shoulder

Question 1

examination of the shoulder - look

Answer 1

Asymmetry of shoulders
skin: scars, erythema, lacerations
soft tissue: loss of muscle bulk, swelling
bone: bony deformity
Deformity near the middle of the clavicle may suggest a previous clavicular fracture
Protrusion of the distal end of the clavicle may suggest AC joint subluxation
The side of the shoulder: athroscopy scars
Scapula: wasting of muscles, wasting of supra and infraspinatus appear as hollow grooves above and below the spine

Question 2

examination of the shoulder - feel

Answer 2

Deformity, tenderness, temperature, swelling
Tenderness over acromioclavicular joint may indicate osteoarthritis
Tenderness over the greater tuberosity may indicate impingement or rotator cuff pathology
palpate longhead of biceps tendon

Question 3

flexion and extension

Answer 3

do active movement first
180 degrees of flexion and 50 degrees of extension
impingement syndrome is typically a painful arc of abduction between 60 and 120 degrees (normal range is 180)
also assess from behind to visualise scapular movement

Question 4

external rotation

Answer 4

with elbows bent assess
usually about 60 degrees
external rotation: most severely affected in frozen shoulder, affected most early in glenohumeral joint arthritis

Question 5

internal rotation

Answer 5

internal rotation: how far the patient is able to reach up their back with their thumb
should be able to reach to the inferior border of the scapula
since they’re in this position, you can do the lift off test

Question 6

lift off test

Answer 6

assesses subscapularis strength
if the patient can’t reach up their back, you can do the belly press test instead

Question 7

how to test infraspinatus

Answer 7

(and teres minor)
external rotation against resistance

Question 8

how to test supraspinatus

Answer 8

30 degrees of flexion and abduction
press down and compare the two shoulders

Question 9

types of shoulder special tests

Answer 9

tests for rotator cuff strength
tests for impingement
cross arm test for AC joint arthritis
tests for instability

Question 10

special tests for rotator cuff strength

Answer 10

sub scapularis lift off test: patient should try to lift their arm off their back against resistance, use the belly press test if the patient can’t reach behind their back
Infraaspinatus and (teres minor) external rotation against resistance
supraspinatus test: 30 degrees of flexion and abduction, compare the two shoulders, vast majority of tears occur in the supraspinatus tendon

Question 11

empty can/jobe’s test

Answer 11

abduct to 90 degrees
thumb pointing up
push up agianst resistance
point thumb down and again push against resistance
both actions are typically painful in impingement but it is typically more painful when pushing down as internal rotation brings the greater tuberosity of the humerus under the acromion process compressing the supraspinatus tendon

Question 12

hawkin’s test

Answer 12

abduct the shoulder and flex the elbow 90 degrees
rotate the arm downward and repeat while adducting the humerus
performing the test in varying degrees of adduction increases sensitivity
internal rotation of the shoulder exacerbates impingement pain

Question 13

cross arm test

Answer 13

test for AC joint arthritis
forcibly adduct the arm across the chest
pain over the acromioclavicular joint is indicative of osteoarthritis

Question 14

special tests for impingement

Answer 14

Empty can test
- flex shoulder to 90 degrees and abduct
- patient pushes up against resistance with thumbs up
- patient pushes up against resistance with thumbs down
- typically more painful wehn thumbs are pointing down as internal rotation brings the greater tuberosity of the humerous under the acromion process compressing the supraspinatus tendon
Hawkins test
- abduct the shoulder 90 degrees and flex the elbow 90 degrees
- passively rotate the patients arm while adducting the humerous
Neer’s test
- patient internally rotates arm with thumb down
- patient forward flexes internally rotated arm, test is positive if this elicits pain

Question 15

tests for AC joint arthritis

Answer 15

cross arm test
- forward flex to 90 ddegrees and adduct across the chest
positive test is pain over the AC joint and may indicate OA

Question 16

interior and posterior draw test

Answer 16

apply anterior and posterior traction force to the humerus to assess the laxity of the humerus
compare the the other side

