Shoulder Pathologies

Question 1

The rotator cuff is formed from which four muscles?

Answer 1

1. Supraspinatus
2. Infraspinatus
3. Teres minor
4. Subscapularis

Question 2

Where do the following rotator cuff muscles have there insertion site?

• Supraspinatus
• Infraspinatus
• Teres minor

Answer 2

Greater tuberosity of humerus

Question 3

What is the function of supraspinatus?

Answer 3

Initiation of abduction

Question 4

What is the role of teres minor and infraspinatus?

Answer 4

External rotation at the shoulder joint

Question 5

Where does the subscapularis have its insertion site and what is the role of this muscle?

Answer 5

Lesser tuberosity of the humerus

Internal rotation at shoulder joint

Question 6

Collectively, what is the function of the rotator cuff muscles?

Answer 6

Pull humeral head into glenoid providing stability

Question 7

What is impingement syndrome?

Answer 7

Pain due to tendons of the rotator cuff muscles due to compression in the subacromial space during movement

Question 8

What is a painful arc?

Answer 8

Pain at between 60-120º on abduction

Question 9

What are the causes of impingement syndrome?

Answer 9

1. Tendonitis
2. Subacromial bursitis
3. AC OA with inferior osteophyte
4. A hooked acromion
5. Rotator cuff tear

Question 10

Where does pain classically radiate in those with painful arc?

Answer 10

Deltoid and upper arm

Question 11

Which clinical test is relevant for painful arc?

Answer 11

Hawkins-Kennedy test

(internally rotates the flexed shoulder which should re-create pain)

Question 12

What are the treatment options for painful arc?

Answer 12

Conservative - NSAIDS, analgesia, physio, (up to 3) subacromial injections

Failure to improve with these methods requires subacromial decompression surgery which creates more space in the subacromial space

Question 13

The classic history or rotator cuff tear involves what?

Answer 13

A sudden jerk in patients >40 which produces subsequent pain and weakness

Question 14

In a rotator cuff tear, which muscle is primarily involved?

Answer 14

Supraspinatus

(large tears may also involve the subscapularis and infraspinatus)

Question 15

What may be seen on examination for rotator cuff tears?

Answer 15

1. Weakness of initiation of abduction (supraspinatus)
2. Internal rotation weakness (Subscapularis)
3. External rotation wekaness ( Infraspinatus)
4. Wasting of supraspinatus

Question 16

How are rotator cuff tears confirmed?

Answer 16

MRI os USS

Question 17

Why is surgery for rotator cuff tears controversial?

Answer 17

1. The tendon is usually diseased and failure of repair is common
2. Large tears may be irrepairable
3. The tendon may be retracted too far

Question 18

What is the non-operative management of rotator cuff tears?

Answer 18

1. Physio - strengthens up remaining cuff muscles allowing compensation for weakened supraspinatus
2. Subacromial injections can aid symptom relief

Question 19

Adhesive capsulitis is characterised by what?

Answer 19

Progressive pain and stiffness of the shoulder in patients between 40-60

Question 20

How long does adhesive capsulitis take to resolve?

Answer 20

18-24 months

Question 21

What is the first thing a patient developing adhesive capsulitis will complain about?

Answer 21

Pain

(this subsides after 2-9 months)

Question 22

After the pain from adhesive capsulitis subsides, what is the next symptoms patients experience?

Answer 22

Increasing stiffness

(for 4-12 months)

This gradually thaws over time

Question 23

What is the principal clinical sign of adhesive capsulitis?

Answer 23

Loss of external rotation

Question 24

Patients with which conditions are particularly at risk of adhesive capsulitis?

Answer 24

1. Diabetes
2. Hypercholesterolaemia
3. Dupuytren’s disease

Question 25

What is the treatment for adhesive capsulitis?

Answer 25

* Physio * Analgesics * Intra-articular injections * After the settling of pain **manipulation under anaesthesia** can be attempted or **surgical capsular release** which divides the capsule

Question 26

What is acute calcific tendonitis and how is it characterised?

Answer 26

Acute onset of severe shoulder pain characterised by deposition of calcium in the supraspinatus tendon

Question 27

In patients with acute calcific tendonitis, where can the calcium depositis be seen on X-ray?

Answer 27

Proximal to the greater tuberosity of the humerus

Question 28

What is the treatment for acute calcific tendonitis?

Answer 28

Self limiting Subacromial steroids and local anaesthesia can control pain

Question 29

What are the two categories of shoulder instability?

Answer 29

1. Traumatic instability 2. Atraumatic instability

Question 30

With traumatic shoulder instability, dislocation usually occurs \_\_\_\_\_\_\_\_\_\_

Answer 30

Anteriorly

Question 31

What is the treatment for traumatic instability?

Answer 31

Rest Physiotherpapy strengthening programme Recurrent dislocations require a Bankart repair which involve sstabilising the shoulder by reattaching the labrumand capsule to the anterior glenoid

Question 32

Which type of patients can have pain from multidirectional subluxations or dislocations?

Answer 32

Patients with generalised ligamentous laxity (idiopathic, Marfan's, Ehlers-Danlos)

Question 33

Where is the pain from biceps tendonitis?

Answer 33

Anterior shoulder pain There is pain on resisted biceps contraction

Question 34

Which treatment may be required to relieve symptoms of biceps tendonitis?

Answer 34

Surgical division of the tendon

Question 35

Patients with spontaneous tendon rupture as a result of biceps tendonitis often have which clinical sign?

Answer 35

Popeye deformity | (due to bunched up biceps muscle)

Question 36

How can tears in the glenoid labrum which are causing pain be identified?

Answer 36

MRI arthrogram (contract injected into joint)

Question 37

What is the treatment for tears in the glenoid labrum?

Answer 37

Biceps tendonotomy or Labral resection or repair

Question 38

What are some other causes of shoulder pain which may or may not be associated with the MSK system?

Answer 38

1. Neck problems can cause referred pain 2. Angina 3. Diaphragmatic irritation due to biliary colic, hepatic or subphrenic abscesses)