Shoulder Flashcards
Which nerves supply cutaneous innervation to the shoulder?
Supraclavicular nerve (from cervical plexus, C3-4)
Axillary nerve (superior lateral brachial cutaneous branch, C5-6)
Which cervical facets can refer pain to the shoulder?
C5-6
C6-7
Which viscera can refer pain to the shoulder?
Heart
Lung and diaphragm
Liver and gallbladder (right)
Which spinal nerve supplies dermatomal innervation to the shoulder?
C4
What are the red flags in shoulder pain that indicate a serious cardiovascular condition?
SOB / dyspnoea Palpitations Pallor Sweating Mental state changes Nausea / vomiting - SSX agg. by exertion
DVT SSX:
- unilateral UL oedema, heaviness, fatigue, discolouration
- visible veins
What are the red flags in a shoulder presentation that indicate a serious respiratory condition?
SOB / Dyspnoea
Pallor / cyanosis
Tacycardia
- SSX ag. by activity and deep breathing
What are the signs and symptoms of a Pancoast tumour?
Horner’s syndrome
Brachial plexus compression (UL weakness, paraesthesia)
What are the 5 serious conditions that need to be considered in a shoulder presentation?
Myocardial ischaemia DVT Pneumonia Osteomyeltis Neoplasia
What are the 4 neurological conditions that need to be considered in a presentation of shoulder pain?
Thoracic outlet syndrome
Cervical radiculopathy
Cervical myelopathy
Burners / stingers
What are PROMs that can be used to assess shoulder pain and dysfunction?
DASH (Disabilities of Arm, Shoulder and Hand) or Quick DASH
SPADI (Shoulder Pain and Disability Index)
UEFI (Upper Extremity Functional Index)
Describe the presentation of an AC sprain including mechanism, presentation, findings and prognosis
Mechanism: FOOSH, traumatic impact
Pain:
- over top of shoulder and lateral clavicle
- aching, sharp on movement
Agg by:
- shoulder movements (especially horizontal flexion / OH)
Findings:
- pain on AC palpation
- positive O’Briens and Scarf tests
Prognosis:
Grade 1: 2-4 weeks
Grade 2: 4-6 weeks
Describe the condition of shoulder instability including pathology, risk factors, presentation and findings
Pathology: instability of GH joint anteriorly, can be caused by lax joint capsule and ligaments and/or pathology of glenoid labrum
Risk factors: previous GH dislocation, repetitive OH movements (UL in abduction and ER, repetitive OH activities)
Presentation:
- global shoulder pain
- agg. by reaching backwards or OH
Findings:
- GH hypermobility
- positive apprehension / relocation test
- diminished rotator cuff strength (esp. external rotators)
Which underlying pathologies can cause subacromial impingement?
Supraspinatus tendinopathy Bicipital tendinopathy Glenoid labrum tear Subacromial bursitis Osteoperosis and osteophytic bone growth
Which 4 clinical tests can be used to test for subacromial impingement?
Empty Can
Hawkin’s Kennedy
Neer’s Impingement
Painful Arc
What are risk factors for the development of subacromial impingement?
Osteoarthritis Postural (Tx kyphosis, GH IR, decreased external rotator strength) Supraspinatus or bicipital tendinopathy Glenoid labrum tear Repetitive OH movements
Describe the presentation of subacromial impingement
Pain:
- anterior / anterolateral shoulder over acromial region, may radiate to upper arm
- early stage: sharp, intermittent and assoc with movement
- late stage: dull, aching and constant
Agg by:
- shoulder abduction (under 15 and over 90)
- shoulder extension and R
- OH movements
- lying on shoulder
Prognosis:
- lengthy recovery (3-12 months) and need to address underlying cause of impingement
- expect gradual return to activity within 1-3 month
Describe the presentation of a glenoid labrum tear including mechanism and pathology, risk factors, presentation, findings and prognosis
Pathology: tear of glenoid labrum (most common type a SLAP tear involving attachment of long head of biceps)
Mechanism: traumatic traction of GH caused by FOOSH, GH dislocation, excessive strain on bicipital tendon, repetitive OH activities with GH abduction and ER
Risk factors:
- GH instability, history of GH dislocation, repetitive OH activities with GH abduction and ER (throwing sports), age related degeneration
Presentation:
- pain deep in GH joint and across anterior GH
- deep and aching pain agg. by OH movements, lifting and carrying
- often comorbid with bicipital tendinopathy, bursitis, SAI, rotator cuff pathology
Findings:
- GH instability
- pain GH movements, esp. OH
- clicking, popping or locking with GH ROM
- decreased strength elbow flexion w pain (bicipital tendon affected)
Tests:
- positive O’Brien’s, positive Anterior Drawer, positive apprehension / relocation
Prognosis:
- surgical intervention needed for full recovery (if SSX aggravating)
Describe the condition of adhesive capsulitis including pathology, presentation, risk factors, and the 3 phases of the condition
Pathology:
inflammation of synovial membrane in GH joint followed by severe capsular fibrosis and contraction
Risk factors: female, diabetes, metabolic or autoimmune disease, previous history adhesive capsulitis (high recurrence)
Presentation:
- acute phase (3-9/12): insidious onset pain and stiffness, sharp pain with extremes of ROM
- adhesive phase (4-12/12): decreasing pain and increasing stiffness, pain present only at extremes of ROM
- thawing phase (1-3 yrs): spontaneous resolution, gradually increasing ROM
What is the typical healing timeframe for adhesive capuslitis?
Resolution (self-limiting) within 1-3 years, high risk of recurrence including on contralateral shoulder
What are the risk factors and typical mechanisms for glenoid labrum tears?
Typical mechanisms:
- overuse of bicipital tendon (heavy carrying, lifting, traumatic overstretch)
- repetitive OH movements with ER and abduction (ie: throwing sports)
- traumatic traction of GH caused by FOOSH or GH dislocation
Risk factors:
- previous Hx GH dislocation or instability
- GH trauma
- OH activities (with ER and abduction, ie throwing sports)
Describe the condition of rotator cuff tendinopathy including risk factors, presentation, findings, and prognosis
Risk factors:
- repetitive OH movements, heavy load bearing, postural or muscular imbalance, decreased mobility, age related degeneration, SAI, bursitis
Presentation:
- pain over area of rotator cuff tendons and into shoulder joint
- dull and aching pain, agg by GH movements (esp abduction and OH), sleeping on affected arm, reaching behind back (ie: seatbelt, jacket arm)
- insidious onset gradually worsening and can become present at rest
Findings:
- decreased GH strength and GH ROM
Tests:
- painful arc, empty can, hawkin’s kennedy, neer’s impingement, lift off (subscapularis)
Prognosis:
- recovery 2-9 months
- SSX reduction 4-6 weeks
What is the typical healing timeframe for a rotator cuff tendinopathy?
Between 2-9 months
typically SSX reduction within 4-6 weeks
Which tests are used in a case of suspected rotator cuff tendinopathy?
Painful Arc Empty Can Hawkin's Kennedy Neer's Impingement Lift off (subscapularis) Resisted abduction (supraspinatus)
What is the typical healing time frame for bicipital tendinopathy?
Recovery 2-9 months
SSX reduction 4-6 weeks
