The shoulder: Clinical assessment:
*symptoms Pain: may arise from the shoulder joint(gleno- humeral or AC joint) or from the surrounding tendons or it may be referred pain from neck, mediastinum or diaphragm. A true shoulder pain is felt antero-laterally over the deltoid.
Stiffness: like frozen shoulder.
Deformity: like winging of scapula.
Weakness: due to neurological disorder or tendon rupture.
Swelling, Loss of function and Shoulder instability.
*Signs: both shoulders are examined from front &behind:
Look at … skin for scar or sinus …shape for shoulder asymmetry, wasting of deltoid &joint effusion.
…position like internal rotation in posterior shoulder ?.
Feel the …skin, soft tissue & bone: start from sternoclavicular joint? clavicle? AC joint ? acromion ? supraspinatus tendon(below acromion with shoulder extension) ? then feel the bicipital groove.
Move … active movement? abduction(180°): early is glenohumeral then the scapula rotate on the chest(scapulothoracic movement), the last 60° is scapulothoracic movement only. Examine also adduction, flexion, extension &rotation.
Passive movement? press on the shoulder with one hand &move the arm with other.
power? of deltoid, pectoralis major &serratus anterior.
*Imaging: plain x-ray(AP &axillary view); arthrography for cuff tear; CT for cuff tear;
MRI for tear &tumor; U/S for tear & Arthroscopy for ? &?.
Disorders of the rotator cuff:
Supraspinatus tendinitis(impingement syndrome):
Anatomy: the rotator muscles are subscapularis, supraspinatus, infraspinatus &teres minor, they stabilize the humerus head when deltoid lift the arm. Their tendons join together forming a sheet (rotator cuff sheet) inserting to greater tuberosity. This cuff pass under an arch formed by coracoid, acromion &coraco-acromial ligament. Between the arch &the cuff is subacromial bursa.
Pathology: the syndrome arises because of impingement of rotator cuff under coraco-acromial arch especially when arm is abducted, flexed &internally rotated(impingement position)e.g. window cleaning.
Causes:
1-OA of acromio-clavicular joint.
2-swelling of the cuff or subacromial bursa as in RA.
3-prolonged or excessive use of arm in impingement position like painting walls.
These cause friction? inflam. reaction &congestion(painful)? more impingement. Sometimes complicated by partial or complete tear. So there is wear, tear &repair.
Repair:
In young? is rapid(acute tendinitis with severe pain that heal rapidly).
In old? the repair is slow, get chronic tendinitis with less severe pain that take long time to heal(months) &may develop partial tear.
In very old? may get complete tear which is painless but never heal.
CF: 3 patterns:
1- sub acute tendinitis(painful arc syndrome): this condition is self-limiting, the patient (<40) develops pain after vigorous activity. O/E: point tenderness is felt anterior to acromion with shoulder in extension; painful arc between 60°-120° of active shoulder abduction(painless with external rotation). Impingement sign: pain in impingement position by raising the arm in flexion, abduction & internal rotation.
2- chronic tendinitis: patient age is between 40-50 years with history of recurrent attacks of sub acute tendinitis after demanding activity with pain worse at night & the patient can not lie on the affected side. O/E: features of sub acute tendinitis plus coarse crepitation when passively rotating the shoulder due to partial tear or cuff fibrosis.
3- cuff disruption: may complicate chronic tendinitis. The patient is over 45 with history of refractory shoulder pain, weakness &stiffness.
partial tear: may occur within the substance or on the deep surface of the cuff.
Full- thickness tear: occur following sprain or jerking injury with sudden pain &inability to abduct the arm. Early, because of pain, it is difficult to differentiate between partial &complete tear. Few weeks later: abduction paradox? the patient can t elevate his arm but if you raise it to 90° then he can keep it up by his deltoid; when he lowers his arm sideway it suddenly drops(drop arm sign).
In long standing cases, there will be wasting of supraspinatus & infraspinatus & OA of the shoulder joint.
Imaging: X-ray? early is normal, but with chronic tendinitis? erosion &sclerosis at greater tuberosity, upward displacement of humeral head, OA of AC joint &later OA of shoulder joint.
Arthrography: may reveal a complete tear if the dye pass from shoulder joint to subacromial space. U/S&MRI: are valuable.
Differential diagnosis of painful shoulder:
Referred pain: cervical spondylosis, mediastinal pathology, cardiac ischemia.
Joint disorders: glenohumeral or acromioclavicular arthritis.
Bone lesions: infection, tumors.
Rotator cuff disorders: tendinitis, rupture, frozen shoulder.
Instability: dislocation or subluxation.
Nerve injury: suprascapular nerve entrapment.
Treatment:
Conservative ?? for uncomplicated tendinitis by:
1-avoiding the impingement position;
2-physiotherapy using U/S &exercise in the position of freedom;
3-NSAID;
4-steroid injection into subacromial bursa.
Surgical ? for
1-Failure of 6 mth conservative ?;
2-persistence recurrence of symptoms in young with complete tear.
The idea is to decompress the rotator cuff by excision of CA lig., undercutting the anterior part of acromion &removing any bony process. This done by either open or arthroscopic acromioplasty. If there is tear, it is repaired. If the AC joint is arthritic, excise the lateral 1cm of clavicle. Large tear is difficult repair &may require tendon transfer or rotator muscle transposition.
Calcification of the rotator cuff:
Acute calcific tendinitis: affect young adults after overuse with sudden shoulder pain, increasing within hours &subsides within few days. O/E: the shoulder is too painful to permit examination.
X-ray: shows calcification over greater tuberosity.
?? arm sling to rest shoulder with NSAID; if pain is severe? steroid injection or rarely surgical removal of calcific material.
Chronic calcification: of the rotator cuff is often asymptomatic &discovered accidentally on X-ray.
Lesions of the biceps tendon
Tendinitis: the long head of biceps tendon arises from supraglenoid fossa &pass under the deep surface of rotator cuff then in the bicipital groove of humerus. So bicipital tendinitis usually occurs together with impingement syndrome &rarely alone following harmful activity. CF: localized tenderness in the bicipital groove. Speed s test: resisted flexion with elbow straight &forearm supinated. Yergason s test: resisted supination of the forearm with elbow flexed.
?? rest, NSAID & steroid injection into biceps tendon sheath.
Rupture: of long head of biceps usually accompanies rotator cuff tear but sometime occurs alone.CF: while lifting, the patient feels a snap followed by pain &bruise. O/E: when the patient flexes his elbow, the detached muscle belly forms a lump in the lower arm. ?? in elderly no surgery is required. In young &active: reattach the distal stump of biceps tendon to the bicipital groove(tenodesis).
Avulsion of distal attachment of biceps: occurs in old people after strenuous effort with pain &weakness at the elbow. O/E: feel the biceps tendon at the elbow while the patient flexes his elbow against resistance. ?? operative reattachment of the tendon to the radial tuberosity. In old or missed cases no ? is needed.
SLAP lesion: fall on outstretched hand may damage the superior labrum anteriorly &posteriorly(SLAP) causing painful click on shoulder abduction. O/E: abduct &externally rotate the shoulder ? click. Diagnosis? MRI arthrogram or arthroscopy. ?? arthroscopic repair.
المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .