* notes * Important
Upper limb disorders
Impingement syndrome (Painful arc syndrome)
-> swimmer’s shoulder
Impingement of supraspinatus tendon between humeral
head against anatomic arc made from anterior edge &
surface of acromion, AC joint, AC ligament
Repetitive friction => micro-haemorrhage =>
edema => tenditins
Signs & symptoms :
- insidious pain onset - pain increases with over the head activities
- night discomfort - shoulder weakness
- ROM: no difference between active and passive
Types:
1. Mild “ WEAR “ 2. Moderate “ TEAR “
- Inflammed rotator cuff - Tendon is thick & fibrotic
- Aching pain +/- weakness - Night pain + shoulder weakness
- Reversible - Micro tear
- Tx: Conservative -> PT, NSAIDs - Tx: Conservative +/- steroid injection
Physical examination:
- Painful arc between +/- 60ْ , +/- 130ْ of abduction -> out of this range, abduction is painless
- Pain on palpation of rotator cuff
- +ve impingement sign (pain, weakness and a loss of movement at the affected shoulder)
Investigations: * Treatment:
- x-ray - Conservative -> pain control + PT
- u/s (good for screening) - Surgical -> Acromioplasty
- MRI: gold standard
1
, Rotator cuff tear:
a sheet of conjoined tendons which connects the rotator cuff muscle to the humeral head
4 main muscles: SITS (Supraspinatus, Infraspinatus, Teres minor, Subscapularis)
They stabilize the humeral head in the glenoid when the arm is extended or abducted
Classification:
1. SIT tears 2. Subscapularis tear
- associated with subacromial impingement - Mechanism:
- Mechanism: - Acute avulsion in younger patients
- degenerative tear in older patients with a hyperabduction/ER injury
- traumatic in patients >40yo
Diagnosis:
- Supraspinatus: pain with Job’s test - Infraspinatus: ER lag sign
- Trees minor: Hornblowers - Subscapularis: Belly press / Lift off
Cuff tear sizes:
- Small: 0-1cm - Medium: 1-3 cm
- Large: 3-5cm - Massive: >5 cm
Investigations:
- x-ray of shoulder (to asses acromion)
- u/s (user dependent)
- MRI: diagnostic standard
- Arthrogram (+ve if dye leaks into subacromial joint)
Treatment:
- Conservative -> PT, NSAIDs, sub-acromial corticosteroid injections
- Surgical -> 1. Subacromial decompression+rotator cuff debridement - partial
2. Rotator cuff repair - arthroscopic/mini repair
3. Tendon transfer
4. Reverse total shoulder arthroplasty
2
Upper limb disorders
Impingement syndrome (Painful arc syndrome)
-> swimmer’s shoulder
Impingement of supraspinatus tendon between humeral
head against anatomic arc made from anterior edge &
surface of acromion, AC joint, AC ligament
Repetitive friction => micro-haemorrhage =>
edema => tenditins
Signs & symptoms :
- insidious pain onset - pain increases with over the head activities
- night discomfort - shoulder weakness
- ROM: no difference between active and passive
Types:
1. Mild “ WEAR “ 2. Moderate “ TEAR “
- Inflammed rotator cuff - Tendon is thick & fibrotic
- Aching pain +/- weakness - Night pain + shoulder weakness
- Reversible - Micro tear
- Tx: Conservative -> PT, NSAIDs - Tx: Conservative +/- steroid injection
Physical examination:
- Painful arc between +/- 60ْ , +/- 130ْ of abduction -> out of this range, abduction is painless
- Pain on palpation of rotator cuff
- +ve impingement sign (pain, weakness and a loss of movement at the affected shoulder)
Investigations: * Treatment:
- x-ray - Conservative -> pain control + PT
- u/s (good for screening) - Surgical -> Acromioplasty
- MRI: gold standard
1
, Rotator cuff tear:
a sheet of conjoined tendons which connects the rotator cuff muscle to the humeral head
4 main muscles: SITS (Supraspinatus, Infraspinatus, Teres minor, Subscapularis)
They stabilize the humeral head in the glenoid when the arm is extended or abducted
Classification:
1. SIT tears 2. Subscapularis tear
- associated with subacromial impingement - Mechanism:
- Mechanism: - Acute avulsion in younger patients
- degenerative tear in older patients with a hyperabduction/ER injury
- traumatic in patients >40yo
Diagnosis:
- Supraspinatus: pain with Job’s test - Infraspinatus: ER lag sign
- Trees minor: Hornblowers - Subscapularis: Belly press / Lift off
Cuff tear sizes:
- Small: 0-1cm - Medium: 1-3 cm
- Large: 3-5cm - Massive: >5 cm
Investigations:
- x-ray of shoulder (to asses acromion)
- u/s (user dependent)
- MRI: diagnostic standard
- Arthrogram (+ve if dye leaks into subacromial joint)
Treatment:
- Conservative -> PT, NSAIDs, sub-acromial corticosteroid injections
- Surgical -> 1. Subacromial decompression+rotator cuff debridement - partial
2. Rotator cuff repair - arthroscopic/mini repair
3. Tendon transfer
4. Reverse total shoulder arthroplasty
2
