SHOULDER Flashcards
(108 cards)
1
Q
What are the 4 most common causes of shoulder pain in primary care?
A
Rotator cuff disorders
Glenohumeral disorders
Acromioclavicular joint disease
Referred neck pain
2
Q
What forms the shoulder joint?
A
An articulation between the head of the humerus and the glenoid cavity of the scapula - the head of the humerus is much larger than the glenoid fossa to give the joint a wide range of movement but to reduce the disproportion in surfaces, the glenoid fossa is deepened by the glenoid labrum, a fibrocartilage rim
The articulating surfaces are covered with hyaline cartilage
3
Q
Ligaments in the shoulder joint?
A
Glenohumeral ligaments
Coracohumeral ligament
Transverse humeral ligament
Coracoacromial ligament
4
Q
What are the Glenohumeral ligaments and where are they?
A
Superior middle and inferior Glenohumeral ligaments - they extend from the humerus to the glenoid fossa on the anterior surface of the shoulder
They act to stabilise the anterior aspect of the joint
5
Q
Where is the coracohumeral ligament and whats the function?
A
It extends from the base of the coracoid process to the greater tubercle of the humerus
Supports the superior part of the joint capsule
6
Q
Where is the transverse humeral ligament and whats the function?
A
Extends between the 2 tubercles of the humerus
It golds the tendon of the long head of the biceps in the inter tubercular groove
7
Q
Where is the coracoacromial ligament and whats the function?
A
It extends between the acromion and coracoid process of the scapula, forming an arch-like structure over the shoulder joint
It resists superior displacement of the humeral head
8
Q
What is the coracoclavicular ligament and what is it made up of?
A
The ligaments running from the coracoid process to the underside of the clavicle
It’s made up of the conoid ligament and the trapezoid ligament
9
Q
What are the bursae within the shoulder joint?
A
subacromial bursa
subscapular recess
Others:
subcoracoid bursa
coracoclavicular bursa
supra-acromial bursa
10
Q
Where is the subacromial bursa located and what is the function?
A
Located deep to the deltoid and acromion, and superficial to the supraspinatus tendon and joint capsule
Reduces fraction beneath deltoid, promoting free motion of the rotator cuff tendons
11
Q
Where is the subscapular bursa located and what is the function?
A
Located between the subscapularis tendon and the scapula
Reduces friction on the tendon during movement of the shoulder joint
12
Q
What movements can the shoulder do?
A
Extension and flexion
Abduction and adduction
Internal and external rotation
Circumduction
13
Q
Muscles involved in extension of the shoulder?
A
Posterior deltoid
Latissimus dorsi
Teres major
14
Q
Muscles involved in flexion of the shoulder?
A
Pectoralis major
Anterior deltoid
Coracobrachialis
15
Q
Muscles involved in abduction of the shoulder?
A
First 0-15 degrees - supraspinatus
15-90 degrees - middle fibres of deltoid
>90 degrees - scapula needs to be rotated so trapezius and serratus anterior
16
Q
Muscles involved in adduction of the shoulder?
A
Pectoralis major
Latissimus dorsi
Teres major
17
Q
Muscles involved in internal rotation of the shoulder?
A
Subscapularis
Pectoralis major
Latissimus dorsi
Teres major
Anterior deltoid
18
Q
Muscles involved in external rotation of the shoulder?
A
Infraspinatus and teres minor
19
Q
What type of joint is the shoulder?
A
Ball and socket
20
Q
Muscles of the rotator cuff?
A
SItS
Supraspinatus (posterior)
Infraspinatus (posterior)
Teres minor (posterior)
Subscapularis (anterior)
21
Q
Function of supraspinatus muscle (in regards to the shoulder)?
A
Abducts arm first 15 degrees
22
Q
Function of infraspinatus muscle (in regards to the shoulder)?
A
External rotation
23
Q
Function of teres minor muscle (in regards to the shoulder)?
A
Adduction and external rotation
24
Q
Function of subscapularis muscle (in regards to the shoulder)?
A
Adduction
Internal rotation
25
What are the diseases recognised under the term “rotator cuff injury”?
