Shoulder and Elbow Flashcards
Red flags: Osteosarcoma (bone cancer)
- Bone pain
- Constant pain or more severity at night
- Swelling/mass/deformity
- Stiffness in the joint
- Fatigue
Red flag: Acute rotator cuff tear
- Usually following trauma
- Pain and weakness
- Sudden loss of ability to raise arm
Red flag: Polymyalgia Rhumatica (an inflammatory disorder)
- Pain and stiffness in neck/shoulder/PGP
Red flag: Giant cell arteritis (inflammation of blood vessels in the brain)
- Tenderness on scalp
- Headaches
- Painful jaw
- Previous history
- 20% of PMR develop GCA
Red flag: AVN of humeral head
- Pain which increases overtime
- Stiffness
Red flag: DVT in upper limb
- Swelling
- Pain
- Visible collateral veins at shoulder girdle
Red flag: Loosening/Infection of shoulder arthoplasty
- Red, hot swollen joint/wound
- Feeling generally unwell
- Signs of sepsis
- Fatigue
- New onset shoulder pain
- Feeling of instability/giving way/dislocation
- History of shoulder replacement
Glenohumeral joint instability: pathophysiology and risk factors
Abnormal movement of the humeral head in the gleniod fossa.
This can be anterior, posterior or multidirectional dislocation.
Can be traumatic or atraumatic
Can result in subluxation or dislocation
Stanmore classification (Jaggi and lambert 2010)
Polar 1- evidence of trauma
Polar 2- atraumatic structural instability
Polar 3- Muscle patterning- no structural deformity just abnormal coordination
Risk factors:
- Age
- Hypermobility
- Male gender
- Participation in collision sports
- Occupations involving upper limb motion above chest height
Signs and symptoms of instability
- Clicking
- Pain
- Subacromial or internal impingement signs
- Increased joint accessory motion
Anterior: increased translation anteriorly
Posterior: increased translation posteriorly
Multidirectional: increased translation in combination of directions
Frozen shoulder: pathophysiology and risk factors
Inflammation of the joint capsule.
The capsule becomes scarred and tightens therefore increasing stiffness and pain in the shoulder
Stage 1- freezing stage (painful) 2-9
- Stage 2- frozen (pain subsides, progressive loss of ROM) 4-12
- Stage 3- thawing (gradual improvement of ROM) 12 +
Risk factors:
- Female
- Over age of 40
- Prolonged immobilization
- After trauma
- Diabetes
Signs and symptoms of frozen shoulder
- Progressive restriction to both activr and passive movement
- Don’t tend to have crepitus (more OA of GHJ)
- Movement restriction in capsular pattern: external rot then flexion then internal rot
- Gradual onset
Management of instability
If traumatic: require ortho review
After relocation or atraumatic:
- Education on condition, symptom management and self management
- Direct to GP
- Physio for mobility, shoulder strengthening and proprioception
Consider referral to ortho if:
- No improvements with physio
- Recurrent dislocations
- Impacting on the person
Management of frozen shoulder
- Education and reassurance than it can take months to years to resolve
- Advise to modify activities
- Direct to GP for pain meds
- Explain that i will be painful, can affect sleep and stiffness may worsen
If symptoms don’t resolve:
- Physio: stretching, manual therapy, acupunture
- Corticosteriod injection
- Surgical management for capsular release
Research for frozen shoulder
The following interventions are suitable for primary care:
NSAIDs
Injection
Home exercise programmes- pain relieving for stage 1 and mobilisations for stage 2
Supervised manual therapy
Vivek Pandey
Glenohumeral and Acromioclavicular OA: pathophysiology and risk factors
Degenerative joint disease or inflammation of a bony joint
When cartilage or other tissues about a joint have been broken down
Risk factors:
- Age
- Obesity
- Glenohumeral instability
- Lifting heavy objects/weights (occupation)
- Chronic alcholism
- Overhead sports
Signs and symptoms of GHJ and ACJ OA
- Pin point pain
- Aggr by activities
- Reduced ROM
- Crepitus
- Difficulty in ADLs: lifting arm
- Progression of symptoms overtime
ACJ pathologies: Irritation or acute injuries
Account for up to 40% of all shoulder injuries
Involves overstretching or tearing of AC or Coracoclavicular ligaments resulting in subluxation and dislocation
Most common mechanisms:
Falling onto an outstretched hand
Direct impact of superior shoulder
During contact sports
Grade 1: minor tear of AC ligaments
Grade 2: vertical subluxation rupture of AC ligaments and stretching of coracoclavicular ligaments
Grade 3: Subluxation with complete rupture of AC and coracoclavicular ligaments
Signs and symptoms of ACJ injuries
- Pain and tenderness over ACJ
- Sometimes radiation into neck
- Aggr factors: overhead activities, reaching across body
- Painful lying on affected side
- Noticeable step
- Pain worse with movement
- Positive scarf and cross arm tests
Management of GHJ and ACJ OA
- Education: symptom management
- Advise continuation of normal activitiees within pain limits
- Refer to GP for pain meds and NSAIDs
- Advise about weight loss
If not improvement:
- Physio: mobility and strengthening
- Corticosteroid injection
- Surgical option
Management of ACJ injuries
- Education on management
- Advise rest and consider a sling for 5-7 days
- Refer to GP
- Start mobilisation and strengthening as symptoms start to settle
- Avoid heavy contact for 8-12 weeks.
