MSK - Shoulder Pain Flashcards
When taking a shoulder pain history - how might patients describe each aspect of SOCRATES?
Shoulder Pain:
- Site:
- Tip of shoulder / on the bone
- Deep / muscular
- Onset:
- Sudden - trauma
- Insidious
- Character:
- Aching, stabbing, burning
- Radiation:
- From chest - pericarditis
- Into neck
- Down arm
- Associated symptoms:
- Reduce range of movement
- Stiffness
- Swelling
- Timeline:
- Worsening progressively?
- Exacerbating / make it better:
- Worse in morning or evening?
- Movement make it better or worse?
- OTC analgesia helping
- Severity:
- Intensity x/10
- Impat on daily living e.g. able to dress self, shopping, work
What special tests might you perform in a shouler exam?
Empty Can Test: - tests for supraspinatus muscle + tendon
- Abduct arm to 90 degrees
- Forward flex arm 30 degrees
- Medially rotate arm and point thumb downwards
- Apply downward pressure (pt resists) - if unable then supraspinatus issue
Lift Off Test: - tests for subscapularis + tendon
- Stand or sit comfortably
- Bring dorsum of hand to lumbar spine
- Ask patient to lift hand backwards away from lumbar spine (involve medial rotation of shoulder)
- Apply resistance (press hand towards spine)
Scarf Test / crossover test: - tests acromial-clavicular joint
- Sit up on edge of couch
- You pot one hand on non-test shoulder (to stabilise pt)
- Use other hand to abduct test arm 90 degrees + straight and then move across patients trunk towards other shoulder
- Pain at end of movement/earlier = abnormal
Hawkins-Kennedy Test: - test for impingement between coracoid + acromioclavicular joint (alternatively Neer’s impingement test)
- Pt sits on edge of couch
- Arm abducted 90 and flexed at elbow 90, plam down
- Medial rotation (bend forearm at elbow 90 degrees towards midline)
What are the main presenting features of a Rotator Cuff injury?
- Painful arc of abduction
- Subacromial impingement - inflammation/irritation of rotator cuff tendons as they pass through subacromial space
- Typically between 60 and 120 degrees
- For rotator cuff tears pain may be in 1st 60 degrees
- Tenderness over anterior acromion
What are the main features of Adhesive Capsulitis ‘Frozen Shoulder’?
- Inflammed + stiff connective tissue surrounding glenohumeral joint
- Features:
- Tend to have pain, then stiffness + pain then long term stiffness alone
- Pain elicited by direct pressure to coracoid process
- Limited shoulder movement in all directions
- Loss of external rotation and abduction (50% pts)
- Risk factors:
- F > M
- Aged 40-70
- Tonic seizures
- Diabetes
- Trauma
- CTD
- Thyroid disease
Which 4 muscle compose the rotator cuff?
What is the action and innervation of the rotator cuff muscles?
-
Supraspinatus:
- Action: abduction (mainly first 15 degrees - then is deltoid) + maintining humeral head in glenoid cavity
- Innervation: suprascapular nerve
-
Infraspinatus:
- Action: external rotation
- Innervation: suprascapular nerve
-
Teres minor:
- Action: external rotation
- Innervation: auxillary nerve
-
Subscapularis:
- Action: internal rotation
- Innervation: upper and lower subscapular nerves
There is a spectrum of rotator cuff injury, consisting of 4 stages - what are they?
- Subacromial impingement (impingement syndrome)
- Clalcific tendonitis
- Rotator cuff tears
- Rotator cuff arthropathy - composed of:
- Rotator cuff tear (big) - causes insufficiency
- Degenerative changes e.g. glenoid/humeral erosions, articular chondral loss, subchondral osteoporosis, humeral head collapse
- Superior migration of humeral head - causes remodeling of acromion termed ‘acetabularisation’ - excavation + thinning
What are the demographics + risk factors for rotator cuff arthropathy?
Demographics:
- F > M
- 7th decade most common
Risk factors:
- Rotator cuff tear
- RA
- Crystalline-induced arthropathy (gout / pseudogout)
- Haemorrhagic shoulder (hemophiliacs and elderly on anticoagulants)
How does rotator cuff arthropathy present?
- Symptoms:
- Pain, night-pain
- Weakness
- Stiffness
- Examination:
- Supraspinatous / infraspinatous atrophy
- Prominence of humeral head anteriorly with elevation of arm
- Limited ROM both active + passive
- Inability to abduct shoulder
- External rotation lag sign - inability to maintain passively externally rotated shoulder with elbow at 90 degrees (when +ve shoulder will medially rotate)
- Supraspinatous tear
- Hornblower sign - can’t externally rotate or maintain passive external rotation of a shoulder placed in 90 degrees of elbow flexion and 90 degrees of shoulder abduction
- Teres minor dysfunction
What does conservation + non-surgical treatment for rotator cuff arthropathy involve?
Conservative:
- Simple analgesia
- Physiotherapy - to recruit deltoid for abduction
Non-surgical:
- Subacromial steroid injection + local anaesthetic
- Check pt isn’t on anticoagulation or diabetic (steroids can induce hyperglycaemia + ↑ risk of infection)
- Steroid injection precludes surgical intervention with prosthesis or bone anchors for 3 months minimum (↑ infection risk)
What surgical interventions may be used in treatment of rotator cuff arthropathy?
- Tendon repair - sutures + bone anchors
- Subacromial decompression - remove inflammed tissue, creating space for normal cuff movement
- Remove osteophytes from under surface of acromion
- Arthroplasty - often aim is to alleviate pain, with ROM remaining restricted e.g. abduction + forward flexion to 90 degrees is good outcome
What are the 3 phases of tendon healing?
- Inflammation
- Proliferation
- Type III collagen produced
- Remodelling
- Replacement of type III collagen with type I
How many ligmanets of the shoulder joint are there and what are they?
5
- Transverse humeral ligament - between greater + lesser tubercles of humerus
- Coracohumeral ligament - coracoids to greater tubercle
- Glenohumeral ligaments: - margin of glenoid fossa to lesser tubercle + anatomical neck of humerus
- Superior
- Middle
- Inferior
What movement is commonly restricted in both osteoarthritis and a frozen shoulder?
- Abduction
- Internal rotation
- Extension
- External rotation
- Flexion
External Rotation
A past medical history of Diabetes or Thyroid disease predisposes to which pathology of the shoulder?
- Biceps tendinopathy
- Frozen shoulder / adhesive capsulitis
- Impingement syndrome
- Osteoarthritis
- Rotator cuff pathology
Frozen shoulder / adhesive capsulitis
- Patients with diabetes or thyroid disease are at higher risk of frozen shoulder
- 10-20% of patients with diabetes will develop frozen shoulder
- Concurrent bilateral frozen shoulder is rare but sequential of the contralateral side is common in these patient groups
- It is unusual to have recurrence of frozen shoulder on the same side
What is the most commonly injured nerve in shoulder dislocation?
- Axillary nerve
- Median nerve
- Musculo-cutaneous nerve
- Mutliple plexus injury
- Radial nerve
Axillary nerve
- he axillary nerve wraps posteriorly around the humerus and is the most commonly injured nerve in dislocation of the shoulder
- This can be tested with sensation in the regimental badge area and through deltoid contraction