Subacromial impingement syndrome
Calcific tendinitis
Rotator cuff tears
Rotator cuff arthropathy
26
What is shoulder impingement syndrome aka?
Rotator cuff tendinopathy
Subacromial impingement
Painful arc syndrome
27
Why is the supraspinatus tendon most commonly implicated in the pathology of shoulder impingement syndrome?
as it runs directly beneath the overhanging acromion, and so is especially predisposed to damage
28
What is the most common cause of shoulder pain?
Subaromial impingement
29
What are the 2 key mechanisms proposed for shoulder impingement syndrome?
Extrinsic compression
Intrinsic degeneration
30
What is the extrinsic compression mechanism for the pathology behind shoulder impingement syndrome?
Direct compression of the rotator cuff tendons against surrounding structures
Congenital or acquired anatomical variations in shape and gradient of the acromion
Reduction in function of scapular muscles that normally allow the humerus to move past the acromion on overhead extension
Abnormalities of glenohumeral joint or weakness in rotator cuff muscles = superior subluxation of the humerus = dynamic narrowing od the subacromial space
31
What is found within the subacromal space?
Rotator cuff tendons
Long head of the biceps tendon
Coraco-Acromial ligament
Subacromial bursa
32
What is the intrinsic compression mechanism for the pathology behind shoulder impingement syndrome?
These are factors specific to the rotator cuff tendon themselves causing degeneration of tendons
Muscle weakness and muscle imbalances
Overuse of shoulder e.g. repetitive micro trauma causing inflammation of tendons and bursa
Tears in the rotator cuff which causes proximal migration of the humeral head
33
Risk factors for shoulder impingement syndrome?
Repetitive above-shoulder activity - e.g. work related or sports related e.g. swimming or throwing
Acromioclavicualr joint arthritis
Physiological hooked acromion shape
Age related degeneration and reduced elasticity of supraspinatus tendon
?Smoking - reduces healing capacity of tendon
Trauma
34
Who does shoulder impingement syndrome usually present in?
Under 25s - active individuals or in manual professions
35
Presentation of shoulder impingement syndrome?
Shoulder pain that is gradual but progressive, localised over the deltoid region and top of shoulder. May be pain at night. Worse during overhead activity. Better with rest. May radiate down upper arm
Significant pain may cause symptoms similar to weakness but no true shoulder weakness will be present unless the pt had progressed to having a significant rotator cuff tear
Movements may be limited by pain but no true stiffness unless pt has progressed to rotator cuff tendinopathy and fibrosis
36
Special tests for subacromial impingement?
Neer’s impingement test
Hawkin’s-Kennedy impingement test
Painful arc test
Jobe’s test
37
How do you carry out Neer’s impingement test?
Dr stabilises the scapula with 1 hand and passively flexes the arm whilst it is internally rotated.
positive if there is pain in the anterolateral aspect of the shoulder.
38
How do you carry out the Hawkins-Kennedy test?
Shoulder and elbow are flexed to 90 degrees with the examiner then stabilising the humerus and passively internally rotates the arm
Positive if pain in anterolateral aspect of shoulder
39
What is the painful arc test?
Instruct pt to abduct arm
Positive test if pt experiences pain between 60-120 degrees of abduction which reduces once past 120 degrees
40
What is jobes test?
Aka empty can test
Arm should be elevated to 90 degrees with the elbow extended, in full internal rotation and pronation of the forearm = thumbs down position as if pouring liquid out of a can
Stabilise the shoulder and apply a downwards pressure to the arm as the pt try’s to resist this motion
Test is positive if pt experiences pain
41
Investigations for ?shoulder impingement syndrome?
Clinical diagnosis
It can be confirmed with MRI imaging
42
Management of rotator cuff disorders?
Rest and avoiding activities that exacerbate symptoms
Analgesia - paracetamol -> oral NSAID
Physiotherapy for 6 weeks
Consider a subacromial corticosteroid injection
If it persists >6 months without response to above Tx then surgical intervention is recommended.
43
What is calcific tendinitis?
Which tendon is most often involved?
Calcification and tendon degeneration near the rotator cuff insertion
Supraspinatus tendon
44
Who does calcific tendinitis most commonly occur in?
