Shoulder

Question 1

Traumatic injuries

Answer 1

Fractures
Dislocations
Acromioclavicular joint
Rotator cuff tear

Question 2

Atraumatic pathology

Answer 2

Instability
Osteoarthritis
Frozen shoulder
Tendinopathy

Question 3

Onward referral: malignancy

Answer 3

Subjective - history of cancer, unexplained/ sudden weight loss, night pain/ pain at rest, night sweats/ fever
Objective - mass or swelling

Question 4

Onward referral: acute rotator cuff tear

Answer 4

Subjective - trauma, pain and weakness
Objective - sudden inability to raise (with or without trauma)

Question 5

Onward referral: septic arthritis

Answer 5

Subjective - fever or systematically unwell
Objective - red shin, hot, painful joint

Question 6

Onward referral: unreduced dislocation

Answer 6

Subjective - loss of movement
Objective - trauma leading to a loss of rotation and abnormal shape

Question 7

Onward referral: inflammatory arthritis

Answer 7

Subjective - swelling, early morning stiffness, family history of rheumatoid arthritis
Objective - swollen joint +/- heat

Question 8

Onward referral: neurological lesion

Answer 8

Subjective - gait disturbance
Objective - unexplained muscle wasting, weakness and sensory loss
UMN - babinski and clonus
LMN - reflexes, dermatomes and myotomes

Question 9

Cervical radiculopathy

Answer 9

Pain in one or both upper limbs corresponding to the dermatome of the involved cervical root
Most common causes - degenerative changes, disc herniation and spondylosis causing bony hypertrophy of facet joints
Urgent referral if severe or progressive motor weakness or sensory loss

Question 10

Cervical radiculopathy: subjective

Answer 10

Peripheral nervous system
Numbness
Weakness
Aggravating and easing linked to neck range of motion
Symptoms may go down the arm

Question 11

Cervical radiculopathy: objective

Answer 11

Symptoms reproduced with cervical spine active and passive range of motion
+/- changes in dermatomes, myotomes and reflexes

Question 12

Cervical radiculopathy: treatment

Answer 12

Reassurance that prognosis is good in most cases
Encourage normal movement and activity

Question 13

Clavicle fracture

Answer 13

Most common in fracture in childhood
Unable to rotate due to injury, movement of the scapula is affected which in turn affects the glenohumeral joint flexion and abduction

Question 14

Clavicle fracture: mechanism of injury

Answer 14

Most common is a fall onto the lateral shoulder

Question 15

Clavicle fracture: subjective

Answer 15

Localised pain
Listen to history and mechanism of injury

Question 16

Clavicle fracture: objective

Answer 16

Protracted shoulder girdle position
Difficult with active protraction, retraction, elevation and depression
Difficulty with glenohumeral flexion and abduction through elevation

Question 17

Clavicle fracture: treatment

Answer 17

Healing times depend on age and location of the fracture and how many pieces
Sling 2-6 weeks of immobilisation

Question 18

Acromioclavicular joint sprain: mechanism of injury

Answer 18

Direct trauma to the lateral aspect of the shoulder or acromion process with the arm adducted
Falling on an outstretched hand or elbow may lead to acromioclavicular joint separation

Question 19

Acromioclavicular joint sprain: subjective

Answer 19

Localised pain over acromioclavicular joint sprain
Aggravated by heavy lifting, over head and across the body movement
Looks different

Question 20

Acromioclavicular joint sprain: objective

Answer 20

Swelling, bruising, tenderness over the joint on palpation
Difficulty with genohumeral flexion and horizontal adduction
Type III and above may have a visible step compared to the other side of the

Question 21

Acromioclavicular joint sprain: treatment

Answer 21

Ligament healing 6-8 weeks
Type I-III manages with physio - normalise joint movement, get deltoid and upper traps working
Proprioception
Return to sport 8-12 weeks to minimise injury
Some type IIIs and above require surgery intervention

Question 22

Traumatic dislocation: anterior dislocation

Answer 22

Most common direction
97% are anterior dislocations

Question 23

Traumatic dislocation: mechanism of injury

Answer 23

Fall on to forward flexed arm in external rotation
Tackling sports where the arm is extended and a posterior force is applied

Question 24

Traumatic dislocation: subjective

Answer 24

Find out clear mechanism of injury
How long was it out of joint for
Who relocated it and where
Was this the first time this has happened
Clinical assessment and radiological investigations should be organised