Question 17

sulcus test

Answer 17

to demonstrate inferior instability of the glenohumeral joint
downward traction force to the humerus
in a positive test, a sulus will be visible under the acromion process

Question 18

apprehension test

Answer 18

either upight or supine
abduct the shoulder and flex the elbow to 90 degrees
externally rotate the shoulder while watching the patient’s face carefully
a positive sign is apprehension on the patients face as the shoulder is about to dislocate
this feeling may be relieved by applying pressure to the front of the humerus

Question 19

special tests for shoulder instability

Answer 19

inferior and posterior draw test (laxity)
- stabilise the shoulder with one hand and grip the humerus with the other and apply anterior and posterior pressure
sulcus test
- apply downward force on the humerus, if positive a sulcus will appear under the acromion process
apprehension test
- abduct the shoulder and flex the elbow to 90 degrees, externally rotate the arm, a positive sign is a look of apprehension on the patient’s face
relocation test
- after the apprehension test, place direct pressure on the anterior aspect of the humeral head

Question 20

tests for biceps tendon pathology

Answer 20

speed’s test
- forward flex the arm to 60 degrees and flex the elbow 20-30 degrees, attempt to flex the elbow against resistance
yergason’s test
- arm abducted and elbow flexed 90 degrees, have patient supinate (turn inward) against resistance

Question 21

special shoulder tests for labral tears

Answer 21

O’brian’s test
- arm internally rotated, forward flexed and in adduction, attempt to resist downard force
- pain indicates labral tear
- if it is more difficult pronated, this my indicate biceps pathology more so than a labral tear

Question 22

the rotator cuff is made up of

Answer 22

subscapularis
infrapsinatus
supraspinatus
teres minor

Question 23

things to ask on history

Answer 23

stability symptoms: clicks or jerks when arm is held over head
stiffness
swelling
deformity: muscle wasting, prominence of AC joint
difficulty dressing, inability to lift objects over should height

Question 24

differential diagnosis of shoulder pain

Answer 24

Referred pain syndromes
oCervical spondylosis
oMediastinal pathology
oCardiac ischaemia
Joint disorders
oGlenohumeral arthritis
oAcromioclavicular arthritis
Bone lesions
oInfection
oTumours
Rotator cuff disorders
oTendinitis
oRupture
oFrozen shoulder
Instability
oDislocation
oSubluxation
Nerve injury
oSuprascapular nerve entrapment

Question 25

Examination findings of rotator cuff pathology

Answer 25

rain with ROM +empty can, +push off test drop arm if full-thickness tear if there is impingement, +neers and +hawkins

Question 26

investigations for rotator cuff pathology

Answer 26

x-ray for all patients US and MRI for imaging of the cuff MRI is gold standard

Question 27

acromial morphology

Answer 27

x-ray with supraspinatus outlet view will allow you to see the acromial morphology Bigliani classification: type 2 and 3 is associated with impingement of supraspinatus as the arm goes into abduction

Question 28

superior migration of the humeral head is seen in

Answer 28

chronic cuff tears there is nothing to hold the humeral head in the joint so it slowly migrates superiorly and arthritis develops humeral head starts to articulate with the acromion and wears the acromion

Question 29

how will MRI help diagnose a rotator cuff tear

Answer 29

will show size and extent of the tear and amount of retraction and atrophy of the muscles

Question 30

management of rotator cuff pathology

Answer 30

tendinopathy or impingement: concervative treatment, physio, subacromial cortisone injections partial thickness tear: physio (up to 12 weeks), possibly subacromial cortisone injection full thickness tear: ortho referral for consideration of surgery, rotator cuff repair

Question 31

types of shoulder impingement

Answer 31

two patterns - acute subacromial impingemnt: under 40, tenndinosus/busitis - chronic - over 40, tendinosus, tendon tear, recurrent episodes with acute on chronic symptoms

