Shoulder pain Flashcards by MA CARMELA CONCEPCION SALES

By the age of 50 about _____of people have some wear and tear of the rotator cuff, making it more injury-prone.

25%

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Disorders of the rotator cuff are common,
especially ________. The most effective tests to diagnose these problems are the
________

supraspinatus tendonopathy

resisted movement tests

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Apart from the AC joint there
are two most significant functional joints—
1
2

the glenohumeral (the primary joint) and the
subacromial complex (the secondary joint)

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a ball and socket joint enveloped by a loose capsule

It is prone to injury from traumatic forces and develops osteoarthritis
more often than appreciated.

glenohumeral joint

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The clinically important ________ lies
above the glenohumeral joint between the head of the humerus and an arch formed by the bony acromion, the thick coracoacromial ligament and the coracoid process

perihumeral space

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The socalled_________ is the space between the undersurface of the acromion and the superior aspect of the humeral head.

This space is normally
narrow (6–14 mm), especially when the arm is
abducted.

‘impingement interval’

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The commonest causes of pain in the shoulder zone ______ and ______

are cervical disorders and periarthritis

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The outstanding common

disorders of the shoulder joint are the __________ and ______

rotator

cuff disorders and adhesive capsulitis

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Labrum/capsule

15–35

Dislocations

History of dislocation, apprehension sign

Instability

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Capsule

40–60

Pain, night pain, loss of movement

Loss of external rotation

Stiffness

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Rotator cuff (fatigue)

30–60

Night pain, pain with overhead activities

Impingement signs

Impingement

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Rotator cuff esp. supraspinatus

50 +

Impingement signs, weakness external
rotation, weakness supraspinatus

Rotator cuff tear

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AC joint cartilage

25–45

Localised AC joint pain

Paxinos sign

AC joint pain

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Glenohumeral joint cartilage

70 +

Pain, loss of movement

Crepitus

Arthritis

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The tendon disorders are diagnosed by_______

pain on resisted movement

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1 Abduction _______
2 Internal rotation ______
3 External rotation*
4 Adduction

Supraspinatus
Subscapularis
Infraspinatus Teres minor* Biceps
Pectoralis major Latissimus dorsi*

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but with capsulitis and subacromial bursitis there is usually restriction in
________

most directions.

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Dxtics for posterior dislocation

shoot-through axillary views (posterior

dislocation

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MRI—a useful imaging method but not

routinely required except for the____

unstable joint

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_______may be caused by local musculoskeletal trauma or inflammation or can be referred from blood or other irritants in the peritoneal cavity

Pain at the shoulder tip

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American studies of college and

national competition swimmers showed ______ had suffered significant pain

40–60%

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Swimmers’ shoulders are forced through
thousands of revolutions each day, so the susceptible area tends to impinge on the coracoacromial arch, leading to the _________, which can
progress with continued stress and age

impingement syndrome

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Stages of Swimmer’s shoulder

Stage 1: pain only after activity
Stage 2: ____
Stage 3:_______

pain at beginning only, then after activity

pain during and after activity, affects
performance

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Mx of Swimmer’s shoulder

Refer for physiotherapy for scapular stabilisation and cervicothoracic mobilisation

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DDx of shoulder pain in the elderly

• polymyalgia rheumatica (increased incidence with age) • supraspinatus tears and persistent ‘tendonitis’ • other rotator cuff disorders • stiff shoulder due to adhesive capsulitis • osteoarthritis of AC and glenohumeral joints • cervical dysfunction with referred pain • the avascular humeral head

The humeral head may become avascular after major _________

proximal humeral fractures

Once the humeral head has collapsed, there is ______

secondary | capsular contracture

________ also referred to as | ‘impingement syndrome’, is the commonest cause of shoulder pain.

Rotator cuff tendonopathy,

Rotator cuff tendonopathy, It may involve one tendon, usually the __________, or more of the rotator cuff tendons

supraspinatus

The severe cases usually involve calcification (calcific periarthritis) of the tendon, which has a very rapid onset, and spread to the subacromial bursa (subacromial bursitis).

Supraspinatus tendonopathy

The impingement tests These are effective tests for supraspinatus lesions as they force impingement of the _____ and ________ under the acromion

rotator cuff and bursa

The impingement tests One of these tests is the_______

‘emptying | the can’ resistance test

What muscle is tested Elevation of the arm is resisted against the therapist’s downward push.

supraspinatus.

Mx of Supraspinatus tendonopathy

Physiotherapy—an active program including scapular stabilising exercises and rotator cuff strengthening

The ideal injection for supraspinous tendinopathy is a specific injection onto the _______ rather than

tendon rather than general infiltration into the | subacromial space

Injection for Supraspinatus tendonopathy

The recommended injection is 1 mL of a soluble or long-acting corticosteroid with 5 mL of 1% lignocaine

Persistent supraspinatus tendonopathy There are three factors to consider with this problem:

A very tight subacromial space Rotator cuff tear or degeneration Calcification of the tendon

Mx of tight subacromial space

Refer for subacromial decompression by division of the thickened coracoacromial ligament

Indication of subacromial decompression

pain persisting beyond 12 months

_________ are common, being present in 4% of people <40 years old and in more than 50% of those over 60 years, but a significant number will become symptomatic over time.

