PANCE Blueprint Musculoskeletal (8%)

Soft tissue injuries of the shoulder (Lecture)

AC Joint Separation

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AC Joint Separation

Patient will present as → a 25-year-old male, a recreational soccer player, presents with acute pain in his right shoulder following a fall onto his outstretched hand during a soccer match two days ago. He reports immediate pain and swelling in the shoulder, with difficulty lifting his arm due to pain. He has not experienced any numbness or tingling in the arm. On physical examination, there is noticeable swelling and tenderness over the acromioclavicular (AC) joint. There is a visible step-off at the AC joint, suggestive of a possible separation. Pain is exacerbated with cross-body adduction and during the O’Brien’s test. Range of motion is limited, especially with abduction and forward elevation due to pain. Neurovascular examination of the upper extremity is normal. Radiographic imaging of the shoulder reveals widening of the AC joint space. The patient is diagnosed with a Grade II AC joint separation. Management includes a brief period of immobilization with a sling to allow for pain control and healing, followed by early range-of-motion exercises as tolerated. The patient is advised to avoid heavy lifting and overhead activities. Anti-inflammatory medications are prescribed for pain management. The patient is referred to physical therapy for shoulder stabilization and strengthening exercises. He is counseled about the importance of adhering to the rehabilitation protocol to ensure proper healing and prevent chronic instability or dysfunction. A follow-up appointment is scheduled in two weeks to evaluate his progress and to adjust the treatment plan if necessary.
An AC joint separation involves damage to the ligaments supporting the AC joint, either sprains or tears, commonly caused by a fall on the shoulder or outstretched hand. This can result in pain, shoulder deformity, and loss of forelimb mobility.

  • Acromioclavicular separation is also referred to as a “separated shoulder
  • Patients may have elevation of the clavicle (step-off deformity) and point tenderness and pain with cross-chest testing

DX: X-rays - Anteroposterior X-rays of both sides of the clavicle are taken

  • To appropriately grade acromioclavicular separations, an x-ray is taken with the patient holding a weight to assess the level of injury to the joint
Acromioclavicular joint sprains are classified based on x-ray findings:

  • Type I: No joint disruption
  • Type II: Subluxation with some overlap of the clavicle and acromion
  • Type III: Complete joint dislocation, usually because the coracoclavicular ligament is torn
  • Types IV, V, and VI are variants of type III based on posterior (IV), superior (V), and inferior (VI) displacement of the distal clavicle)

Rockwood classification of acromioclavicular joint injury

TX: Conservative management is possible for mild to moderate injuries because they can be managed with a sling and analgesia

  • More severe injuries usually will require operative repair
Cross Chest Test Video
Grade3ACsepMark

Grade 3 AC joint separation

References: Merck Manual · UpToDate

Biceps Tendonitis

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Biceps Tendonitis

Patient will present as → a 33-year-old man who complains of left anterior shoulder pain for 4 weeks. The pain is made worse with overhead activities. On examination, you note maximal pain in the shoulder with palpation between the greater and lesser tubercle. Pain in the shoulder is exacerbated when the arm is held at the side, elbow flexed to 90 degrees, and the patient is asked to supinate and flex the forearm against your resistance.
Biceps tendinitis is an inflammation or irritation of the upper biceps tendon. Also called the long head of the biceps tendon, this strong, cord-like structure connects the biceps muscle to the bone in the shoulder socket

  • The patient will present with → pain in the biceps groove
  • Anterior shoulder pain - may have pain radiating down the region of the biceps. Symptoms may be similar in nature and location to the rotator cuff or subacromial impingement pain.
  • Pain with resisted supination of the elbow

Provocative factors:

  • Sleeping on the affected shoulder
  • Repetitive motion (overhead activity, pulling, lifting)
  • Worse during the follow-through of throwing motion

DX: X-ray to rule out a fracture

  • Ultrasound: can show thickened tendon within the bicipital groove
  • MRI (MR arthrography) is the most sensitive and specific test for biceps tendinitis - can show thickening and tenosynovitis of proximal biceps tendon - increased T2 signal around biceps tendon.
  • "Popeye" deformity - indicates a biceps tendon rupture
BicepstendonRupture - Copy

Proximal biceps tendon rupture on the right demonstrating a classic "Popeye" deformity

TX: Treat with Rest (immobilize in sling), NSAIDs, PT strengthening, and steroid injections

  • Surgical release is reserved for refractory cases of bicep pathology seen during arthroscopy

Special tests:

Speed test: Pain elicited in the bicipital groove when the patient attempts to forward elevate shoulder against examiner resistance while the elbow is extended and forearm supinated. Positive if the pain is reproduced. It may also be positive in patients with SLAP lesions.