30-60 year old women
45
Presentation of calcific tendinitis?
20% dont have symptoms
Intermittent shoulder pain particuarly during shoulder flexion. As it progresses it may become constant and more severe
May disrupt sleep
Loss of shoulder ROM
46
Diagnosing calcific tendinitis?
XR
47
Causes of rotator cuff tears?
Injuries/trauma
Degenerative micro tears with age and use - may be related to overhead activities e.g. playing tennis or overhead construction work
48
Presentation of rotator cuff tear?
May be an acute or gradual onset of,….
Shoulder pain over lateral aspect of shoulder
Inability to abduct arm >90 degrees
Pain may disrupt sleep
Tenderness over greater tuberosity
49
Investigations for rotator cuff tear?
Will likely require an urgent XR to exclude a fracture
USS or MRI can diagnose them
50
Management of rotator cuff tear?
Conservative - analgesia, PT, activity modification
Surgical e.g. arthroscopic rotator cuff repair
51
What is the main complication of a rotator cuff tear?
Adhesive Capsulitis
(40% of those with age-related tears will have enlargement of their tears within 5 years and 80% of these people will become symptomatic)
52
What is rotator cuff arthropathy?
A specific pattern of shoulder degenerative joint disease
a massive rotator cuff tear -> degenerative changes of the glenohumeral joint -> Superior migration of humeral head
53
Presentation of rotator cuff arthropathy?
Shoulder pain, particuarly at night
Unable to abduct the affected arm above 90 degrees
Weakness
54
Investigations for rotator cuff arthropathy?
XR - shows high riding humerus, decreased joint space, osteoarthritis changes, demoralisation of the humerus
55
Management of rotator cuff arthropathy?
Conservative - analgesia, PT, steroid injections
Surgery - arthroscopic debridement, hemiarthroplasty, reverse shoulder replacement
56
Pain in subacromial impingement vs rotator cuff tears?
With subacromial impingement the pain is typically between 60-120 degrees
With rotator cuff tears the pain may be in the first 60 degrees and pain is likely more severe
57
How does subacromial bursitis present?
Lateral or anterior shoulder pain with tenderness over the subacromial region
Pain is often worse at night, interrupting sleep
May also be swelling and tenderness
58
What are the 3 stages of shoulder impingement as described by Neer?
Stage 1 - oedema and haemorrhage of the subacromial bursa and cuff - typically in pt <25
Stage 2 - irreversible fibrosis and tendinitis of rotator cuff - 25-40 year olds
Stage 3 - partial or complete tears of rotator cuff - typically >40 YOs
59
What is frozen shoulder aka?
Adhesive capsultiis
60
Who is adhesive capsulitis most common in?
Middle-aged females
Diabetics - up to 20% of diabetics may have an episode of frozen shoulder
61
Features of adhesive capdulits?
6 months - 2 years..
- painful phase - shoulder pain and its often worse at night
- stiff phase - affects active and passive movements and external rotation is most affected. Likely painless
- thawing phase - gradual improvement in stiffness and a return to normal
bilateral in up to 20% of patients
62
Primary vs secondary adhesive capsulitis?
Primary – occurring spontaneously without any trigger
Secondary – occurring in response to trauma, surgery or immobilisation. Often associated with rotator cuff tendinopathy, subacromial impingement syndrome.
63
Pathophysiology of adhesive capsultiis?
Inflammation and fibrosis in the joint capsule lead to adhesions which bind the capsule and cause it to tighten around the joint, restricting movement
64
Diganoisis of adhesive capsulitis?
Clinical diagnosis
XR will be unremarkable but can rule out pathology
MRI can reveal a thickening of the glenojumeral joint capsule and can rule out other conditions
65
Management of adhesive capsultis?
Activity modification
Analesia
Supervised PT
Intra-articular corticosteroid injection
(No single intervention has been shown to improve the outcome in the long term)
66
Who is glenohumeral OA common in?
Adults >60
More common in women
Those with prior trauma, rotator cuff tears, glenohumeral instability etc
Those who had a lot of overhead activity e.g. tennis
67
Presentation of glenohumeral OA?
