Shoulder

Question 1

Rotator cuff syndrome

Answer 1

Compromises several conditions with distinct clinical features

Question 2

Rotator cuff syndrome; degeneration

Answer 2

Age- micro tears- potential scarring, calcium deposits
Common site= ‘critical zone’ of supraspinatous near insertion

Question 3

Rotator cuff syndrome: trauma/impingement

Answer 3

Supraspinatous= liability to injury
E.g., lifting weight, or stop yourself falling
Much more likely if cuff is already degenerate

Question 4

Rotator cuff syndrome: vascular reaction

Answer 4

In attempt to repair torn tendon, new blood vessels grow in + calcium deposits are re absorbed
This reaction may cause congestion + P

Question 5

Rotator cuff syndrome clinical presentation

Answer 5

Shoulder P, weakness
Onset may be sudden
P typically appears over front/lateral aspects of shoulder
Tenderness felt at ant edge of ado iron
Always compare to other shoulder

Question 6

Subacute tendinitis

Answer 6

Pt develops ant shoulder P after vigorous or unaccustomed activity e.g., swimming
Shoulder looks normal but appears acutely tender along ant edge of acromion
Arm in ext- palpate this point- supraspinatous tendon exposed, arm into flex- no P

Question 7

Chronic tendinitis

Answer 7

Most prevalent in 40-50
History of recurrent attacks of subacute tendinitis
P settles with rest, ant-inflam treatment
P reoccurs when more demanding activities are resumed
P usually worse at night, Pt can’t sleep on affected side

Crepitus or palpable over snapping over rotator cuff when shoulder rotated

Question 8

Rotator cuff tears

Answer 8

Pt usually over 45
History of P with increasing stiffness/weakness
P can be eliminated by injection local an atheistic- if abduction is now possible only partial tear, still not possible= full tear

Question 9

Rotator cuff tears cause/post tear- Hx

Answer 9

Prior trauma- lifting or throwing
Degeneration- elderly

Question 10

Rotator cuff tear S+S

Answer 10

Weakness in specific rotator cuff movements
Abnormal scapulohumeral movement

Question 11

Rotator cuff DDX

Answer 11

Supraspin rupture
Impingement syndrome
Congential ligament laxity

Question 12

Conservative treatment of rotator cuff tears

Answer 12

Tendinitis when self-limiting + symptoms settle after aggravating activity is eliminated
Physiotherapist- strengthening
NSAIDs
If this doesn’t work, injection of corticosteroid into sub acromion space
Modification of activity for 6 months

Question 13

Surgical treatment of rotator cuff tear

Answer 13

If Pt has useful ROM, strength + well-controlled P, no operative measure appropriate
If symptoms do not subside 3 months, consider operation
Indication more pressing if evidence of full tear in young person
Decompress rotator cuff by removing structures pressing on it
Procedure allows for early rehab

Question 14

Repair of tears

Answer 14

Indicators for operative repair are chronic P weakness of shoulder, signs ant loss of function
Younger + more active= greater justification for surgery
Procedure either open or arthroscopy
Advantages of arthroscopy - no soft issue damage, faster rehab, better cosmetic appearance

Question 15

Bicipital tendonitis

Answer 15

P over ant shoulder
Hx of repetitive elbow flexion

Question 16

Bicipital tendonitis S+S

Answer 16

P with direct palpation of BLH tendon
P with resisted horizontal adduction

Question 17

Torn long head of bicep

Answer 17

Degeneration + distraction of tendon is common, often associated with rotator cuff problems
Pt usually middle aged/elderly
While lifting heavy object, feel a snap, aching, brushing over front of arm
During elbow flexion, bicep contracts into prominent lump
Function usually so little no treatment required

Question 18

SLAP lesion

Answer 18

Superior part of glenoid labrum anteriorly + posteriorly

Question 19

SLAP lesion epidemiology

Answer 19

Fall on outstretched arm
HX of fall followed by P

Question 20

SLAP lesion risk factor

Answer 20

Overhead and contact sport

Question 21

Clinical presentation of SLAP lesion

Answer 21

As P settles, Pt continues to experience painful click whilst lifting arm above shoulder height
Non-specific shoulder P may describe deep P in association with weakness or stiffness

Question 22

Prognosis of SLAP lesions

Answer 22

3-4 months

Question 23

Chronic instability of shoulder

Answer 23

Glenoid socket is very shallow + Jt held by fibrocartilagenoous glenoid labrum + by surrounding muscles/ligaments
If these structures give way, shoulder will lack stability

Question 24

Anterior dislocation

Answer 24

Most common
Usually follows acute injury whereby arm is forced into abd, ER + ext

Question 25

Recurrent dislocation

Answer 25

Labrum + capsule often detached from anterior rim of glenoid 1/3 Pt under age 30 1/5 over 50

Question 26

Anterior subluxation

Answer 26

Jt feels as if it ‘pops out’, only partial dislocation May describe ‘catching’ sensation, followed by numbness + weakness- dead arm syndrome

Question 27

Posterior dislocation

Answer 27

Rare Usually due to violent jerks in unusual positions (e.g., following an epileptic fit)

