Week 4 - C - Shoulder - Painful arc. rotator cuff tears, adhesive capsulitis, calcific tendonitis, instability, popeye

Question 1

What is the shoulder joint also known as? What type of joint is the shoulder joint and what forms it?

Answer 1

The shoulder joint is also known as the glenohumeral joint

It is a synovial ball and socket joint formed by the humeral head and the scapular glenoid

Question 2

The shape of the glenohumeral joint and the complex interplay between bony anatomy and the supporting muscles affords a wide range of movement. WHat provides the shoulder joint with stability?

Answer 2

The shoulder joint has a lack of inherent bony stability

It is the surrounding musculature that plays an essential role in providing the joint with stability

Question 3

The rotator cuff is formed by four muscles hold the humeral head in place at the same time as providing a number of essential movements: What are these four muscles?

Answer 3

Supraspinatus

Infraspinatus

Teres minor

Subscapularis

Question 4

What is the insertion of the different rotator cuff muscles?

Answer 4

Supraspinatus - inserts into the upper facet of the greater tubercle of the humerus

Infrapsinatus - inserts into the middle facet of the greater tubercle of the humerus

Teres minor - inserts into the lower facet of the greater tubercle of the humerus

Subscapularis - inserts into the lesser tubercle of the humerus

Question 5

State the movements allowed by each of the rotator cuff muscles

Answer 5

Supraspinatus is responsible for initiation of abduction of the arm (first 1-015 degrees)

Infraspinatus and teres minor are responsible for external(lateral) rotation of the arm

Subscapularis is responsible for internal (medial) rotation of the arm

Question 6

Collectively the rotator cuff muscles serve the crucial function of pulling the humeral head into the glenoid to provide a stable fulcrum for the powerful deltoid muscle to abduct the arm The rotator cuff muscles are under significant repeated stress and acute or degenerate tendon tears can occur which can cause pain and disability. * What can chronic rotator cuff insufficiency lead to?

Answer 6

Chronic rotator cuff insufficiency can lead to glenohumeral OA

Question 7

Shoulder problems tend to occur in different age groups What are the typical causes of shoulder pain in * Younger adult * Middle aged adult * Elderly

Answer 7

Younger adult - instability is the usual source of pain

Middle aged adult - rotator cuff tears (grey hair, cuff tear) and frozen shoulder are often the problem

Elderly - glenohumeral OA becomes more likely

Question 8

What is shoulder impingement syndrome? aka painful arc syndrome - which tendon is predominantly affected What degrees does the painful arc typically occur around?

Answer 8

Shoulder impingement syndrome is where the tendons of the rotator cuff - predominantly the supraspinatus - are compressed in the tight subacromial space during movement producing pain

Typically the patient has a painful arc between 60 to 120 degrees

Question 9

What are different causes of painful arc syndrome?

Answer 9

* Tendonitis subacromial bursitis (calcified surpraspinatus tendon causes subacromial bursitis)

* Acromioclavicular osteoarthritis

* A hooked acromion rotator cough tear

Question 10

How does painful arc syndrome typically present? What shoulder examination test can recreate the patients pain?

Answer 10

Painful arc syndrome characteristically radiates to the deltoid and upper arm

Tenderness may be felt below the lateral edge of the acromion

Hawkins Kennedy test recreates the patients pain by internally rotating the flexed shoulder

Question 11

What is the treatment of painful arc syndrome?

Answer 11

Treatment is conservative in the first instance

Majority settle with NSAIDs, analgesia and pysiotherapy

Question 12

Which cause of painful arc syndrome may benefit from intraaticular steroid injects?

Answer 12

Tendonitis subacromial bursitis and acromioclavicular OA may benefit from intra-articular steorid injections

Question 13

Cases which do not improve with conservative management (NSAIDs, analgesia, physiotherapy, steroid injections), may benefit from what?

Answer 13

May benefit from subacromial decompression surgery - During a subacromial decompression procedure, your surgeon will aim to make more space under your acromion by removing some of the bone and tissue from its underside.

Most often carried out as keyhole surgery

Question 14

The tendons of the rotator cuff can tear with minimal or no trauma as a consequence of degenerate changes in the tendons. What is a classic history of a rotator cuff tear?

Answer 14

Classic history is a sudden jerk (eg holding a rail on bus which suddenly stops) in a patient >40 years of age

* With subsequent pain and weakness

Question 15

At least 20% of over 60 year olds have asymptomatic cuff tears due to tendon degeneration. In theory, rotator cuff tendons can tear in young patients due to a significant injury (including shoulder dislocation) although this is very uncommon. Rotator cuff tears can be partial or full thickness Which tendon is usually involved? What can large tendons extend into?

Answer 15

Rotator cuff tears usually involve the supraspinatus tendon

Large tears can extend into subscapularis and infrapspinatus

Question 16

What symptoms arise depending on the tendon affected by the tear?

Answer 16

Rotator cuff tears can be asymptomatic - usually in tendon degeneration

However symptomatic tears present with pain and weakness

Supraspinatus - weakness of initiation of abduction

Infraspinatus - weakness of external rotation

Subscapularis - weakness of internal rotation

Question 17

How are tears confirmed?

Answer 17

Tears are confirmed on ultrasound scan or on MRI

Ultrasoud is good for tendon imaging

MRI tends to be better for imaging of labral (glenoid labrum) tears

Question 18

The optimal treatment of rotator cuff tears remains controversial What is the non-operative management? What is the operative management?

Answer 18

Non-operative management involves physiotherapy to strengthen the remaining cuff muscle which can compensate for the loss of supraspinatus

Operative management involves open or arthroscopic rotator cuff repair with subacromial decompression

Question 19

Why is rotator cuff repair surgery not always the choice for treatment?