Question 25

Traumatic dislocation: objective

Answer 25

Orthopaedic instruction following review in A&E/ fracture clinic Assess range of motion Assess shoulder position Assess level of apprehension Clear on rehab targets and expectations

Question 26

Traumatic dislocation: treatment

Answer 26

Early referral to physio to start mobilisation as pain allows Working in range and isometric strength to build stability Progress as per rehab goals Proprioception Unreduced dislocation - same day emergency referral Acute rotator cuff tear - urgent referral

Question 27

Traumatic dislocation: bankart lesion

Answer 27

Avulsion injury of the labrum

Question 28

Traumatic dislocation: Hill-Sachs lesion

Answer 28

Compression fracture of the numeral head

Question 29

Traumatic dislocation: risk factors

Answer 29

<40 years - 13 times more likely of recurrent instability Men - 3 times more likely of recurrent instability Greater tuberosity fracture - 7 times more likely to recurrent instability Hyperlaxity - 3 times more likely to recurrent instability

Question 30

Atraumatic dislocation

Answer 30

Mobility + stability =balance Increased mobility + decreased stability = imbalance

Question 31

Atraumatic dislocation: mechanism of injury

Answer 31

Onset - gradual vs sudden, falls out vs pulls out Party trick

Question 32

Atraumatic dislocation: subjective

Answer 32

Doesn’t feel right, not in place Feels like it need to click Past medical history - connective tissue disorders/ EDS, marfans, hyper mobility

Question 33

Atraumatic dislocation: objective

Answer 33

Functional tasks Normally have a full range of motion Check Proprioception, muscle power, whole kinetic chain; squat, SLS, bridge

Question 34

Atraumatic dislocation: treatment

Answer 34

Rotator cuff strengthening Proprioception Speed work Use whole kinetic chain Check psychological factors - regain confidence and reduce fear Improve general activity Physio is successful in the majority of cases as long as it is the right programme, conducted properly and adhered to

Question 35

Frozen shoulder/ adhesive capsulitis

Answer 35

Thickening, fibrosis and shrinking of the inflamed capsule Loss of passive external rotation with arm by their side Common age - 35-65 years

Question 36

Frozen shoulder/ adhesive capsulitis: mechanism of injury

Answer 36

Painful contracture of the glenohumeral joint capsule which leads to stoiffness and loss of range 1. Painful 2-9 months 2. Stiffness 4-12 months 3. Resolution 12-42 months

Question 37

Frozen shoulder/ adhesive capsulitis: subjective

Answer 37

Idiopathic (gradual onset) or secondary to trauma Global pain around deltoid and worsening stiffness Difficulty with functional tasks - bra, deodorant, coat, changing gear Past medical history - cardiovascular disease, diabetes, previous rotator cuff issues

Question 38

Frozen shoulder/ adhesive capsulitis: objective

Answer 38

Reduced active and passive range of motion in capsular pattern - limited external rotation Obtain an x-ray to differentiate between frozen shoulder and mechanical glenohumeral incongruence Nomal x-ray with above symptoms will indicate frozen shoulder

Question 39

Frozen shoulder/ adhesive capsulitis: treatment

Answer 39

Depends on the phase, severity and restriction Aims are to reduce pain, improve/ maintain movement, return to normal activities Symptoms aren’t improving after 6 weeks refer to secondary care

Question 40

Rotator cuff tendinopathy, tears bursitis: mechanism of injury

Answer 40

Gradual onset or after a change in load/ activity - job, sport, life change or training

Question 41

Rotator cuff tendinopathy, tears bursitis: subjective

Answer 41

Pain when lifting - e.g. kettle Pain overhead activities or sustained position in abduction - e.g hair dressing Pain at night die to laying on the shoulder

Question 42

Rotator cuff tendinopathy, tears bursitis: objective

Answer 42

Painful arc of abduction in the scapular plane - between 70 and 120 degrees Worse with thumb down and resistance Isometric testing Belly press Lift off Prone rotator cuff Kinetic chain

Question 43

Rotator cuff tendinopathy, tears bursitis: treatment

Answer 43

Pain relief Reassurance Good rotator cuff rehab to increase strength and then progressive overload Weight bearing exercises, functional, using the kinetic chain to support the shoulder