- Return to normal activities
If no improvement:
- Physio
- grade 3 or higher dislocations: surgery
Research for ACJ injuries
Management of acute and chroni ACJ injuries is not clarified in current literature
Aim for low grade injuries to be treated conservatively
Biceps brachii tendinopathy: pathophysiology and risk factors
Caused by repetitive micro trauma to the tendon which causes micro tears
Leading to degeneration of the tendon and disorganisation to collagen
Cook and Purdam 2009 came up with the tendinopathy continuum which involved reactive tendinopathy, tendon disrepair and degenerative tendinopathy
Risks:
- Sporting activities- repetitive motions
- Affects young and middle aged more
- Degenerative changes can affect elderly
Signs and symptoms of Biceps Tendinopathy
- Throbbing, aching pain
- Aggr factors: lifting, pulling, pushing
- Ease: rest unless irritable
- Usually present gradually
- Overuse overhead activities
- Tenderness in palpation of biceps tendon
Biceps tendon rupture/tear of the Proximal (long-head): pathophysiology and risk factors
Rupture or tear of the long head of biceps tendon which attaches on top of the glenoid fossa
(do not tend to have a specific mechanism of injury unlike distal ruptures)
Risk factors:
- Age - predominately 40-60 or young people following a trauma e.g falling on an outstretched hand
- Previous shoulder problems
- Smoking
- Rheumatoid arthritis
- Corticosteriod use
Signs and symptoms of Proximal Biceps rupture or tear
- Sudden and painful popping or snapping
- ‘popeye’ appearance
- Pain limited weakness
- AROM and PROm usually available but restricted by pain
- Positive speeds, yergasons
Biceps tendon rupture/tear of the Distal tendon: pathophysiology and risk factors
Tear or rupture of the biceps tendon which attaches to the bicipital tuberosity of radius
Risk factors and causes:
- Uncommon, 3% of all tendon injuries
- Common in middle-aged males
- Heavy manual jobs or sporting activities
- Excessive force being transferred through the biceps from an extended elbow position into the flexed one
Signs and symptoms of distal biceps rupture
- Trauma
- Painful swollen elbow
- Sudden popping sound
- Elbow flexion and supination usually weak
- AROM and PROM usually restricted because of pain
- Positive hook test for complete
- Retracted muscle in upper arm
Management of biceps tears/ruptures and tendinopathy
- Education on biceps related condition, symptom management and self management strategies
- Advise of heat/ice application for pain
- Advise on rest from aggr factors
- Direct to GP
If no improvement after 6/52:
- Physio for stretching, strengthening for elbow and shoulder
- Corticosteroid injections NOT for distal rupture
- Surgeries arent use fro proximal ruptures
- Surgery for recurrent tendinopathy
Research for proximal rupture
Management usually begins with:
- Non-steriodal anti-inflammatory drugs
- Physical activity: lacks analysis of outcomes]
- Injections: short term use only
Research for distal rupture
Surgical intervention better than non-surgical intervention
Marco Cuzzolin
Rotator cuff related pain: pathophysiology and risk factors
Its an umbrella term for different shoulder conditions:
- Subacromial pain syndrome (bursitis)
- Rotator cuff tendinopathy
Extrinsic compression= pinching of rotator cuff tendons on acromion resulting in microtrauma to cuff tendons
Intrinsic compression= degeneration leading to instability , reduction in subacromial space and increasing suseptibility of compressive factors
- Symptomatic partial and full thickness rotator cuff tears
Typically affects ages 35-75
Age- degeneration or trauma
Gender
Signs and symptoms of Rotator cuff related pain
