Shoulder pain Flashcards
By the age of 50 about _____of people have some wear and tear of the rotator cuff, making it more injury-prone.
25%
Disorders of the rotator cuff are common,
especially ________. The most effective tests to diagnose these problems are the
________
supraspinatus tendonopathy
resisted movement tests
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)
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
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
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’
The commonest causes of pain in the shoulder zone ______ and ______
are cervical disorders and periarthritis
The outstanding common
disorders of the shoulder joint are the __________ and ______
rotator
cuff disorders and adhesive capsulitis
Labrum/capsule
15–35
Dislocations
History of dislocation, apprehension sign
Instability
Capsule
40–60
Pain, night pain, loss of movement
Loss of external rotation
Stiffness
Rotator cuff (fatigue)
30–60
Night pain, pain with overhead activities
Impingement signs
Impingement
Rotator cuff esp. supraspinatus
50 +
Impingement signs, weakness external
rotation, weakness supraspinatus
Rotator cuff tear
AC joint cartilage
25–45
Localised AC joint pain
Paxinos sign
AC joint pain
Glenohumeral joint cartilage
70 +
Pain, loss of movement
Crepitus
Arthritis
The tendon disorders are diagnosed by_______
pain on resisted movement
1 Abduction _______
2 Internal rotation ______
3 External rotation*
4 Adduction
Supraspinatus
Subscapularis
Infraspinatus Teres minor* Biceps
Pectoralis major Latissimus dorsi*
but with capsulitis and subacromial bursitis there is usually restriction in
________
most directions.
Dxtics for posterior dislocation
shoot-through axillary views (posterior
dislocation
MRI—a useful imaging method but not
routinely required except for the____
unstable joint
_______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
American studies of college and
national competition swimmers showed ______ had suffered significant pain
40–60%
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
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
Mx of Swimmer’s shoulder
Refer for physiotherapy for scapular stabilisation and cervicothoracic mobilisation
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
