Wk4 Shoulder Pain Flashcards
What is the prevalence of shoulder pain?
7-26%
3rd most common MSK problem
Most shoulder complaints arise from intrinsic causes or extrinsic causes?
Intrinsic causes involving articular and periarticular structures
Extrinsic: neurologic disorders or visceral conditions
What is the most common cause of referred pain to the shoulder?
Cervical spine disease
What is the prevalence of symptomatic rotator cuff disorders?
Prevalence increases with age.
2.8% : 30+
15%: 70+
What is the first step in assessing shoulder pain?
To consider intrinsic versus extrinsic causes
If the shoulder pain is not quite related to shoulder and arm movements, which causes should be considered?
Extrinsic causes
For intrinsic causes of the shoulder pain, what is the modality of the pain?
Pain increase with shoulder and arm movement.
For extrinsic shoulder pain, which causes should be ruled in or out?
Neurologic causes
What is usually the extrinsic source of shoulder pain?
Cervical or thoracic processes or abdominal causes such as gallbladder
For intrinsic causes of shoulder pain, what should we consider?
Whether there was any trauma
For intrinsic causes of shoulder pain, if there is history of trauma, which condition should be considered?
Fracture
Dislocation
Rotator cuff tear
Labrum tear
For intrinsic causes of shoulder pain, if there is no history of trauma, what should we consider next?
Determine whether the pain occurs with only active TOM as it stress the muscles, tendons and ligaments.
Which condition should we consider for intrinsic shoulder pain?
Soft tissue disorders
- Rotator cuff tendonitis
- Biceps tendonitis
- Rotator cuff tendinopathy/tear
- Subacromial bursitis
For intrinsic causes of shoulder pain without history of trauma, pain occurs during active and passive motions, which conditions should we consider?
Consider the involvement of glenohumeral joint (OA, frozen shoulder, gout osteonecrosis) or AC joint disease (separation or OA)
osteonecrosis: loss of blood supply to bone tissue —> death of bone cells
In intrinsic shoulder pain, pain occurs in elevation of arm above the head. What does it suggest?
Impingement syndrome
In intrinsic shoulder pain, pain occurs when lifting items with the biceps or with writs supination. What does it suggest?
Biceps tendinitis
In the primary care, which conditions has the highest prevalence regarding intrinsic shoulder pain?
Impingement syndrome/ Rotator cuff tendinitis
Is it common for patient to have more than one diagnosis for intrinsic shoulder pain?
Yes
What is the difference between “tendinopathy” and “tendonitis” ?
Tendinopathy (swelling & pain): degeneration of the collagen protein that form the tendon.
Tendonitis: inflammation of the tendon
With non-operative treatment, would patients with rotator cuff disease improve symptoms?
Yes. Some patients with full-thickness rotator cuff tears can compensate to recover function with non-operative treatment, even though the tear does not heal without surgery.
Would partial rotator cuff tears or full-thickness tearing be asymptomatic ?
Yes. Asymptomatic shoulders of partial rotator cuff tears were present in 20% of the population, and 15% had full-thickness tearing.
What is the progress of larger rotator cuff tears look like?
Larger tears tend to progress with time and eventually become irreparable due to significant tendon retraction/muscle atrophy when tendon tissue quality does not allow repair.
Smaller rotator cuff tear are less likely to propagate.
Rotator cuff tendons experience structural changes over the years due to repetitive contact of the tendons with movements. What is our rule here?
Be sensitive enough to depict changes that are reversible.
Initially the reaction of the tendon to load, friction, and activity results in small changes with disorganized extracellular matrix and subtle inflammatory reaction around the tendon, What would you see on imaging?
Peritendinitis and focal thickness of the tendon. (MR or US)
Progressive histological changes of rotator cuff tendon include:
- mucoid degeneration
- chondral metaplasia
- amyloid deposition
- increase of fibroblastic cell
- neovascularization
What do these changes suggest?
They suggest the presence of degenerative tendinopathy and are the precursors of tendon tears.
When rotator cuff tendon is unable to heal and restore its normal histological structure, what will happen?
It will lead to partial tear with scar formation and it can decrease mechanical properties.