Question 32

symptoms of impingment

Answer 32

painful arc

Question 33

management of impingement

Answer 33

rest, nsaids, physio, steroid injections subacromial decompression (acromioplasty)

Question 34

acromioplasty

Answer 34

acromial spur is burred back ligament is released and bursectomy this provides space for the tendonn in the subacromial space during shoulder abduction

Question 35

frozen shoulder symptoms

Answer 35

adhesive capsulitis joint capsule becomes inflamed and thickens and constricts pain for >3 months progressive loss of ROM age >40, female risk factor immobility, hypothyroidism, diabetes, adjacent surgery eg. mastectomy 2 year time course, not full resolution in all patients by many content without surgery

Question 36

exam findings in adhesive capsulitits

Answer 36

limited active and passive range of motion external rotation is often 50% of normal, often the first to be affected differs for other cuff pathology where passive range is usually maintained, if frozen shoulder there is definite end point in ROM

Question 37

stages of frozen shoulder

Answer 37

freezing stage - the pain will be the most severe in the outer shoulder, range of motion is lessened frozen stage - pain is less intense but the shoulder is stiff thawing stage - range of motion returns and adhesive capsulitis resolves

Question 38

diagnosis of adhesive capsulitis

Answer 38

clinical, most investigations are usually normal x-ray to rule out fracture of OA US/MRI if concerned about rotator cuff pathology

Question 39

management of adhesive capsulitis

Answer 39

set expectations some patients are not willing to wait 2 years for this to resolve on its own pain control, gentle ROM exercises, hydrotherapy intra-articular cortisone injection under cT guidance: injection needs to be in the joint itself or it wont work MUA - manipulation under aneasthetic, tearing through the capsule to release the tight thickened capsule arthroscopic release - surgeon divides the capsule using arthroscopic instraments

Question 40

shoulder dislocation

Answer 40

reduce and immobilise for 3-10 days in a sling after a short period of immobilisation, most patients are referral to physio with focus on restoring strength of the dynamic glenohumeral stabilisers early rehab to achieve full pain free motion (you shouldnt immobilise or too long)

Question 41

how soon can you return to sport after shoulder dislocation

Answer 41

21 days

Question 42

recurrent shoulder dislocation

Answer 42

with recurrent dislocations, glenoid bone loss increases bankart tear of anterior inferior labrum (because more than 95% of shoulder dislocations are anterior dislocations) hall-sachs lesion - bony lesion produced by the posterior humeral head hitting the anterior glenoid rim, this lesion will become bigger with repeated dislocations

Question 43

surgical options for recurrent shoulder dislocations

Answer 43

arthroscopic stabilisation/bankhart repair - repair the torn labrum back onto the glenoid using suture anchors laterjet procedure - transfer of the chorocoid to the glenoid through a split in the subscapularis tendon, creates a sling effect

Question 44

shoulder dislocation in the older patient

Answer 44

beware very high incidence of cuff tear, often massive tear have low threshold for imaging in >60

Question 45

osteoarthritis

Answer 45

age >50 progressive pain with activity decreased ROM impingement symptoms history of rotator cuff injury, previous trauma, or shoulder injury

Question 46

OA on examination

Answer 46

decreased ROM pain and crepitus at extreme of motion

Question 47

4 cardinal findings on x-ray of OA

Answer 47

loss of joint space osteophyte formation subchondral sclerosis subchondral cysts

Question 48

cuff tear arthropathy

Answer 48

different to classic OA caused by a large or massive tear of the cuff disrupts the balance of the shoulder joint leads to superior migration of the humeral head superior glenoid erosion and erosion of the acromion

Question 49

management of OA

Answer 49

non operative: physio, simple analgesics, cortisone injections rest and activity modification surgery - total shoulder arthroplasty, best for active patients

Question 50

types of shoulder arthoplasty

Answer 50

anatomical arthroplasty - patient needs a functioning rotator cuff for this to work reverse arthroplasty - used for patient with a deficient rotator cuff such as those with cuff tear arthropathy