Regional Peri-Articular Pain - Shoulder

Question 1

What are the common differentials for shoulder pain?

Answer 1

Acute (calcific) rotator cuff tendonitis
Chronic rotator cuff tendonitis
Rotator cuff tear
Adhesive capsulitis
Subacromial bursitis
Cuff arthropathy
Osteoarthritis
Rheumatoid arthritis
Polymyalgia rheumatica

Question 2

How does articular pathology present?

Answer 2

Global sx affecting all movements

Question 3

What are the two main types of articular pathology?

Answer 3

Inflammatory
-morning stiffness easing on movement
Degenerative
-worse after repeated use

Question 4

What are the peri-articular causes of shoulder pain?

Answer 4

Acute (calcific) rotator cuff tendonitis
Chronic rotator cuff tendonitis
Rotator cuff tear
Adhesive capsulitis
Subacromial bursitis

Question 5

What is Acute (calcific) Rotator Cuff Tendonitis?

Answer 5

Deposition of apatite in supraspinatus tendon, leading to intense inflammation/swelling

Question 6

How does Acute (calcific) Rotator Cuff Tendonitis present?

Answer 6

Young patients
Aching pain following overuse
   -pain increases to climax, then resolves over few days
Arm held immobile
   -joint too tender to touch

Question 7

What investigation may be appropriate in Acute (calcific) Rotator Cuff Tendonitis?

Answer 7

X-ray (calcification above greater tuberosity)

Question 8

What is the management of Acute (calcific) Rotator Cuff Tendonitis?

Answer 8

Resting arm in sling
NSAIDs
Intra-capsular corticosteroid/lignocaine injections

Question 9

How long does Acute (calcific) Rotator Cuff Tendonitis take to resolve?

Answer 9

1-3wks

Question 10

What is Chronic Rotator Cuff Tendonitis?

Answer 10

Subacute/chronic vascular response causing pain/stiffness

Question 11

What causes Chronic Rotator Cuff Tendonitis?

Answer 11

Overuse/minor tears of rotator cuff causing subacute/chronic vascular response

Question 12

How does Chronic Rotator Cuff Tendonitis present?

Answer 12

Pain in shoulder
   -worse at night
   -worse when abducting/elevating arm
Tenderness below anterior edge of acromion
Painful arc (60-120o) present
Power normal

Question 13

What investigation may be appropriate in Chronic Rotator Cuff Tendonitis?

Answer 13

X-ray (calcification from former events)

USS/MRI (diagnostic)

Question 14

What is the management of Chronic Rotator Cuff Tendonitis?

Answer 14

NSAIDs
Corticosteroid injection
Physiotherapy
Arthroscopic decompression of rotator cuff
-excision of coraco-acromial ligament & osteophytes

Question 15

What causes Rotator Cuff Tears?

Answer 15

Trauma (younger pts)

Spontaneously (elderly pts)

Question 16

What are the two main types of Rotator Cuff Tear?

Answer 16

Partial
   -frequently occur w/ (may precipitate) chronic tendonitis
   -can repair naturally
Complete
   -will not repair naturally

Question 17

How do Rotator Cuff Tears present?

Answer 17

‘Sprain’ of shoulder, limited abduction after event

Question 18

What are the signs on examination of Rotator Cuff Tears?

Answer 18

Tenderness over ant acromium

Abduction paradox

Question 19

What is the abduction paradox?

Answer 19

Once arm has been lifted above shoulder it can be held there by deltoid
When pt lowers arm it suddenly drops

Question 20

How can partial/complete Rotator Cuff Tears be distinguished?

Answer 20

Intra-articular anaesthetic injection

-partial tears regain abduction movement when pain abolished

Question 21

What investigations may be appropriate in Rotator Cuff Tears?

Answer 21

USS/MRI/arthroscopy (confirm diagnosis)

Question 22

How is the acute phase of a Rotator Cuff Tear managed?

Answer 22

Heat
Exercises
Local anaesthetic injections

Question 23

When can the extent of a Rotator Cuff Tear be assessed?

Answer 23

3 weeks

Question 24

How are Complete Rotator Cuff Tears managed?

Answer 24

Surgically repaired in younger individuals

Question 25

How are Partial Rotator Cuff Tears managed?

Answer 25

Conservatively treated to allow natural healing

Question 26

What is Adhesive Capsulitis?

Answer 26

Also known as frozen shoulder, more common diabetes

Question 27

How does Adhesive Capsulitis present?

Answer 27

``` Initial progressive 'deep' pain -stops pt sleeping on affected side -subsides after few mo Increasing stiffness -worsens as pain subsides -lasts 6-12 mo Resolves spontaneously after 18mo ```

Question 28

What are the signs on examination of Adhesive Capsulitis?

Answer 28

Limited signs, joint cannot be moved due to pain | Limited external rotation

Question 29

How is Adhesive Capsulitis managed?

Answer 29

Reassurance NSAIDs Intra-articular steroid injections

Question 30

What is Subacromial Bursitis?

Answer 30

Inflammation of the bursa below the acromion

Question 31

What causes Suabcromial Bursitis?

Answer 31

Repetitive overhead lifting/pulling | Trauma

Question 32

How does Subacromial Bursitis present?

Answer 32

Burning pain - worse when lifting above head - stiffness when passively abducting arm

Question 33

What investigations may be appropriate in Subacromial Bursitis?

Answer 33

USS/MRI (to distinguish from cuff pathology)

Question 34

What is the management of Subacromial Bursitis?

Answer 34

NSAIDs | Avoid exacerbating movements

Question 35

What is a Rotator Cuff Syndrome?

Answer 35

Any peri-atricular pathology until diagnosis has been confirmed radiologically

Question 36

What are the potential complications of rotator cuff pathology?

Answer 36

Subluxation of humeral head | Cuff arthropathy

Question 37

What is Painful Arc/Impingement Syndrome?

Answer 37

Painful arc from 80-120o - due to swelling/oedema - decreases space b/w humeral head & acromion

Question 38

How can Impingement Syndrome due to articular/peri-articular pathology be distinguished?

Answer 38

Articular -painful on both active/passive movements Peri-articular -less painful on passive movements

Question 39

What is the classic presentation of ACJ OA?

Answer 39

Painful high arc Crepitus Global pain/stiffness Scarf test +ve

Question 40

What is the Scarf Test?

Answer 40

Passive adduction across body horizontally causing pain