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Shoulder Disorders

Oct 19, 20254 min read

Common Chronic Shoulder Disorders

Objectives

  • Revision of anatomy

  • Discuss common disorders

    • Shoulder instability
    • Rotator cuff (impingement) syndrome
    • Supraspinatus tendinitis
    • Biceps tendinitis
    • Adhesive capsulitis (frozen shoulder)
    • Shoulder arthritis
    • Scapular winging

Anatomy

  • Glenohumeral Joint
  • Sternoclavicular Joint
  • Acromioclavicular Joint
  • Scapulothoracic Joint

Common Shoulder Complaints

  • Pain
    • Localized
    • Generalized
    • Painful arc
  • Loss / limitation of function
    • Stiffness
    • Painful

Shoulder Pain

  • INTRINSIC
    • Due to causes in the shoulder region
  • EXTRINSIC
    • Due to referred pain from outside the shoulder

Shoulder Instability

  • Shoulder (glenohumeral) joint is the most commonly dislocated joint of body

  • Instability means

    • Excessive movement of humeral head on the glenoid during active shoulder movement
    • May lead to recurrent dislocation

Shoulder RestraintsZ

  • Static:
    • Glenoid labrum
    • Capsule
    • Ligaments around capsule
  • Dynamic:
    • Rotator cuff muscles
    • stabilize the humeral head within the glenoid

Types of Instability

According to Direction

  • Anterior
    • The commonest
    • Following acute traumatic dislocation
  • Posterior
    • Due to a violent jerk in an unusual position
  • Multi-directional
    • Ligament laxity

Classification Systems

  • TUBS
    • Traumatic
    • Unilateral
    • Bankarts lesion
    • Surgery
  • AMBRI
    • Atraumatic
    • Multidirectional
    • Bilateral
    • Rehabilitation or Inferior capsular shift

Traumatic – Soft Bankart

  • No bony lesion seen on x-ray
    • A tear in the labrum and capsule

Rotator Cuff Disorders

  • Anatomy:
    • Originate from the scapula
    • Pass under coraco-acromial arch
    • Insert in the Greater & Lesser tuberosities
    • Separate from the ligament by bursa
insertionPositionMuscle
G tuberosityaboveSupraspinatus
G tuberositybehindInfraspinatus
G tuberositybehindTeres minor
L tuberosityIn frontSubscapularis

  • Rotator cuff syndrome - which comprises several conditions with distinct clinical features and natural history:
    • Acute tendinitis (painful arc syndrome)
    • Chronic tendinitis (impingement syndrome)
    • Rotator cuff tears

R.C.D - Acute Tendinitis

  • Supraspinatus tendinitis
    • The supraspinatus is the most commonly injured rotator cuff M
  • Clinical features:
    • Young adult
    • Sever Pain, tenderness
    • painful initiation of abduction
    • X-ray:
      • Normal
      • Area of calcification

Supraspinatus Tendinitis

  • Treatment:
    • Rest
    • NSAIDS
    • Physiotherapy
    • Local steroid injection
    • Surgery: (acromioplasty, decompress the rotator cuff) If symptoms do not subside after 3 months of conservative treatment, or if they recur persistently after each period of treatment

R.C.D - Impingement Syndrome

  • Chronic tendinitis
  • Causes
    • Over-use / Minor tears
    • Impingement under the coracoacromial arch
    • Osteophytes in under surface of acromioclavicular joint
    • Curved acromion

  • Clinical features
    • Age 40-60 years
    • Pain
    • Shoulder looks normal or wasted
    • Tenderness
    • Painful abduction arch (60° To 120°)
    • Neer’s test (+ve)
    • Hawkin’s test (+ve)

  • X-ray:
    • Calcification
    • Degenerated AC jt.
  • MRI:
    • Bursitis / Thickening of tendon

Treatment

  • Non-operative:

    • Activity modification
    • Sub-acromial steroid injection
    • NSAIDS
    • Rotator cuff and scapular stabilizing exercises

  • Surgery:

    • Arthroscopic
      • Acromioplasty
      • Rotator cuff repair

R.C.D - Tears- Predisposing factors

  • Degeneration (middle age)

  • Chronic irritation by osteophyte

  • Underlying disease, e.g., Rheumatoid

  • Precipitating factor: trauma

  • Types

    • Incomplete
    • Complete

  • Clinical picture

    • Typical presentation: trauma, pain, limited abduction

    • Early stage – normal appearance; late stage – wasting of the supraspinatus and infraspinatus muscles

    • Tenderness over the greater tuberosity

    • After a few weeks

      • Incomplete tear: pain and range of motion improve
      • Complete tear: pain improves, but active range of motion decreases; passive motion remains painless and the drop‑arm sign may appear

  • Imaging

    • X‑ray: early – normal; late – degenerative changes
    • MRI – image of choice

  • Treatment

    • Incomplete tear: physiotherapy, NSAIDs
    • Complete tear: surgical repair

Biceps Tendon Disorders

  • Tendinitis:
    • Often associated with impingement
    • Pain
    • Tenderness: Bicepital groove
    • Painful forward flexion
    • Speed/Yergason test
    • Treatment:
      • NSAID
      • Local steroid injection
      • Surgery
        • Tenotomy / Tenodesis

Adhesive Capsulitis (Frozen Shoulder)

  • Presentation
    • Pain and restriction of movements
  • Causes
    • Trauma, breast surgery, diabetes & immobilization
  • Self-limiting with 3 stages
    • Painful stage
    • Stiff stage
    • Thawing stage: The range of motion of shoulder begins to improve

Treatment

  • Conservative
    • Intra-articular injection
    • Physiotherapy
  • Surgical
    • Manipulation under anesthesia
    • Arthroscopic release of adhesions

Acromioclavicular Arthritis

  • Clinical Features
    • Pain, localized tenderness
    • Pain on abduction above shoulder level

Shoulder Summary

  • Common Symptoms
    • Pain
    • Loss of Function
    • Stiffness
    • Instability
  • Common Disorders
    • Shoulder instability
    • Rotator cuff (impingement) syndrome
    • Supraspinatus tendinitis
    • Biceps tendinitis
    • Adhesive capsulitis (frozen shoulder)
  • Diagnostic Approach
    • History
    • Clinical examination
    • Imaging investigations

Graph View

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