- Pain is sharp, shooting or stabbing
- Can have some non-dermatomal pins and needles or numbness
- Aggr factors: lifting arm, overload activities, overhead, reaching behind back
- Positive drop arm test
- Severe pain and weakness with tears
- AROM and PROM are painful
- PROM usually full, AROM restricted in flexion and abduction
- Positive Hawkins, Empty can
Management of RCRSP
- Education on condition, symptom and self management
- Advise to rest during acute stage with gradual increase in activity
- Activity modification
- Direct to GP
If symptoms don’t improve:
- Physio: postural correction, motor control retraining, stretching, rotator cuff and scapular muscle and manual therapy (6-12 weeks)
- Subacromial corticosteriod injection
- 12/52 weeks no improvement= surgery
Exercise based approach for rotator cuff related shoulder pain like impingement, tendinopathy and partial or full tears
Manual therapy effectiveness requires further research
Jeremy Lewis
Tennis elbow: pathophysiology and risk factors
Overuse injury cause by overload at the origin of the common extensor tendon
- Leading to tendinosis and inflammation of associated tendons
Both men and women
35-54 age
Risks:
- Age
- Repetitive risk felxion activities
- Occupation with repetitive heavy lifting
Signs and symptoms of tennis elbow
- Pain on palpation on and around the lateral epicondyle
- Present gradually
- Pain and weakness on resisted wrist extension
- Aggrs: gripping, lifting
- Positive Maudsleys, Mills and cozens
Golfers elbow: pathophysiology and risk factors
Overuse injury cause by overload at the origin of the common flexor tendon
- Leading to tendinosis and inflammation of associated tendons
Men and women
35-54 years
Risks:
- Repetitive elbow movement activities especially flexion
- Sports involving gripping and throwing
Signs and symptoms of golfers elbow
- Tenderness on palpation of medial epicondyle
- Aggrs factors: gripping, lifting, activities involving wrist flexion
- Present gradually
-Pain and weakness on resisted wrist flexion
Management of golfers and tennis elbow
- Education
- Advise on heat/ice for pain relief
- Rest from aggrs factors
- Direct to GP
if symptoms dont improve 6/52:
- Physio for stretnching and strengthening
- Only injecting in severe cases
- No improvement after 6-12 months consider surgery
Cubital tunnel: Pathophysiology and risk factors
Peripheral entrapment neuropathy affecting the ulna nerve as it courses through the medial elbow region
- caused by pressure or traction, trauma, pathologies (RA, OA, tumours, fractures)
2 times more likely in men
Risks:
Occupations involving repetitive elbow flexion and extension movements
Prolonged leaning on elbows
Obesity
Diabetes
Over 40 yrs
Signs and symptoms of cubital tunnel
-Pain, numbness and tingling in the ulnar nerve sensory distribution
-Weakness with gripping activities and in chronic cases can describe loss of fine dexterity
-Tenderness surrounding the medial epicondyle and cubital fossa
-Aggr factors: leaning on the elbows (medial aspect) or by flexion and extension of the elbow
-Weakness of muscles innervated by ulnar nerve
-Positive tinnels and froments sign
Management of cubital tunnel
- Education
- Activity modification
- Elbow splinting or wrapping elbow to avoid excessive flexion
- Consider epiclasp elbow strap (4-6 weeks)
- Direct to GP
No improvement:
Physiotherapy for joint mobs, stretching and neural mobilisation
In severe cases surgery
What are the red flags to look out for when assessing the shoulder/elbow?
- Osteosarcoma
- Acute rotator cuff tear
- Polymyalgia Rheumatica
- Giant cell arthritis
- AVN of humeral head
- DVT in upper limb
- Loosening/infection