When would surgical treatment for rotator cuff tendon tears be suggested?
When conservation measure fails to treat those tears are smaller than 50%
How can tendon tear be confirmed?
Only by imaging such as MR or US
Drop arm test will be positive in which two situation?
- a complete tear of rotator cuff tendon
- No tear is present, pain due to inflammation of the tendon.
Which rotator cuff tear occur in younger population and is related to traumatic events?
Insertional tear
Which rotator cuff tear are the most frequent one? What is the characteristics?
Partial articular surface tear (aka. PASTA)
PASTA doesn’t heal properly and have the tendency to progress to full-thickness tears.
Which rotator cuff tear is associated with subacromial and coracohumeral arch degenerative changes?
Bursal-side tears
Which type of rotator cuff tear has the tendency to heal and why?
Bursal-side tears because their adequate blood supply.
In rotator cuff tendon tear, how would you define full-thickness tears?
Full-thickness tears are those tears extend from articular side to the bursal side.
In rotator cuff tear, where would you find the most full-thickness tears?
Most tears are found in supraspinatus. Frequency of subscapularis tendon tears rises.
In rotator cuff tendon tear, how does fat atrophy impact prognosis?
If fat atrophy is over 50%, higher recurrence .
Fat atrophy: degeneration of muscle tissue, muscle fibers are replaced by fatty tissue
What is the characteristics of a massive rotator cuff tendon tear?
Involvement of two or more tendons or a retraction greater than 5cm (tendon has moved away from its original place due to injury)
In the condition of a massive rotator cuff tear, there will be a progressive migration of the humeral head. What is the direction of this migration?
Superiorly
What is the most common symptom of rotator cuff disease?
Shoulder and arm pain/weakness during overhead activities.
As there is shoulder/arm pain associated with overhead activities in rotator cuff disease. How is the pain described?
Dull pain becoming sharp during overhead motion.
Is the presence of pain required to diagnose rotator cuff tendon disease?
No. Chronic full-thickness rotator cuff tear may present without pain, yet loss of active motion
In the condition of rotator cuff disease, should we exam neck and elbow?
Yes. The neck and the elbow should also be examined to exclude the possibility that the shoulder pain is referred from either of these regions.
During inspection, what would venous distention indicate?
Venous distention may indicate an extrinsic causes for the shoulder pain.
If atrophy of supraspinatus or infraspinatus is inspected, what’s the next step?
A further work-up for conditions such as:
- rotator cuff tear
- suprascapular nerve entrapment
- neuropathy
The first 20 to 30 degrees of shoulder abduction, is scapulothoracic motion required?
NO
Which degree of painful arc test indicates subacromial or rotator cuff disorder?
Shoulder pain between 60 to 120 degree
What are the pain provocation test for rotator cuff disease?
Cross body adduction
neer
painful arc
passive abduction
Hawkins
Yocum
What would a positive cross body adduction test indicate?
Pain with adduction is a positive test for AC joint involvement
What would a positive neer impingement test indicate?
Pain indicates subacromial impingement/rotator cuff tendinitis disorder
What would a positive Hawkins impingement test indicate?
Supraspinatus impingement/rotator cuff tendinitis
When both the Hawkins and Neer signs are absent, what does a negative LR indicate?
the negative LR is helpful at 0.1
What does weakness during Drop Arm Test indicate?
Supraspinatus rotator cuff tear or bicipital tendinitis
What does pian or weakness during Dropping Sign suggest?
Infraspinatus involvement/tear
If the patient is not able to maintain external rotation, positive external rotation lag test, what does it indicate?
supraspinatus and infraspinatus disorder
If the patient is not able to hold their hands in internal rotation, positive for internal rotation lag test, what does it indicate?
Subscapularis disorder
If the patient is not able to lift the hand away from the back by internally rotating them, what does it indicate? (Positive Gerber Lift Off test)
Subscapularis muscle
What does positive external rotation resistance test suggest?
Infraspinatus disorder
What does positive empty/full can test suggest?
Lesion of the supraspinatus muscle and tendon
What does positive “Resisted Abduction Test” suggest?
Impingement
What does positive “Patte Test” suggest?