Question 28

Instability Hx

Answer 28

Prior trauma Pt may be able to demonstrate inc ROM Pt may have impingement type symptoms due to excess GH movement

Question 29

Instability S+S

Answer 29

Observation of sulcus sign Frequent subluxation

Question 30

Instability DDX

Answer 30

Rotator cuff strain Impingement syndrome Congenital ligament laxity

Question 31

Ant instability- indications for operative treatment

Answer 31

Frequent dislocations Fear of recurrent subluxation Dislocation sufficient to prevent participation in everyday activities

Question 32

Posterior instability

Answer 32

May persist after acute post dislocation Usually takes form of subluxation rather than full dislocation When arm is held in flex + IIR

Question 33

Post instability treatment

Answer 33

Treatment usually conservative Muscle strengthening exercises + voluntary control of Jt Operative reconstruction indicate only if disability is marked, no gross Jt laxity + structural abnormality found using CT/MRI

Question 34

Atraumatic instability treatment

Answer 34

Usually treated by Pt to strengthen muscles + restore proprioception Occasionally surgery needed to tighten capsule

Question 35

Example of Atraumatic instability

Answer 35

Voluntarily subluxation or dislocate their shoulders Can become involuntary Treatment requires physiotherapist + sometimes psychological counselling - surgery should avoided

Question 36

Disorders of GH Jt- TB arthritis

Answer 36

Uncommon in shoulder Usually starts as osteitis rarely diagnosed till arthritis has intervened Pt usually adults Constant ache + stiffness lasting many months Striking features include muscle wasting around the shoulder

Question 37

TB arthritis treatment

Answer 37

Anti-TB drugs Rest until acute symptoms have settled Movement encouraged If repeated flares, or if articulate surfaces are destroyed, Jt should be arthrodesed

Question 38

Disorders of GH- RA

Answer 38

AC, GH + synovial pouches commonly involved in RA Chronic synovial leads to rupture of rotator cuff + Jt erosion Pt usually has generalised arthritis, complaints of P + difficulty with tasks which involve lots of movement Passive movements are painful + marked with crepitus

Question 39

RA treatment

Answer 39

In general, measures do not control synovitis, corticosteroids may be injected If synovitis persists, surgical options are available

Question 40

Disorders of GH- OA

Answer 40

Usually secondary to other obvious disorders (local trauma, long standing rotator cuff lesion, rheumatoid disorders, a vascular neurosis of head of humerus) Pt usually 50-60 History of previous shoulder problems Most typical sign= progressive restriction Analgesics, anti-inflam relieve P, exercise may improve mobility

Question 41

Rapidly destructive shoulder arthropathy epidemiology

Answer 41

Crystal induced, rapidly progressive arthopathy Sometimes associated with massive tears of rotator cuff

Question 42

Clinical presentation of rapidly destructive arthopathy

Answer 42

Swelling X-ray shows bizarrely destructive form of arthritis Similar conditions encountered in other Jts

Question 43

Prognosis of rapidly destructive arthropathy

Answer 43

No satisfactory treatment Arthroplasty may relive P but will not improve function because Jt is unable

Question 44

Congenital elevation of scapula

Answer 44

One remains higher than other- visible by 3 months of life Smaller than usual + somewhat prominent Abduction limited Associated symptoms- Fuchs on of Csp, kyphosis or scoliosis likely Mild cases left untreated Marked limitation of abduction or severe deformity= operation

Question 45

Klippel-Feil syndrome

Answer 45

Rare congenital disorder Compromises bilateral failure of scapula descent + fusion of several Csp vertebrae Neck usually short + may be webbed, Csp motion limited Condition usually left untreated

Question 46

Winged scapula

Answer 46

Scapula just under skin, like small wing Due to weakness of serrated anterior (stabilises scapula on thoracic cage) May cause asymmetry of shoulders, often not apparent until Pt contracts serrated ant against resistance Can gradually improve Even if it doesn’t, disability usually slight Can be stabilised by tendon transfer

Question 47

Weakness of serrated anterior may arse from..

Answer 47

Damage to long thoracic nerve Injury to brachial plexus of 5-7 nerve roots Viral infection of nerve roots Certain types of muscular dystrophy

Question 48

Grating scapula

Answer 48

Found in about 1/3 of normal people Cause usually not found but occasionally an X-ray will show osteochondroma Involves popping, grating, grinding or snapping of bones + tissue in the shoulder blade area when lifting or moving the arm

Question 49

AC instability

Answer 49

Common, resulting from dislocation of AC + rupture of ligaments which surround end of clavicle Pt may complain of discomfort + weakness during strenuous with arm above shoulder On exam, fairly obvious bump over AC+ Direct pressure may be painful If diagnosis not obvious on x-ray, re-exam with Pt standing + holding heavy object will drag shoulder down + show displacement Condition causes little disability during non-strenuous activity + treatment unnecessary

Question 50

OA of AC

Answer 50

Common in elders Develops spontaneously When it occurs in younger individuals it may be due to previous injury or repetitive stress Pt complains of P over top of shoulder, particularly whilst using arm above shoulder height Tenderness + localised swelling to AC If analgesics + corticosteroid injections are ineffective, P may be relived by excision of lateral end o clavicle