Answer 19

The tendon is usually diseased and failure of repair occurs in around 1/3rd of cases

Question 20

What age group of patients are affected by frozen shoulder? What is frozen shoulder and what is it also known as?

Answer 20

Frozen shoulder aka adhesive capsulitis tend to affect middle aged patients (between 40 and 60)

It is a disorder characterized by progressive pain and stiffness of the shoulder due to the capsule and glenohumeral ligaments becoming inflamed, then thickening & contracting

Question 21

Describe the progression of the symptoms of adhesvie capsulitis? * how long does it take for pain to subside * How long does it take for stiffness to ‘thaw’?

Answer 21

Patient will initially complain of pain which will subside after 2-9 months

Stiffness increases for around 4-12 months and then gradually thaws out

The condition should be fully resolved by 18-24 months after onset of symptoms with good recovery of shoulder motion

Question 22

What is the principle clinical sign of frozen shoulder? Which movements are restricted? What othr condition can present similarly?

Answer 22

The principle clinical sign of frozen shoulder is the loss of external rotation

All movements are somewhat restricted however OA of the shoulder can occur similarly however this tends to affect oler patients

Question 23

The aetiology of frozen shoulder is unlcear What may the condition follow sometimes? Patients with what conditions are prone?

Answer 23

Frozen shoulder may follow an innocous triggering injury and sometimes occur after shoulder surgery

Patients with diabetes particularly are prone

Also associations with hypercholesterolaemia and Duputryens (similar thickened fascial tissue is found histiologicallY)

Question 24

Treatment in the majority of cases is non-operative with the aim of relieving pain and to prevent further stiffening while the condition resolves naturally What are the conservative management options in this condition? What is different about the injection location compared to painful arc?

Answer 24

Conservative management includes physiotherapy and analgesia

Intra-articular steroid injections are gleno-humeral rather than sub-acromial (impingement syndrome) and can help in the painful phase

Question 25

Once the pain has settled, if the patient cannot tolerate functional loss due to stiffness, what can hasten the recovery?

Answer 25

Recovery can be hastended by manipulation under anaesthetic (which tears the capsule) or surgical capsular release - which divides the capsule leading to improved motion

Question 26

What symptoms does acute calcified tendinitis result in? What tendon is calcium deposited in in this condition?

Answer 26

Acute calcified tendonitis results in tthe acute onset of severe shoulder pain and is characterised by calcium deposition in the supraspinatus tendon

Question 27

How is acute calcified tendonitis diagnosed and where is the calcium deposition seen on this scan?

Answer 27

Calcium deposition is diagnosed on xray and is seen just proximal to the greater tuberosity (deposition of calcium hydroxyapatite crystals)

Question 28

Acute calcific tendonitis is self-limiting with pain easing as the calcification resorbs How can pain relief be achieved in this condition?

Answer 28

Great pain relief is achieved with subacromial steroid and local anaestetic injection

Question 29

Instability of the shoulder involves painful abnormal translational movement or subluxation and/or recurrent dislocation. What are the two sub-type patterns of shoulder instability?

Answer 29

Traumatic instability - where patients can experience a traumatic dislocation or Atraumatic instability where patients with generalised ligament laxity are affected

Question 30

What is the common direction for traumatic shoulder dislocation to occur in? How is it treated? What is recurrent rate of dislocation in \* Patients under 20s \* Patient over 30s

Answer 30

Shoulder disloctions are typically anterior Shoulder stabilized with reduction, rest and a physiotherapy strengthening programme \* 80% re-dislocation rate for patients under 20s \* 20% re-dislocation rate for patients over 30s

Question 31

What is the repair that can be carried out in patient with recurrent dislocations due to trauma?

Answer 31

In patients with recurrent dislocations, a Bankart repair can stabilise the shoulder - this happens by re-attaching the labrum and capsule to the anterior glenoid which was torn off in the first dislocation

Question 32

What are different causes of atruamatic instability? What directions can the subluxations/dislocations be in these causes?

Answer 32

Atraumatic instability is usually from patients with generalised ligamentous laxity - idiopathic, Ehler's danlos and Marfans They can have multidirectional (anterior, posterior or inferior) subluxations / dislocations

Question 33

Why is treatment for atruamatic shoulder instability difficult?

Answer 33

Treatment is difficult as soft tissue procedures may not work due to the generalised ligamentous laxity

Question 34

What symptoms does inflammation of the tendon of long head of the biceps present with? When is it characterisitcally worse? \* (condition known as long head of the biceps tendinopathy)

Answer 34

Inflammation of the tendon of long head of the biceps causes anterior shoulder pain The pain is characteristically worse on resisted biceps contraction

Question 35

What may be required to relieve the symptoms of long head of the biceps tendinopathy?

Answer 35

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

Question 36

When the long head of the biceps tendon is inflamed, it can spontaneously rupture What is the deformity that can arise due to this known as?

Answer 36

When the tendon ruptures, it can cause the biceps muscle to bunch up into a ball causing what is known as the Popeye deformity

Question 37

Tears in the anterior (inferior) glenoid labrum when there is an anterior shoulder dislocation are referred to as Bankart lesons What are tears in the glenoid labrum where long biceps tendon attaches known as?

Answer 37

Tears in the superior aspect of the glenoid labrum where the long biceps tendon attaches are known as SLAP lesions (superior labral tear from anterior to posterior)

Question 38

How do SLAP lesions present and how can they be identified?

Answer 38

SLAP lesions can cause pain and diagnosis is difficult however may be able to be identified on MRI arthogram (contrast injected into the joint)

Question 39

What is the treatment of SLAP lesions?

Answer 39

Treatment is controversial - biceps tenotomy may be enough or labral resection or repair may help