Infraspinatus/teres minor involvement
Both positive external rotation lag test and internal rotation lag test would suggest which condition?
Full rotator cuff tear
What does a negative “internal rotation lag test” suggest?
Rule out rotator cuff disease
What does positive drop arm test indicate ?
Largely increase the likelihood for any rotator cuff disease
Which three tests, if all positive, have the highest positive LR for rotator cuff disease?
External rotation lag
Internal rotation lag
Painful Arc
What does a high riding humeral head in X ray suggest?
Supraspinatus tear
If we want to visualize rotator cuff tear such as the degenerative changes, which imaging should we order?
X ray
Which image should be used to evaluate soft tissues of the shoulder?
MRI & ultrasound
Which image should be used for evaluating an infection post arthroplasty, or suspected metastases?
Radionuclide bone scan
To detect fracture displacement, angulation (formation of angle)/complexity, prosthetic joint (artificial joint), or aid in preoperative planning, which imaging should be chosen?
CT scan
To detect full-thickness rotator cuff tears, which imaging should be used?
MRI or ultrasound
To better at detecting partial tears of rotator cuff, which imaging should be chosen?
Ultrasound
To evaluate a suspected labral tear or shoulder instability, which imaging is the gold standard?
MR arthrography
To facilitate the identification of ligamentous or tendon injuries, intraarticular ‘loose’ body, cartilage or synovial abnormalities, loosening of joint prosthesis (artificial device) and sinus tracts (due to infection or inflammation), which imaging can be used?
Arthrogram
What is the progression of impingement syndrome?
Full thickness rotator cuff tears and secondary glenohumeral osteoarthritis .
What is the progression of untreated supraspinatus tendonitis?
Rotator cuff tears
When full thickness subscapularis tendon tears are detected, what is the next step?
Surgical repair because untreated tears usually lead to premature osteoarthritis of the shoulder
What is a particularly useful clinical sign for diagnosing adhesive capsulitis (“frozen shoulder”)?
Decreased ROM to external rotation
After indirect trauma, which imaging should be used to rule out rotator cuff lesion?
Ultrasound
What is the most common cause of shoulder pain?
Shoulder impingement syndrome
Which should pathology occur frequently in overhead throwers or manual laborers?
Internal shoulder impingement syndrome (elevation of arm)
Which condition results from inflammation, irritation and degeneration of the anatomic structures within the subacromial space?
External shoulder impingement syndrome
What is the main cause of shoulder impingement syndrome?
Narrowing of the subacromial space
Patient come in with complaints that pain upon lifting arm or with lying on the affected side, relief with rest, anti-inflammatory medications and ice, no history of direct trauma, which condition would you suspected?
Shoulder impingement syndrome
what would a wide CSA and low AHD suggest?
Rotator cuff pathology
In the condition of shoulder impingement syndrome, if there is no clinical improvement after 6 weeks of therapy, what’s next?
Order MRI
What is the risk population of adhesive capsulitis?
40-65 yoa
Females
Perimenopause
Endocrine disorder (secondary frozen shoulder)
Restriction of passive and active shoulder movement in all directions, especially limitation of movement of external rotation with the elbow by the side of trunk, is a key alerting feature of which condition?
Adhesive capsulitis
what is the prognosis of frozen shoulder?
self-limiting of approximate 1-3 years duration mostly
The patient fall on an outstretched and abducted arm, which shoulder pathology might be indicated?
Shoulder dislocation (anterior)
The patient fall from a height, epileptic seizures or electric shocks, which shoulder condition might be indicated?
Shoulder dislocation (posterior)
Patients who had traumatic shoulder dislocation have labral injury. Anterior inferior labrum is torn. What is it described?
Bankart lesions
What type of shoulder condition would you see in athletes if they involve in overhead and throwing sports (swimmers, gymnasts, pitchers) and report having ‘sliding’ sensation during exercises?
Atraumatic shoulder dislocations
Obvious deformity of shoulder with the humeral head dislocated anteriorly and the patient holds the shoulder and arm in an externally rotated position. Which shoulder condition is indicated?
