Shoulder Problems Flashcards
what rotator cuff muscles attach to greater tuberosity
supraspinatus, infraspinatus and teres minor supraspinatus = initiation of abduction other two = external rotators
what rotator cuff muscles attach to lesser tuberosity
subscapularis = principle internal rotator
what shoulder problems likely in younger adult
instability
what shoulder problems likely in middle aged
rotator cuff tears (grey hair, cuff tear) and frozen shoulder
what shoulder problems likely in elderly
glenohumeral OA
what is impingement syndrome (painful arc)
syndrome where the tendons of the rotator cuff (predominantly supraspinatus) are compressed in the tight subacromial space during movement producing pain
what causes impingement syndrome
tendonitis subacromial bursitis, acromioclavicular OA with inferior osteophyte and a hooked acromion rotator cuff tear
what are symptoms of impingement syndrome
painful arc between around 60 and 120 degrees of abduction as an inflamed area of supraspinatus tendon passes through subacromial space pain from impingement characteristically radiates to deltoid and upper arm tenderness may be felt below the lateral edge of the acromion
how is impingement syndrome diagnosed
hawkins-kennedy test (internally rotating flexed shoulder) recreates patients pain diagnosis should exclude cervical radiculopathy
what are conservative treatment of impingement syndrome
NSAIDs, analgesics, physiotherapy and subacromial injection of steroid (up to 3 injections required)
if conservative treatment of impingement syndrome doesn’t work, what next
subacromial decompression surgery to create more space for tendon to pass through can be done as open procedure or minimally invasive arthroscopic techniques
in what circumstances can rotator cuff tears occur
minimal or no trauma as result of degenerative changes in tendons in older patients can also occur in younger patients due to injury (inc shoulder dislocation), athletes (throwing) or manual workers (painters) but this is uncommon
what rotator cuff muscle do tears usually almost always involve
tears can be partial or full thickness and usually involve supraspinatus large tears can extend into subscapularis and infraspinatus
what % of over 60 have asymptomatic cuff tears due to tendon degeneration
20
what is a classic history of a rotator cuff tear
sudden jerk (eg holding rail on bus n it stops) in age >40 with subsequent pain and weakness difficult sleeping on affected side, reaching overhead and on lifting
what muscle movements is there weakness in in rotator cuff tears
initiation of abduction (supraspinatus), internal rotation (subscapularis) or external rotation (infraspinatus). Wasting of supraspinatus may also be seen
how can rotator cuff tears be diagnosed
tears confirmed on US or MRI probs want to get xray to rule out OA
what is treatment options for rotator cuff tears
They are managed conservatively with rest, physio, SA steroid injections or surgically with either arthroscopic or open subacrominal decompression and rotator cuff repair
what is adhesive capsulitis
frozen shoulder = disorder characterised by progressive pain and stiffness of shoulder in patients between 40 and 60, resolving in around 18-24 months
what is pathophysiology of adhesive capsulitis
the capsule and glenohumeral ligaments become inflamed then thicken and contract
what causes adhesive capsulitis
unclear cause, sometimes history of innocuous triggering injury or surgery but often not. At higher risk if diabetic and condition also been associated with hypercholesterolaemia and dupuytrens (similar thickened fascia found histologically)
what are symptoms of adhesive capsulitis
initially pain which will subside (after around 2-9 months) as stiffness increases (for 4-12 months) and then the stiffness will gradually thaw out over time with good recovery of shoulder
what is principle clinical sign of adhesive capsulitis
loss of external rotation (along with restriction of other movements) which can also occur in OA but OA tends to be even older patients
what is treatment of adhesive capsulitis
physiotherapy and analgesics IA (gleno-humeral rather than subacromial) injections may help.
what about if once pain settled, patient cannot tolerate function loss in adhesive capsulitis, what can be done
recovery can be hastened by manipulation under anaesthetic (which tears capsule) or surgical capsular release (done arthroscopically) which divides capsule leading to improved motion
what is acute calcific tendonitis
calcium deposition in the supraspinatus tendon
what is symptoms of acute calcific tendonitis
acute onset of severe shoulder pain
how is acute calcific tendonitis diagnosed
calcium deposition in the supraspinantus tendon seen on xray just proximal to greater tuberosity
how is acute calcific tendonitis treated
great relief of pain achieved with subacromial steroid and local anaesthetic injection condition is self limiting with pain easing as calcification resorbs
what does instability of shoulder involve
painful abnormal translational movement or subluxation and/or recurrent dislocation
what two types of instability exist
traumatic and atraumatic
although some shoulders which experience a traumatic anterior dislocation settle and stabilise after reduction and physio, what happens to others
do not stabilise and develop further dislocations or subluxations often with minimal force 80% redislocation rate in under 20s and 20% redislocation in over 30s
what surgery can stabilise the shoulder in those who have recurrent dislocations
Bankart repair (open or arthroscopic) can stabilise shoulder by reattaching the labrum and capsule to the anterior glenoid which was torn off in first dislocation
what causes atraumatic instability and why is treatment difficult
patients with generalised ligamentous laxity (idiopathic, ehlers-danlos, marfans) can have pain from recurrent multidirectional (anterior, posterior and inferior) subluxations or dislocations treatment difficult as soft tissue procedures may not work
what is biceps tendonitis and what is symptom
inflammation of tendon of long head of biceps anterior shoulder pain with pain on resisted biceps contraction
what is treatment of biceps tendonitis
surgical division of the tendon with or without attachment to the proximal humerus may be required to relieve symptoms
what is complication of biceps tendonitis
tendon can spontaneously rupture resulting in relief of symptoms however some are left with bunched up biceps muscle known as popeye deformity
what are SLAP lesions and how is it diagnosed
tears in the glenoid labrum where the long biceps tendon attaches, causing pain diagnosis difficult but may be identified on MRI arthrogram (contrast injected into joint)
how are SLAP lesions treated
controversial = biceps tenotomy may be enough or labral resection or repair may help
what other conditions can present with shoulder pain
neck problems angina pectoris diaphragmatic irritation (biliary colic, hepatic or subphrenic abscess)
