Shoulder and elbow problems

Question 1

What are the main shoulder problems seen in teens/20s?

Answer 1

Fractures and instability - tend to be high energy/velocity injuries

Question 2

What are the main shoulder problems seen in 30s/40s?

Answer 2

Rotator cuff problems i.e impingement or tear and frozen shoulder ‘adhesive capsulitis’

Question 3

What are the main shoulder problems seen in 50s/60s?

Answer 3

Impingement and Acromioclavicular joint problems

Question 4

What is the main shoulder problem seen over 70s?

Answer 4

Degenerative rotator cuff and joint

This leads to partial dislocation (subluxation) of shoulder + arthritis between humeral head and clavicle

Question 5

In which 3 principal directions can the shoulder dislocate?

Answer 5

• Anterior 90%
• Posterior 9%
• Inferior 1%

Question 6

An inferior dislocation is rare. What is a common cause of this type of dislocation?

Answer 6

A fall over a long distance with the arm outstretched above the head

Question 7

An anterior dislocation is the most common type of shoulder dislocation.

What are 3 common causes of this type of dislocation?

Answer 7

• Electric shocks
• Epileptic fits
• Sports

It is commonly caused by an excessive amount of abduction and external rotation (like how you arm is when you go for a volleyball strike)

Question 8

How is a dislocated shoulder treated? (4)

Answer 8

• Manipulation (putting the joint back into normal alignment) by reduction of the joint +/- under sedation
• Immobilisation - in a sling with the arm positioned in adduction and internal rotation
• Physio
• Surgery - if there is recurrent dislocation

Question 9

What is subacromial impingement (shoulder impingement)?

Answer 9

Common cause of shoulder pain as a result of irritation of the rotator cuff tendons resulting from any pathology which narrows the subacromial space or increases the size of the contents (swelling).

• Common cause = inflammation / irritation of the bursa (in the subacromial space) due to overuse of the shoulder. As a result, there is narrowing of this space so then when you abduct your arm, your rotator cuff rubs against (‘impinges on’) the acromion.
• It is a vicious cycle as the rubbing of the rotator cuff tendons result in swelling, which further narrows the subacromial space.
• In older patients, you might see bony spurs that form on the under surface of the acromium that eccentuate the impingement problem.

Question 10

What is the ‘painful arc’ and what does it confirm?

Answer 10

A quick test of movement in the arm. Pain that arises with abduction of the arm between 60 degrees and 120 degrees.

In shoulder impingement, the initial abduction of the arm is not painful but as they abduct the arm further the pain increases and then eases off again above 120 degrees.

A positive test suggests subacromial or rotator cuff disorders.

Question 11

How is shoulder impingement treated?

Answer 11

• Subacromial Steroid injection – calms down inflammation and improves the space available for the rotator cuff
• Physio
• If necessary - sugery - Arthroscopic subacromial decompression which aims to increase the size of the subacromial area and reduce the pressure on the muscle. Also shaves away bony spurs (more common in elderly).

70% of patients see improvement with the injection and physio alone

Question 12

What is frozen shoulder (‘Adhesive Capsulitis’)?

Answer 12

Stiff and painful shoulder - comes on quickly but can last up to 18-24 months - need to mobilise the shoulder quickly in order to prevent further damage/stiffness.

It affects the glenohumeral joint (shoulder joint)

There are 2 main types - primary or secondary (trauma/injury i.e dislocation).

Timeline of frozen shoulder:

• Starts with severe pain and all movements of shoulder are restricted.
• As the pain gets better the stiffness gets worse.
• Then there is thawing of stiffness and motion returns but it doesn’t always return to normal

Question 13

How is frozen shoulder treated? (4)

Answer 13

The majority are treated with:

• Steroid injection - for inflammation
• Physio

If frozen shoulder is detected early you can carry out:

• Hydrodilatation - inject fluid into the joint to stretch the joint capsule and improve mobility

Surgery is also an option if other treatment options do not work

Question 14

What are the 2 main causes of rotator cuff tears?

Answer 14

• Trauma - younger people
• Degenerative

Question 15

What is the rotator cuff?

Answer 15

A group of 4 muscles that originate from the scapula and attach to the humeral head.

They stabilise the shoulder joint and are involved in movement of the arms such as abduction and internal and external rotation.

Question 16

Which muscles make up the rotator cuff?

Answer 16

• Supraspinatus
• Infraspinatus
• Subscapularis
• Teres minor

Question 17

What happens when one of the muscles within the rotator cuff is torn?

Answer 17

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. This weakens the shoulder

Can be a partial tear or complete tear

Question 18

Which imaging modalities can confirm a rotator cuff tear? (2)

Answer 18

• USS - more sensitive on whether it is a complete or partial tear
• MRI - good quality imaging of muscle

Question 19

How is a rotator cuff tear treated?

Answer 19

• Acute = early surgery
• Chronic (degenerative) = surgery if symptomatic

Depends on size, time and age

Question 20

What is superior capsular reconstruction?

Answer 20

This is an option if the patient has a massive, irreparable rotator cuff tear

It involves using a cadaveric skin graft to reconstruct the joint capsule (not tendon) to try and reduce subluxation of shoulder and improve deltoid function

Question 21

Types of shoulder arthritis

Answer 21

• Osteoarthritis - less common in shoulder
• Inflammatory arthritis
• Post-traumatic arthritis

Question 22

Which procedure is commonly carried out for an arthritic shoulder (if the rotator cuff is in tact)?

Answer 22

Total shoulder arthroplasty i.e shoulder joint replacement - custom made implants

Question 23

What are some common elbow problems? (4)

Answer 23

• Fractures & dislocations in young
• Tendinopathies in middle age
• Degenerative disease in elderly - rarer than knee, hip etc
• Cubital Tunnel syndrome at any age - traps the ulnar nerve - tingling sensation + pain