Acute traumatic dislocations
The patient hold the shoulder and arm in an internally rotated position after trauma, which shoulder condition is indicated?
Posterior shoulder dislocation
Anterior aspect of the glenoid labrum and rim is damaged due to anterior shoulder dislocation. Which lesion would be indicated?
Bankart lesion.
If the patient has the first dislocation, which imaging should be done and why?
Radiograph to be done before reduction to detect fractures as it is commonly seen in the first dislocation.
Which lesion would be caused from forceful impaction of the humeral head against the anteroinferior glenoid rim when the shoulder is dislocated anteriorly?
Hill-sachs lesion
Under which condition, would you ask for referral?
- At risk for 2nd dislocation
- Patients who dont respond to conservative approach
- Chronic instability
What would you see commonly in patient with a traumatic incident and unilateral shoulder dislocation ?
Bankart lesion
When the patient has a second shoulder dislocation ,what is the intervention?
Operative intervention is the only treatment
What would repeated shoulder dislocations lead to?
Increase the risk of arthritis and further bony deterioration
For proximal biceps tendinitis, it’s the primary or secondary presentations more common?
Secondary. (concomitant with other primary shoulder pathologies). Proximal biceps tendinitis is highly correlated with rotator cuff disease.
Which population would have primary isolated biceps tendinitis?
Younger, athletic population (baseball, softball and volleyball)
What is characteristic for a complete long head biceps tendon rupture?
A ‘popeye’ deformity
When doing uppercut test, the patient experience pain or a painful pop over the anterior shoulder near the bicipital groove region, which shoulder pathology is indicated?
Proximal Biceps Tendinitis
Patient feels pain when doing supination against resistance while also externally rotate the arm against resistance. Which shoulder pathology is indicated? (Yergason test)
Proximal Biceps Tendinitis
What does positive Speed test, as pain is elicited in the bicipital, indicate?
Proximal Biceps Tendinitis
When eliciting bicipital groove pathology, what other pathologies should clinician attempt to examine ?
Possible associated labral (AC joint)or rotator cuff pathologies or shoulder gridle instavility
Which test should be used for SLAP lesions?
O’Brien test/Active Compression test
What are the imaging option for Proximal Biceps Tendinitis?
Radiography (normal mostly)
Ultrasound
MRI/MRA
To delineate other associated shoulder pathologies in the condition of proximal biceps tendinitis, what imaging should be chosen?
MRI (or edema)
To evaluate the long head biceps tendon’s position in the bicipital groove, which imaging should be chosen?
MRI
If patient present with partial-thickness tear of the long head biceps tendon, what’s the next step?
Surgery
If the patient present with Medial LHB tendon subluxation/dislocation, what is the next step?
Surgery
Patient has persistent, debilitating symptoms of proximal biceps tendon pathology, what is the next step?
Surgery (tenotomy/tenodesis)
What kind of biceps rupture would result from excessive eccentric force as the arm is brought into extension from flexion during activities such as weightlifting, wrestling and labor-intensive job?
Distal biceps rupture
What does weakness of elbow flexion and forearm supination indicate?
Distal biceps rupture
How is the prognosis of proximal biceps rupture and distal biceps rupture?
Proximal biceps rupture patients has good prognosis while distal bicep rupture patients don’t.
This patient fell on an outstretched hand/elbow, a direct trauma to the lateral shoulder/acromion process with arm in adduction. Swelling, bruising, deformity of the AC joints are observed. “Piano key sign’ are observed with an elevation of the clavicle that rebounds after inferior compression. Which shoulder pathology might be?
AC joint separation
What may AC injury be associated with?
- Fractured clavicle
- impingement syndromes
- Neurovascular insults (rare)
Once AC joint injury is suspected, what evaluation should be done?
Evaluate the entire clavicle for possible fracture/sternoclavicular injury and a full neurovascular exam on affected extremity
What imaging options are there for AC joints
standard x-ray for diagnosis of AC joint injury.
Weighted stress view to evaluate displacement of joint
MRI/ultrasound for continued uncertainty
What is the most common causes of AC symptoms in adults ?
Osteoarthrosis
Is AC joint tenderness and compression tenderness diagnostically helpful?
No
