MSK

Question 1

What are the common causes of shoulder pain?

Answer 1

• Subacromial pain syndrome
• Frozen shoulder
• Glenohumeral osteoarthritis
• Acromioclavicular joint disorders
• Referred neck pain
• Serious pathology

Question 2

What is the 4S model for assessing a shoulder?

Answer 2

1. Site of pain
2. Serious?
3. Stiff?
4. Stability?

Question 3

What do different sites of shoulder pain usually indicate?

Answer 3

Round the back- neck pain
Over deltoid- subacromial or glenohumeral
On AC joint- Acromioclavicular pathology

Question 4

What are red flags for shoulder pain?

Answer 4

Symptoms of:
- Tumours (primary bone or apical lung tumour)
- Infection
- Trauma/ dislocation/fracture
-Neurological sx

Question 5

What does loss of passive range of motion in shoulders usually indicate?

Answer 5

OA or capsulitis

Question 6

What are the two types of stiffness in shoulder hx and what do they usually mean?

Answer 6

1. Stiffness after inactivity. Common as people get older and in OA. Pronounced in inflammatory conditions.
2. Loss of passive range of movement in a joint- Frozen shoulder (capsulitis) and Glenohumeral OA.

Question 7

What is shoulder impingement?

Answer 7

Commonly used term to represent a physical sign found on certain tests resulting from trapping of structures in the subacromial space. Impingement is not a diagnosis. Symptoms suggestive of having impingement include sudden, sharp, stabbing pain on certain movements (e.g reaching for an object). There are many causes of the impingement sign.

Question 8

Do we need to test rotator cuff muscles?

Answer 8

The action of each separate rotator cuff muscle is somewhat academic. They work together and isolating which is injured is only relevant if planning surgery.

Question 9

What is subacromial pain syndrome?

Answer 9

Umbrella term for a condition characterised by pain arising from structures in the subacromial space.
(If there is compression or pinching of the structures, there may be signs of impingement!)

Question 10

What structures may be involved in subacromial pain syndrome?

Answer 10

Rotator cuff- tendenopathy, tears, calcific tendonitis.
Bursa- Bursitis
Structures encroaching the subacromial space- Osteophytes, a ‘hooked’ acromion.

Question 11

Is it useful to image the rotator cuff in primary care?

Answer 11

Rarely helpful as doesn’t change management. Can also reveal irrelevant findings which can cause considerable anxiety and may be a barrier to engagement with physiotherapy.
Therefore- do not perform shoulder USS or MRI in primary care.

Question 12

Does the size of a rotator cuff tear matter?

Answer 12

Almost half of full thickness tears are asymptomatic. Shoulder pain is not related to the severity of structural pathology on ultrasound imaging.

Question 13

What to do if acute traumatic rotator cuff tear suspected?

Answer 13

Shoulder pain with an inability to abduct 90 degrees immediately after acute trauma is a red flag for same day referral.
Inability to abduct over 90 degrees more than two weeks after a traumatic shoulder injury should be referred to a specialist clinic.

Question 14

What is the conservative management for subacromial pain syndrome?

Answer 14

Relative rest to allow an acute flare to settle.
Patient information
Modification of causative activity (consider an occupational health opinion for work-related upper limb disorders, or input from a qualified sports coach to address technique issues, e.g. freestyle swimming).
NSAIDs: reduce pain in people with acute tendinopathy and bursitis.
Physiotherapy: likely to be beneficial (manual treatment, therapeutic exercise).
Injection: likely to be beneficial, but BESS recommends no more than two.

Question 15

Is surgery needed for rotator cuff disorders?

Answer 15

BMJ suggests that subacromial decompression surgery should not be recommended due to no benefit shown in trials over no surgery or placebo + surgery has harms including greater risk of frozen shoulder.

Question 16

What is frozen shoulder?

Answer 16

Clinical condition characterised by progressive pain and stiffnedd with a thickened, fibrosed joint capsule.

Question 17

What are the features of frozen shoulder?

Answer 17

Cause is unknown.
Peak onset 40-60 years.
More common in females and those with diabetes.

Question 18

What is common in the history of frozen shoulder?

Answer 18

Insidious-onset shoulder pain.
Pain at night (disturbs sleep, sore to lie on it).
Possibly a history of minor trauma prior to onset.

Question 19

What are the features on examination of a frozen shoulder?

Answer 19

A ‘stiff shoulder’.
Restriction in range of movement (active AND passive). Significant loss of passive external rotation is key.

Question 20

Do we need to do investigations in frozen shoulder?

Answer 20

Frozen shoulder is a clinical diagnosis. However, X-ray of a stiff shoulder is recommended because it can help exclude significant glenohumeral osteoarthritis but, importantly, also help exclude sinister differential diagnoses, e.g. an apical lung tumour.
Most patients with shoulder pain have discomfort at night as they’re lying on the sore part which, in itself, probably doesn’t constitute a red flag. We need to dig a little deeper: they may also describe unremitting or escalating pain. A plain X-ray can help reassure us that there’s nothing destructive taking place.
Consider bloods if bilateral pain/stiffness (?polymyalgia rheumatica – see separate article).

Question 21

What is the natural history in frozen shoulder?

Answer 21

Freezing-
Progressively worsening pain and stiffness (loss of passive range of movement).
Frozen-
Improving pain but persistent stiffness.
Thawing- Improvement in stiffness

Question 22

What is the usual outcome in frozen shoulder?

Answer 22

usually self limiting, with most making a full recovery in 1-3 years.
Recurrence is rare.
20% develop contralateral frozen shoulder later in life.

Question 23

What is the best treatment for frozen shoulder?

Answer 23

Patient education is important, especially managing expectations about the likely time course.
No evidence that any analgesic is more effective than another so use paracetamol/NSAIDs first line.
The mainstay of non-surgical intervention is physiotherapy +/- corticosteroid injection.
The main surgical procedures are manipulation under anaesthetic and arthroscopic capsular release.

Question 24

Is it worth watching and waiting in frozen shoulder?

Answer 24

This is a self-limiting condition so some may choose watchful waiting – for example, in very mild disease or those unable to do any exercises. However, most will need and want a more active intervention to speed recovery. Simple measures such as sleeping on the unaffected side, using pillows for support, and hot and cold treatments may help, but it may take more than 3 years to recover.