The rotator cuff is formed from which four muscles?
- Teres minor
Where do the following rotator cuff muscles have there insertion site?
- Teres minor
Greater tuberosity of humerus
What is the function of supraspinatus?
Initiation of abduction
What is the role of teres minor and infraspinatus?
External rotation at the shoulder joint
Where does the subscapularis have its insertion site and what is the role of this muscle?
Lesser tuberosity of the humerus
Internal rotation at shoulder joint
Collectively, what is the function of the rotator cuff muscles?
Pull humeral head into glenoid providing stability
What is impingement syndrome?
Pain due to tendons of the rotator cuff muscles due to compression in the subacromial space during movement
What is a painful arc?
Pain at between 60-120º on abduction
What are the causes of impingement syndrome?
- Subacromial bursitis
- AC OA with inferior osteophyte
- A hooked acromion
- Rotator cuff tear
Where does pain classically radiate in those with painful arc?
Deltoid and upper arm
Which clinical test is relevant for painful arc?
(internally rotates the flexed shoulder which should re-create pain)
What are the treatment options for painful arc?
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
The classic history or rotator cuff tear involves what?
A sudden jerk in patients >40 which produces subsequent pain and weakness
In a rotator cuff tear, which muscle is primarily involved?
(large tears may also involve the subscapularis and infraspinatus)
What may be seen on examination for rotator cuff tears?
- Weakness of initiation of abduction (supraspinatus)
- Internal rotation weakness (Subscapularis)
- External rotation wekaness ( Infraspinatus)
- Wasting of supraspinatus
How are rotator cuff tears confirmed?
MRI os USS
Why is surgery for rotator cuff tears controversial?
- The tendon is usually diseased and failure of repair is common
- Large tears may be irrepairable
- The tendon may be retracted too far
What is the non-operative management of rotator cuff tears?
- Physio - strengthens up remaining cuff muscles allowing compensation for weakened supraspinatus
- Subacromial injections can aid symptom relief
Adhesive capsulitis is characterised by what?
Progressive pain and stiffness of the shoulder in patients between 40-60
How long does adhesive capsulitis take to resolve?
What is the first thing a patient developing adhesive capsulitis will complain about?
(this subsides after 2-9 months)
After the pain from adhesive capsulitis subsides, what is the next symptoms patients experience?
(for 4-12 months)
This gradually thaws over time
What is the principal clinical sign of adhesive capsulitis?
Loss of external rotation
Patients with which conditions are particularly at risk of adhesive capsulitis?
- Dupuytren's disease
What is the treatment for adhesive capsulitis?
- Intra-articular injections
- After the settling of pain manipulation under anaesthesia can be attempted or surgical capsular release which divides the capsule
What is acute calcific tendonitis and how is it characterised?
Acute onset of severe shoulder pain characterised by deposition of calcium in the supraspinatus tendon
In patients with acute calcific tendonitis, where can the calcium depositis be seen on X-ray?
Proximal to the greater tuberosity of the humerus
What is the treatment for acute calcific tendonitis?
Subacromial steroids and local anaesthesia can control pain
What are the two categories of shoulder instability?
- Traumatic instability
- Atraumatic instability
With traumatic shoulder instability, dislocation usually occurs __________
What is the treatment for traumatic instability?
Physiotherpapy strengthening programme
Recurrent dislocations require a Bankart repair which involve sstabilising the shoulder by reattaching the labrumand capsule to the anterior glenoid
Which type of patients can have pain from multidirectional subluxations or dislocations?
Patients with generalised ligamentous laxity
(idiopathic, Marfan's, Ehlers-Danlos)
Where is the pain from biceps tendonitis?
Anterior shoulder pain
There is pain on resisted biceps contraction
Which treatment may be required to relieve symptoms of biceps tendonitis?
Surgical division of the tendon
Patients with spontaneous tendon rupture as a result of biceps tendonitis often have which clinical sign?
(due to bunched up biceps muscle)
How can tears in the glenoid labrum which are causing pain be identified?
MRI arthrogram (contract injected into joint)
What is the treatment for tears in the glenoid labrum?
Labral resection or repair
What are some other causes of shoulder pain which may or may not be associated with the MSK system?