Question 51

Tendinitis/bursitis/sub acromial impingement

Answer 51

Subacromial impingement= rotator cuff tendinitis or bursitis

Question 52

Subacromial impingement epidemiology

Answer 52

Irritation of rotator cuff underneath acromion Exact cause unclear Born with ‘hooked acromion’ will predispose impingement Intrinsic rotator cuff weakness

Question 53

Age groups affected by subacromial impingement

Answer 53

>40

Question 54

Risk factors of subacromial impingement

Answer 54

Sport Work related activities (overhead motion)

Question 55

Clinical presentation of subacromial impingement

Answer 55

Inflam of bursa between rotator cuff + acromion Recent Hx of over activity P on top of shoulder Localised tenderness, inflam, oedema, loss of function Most symptoms begin gradually, have chronic component that progresses over several months Bursitis can cause crepitus Assess Csp for radiculopathy

Question 56

Prognosis of subacromial impingement

Answer 56

Best initial intervention= activity modification, NSAIDs, subacromial injections, PT program Arthroscopy for failure of conservative treatment- 3-6 months- + impingement

Question 57

Calcification tendinitis

Answer 57

Multi focal, cell-mediated calcification of tendon usually followed by spontaneous resorption

Question 58

Epidemiology go calcification tendinitis

Answer 58

Build up on calcium in tendon Genetic predisposition Abnormal cell growth Bodily production of anti-inflam agents Metabolic diseases, such as diabetes

Question 59

Age groups affected by calcification tendinitis

Answer 59

40-60 Women more likely to be affected

Question 60

Risk factors of calcification tendinitis

Answer 60

Perform lots of overhead motions More common in people who play sports routinely Can affect anyone

Question 61

Clinical presentation of calcific tendinitis

Answer 61

May have minimal/no symptoms during formative phase Acute symptoms common in restorative phase, P related to increased intratendinus pressure from influx of inflam cells, oedema, swelling, etc Increased tendon vol= increased restriction of subacromial space Examine Csp

Question 62

Acute phase of calcific tendinitis

Answer 62

Painful catching caused by localised impingement of calcified mass of coracoacromial arch, can easily be confused with acute infection

Question 63

Chronic phase of calcific tendinitis

Answer 63

Supra/infraspinatous atrophy, severe P due to guarding against motion During this provocative tests such as impingement can be nearly impossible due to significant loss of motion

Question 64

Prognosis of calcific tendinitis

Answer 64

PT, NSAIDs, steroid injections Calcific deposits remain, symptoms will resolve Daily exercise program to avoid mobility loss Surgery suggested when- symptoms progress despite treatment (3-6 months refer), when P interferes with daily activity

Question 65

Clinical presentation of calcific tendinitis

Answer 65

Should P on top Movement aggravates (specifically horizontal direction) Typical complaints include inability to sleep on affected side Overall should have nearly full but painful ROM

Question 66

Prognosis of calcific tendinitis

Answer 66

NSAIDs Intra-articulate injection of cortisone Surgical excision of JT if P persists Refer at 3-6 months

Question 67

Frozen shoulder/adhesive capsulitis epidemiology

Answer 67

Capsule thickens + tightens around Jt, restricting movement Primary is idiopathic Secondary associated with other medical condition Diabetes has high association, incidence= 2-4 x more likely Could be result of other conditions such as cervical disc degen, or CNS disorders

Question 68

Age groups affected by arthritis

Answer 68

Pt 40-60 Usually females Weeks of shoulder P + Rx

Question 69

Risk factors of arthritis

Answer 69

Having to keep shoulder still for long period (e.g., after surgery) Diabetes, CCD, CNS disorder Hx of trauma

Question 70

Clinical presentation of frozen shoulder

Answer 70

P, limited ROM Loss of both activity + passive shoulder motion Diagnosis of exclusion

Question 71

DDX Ad Cap

Answer 71

Cervical patho Impingement syndrome Rotator cuff tear Arthritis Disuse syndrome

Question 72

Inflam stage of ad cap

Answer 72

Few weeks- 9 months- insidious onset of P + stiffness around shoulder

Question 73

Adhesive stage of ad cap

Answer 73

4-12 months- P gradually subsides but stiffness persist

Question 74

Resolution of ad cap

Answer 74

5-24 months- spontaneous but gradual improvement in ROM

Question 75

Prognosis of arthritis

Answer 75

NSAIDs, analgesics ROM activities to tolerance Should be gradual return takes 6-12 months

Question 76

Subacromial bursitis Hx

Answer 76

P over superior or lateral GH Jt at night, difficulty sleeping

Question 77

Subacromial bursitis S+S

Answer 77

Tender palpation over acomion/deltoid Reduced shoulder ROM in abduction + flexion P may be relieved by GH inferior distraction

Question 78

Supraspinatous tendonitis Hx

Answer 78

P with overhead movements or hand placed behind back

Question 79

Supraspinatous tendonitis S+S

Answer 79

Exquisite P with resisted supraspinatous movements +ve empty can