Shoulder and Elbow problems

Question 1

Which shoulder problems are teens / 20-30 yr olds most likely to present with?

Answer 1

Fractures and instability (dislocations/subluxations)

Question 2

Which shoulder problems are adults in their 30s and 40s most likely to present with?

Answer 2

Rotator cuff disease

Capsulitis

Question 3

Which shoulder problems are adults in their 50s and 60s most likely to present with?

Answer 3

Impingement (subacromial bursitis)
Adhesive capsulitis (frozen shoulder)

Question 4

Which shoulder problems are adults over the age of 70 most likely to present with?

Answer 4

Degenerative problems

• degeneration of the rotator cuff
• osteoarthritis

Question 5

What red flag signs/symptoms should be excluded when a patient presents with shoulder pain/stiffness?

Answer 5

History of previous malignancy, and red flag signs suggestive of malignancy (weight loss, swelling, mass etc)
Skin erythema, fever - suggest a tumour or infection
Features of systemic illnesses such as polymyalgia rheumatica, giant cell arteritis or rheumatoid arthritis
Change in shoulder contour and/or history of trauma - suggest an unreduced dislocation
Sensory/motor deficit - neurological lesion

Question 6

What is rotator cuff impingement?

Answer 6

Impingement of the rotator cuff tendon at its insertion into the humeral head under the acromion during shoulder abduction.
aka subacromial bursitis, tendonitis/tendinopathy

Question 7

What causes rotator cuff impingement?

Answer 7

Reduced volume of the subacromial space, or

Increased size of the contents of the subacromial space

Question 8

Describe the presentation of rotator cuff impingement

Answer 8

Full range of (passive) movement

Painful arc test is positive

Question 9

Describe the treatment options for rotator cuff impingement

Answer 9

Physiotherapy
Subacromial steroid injection
Recurrent disease may require arthroscopic subacromial decompression

Question 10

How would you differentiate between rotator cuff inflammation/impingement and tear?

Answer 10

Ultrasound or MRI

Question 11

What is adhesive capsulitis?

Answer 11

aka frozen shoulder
Fibrotic thickening of the glenohumeral joint capsule, resulting in a restricted range of movement in all directions (but particularly external rotation)

Question 12

Describe the course of adhesive capsulitis

Answer 12

Eventually self limiting, has three stages:

1. Shoulder pain - peaks at about three months
2. Stiffness - begins as pain starts to ease
3. Thawing - stiffness reduces and is back to normal* by around 18-24 months

*movement often does not return to its original range/ease; there is often some residual stiffness

Question 13

How is adhesive capsulitis diagnosed?

Answer 13

Clinical diagnosis

X-rays often normal; useful for excluding other conditions

Question 14

Describe the management options for adhesive capsulitis

Answer 14

Physiotherapy - aids retention of movement
NSAIDs (analgesia)
Steroid injections (during early stages)
May require surgery

Question 15

What is calcific tendonitis?

Answer 15

Deposits of crystalline calcium phosphate form in the rotator cuff tendon, particularly the supraspinatus tendon
Presents with severe shoulder pain
Full range of (passive) movement on examination
Eventually self-limiting

Question 16

Give three extrinsic causes of shoulder pain

Answer 16

Referred pain
 - neck, myocardial ischaemia, diaphragm
Polymyalgia rheumatica
Malignancy
 - apical lung tumours, metastases

Question 17

How does osteoarthritis affect the shoulder?

Answer 17

Global reduction in range of movement

- External rotation is particularly restricted

Question 18

Name two tendinopathies of the elbow

Answer 18

Tennis elbow: lateral epicondylitis

Golfer’s elbow: medial epicondylitis

Question 19

Which nerve is affected by cubital tunnel syndrome

Answer 19

Ulnar nerve

Question 20

Describe the aetiology of cubital tunnel syndrome

Answer 20

Prolonged leaning on the elbow
Excessive and prolonged elbow flexion
Risk increased by damage to (medial) elbow ligaments e.g. by baseball/cricket pitching)

Question 21

Describe the management options for cubital tunnel syndrome

Answer 21

Splinting the elbow at 45 degrees

May require surgical decompression