Asymptomatic rotator cuff tears

Diagnsois of rotator cuff tears

* supraspinatus weakness * weakness in external rotation * impingement (in external or internal rotation or both)

Specificity of 3 signs of rotator cuff tears

98%

It is the only inflammatory disorder around the shoulder joint where localised tenderness is a reliable sign.

Subacromial bursitis

Mx of Subacromial bursitis (injection)

Large local injection of 5–8 mL of local anaesthetic into and around the bursa just beneath the acromion, followed immediately by 1 mL of corticosteroid (long-acting) into the focus of the lesion

_________ is an acute inflammation affecting the glenohumeral joint, which becomes fibrotic and contracted

Adhesive capsulitis or capsulosis

AKA froxen shoulder

Adhesive capsulitis or capsulosis

ddx for Adhesive capsulitis or capsulosis

monoarticular rheumatoid arthritis, a crystal arthropathy such as gout, and septic arthritis.

3 stages of adhesive capsulitis

1 ‘freezing, frozen and thawing’—an inflammatory painful phase of 2–9 months 2 a fibrotic contracted phase of 4–12 months 3 partial or complete resolution of 5–26 months

Adhesive capsulitis: For severe pain oral _______ rapidly alleviate pain, improve function and may provide sustained benefit

corticosteroids

Modern Tx of adhesive capsulitis

The modern treatment is arthrographic hydrodilatation of the glenohumeral joint with a large quantity of sterile solution (to stretch the capsule) ± corticosteroid.

Modern Tx of adhesive capsulitis The rule is: if very stiff use ______ if more mobile use a _____

arthroscopy; distension procedure

_____of people with adhesive capsulitis do not regain full normal movement if untreated

Fifty per cent

Exercises in adhesive capsulitis

Exercise in the acute phase can exacerbate pain but | a gentle program is useful when it settles.

______ is a lesion such as fraying or tearing of the long head of the biceps, which causes pain in front of the shoulder

Bicipital tendonopathy

Yergason test for bicipital tendonopathy

pain on resisted flexion of the elbow joint and on resisted supination with the elbow flexed to 90 ° and forearm pronat

bicipital tendonopathy Sometimes it is possible to elicit local tenderness by palpation along the course of the tendon in the ______

bicipital groove

bicipital tendonopathy CX

complete rupture and subluxation | of the tendon out of its groove.

It may be spontaneous or occur after lifting or falling on the outstretched hand. The patient usually feels a tearing or snapping sensation in the shoulder.

Rupture of the biceps tendon

surgical intervention for ruptured biceps tendon is appropriate for

young, active people, especially those in power sports.

It is very important not to misdiagnose _________ in the older person (over 50 years) presenting with bilateral pain and stiffness in the shoulder girdle

polymyalgia rheumatica

Consider this condition if there is a history of electric shock or a tonic–clonic convulsion. The major clinical sign is painful restriction of external rotation, which is usually completely blocked

Posterior dislocation of the shoulder

______ and ________ or | both, are probably more common than recurrent dislocations, yet frequently are not diagnosed

Recurrent anterior or inferior subluxations,

_________ | is considered the best investigation for Recurrent anterior or inferior subluxations,

Air-contrast CT arthrography

The ________ is the ring of fibrous tissue attached to the rim of the glenoid and provides volume to the cavity and stability to the glenohumeral joint

glenoid labrum

Injuries to the labrum are divided into :

superior labrum anterior to posterior | (SLAP) or non-SLAP lesions and further into stable and unstable lesion

________ lesions include degenerative, flap and vertical labral tears as well as unstable lesions such as the classic Bankart lesion

Non-SLAP

_________the labrum and | capsule is detached from the rim

Bankart lesion,

This is usually secondary to local trauma, longstanding rotator cuff lesions and multiple surgical interventions. Shoulder movements are stiff and usually restricted in all directions

Osteoarthritis of the glenohumeral joint

This condition is usually traumatic or degenerative and is relatively common in builders and sportspeople, especially rowers, and the elderly

Acromioclavicular osteoarthritis

What test A key test for AC joint pain pain is elicited on compression of the joint by placing one hand on the back of the acromion and one on the clavicle.

Paxinos sign

_______ and ______ are very refractory to | treatment and tend to last for several months.

Tendonitis and bursitis

Test for ________ (including | swimmer’s shoulder) with the impingement tests, including the ‘emptying the can’ test

supraspinatus disorders

_______ is the investigation of choice for painful disorders of the rotator cuff, especially to investigate tears in tendons

Modern ultrasound

An elderly person presenting with bilateral | shoulder girdle pain has ________until proved otherwise

polymyalgia rheumatica