Progressive activity-related pain that is deep in the joint and worsens by end of day
Often present at rest and interferes with sleep
Stiffness is worse in the morning or after sitting for a while
Crepitus
68
Signs that the acromioclavicular joint is damaged?
Point tenderness
Shoulder pain on high abduction
Scarf test pain
There may be swelling and visible deformities
69
Most common conditions affecting the acromioclavicular joint?
Arthritis
Fractures
Separations
Injury to this joint is relatively common especially during collision sports such as rugby following a FOOSH
70
What is a labrum?
A rim of cartilage that creates a deeper socket for the head of the humerus to fit into
71
What is a bankart lesion?
An injury. To the anteroinferior aspect of the glenoid labrum
A common complication of anterior shoulder dislocation or repeated anterior shoulder subluxations
72
What is a SLAP tear?
Superior labrum from anterior to posterior - a Labral tear where the labrum connects to the biceps tendon (superior part of labrum)
E.g. FOSH, forceful overhead arm motion, truing to catch a heavy object etc
73
Symptoms of a torn glenoid labrum?
Dull or aching pain in the shoulder
Difficulty performing normal shoulder movements - loss of strength and decreased range of motion
Catching, locking, popping, grinding
Bankart lesion may cause instability -> frequent shoulder dislocation
SLAP tear often causes pain at the front of the shoulder near the biceps tendon
74
Referred pain from where commonly causes shoulder pain?
Neck
Diaphragm - Gallstones or pancreatitis or liver disease, lung disease
Heart - angina
Ruptured ovarian cyst or ectopic pregnancy
75
What are the 2 types of bicep tendon tears?
Partial tears. Many tears do not completely sever the tendon.
Complete tears. A complete tear will split the tendon into two pieces.
76
Why can most pt’s continue to use their biceps even after a complete tear?
As usually its the long head of the bicep that tears and the short head is undamaged so this can carry out the actions
77
Causes of bicep tendon tears?
Injury e.g. FOSh or lifting something too heavy
Overuse - fraying of tendon which also occurs naturally as we age
78
How does a bicep tendon tear present?
Sudden, sharp pain in upper arm - worse with lifting/pulling
May be an audible pop
Cramping of biceps muscle with strenuous use of arm
Bruising
Weakness in shoulder
Difficulty with pronation or supination of hand
Bulge will appear in the upper arm with a dent closer to the shoulder - popeye muscle
79
Managment of acromioclavicular joint injuries?
If mild sprain (grade I and II) - rest, analgesia, gentle mobilisation, refer to normal activities but avoid heavy lifting and contact sports for 8-12 weeks
If more severe injury (grade III, IV, V, VI) then refer to ortho
80
What is shoulder instability?
A loss of shoulder comfort and function due to undesirable translation of the humeral head on the glenoid fossa
81
What is the most common direction for shoulder instability?
Anterior instability - translation of the humeral head in the anterior direction
82
What are the 2 main types of atraumatic shoulder instabilities?
Congenital instability - laxity of structures in the shoulder since birth
Chronic recurrent instabilities - may be seen after shoulder surgery or just overtime when microtrauma leads to instability of the GH joint
83
What is the most common joint of the body to dislocate?
The shoulder - it accounts for 50% of all major joint dislocations
84
What % of shoulder dislocations do anterior dislocations account for?
>95%
85
What is subluxation?
Partial dislocation of the shoulder where the humeral head does not come fully out and so naturally pops back into place shortly afterwards
86
What caused anterior dislocations of the shoulder?
This can occur when the arm is forced posteriorly whilst abducted and externally rotated at the shoulder (this is due to the lack of ligamentous support here)
87
What causes posterior dislocations to the shoulder?
When the humeral head is forced posteriorly in internal rotation while the arm is abducted Electric shocks and seizures
88
What can be damaged alongside an anterior shoulder dislocation?
Glenoid labrum tear - bankart lesions (anterior portion of labrum)
Hill-Sachs lesions
Axillary nerve damage
Fractures on humerus, acromion of scapula or clavicle
Rotator cuff tears
89
What are Hill-Sachs lesions?
Compression fractures of the posterolateral head of the humerus - a cortical depression
This is because… as the shoulder dislocates anteriorly, this part of the humerus impacts with the anterior rim of the glenoid cavity.
