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Soft tissue shoulder disorders (Frozen shoulder (Diagnosis (Examination …
Soft tissue
shoulder disorders
Rotator
cuff tears
Aetiology
Trauma (young patients)
Degenerative (older patients)
Diagnosis
History
HPC: mechanism of injury, prev injury
PMH: joint disorder, other conditions
DH: analgesia, other meds, allergies
FH: joint problems
SH: occupation, social support
Examination
Shoulder: weakness in affected cuff muscle, painful arc
C-spine, elbow: check for referred pain
Neurovascular
Investigations
Imaging: USS shoulder (tears), MRI (quantify wasting)
Pathophysiology
Rotator cuff muscles (supraspinatus, infraspinatus, subscapularis, teres minor)
Tendons merge and insert into humerus
Act to stabilise joint, limit abduction and int/ext rotation
Clinical presentation
Painful shoulder (night pain)
Weak shoulder (can't abduct first 90 degrees)
Epidemiology
40y
Management
Conservative
Rest
Medical
Analgesia
Surgical
Indication: incomplete tear with persisting symptoms,
complete tear
MOA: arthroscopic/open repair
Impingement
syndrome
Pathophysiology
Inflammation of subacromial bursa
Catches on acromion as arm elevated, causing pain
Rotator cuff tendons can get inflamed/fibrotic
Clinical presentation
Shoulder pain (deltoid, may radiate down lateral arm to hand in C5 dermatome, worse on arm elevation and at night)
Epidemiology
50y
Diagnosis
History
HPC: mechanism
PMH: previous injury, other conditions
DH: analgesia, allergies
SH: occupation, support
Examination
Pain between 70-120 degrees (painful arc)
Investigations
Imaging: USS, MRI
Management
Conservative
Rest, avoid exacerbating movements
Medical
Analgesia
Steroid injections (CI any arthropathy, as can tear)
Surgical
Indication: severe
MOA: decompression, cuff repair
Biceps
problems
Biceps
tendinopathy
Diagnosis
History
HPC: mechanism
DH: analgesia
SH: occupation
Examination
Shoulder: pain on flexion, reduced flexion
Investigations
USS shoulder
Management
Medical
Analgesia
Steroid injection
BUT risks rupture of long head
Clinical presentation
Shoulder pain (anterior shoulder, arm flexion)
Weak flexion
Pathophysiology
Inflamed long head biceps tendon
Pain on biceps contraction
Ruptured
biceps tendon
Pathophysiology
Complete dissociation from forearm
Flexion causes bunching of biceps in arm
Clinical presentation
Pain
Lump on anterior arm
Diagnosis
History
HPC: mechanism
PMH: previous injuries
DH: analgesia, allergies
SH: occupation, support
Investigations
Imaging: USS shoulder
Examination
Shoulder: pain on flexion, Popeye sign
Management
Surgery
Indication: loss of function (rare)
MOA: repair of tendon
Conservative
Supportive care
Medical
Analgesia
Frozen shoulder
Epidemiology
40-50y
Clinical presentation
Pain (severe, night)
Stiffness
Reduced movement
Pathophysiology
Fibroblastic inflammation and fibrosis of capsule
Tendons/ligaments thicken, capsule shrinks
Restricted movement and pain
Risk factors
DM
CVD
Cervical spondylitis
Thyroid disease
Shoulder trauma
Natural history
Painful:
acute pain , reduced anduction/ext rotation (1y)
Frozen:
progressive stiffness, less pain (6-12m)
Thawing:
resolution of stiffness (1-3y)
Diagnosis
Examination
Shoulder: reduced ROM (partic abduction and ext rotation), pain
C-spine, elbow
Investigations
Bloods: glucose, lipids, TFTs
Imaging: USS shoulder
History
HPC: onset, phase
PMH: DM, CVD, thyroid, spondylitis, trauma
DH: analgesia, allergies
SH: occupation, support
Management
Medical
Analgesia (NSAIDs)
Steroid injections (glenohumoral joint)
Surgical
Manipulation under anaesthesia
Arthroscopic capsule release
Conservative
Watch and wait
Physiotherapy (thawing stage)
Shoulder OA
Clinical presentation
Painful shoulder
Stiff shoulder
Diagnosis
History
HPC: onset, character
PMH: other OA
DH: analgesia, allergies
SH: occupation, support
Examination
Shoulder: reduced ROM (active=passive)
C-spine, elbow
Neurovascular
Investigations
Imaging
X-ray: loss joint space, osteophytes, sclerosis
Epidemiology
Elderly
Management
Medical
Analgesia (NSAIDs)
Steroid injections
Surgery
Indication: moderate impairment, intact rotator cuff and glenoid
MOA: arthropasty (hemi/complete); reverse replacement (ball in glenohumoral joint, cup in humeral head) if rotator cuff instability
Outcome: reduced ROM, but improved function and pain
Conservative
Education and advice
Weight loss
Physiotherapy
ACJ OA
Aetiology
Trauma
Degenerative
Clinical presentation
Pain (point tender on ACJ, worse high elevation)
Epidemiology
Young weightlifters, painters/decorators
Diagnosis
History
HPC: onset, SOCRATES
PMH: other OA
DH: analgesia, allergies
SH: occupation, hobbies, support
Examination
Shoulder: Hawkins/Scarf test +ve
C-spine, elbow exam
Investigations
Imaging
X-ray: loss of joint space, osteophytes, sclerosis
Management
Medical
Analgesia (NSAIDs)
Steroid injections
Surgical
Indication: conservative not worked
MOA: excision of ACJ
Conservative
Rest
Rotator cuff
arthropathy
Calcifying
arthropathy
Clinical presentation
Painful shoulder
Weakness
Stiffness
Diagnosis
History
HPC: SOCRATES, weakness, stiffness
PMH: prev trauma
DH: analgesia, allergies
SH: occupation, sports, support
Examination
Shoulder: Hawkins test +ve
C-spine, elbow exam
Neurovascular
Investigations
Imaging
USS/MRI shoulder
Pathophysiology
Calcifying arthropathy
Acute inflammation and calcification of supraspinatus tendon
Management
Conservative
Physiotherapy
Medical
Analgesia (NSAIDs)
Steroid injections
Surgical
Indication: severe cases
MOA: excision of calcification
Epidemiology
~40y
Supraspinatus
arthropathy
Clinical presentation
Painful shoulder (pressure on partially adducted arm)
Weakness
Stiffness
Diagnosis
History
HPC: onset, symptoms
PMH: previous trauma
DH: analgesia, allergies
SH: occupation, sports, support
Examination
Shoulder: painful arc; Neer/Hawkins +ve, may be Jobe +ve
C-spine, elbow exam
Neurovascular
Investigations
Imaging
USS/MRI (soft tissue injury)
Pathophysiology
Tendonitis and partial rupture of tendon
Management
Conservative
Avoid causative movements
Physiotherapy
Medical
Analgesia
Steroid injections
Surgery
Indication: persistent pain
MOA: arthroscopic subacromial decompression (camera into subacromial space, remove spurs, repair any tears)
Epidemiology
Middle aged (35-60y)