cuff tendinopathy?

A
  • Steroid injection
  • Friction
  • Holistic Treatment
75
Q

Objective findings for tendinopathy of long head of biceps?

A
  • Painful resisted elbow flexion

- Painful arc

OMS Peripheral (8 decks)

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