Shoulder Elective Flashcards
Examples of shoulder elective
-Subacromial impingement syndrome
-Adhesive capsulitis
Describe subacromial impingement syndrome with pathophysiology
-The most common cause of shoulder pain (~60%)
-Due to compression of the rotator cuff muscles between the humeral head and superior structures (acromion, ACJ, CA ligaments)
=Leads to inflammation of the bursa
-Extrinsic compression (direct from RC tendons due to narrowing or superior translation of humeral head on abduction when RC muscles weaken)
-Intrinsic degeneration (of tendons, trauma recovery)
Presentation of subacromial impingement syndrome
-Similar to cuff tears
-Pain, gradual onset but progressive, localised over deltoid region (can radiate down upper arm)
=Worse with overhead activities
=At night (poor prognostic indictor)
=Improves with rest
-No weakness (compression not supraspinatus injury unless significant RC tear)
Stage 1: haemorrhage and oedema surrounding tendons
Stage 2: tendinopathy, fibrosis, inflammation
Stage 3: tears, arthritic changes
-NAD look and feel
-Reduced active ROM, with preserved passive ROM
-Tenderness over anterior acromion (subacromial bursitis)
-Special tests: painful arc (60 and 120 degrees), Neer (pain passive flexion of shoulder beyond 90, Hawkins (pain passive internal rotation and flexion to 90)
Investigation of subacromial impingement syndrome
-Generally, a clinical diagnosis
-USS superficial tendon damage and established bursitis, tears
-XR may show features of chronic cuff tear, arthritis
-MRI can evaluate the severity (unclear diagnosis RC deficit suspected, management exhausted): inflammation in subacromial space
Management of subacromial impingement syndrome
-First line: NSAIDs, subacromial steroid injection, physiotherapy
-If fails: subacromial decompression, bursectomy
Describe adhesive capsulitis and aetiology
-2-5% population, more common women, 40-70 yrs
-Fibroblastic proliferation of the joint capsule, causing it to adhere to itself and the humerus
=Similar to Dupuytren’s disease
=Most common in middle-aged females
-Idiopathic (most)
=Diabetes (20% have episodes)
=Thyroid
-Post-traumatic
=Fracture around shoulder
-Post-surgical
=Rotator cuff repairs
=Prox. humerus fixation
Clinical features of each stage of adhesive capsulitis
- Freezing (2-9 months)
-Diffuse pain around shoulder
-Bilateral in up to 20%
-Often worsens at night
-Minimal stiffness - Frozen (4-9 months) (adhesive)
-Pain diminishes
-Stiffness becomes predominant feature
-External rotation most commonly affected, more than internal rotation or abduction
-Both active and passive ROM equally affected - Thawing (6-24 months) (recovery)
-Pain and stiffness subsides
-Rarely return to baseline
=Episode typically lasts between 6 months and 2 years
Investigation of adhesive capsulitis
-Clinical, imaging if atypical or persistent symptoms
-XR and MRI – little to see, but may identify other / associated pathology (decreased capsular volume, thickened capsule)
-USS= thickening of coracohumeral ligament and soft tissue structures in rotator cuff interval
Management of adhesive capsulitis
-First line: NSAIDs, intra-articular steroid injection (oral?), physiotherapy, heat therapy
-If this fails (>6 months of intensive PT):
=Distension arthrogram
=MUA
=Capsular release
Risk factors of SIS
-Young patients (<25), RC pathology >40 with progression
-Occupational above shoulder activity (throwing athletes)
Extrinsic
-Glenohumeral joint instability (existing RC weakness or dysfunction)
-Repetitive above shoulder activity
-ACJ arthritis (osteophytes reduce subacromial space)
-Acromion shape (hooked morphology narrow space)
Intrinsic
-Age (degeneration and reduced elasticity of tendon)
-Smoking (reduced healing capacity?)
-Trauma (damage to RC tendons from falls or traction injury)
Complications of SIS
-Progression to rotator cuff tears
-Rotator cuff arthropathy: a pattern of glenohumeral arthritis secondary to rotator cuff degeneration
-Adhesive capsulitis
