Shoulder

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Adhesive Capsulitis (frozen shoulder)

Frozen shoulder characteristically presents with long term pain in the shoulder followed by stiffness and loss of range of movement. This then resolves on its own after 18-24 months (a long time!)

Typically affects women aged between 40-60 years old.

Cause is unknown, however certain groups are predisposed to it such as diabetics.

Management:

Usually involves physiotherapy and analgesia
IA injections can help in the painful stage
Manipulation under anaesthetic or surgical capsular release can be used for those who do not tolerate the functional loss in the stiffening phase of the disease

3 stages of Frozen Shoulder:

Pain
Freezing stage
Thawing stage

The Rotator Cuff

To fully understand shoulder pathology it is important to have an appreciation of the rotator cuff.

The rotator cuff is comprised of four muscles:

supraspinatus, infraspinatus, teres minor and subscapularis.

You can remember this from the acronym ‘SItS’ with a small t to remind you it’s teres minor – not major.

These muscles function to stabilise the shoulder at the glenohumeral joint especially during abduction. The glenohumeral joint is where the glenoid capsule of the scapula and head of the humerus come together.

Each muscle has a specific role:

· Supraspinatus – Initiation of abduction at the shoulder joint (first 15 degrees)

· Infraspinatus and teres minor – External rotation at the shoulder joint

· Subscapularis – Internal rotation at the shoulder joint

Impingement Syndrome

Impingement syndrome, or rotator cuff tendonitis, occurs when rotator cuff tendons become irritated. Generally, this is not associated with trauma. There is a relative lack of space anatomically between the rotator cuff tendons which attach to the super aspect of the humerus and the roof of the shoulder joint (the acromion). This is called the subacromial space.

Aetiology:

The rotator cuff tendon may become swollen or irritated from overuse which is commonly seen in sports injuries such as swimming or tennis, however this can also happen due to old age. Alternatively, injury or overuse of the shoulder can lead to subacromial bursitis – inflammation of the fluid filled cushion within the subacromial space. Bursitis reduced the amount of space in the subacromial space. Anatomical variants in the same of the acromion may predispose some individuals to impingement syndrome. Finally, with old age, bony spurs can develop from the acromion and impinge on rotator cuff tendons.

Of the four rotator cuff muscle tendons, it is the supraspinatus tendon that is by far the most likely to be associated with impingement syndrome. Between 60 and 120 degrees of abduction is when there is the least space between the rotator cuff tendons and the acromion, hence anything requiring this movement elicits the most pain.

Impingement syndrome may progress to a rotator cuff tear.

How might impingement syndrome present?

Pain may radiate to the deltoid or upper arm. Below the lateral edge of the acromion is often the location where pain is felt. This is worsened with any movement involving the arms being above the head. There may also be muscle weakness

How do we examine for shoulder impingement?

Testing for impingement at the shoulder joint involves movements to reduce the amount of space in the subacromial space to check for any associated pain.

This is achieved through 4 main tests:

Shoulder abduction which involves asking the patient to fully abduct their arm. A positive result involves a ‘painful arc’ – there is pain on active movement and loss of power, especially if it is against resistance.
Hawkins-Kennedy where the shoulder is flexed anteriorly, and the elbow is bent. From this position the arm is internally rotated. Pain suggests impingement.
Jobe’s test is used to test supraspinatus power. It involves pronating the arm so that the thumb points to the floor. The arm should be at right angles to the body. It is the same movement you would make when emptying a can onto the floor. In this position slight downwards pressure is applied to the arm. If this causes discomfort a tear or marked inflammation of the supraspinatus may be the underlying cause.
The Scarf test involves abducting the shoulder across the body and over the other shoulder – as if the patient’s arm is a scarf. Pain felt during this test is associated with acromioclavicular joint pathology. In the elderly osteoarthritis of the acromioclavicular joint is a major cause for impingement syndrome.

How to treat shoulder impingement?

Generally, treatment is conservative involving NSAIDs, physiotherapy referral to strengthen chest and back muscles to ‘pull’ the shoulder down increasing space, or steroid injections of which up to three can be undertaken.

Surgical measures may be considered if the aforementioned techniques fail to resolve symptoms. The surgical procedure involved is subacromial decompression which can be undertaken as open surgery or arthroscopically.

Traumatic Instability

Traumatic instability a complication of previous shoulder injury that results in the painful instability of the shoulder joint that results in translational movement, subluxation and even dislocation.

Recurrence of injury correlates with age. Under 20s have a re-dislocation rate of up to 90% and those over 30 just 20%.

Calcific Tendonitis

A build-up of calcium deposits in the rotator cuff. The exact cause is not known.

Presents as impingement syndrome due to narrowing of space between the rotator cuff and acromion. Can take 5 – 10 years for symptoms to subside.

Occurs most commonly in 30 – 60 year olds.

Diagnosis can be confirmed on plain X-ray or Ultrasound.

Management:

- NSAIDs + painkillers

- Physio

- Corticosteroid injections

- If the steps above do not diminish then surgical debridement and excision of the calcium deposit may be indicated.

Case 1:

A 46-year-old female comes to your practice worried about a shoulder problem. She has never experienced anything like this before and does not attend the practice often. She describes a dull achy pain in her left shoulder a few months for which she takes pain killers. She finds her shoulder very stiff and she can no longer move it well. Her past medical history includes type 2 diabetes well controlled on diet. She is on no regular medications. No relevant family history.

What is your main differential diagnosis?

Adhesive Capsulitis (frozen shoulder)

What characteristic examination feature would you expect to observe on shoulder movement?

Loss of external rotation

Case 2:

Gerald Smith, 65, presents to his GP with pain in his shoulder which has been worsening over the previous few months. He says his shoulder isn’t stiff but he has been in severe pain the last few days when his wife has had him lifting boxes out the attic. This has also been difficult as he feels he’s lost strength in his arm.

PMHx – Hypertension

FHx – Nothing of note

SHx – Drinks approximately 12 units with his friends at the pub on Fridays

What is the main differential diagnosis?

Impingement Syndrome

References

https://www.youtube.com/watch?v=vARsKXb7wNc
https://www.nhs.uk/conditions/shoulder-impingement-syndrome/
https://www.youtube.com/watch?v=7l0jLl4bvbg
Coretext – Section 5 – Upper Limb – Shoulder – 1.1 Impingement syndrome
Macleod’s Clinical Examination – 13^th Edition
MSK cortex > Session 5: Upper Limb > Shoulder > 1.3 Adhesive Capsulitis (frozen shoulder)
https://orthoinfo.aaos.org/en/diseases--conditions/frozen-shoulder
https://www.physio-pedia.com/Adhesive_Capsulitis

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