Shoulder and Elbow

Question 1

Elbow pain - common causes

Answer 1

Osteoarthritis
Rheumatoid arthritis 
Gout
Tennis elbow
Golfer's elbow

Question 2

Difference between Tennis elbow and Golfer’s elbow

Answer 2

Tennis elbow - overuse injury involving eccentric overload at the origin of the extensor tendon
- pain over the lateral epicondyle
Golfer’s elbow - overuse syndrome of flexor-plantar mass origin
- pain over medial epicondyle

Question 3

Olecranon bursitis - clinical features

Answer 3

Localised swelling 
Local tenderness
Pain
Full range of motion 
Erythematous 
Fever
Warm to touch

Question 4

Olecranon bursitis - cause

Answer 4

Inflammation of the bursa overlying the olecranon of the ulnar

Question 5

Lumps/swellings of elbow

Answer 5

Olecranon bursitis 
Rheumatoid nodules
Gout
Septic Arthritis 
Osteophytes

Question 6

Shoulder pain - causes

Answer 6

Osteoarthritis 
Rotator cuff tear
Tendinitis 
Frozen shoulder 
Thoracic outlet syndrome 
Bursitis

Question 7

Osteoarthritis - radiological findings

Answer 7

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

Question 8

Shoulder osteoarthritis - non-operative management

Answer 8

Physical therapy
NSAIDs - for pain and inflammation
Intra-articular injections e.g. corticosteroids
DMARDs - RA

Question 9

Shoulder osteoarthritis - operative management

Answer 9

Total shoulder arthroplasty - more common, requires an intact rotator cuff
Hemiarthroplasty - performed in younger patients, or those with a torn rotator cuff
Arthroscopic debridement

Question 10

Shoulder instability - clinical features

Answer 10

Anterior 
- arm held abducted and externally rotated 
- loss of normal contour of the deltoid 
- prominent acromion 
- palpable humeral head anteriorly
- pain
Posterior 
- arm abducted and internally rotated 
- posterior prominence of the head of the humerus
- pain

Question 11

Shoulder instability - radiological features

Answer 11

Anterior - AP film
- humeral head appears to have moved inferior and medial
Posterior - axillary, lateral view required
- light bulb appearance on AP film
- loss of the normal half-moon overlap sign

Question 12

Shoulder instability - static shoulder stabilisers

Answer 12

Scapulohumeral ligaments 
- superior glenohumeral ligaments 
- coracohumeral ligament 
- middle glenohumeral ligaments 
- anterio-inferior glenohumeral ligament 
Posterior capsule

Question 13

Shoulder instability - dyanamic shoulder stabilisers

Answer 13

Rotator cuff muscles (primary role)
- supraspinatus, infraspinatus, subscapularis and teres minor 
Rotator interval 
Long-head of biceps 
Periscapular muscles

Question 14

Shoulder instability - complications

Answer 14

Damage to axillary nerve - numbness and sensory loss to lateral shoulder and inability to abduct the arm
Injury to the brachial plexus, axillary artery and axillary vein
Avulsion fractures of tubercles
Recurrent shoulder instability
Rotator cuff injury

Question 15

Adhesive capsulitis - description

Answer 15

a. k.a. frozen shoulder

- pain and loss of motion in the shoulder with no other cause

Question 16

Adhesive capsulitis - clinical features

Answer 16

Dull pain
Stiffness (self-limiting)
Painful arc
Decreased range of movement (especially external rotation)
- both active and passive
- affects the glenohumeral joint

Question 17

Adhesive capsulitis - stages

Answer 17

Stage 1 (freezing stage)
- minimal synovitis
- pain
- decreased range of movement 
Stage 2 (frozen stage)
- proliferative synovitis with contraction of the capsule and adhesions of axillary recess 
Stage 3 (thawing stage)
- contracted capsule 
- follows the end of the inflammation

Question 18

Adhesive capsulitis - management

Answer 18

Non-operative
- NSAIDs, physical therapy and intra-articular steroid injections
- usually successful within 3-6 months
Operative
- manipulation under anaesthesia (indicated when drug treatments and NSAIDs fail)
- arthroscopic surgical release (indicated only once extensive therapy has failed)

Question 19

Subacromial impingement - clinical features

Answer 19

Pain
- insidious onset
- exacerbated by overhead activities
- night pain, especially when lying on affected side
Movement restriction - depends on the muscle involvement
Painful arc between 60 and 120 degrees

Question 20

Subacromial impingement - complications

Answer 20

Can easily progress to rotator cuff tendonitis or rotator cuff tear

Question 21

Subacromial impingement - treatment

Answer 21

Non-operative
- avoid overhead movements
- NSAIDs
- physical therapy 
- glucocorticoid injections 
Operative management 
- arthroscopic decompression 
- open acromioplasty if acromion narrows

Question 22

Rotator cuff - anatomy

Answer 22

Supraspinatus 
- superior to spine of scapula 
- innervated by suprascapular nerve 
Infraspinatus 
- inferior to spine of scapular 
- innervated by suprascapular nerve 
Teres minor 
- inferior to subscapularis and infraspinatus 
- innervated by axillary nerve
Subscapularis 
- immediately deep to the scapula 
- innervated by upper and lower subscapular nerve

Question 23

Rotator cuff tear - clinical features

Answer 23

Pain
- deltoid pain
- exacerbated by overhead movements
- acute = sudden onset pain and weakness
Weakness
- loss of active range of movement
- normal or increased passive range of movement

Question 24

Rotator cuff tear - treatment

Answer 24

Degenerative rupture (in elderly or inactive patients)
- NSAIDs and physical therapy
- glucocorticoid injections
Traumatic rupture (in active patients)
- surgical treatment
- rotator cuff repair (mini-open or arthroscopic)
- subacromial decompression and rotator cuff debridement
Massive tear
- reverse total shoulder arthroplasty