90
Consequence of a Hill-Sachs lesion?
This damages this part of the humeral head which makes the shoulder less stable and at risk of further dislocations
91
What is a bony bankart lesion?
When the labrum tears and a part of the bony glenoid fractures
Its a direct result of anterior dislocation of the humeral head
92
Presentation of axillary nerve damage?
Loss of sensation in the regimental badge area over the lateral deltoid
Leads to motor weakness in the deltoid and teres minor muscles - abduction and external rotation
93
Presentation of an anterior shoulder dislocation?
Pt will hold arm in abduction and external rotation
Deltoid will appear flattened and the head of the humerus will cause a palpable bulge at the front of the shoulder
All movements limited and painful
94
What must you assess following a shoulder dislocation?
Assess for fractures
Assess for vascular damage - pallor, cap refill, pulses
Assess for nerve damage e.g. loss of sensation in regimental patch area
95
Presentation of posterior shoulder dislocation?
Arm will be abducted and internal rotated
May lose deltoid contour
May notice posterior prominence of head of humerus
96
What is the apprehension test?
A special test to assess for shoulder instability specifically in the anterior dislocation
Pt lies supine. Shoulder is abducted to 90 degrees and elbow is flexed to 90 degrees. Shoulder is slowly externally rotated. As the arm approaches 90 degrees of external rotation, pts with shoulder instability will become apprehensive - no pain!
97
Investigtaions for shoulder dislocation?
XR may be done to confirm dislocation and exclude fractures - not always required! But XR are always performed after reduction to confirm the shoulder is reduced and assess for fractures
MRI of shoulder with contrast can be done to assess shoulder for damage and planning surgery e.g if suspected bankart lesions
Arthroscopy can be done
98
Acute management of shoulder dislocations?
Analgesia, muscle relaxants and sedation (can be done without analgesia and sedation but its better if done with as it ensures rotator cuff muscles are relaxed)
Gas and air may be used
A broad arm sling to support the arm
Closed reduction of the shoulder
Surgery may be required if fractures
Post-reduction XR
Immobilisation with a sling for 1-3 weeks
PT 4-12 weeks
99
Why do shoulder dislocations need to be reduced as soon as possible?
Muscle spasms occur over time making it harder to relocate the shoulder
And to reduce the risk of neurovascular injury
100
Ongoing management following reduction of a shoulder dislocation?
High risk of recurrent dislocation esp if younger pt
So PT is recommended
Shoulder stabilisation surgery may be done e.g. to repair bankart lesions, tighten the shoulder capsule, correct bony injuries or correct Hill-Sachs lesions)
101
How common are recurrent instability/dislocations following a shoulder dislocation?
Overall 20%
In pt’s <20 chance is up to 90%
102
Rotator cuff tear vs shoulder dislocation symptoms?
Rotator cuff tear will also present with shoulder pain, weakness and reduced range of movement
But… absence of any joint deformity!
103
What are the 2 tendons of the biceps muscle and where do they attach?
The long tendon - attaches to the glenoid
Short tendon - attaches to the coracoid process
104
What % of bicep ruptures affect the long tendon?
>90% of cases
105
Risk factors for biceps rupture?
Heavy overhead activities
Shoulder overuse or underlying shoulder injuries which may stress the biceps tendon
Smoking
Corticosteroids; these weaken tendons
106
Mechanism of injury for a proximal biceps rupture?
typically occurs when the biceps are lengthened and contracted and a load is applied. e.g. the descent phase of a pull-up.
107
Investigtaions for suspected biceps rupture?
Start with a basic examination, palpate the long head and distal biceps tendon and assess neurovascular function the upper extremities
The biceps squeeze test: If it is intact then a squeeze will cause forearm supination
Musculoskeletal ultrasound by a skilled clinician and should always be the first investigation for suspected biceps tendon rupture
If suspected distal biceps rupture then an urgent MRI should be performed as its diagnosis on clinical signs is challenging and it usually requires surgical intervention
108
What is TUBS?
Traumatic Unilateral dislocations with a Bankart lesion requiring Surgery - aka traumatic anterior shoulder instability
