Shoulder Problems

Question 1

what rotator cuff muscles attach to greater tuberosity

Answer 1

supraspinatus, infraspinatus and teres minor supraspinatus = initiation of abduction other two = external rotators

Question 2

what rotator cuff muscles attach to lesser tuberosity

Answer 2

subscapularis = principle internal rotator

Question 3

what shoulder problems likely in younger adult

Answer 3

instability

Question 4

what shoulder problems likely in middle aged

Answer 4

rotator cuff tears (grey hair, cuff tear) and frozen shoulder

Question 5

what shoulder problems likely in elderly

Answer 5

glenohumeral OA

Question 6

what is impingement syndrome (painful arc)

Answer 6

syndrome where the tendons of the rotator cuff (predominantly supraspinatus) are compressed in the tight subacromial space during movement producing pain

Question 7

what causes impingement syndrome

Answer 7

tendonitis subacromial bursitis, acromioclavicular OA with inferior osteophyte and a hooked acromion rotator cuff tear

Question 8

what are symptoms of impingement syndrome

Answer 8

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

Question 9

how is impingement syndrome diagnosed

Answer 9

hawkins-kennedy test (internally rotating flexed shoulder) recreates patients pain diagnosis should exclude cervical radiculopathy

Question 10

what are conservative treatment of impingement syndrome

Answer 10

NSAIDs, analgesics, physiotherapy and subacromial injection of steroid (up to 3 injections required)

Question 11

if conservative treatment of impingement syndrome doesn’t work, what next

Answer 11

subacromial decompression surgery to create more space for tendon to pass through can be done as open procedure or minimally invasive arthroscopic techniques

Question 12

in what circumstances can rotator cuff tears occur

Answer 12

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

Question 13

what rotator cuff muscle do tears usually almost always involve

Answer 13

tears can be partial or full thickness and usually involve supraspinatus large tears can extend into subscapularis and infraspinatus

Question 14

what % of over 60 have asymptomatic cuff tears due to tendon degeneration

Answer 14

20

Question 15

what is a classic history of a rotator cuff tear

Answer 15

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

Question 16

what muscle movements is there weakness in in rotator cuff tears

Answer 16

initiation of abduction (supraspinatus), internal rotation (subscapularis) or external rotation (infraspinatus). Wasting of supraspinatus may also be seen

Question 17

how can rotator cuff tears be diagnosed

Answer 17

tears confirmed on US or MRI probs want to get xray to rule out OA

Question 18

what is treatment options for rotator cuff tears

Answer 18

They are managed conservatively with rest, physio, SA steroid injections or surgically with either arthroscopic or open subacrominal decompression and rotator cuff repair

Question 19

what is adhesive capsulitis

Answer 19

frozen shoulder = disorder characterised by progressive pain and stiffness of shoulder in patients between 40 and 60, resolving in around 18-24 months

Question 20

what is pathophysiology of adhesive capsulitis

Answer 20

the capsule and glenohumeral ligaments become inflamed then thicken and contract

Question 21

what causes adhesive capsulitis

Answer 21

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)

Question 22

what are symptoms of adhesive capsulitis

Answer 22

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

Question 23

what is principle clinical sign of adhesive capsulitis

Answer 23

loss of external rotation (along with restriction of other movements) which can also occur in OA but OA tends to be even older patients

Question 24

what is treatment of adhesive capsulitis

Answer 24

physiotherapy and analgesics IA (gleno-humeral rather than subacromial) injections may help.

Question 25

what about if once pain settled, patient cannot tolerate function loss in adhesive capsulitis, what can be done

Answer 25

recovery can be hastened by manipulation under anaesthetic (which tears capsule) or surgical capsular release (done arthroscopically) which divides capsule leading to improved motion

Question 26

what is acute calcific tendonitis

Answer 26

calcium deposition in the supraspinatus tendon

Question 27

what is symptoms of acute calcific tendonitis

Answer 27

acute onset of severe shoulder pain

Question 28

how is acute calcific tendonitis diagnosed

Answer 28

calcium deposition in the supraspinantus tendon seen on xray just proximal to greater tuberosity

Question 29

how is acute calcific tendonitis treated

Answer 29

great relief of pain achieved with subacromial steroid and local anaesthetic injection condition is self limiting with pain easing as calcification resorbs

Question 30

what does instability of shoulder involve

Answer 30

painful abnormal translational movement or subluxation and/or recurrent dislocation

Question 31

what two types of instability exist

Answer 31

traumatic and atraumatic

Question 32

although some shoulders which experience a traumatic anterior dislocation settle and stabilise after reduction and physio, what happens to others

Answer 32

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

Question 33

what surgery can stabilise the shoulder in those who have recurrent dislocations

Answer 33

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

Question 34

what causes atraumatic instability and why is treatment difficult

Answer 34

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

Question 35

what is biceps tendonitis and what is symptom

Answer 35

inflammation of tendon of long head of biceps anterior shoulder pain with pain on resisted biceps contraction

Question 36

what is treatment of biceps tendonitis

Answer 36

surgical division of the tendon with or without attachment to the proximal humerus may be required to relieve symptoms

Question 37

what is complication of biceps tendonitis

Answer 37

tendon can spontaneously rupture resulting in relief of symptoms however some are left with bunched up biceps muscle known as popeye deformity

Question 38

what are SLAP lesions and how is it diagnosed

Answer 38

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)

Question 39

how are SLAP lesions treated

Answer 39

controversial = biceps tenotomy may be enough or labral resection or repair may help

Question 40

what other conditions can present with shoulder pain

Answer 40

neck problems angina pectoris diaphragmatic irritation (biliary colic, hepatic or subphrenic abscess)