Yergason’s test: Elbow flexed 90 degrees, wrist supination against resistance. Positive if the pain is reproduced.

Yergason’s Test Video Speed's Test Video

References: Merck Manual · UpToDate

Rotator cuff tendinopathy/tear

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Rotator cuff tendinopathy and tear

Patient will present as → a 69-year-old male with right shoulder pain for the past several months. He reports that he cannot reach above his head without severe pain. As a retired carpenter, he reports that this has significantly impacted his quality of life. Additionally, he is unable to lie on his left side at night due to shoulder pain. On physical exam, there is focal tenderness over the left anterolateral shoulder. Radiography reveals reduced space between the acromion and humeral head.
A patient will present with → shoulder pain with overhead activity or at night when lying on the arm or weakness and immobility after acute injury

  • Injury to one or more of the rotator cuff muscles, typically due to tear or tendinopathy, rotator cuff muscles, which are all innervated by C5 and C6, are the SITS
  • The supraspinatus muscle is most commonly injured
  • Risk factors: older age, smoking, repetitive overhead reaching
    • Acute avulsion injuries typically follow a trauma
    • Chronic degenerative tears - repetitive overhead motions, tendon weakening due to degenerative changes, and chronic impingement
  • Shoulder pain is exacerbated by sleeping on the affected shoulderreaching overhead, and limited function of the shoulder
  • Severe focal tenderness at the insertion of supraspinatus (anterolateral shoulder) and decreased active elevation with a normal passive range of motion
Shoulder motion with rotator cuff (supraspinatus)

The action of the supraspinatus muscle forms the shoulder abduction

DX:  Radiography for all patients as initial imaging - loss of subacromial space due to upward migration of humeral head

  • Magnetic resonance imaging (MRI) is the most accurate test
1 MRI. Complete tear and rupture of the supraspinatus tendon. Wide transmural damage (2.4 x 2.4 cm).

MRI. Complete tear and rupture of the supraspinatus tendon

TX: Treat with physical therapy (for all patients), NSAIDs, steroid injections, and surgical repair for patients with complete tears or for those who fail 3-6 months of conservative management

There are 4 muscles in the rotator cuff (SITS)

Rotator cuff muscles

Anterior and posterior view of the rotator cuff muscles.

 

Supraspinatus tear or inflammation:

  • Empty can test: 90 degree abduct, 30 degree flex, rotate internal. Apply downward pressure.
  • Full can test: 90 degree abduct, 30 degree flex, rotate external. Apply downward pressure.
  • Arm drop: Arm passively abducted and actively adducted slowly

Subscapularis tear or inflammation:

  • Lift off test: Elbow 90 degree, rotate medially against resistance.

Teres minor/infraspinatus tear or inflammation:

References: Merck Manual · UpToDate

Question 1
Which of the following rotator cuff tendons is most likely to sustain injury because of its repeated impingement (impingement syndrome) between the humeral head and the undersurface of the anterior third of the acromion and coracoacromial ligament?
A
Supraspinatus
B
Infraspinatus
Hint:
See A for explanation
C
Teres minor
Hint:
See A for explanation
D
Subscapularis
Hint:
See A for explanation
Question 1 Explanation: 
A critical zone exists for the supraspinatus tendon due to its superior insertion site. It is susceptible for injury because it has a reduction in its blood supply that occurs with abduction of the arm. Impingement of the shoulder is most commonly seen with the supraspinatus tendon, the long head of the biceps tendon and/or the subacromial bursa.
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osmosis Osmosis
Picmonic
Rotator Cuff

The rotator cuff is a group of muscles and tendons which act to stabilize the shoulder. It is comprised of four muscles, the supraspinatus, infraspinatus, teres minor and subscapularis. External rotation is done with the teres minor and infraspinatus, while internal rotation is controlled by the subscapularis. Abduction of the arm occurs through flexion of the supraspinatus.

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Adhesive Capsulitis - AKA frozen shoulder

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Adhesive Capsulitis (frozen shoulder)

Patient will present as → a 52-year-old female presents with a six-month history of progressive shoulder pain and stiffness. She reports that the pain is constant, worsens at night, and is aggravated by movements, especially when reaching overhead or behind her back. She also notes a significant reduction in her shoulder’s range of motion. The patient mentions a history of type 2 diabetes and a sedentary lifestyle. On examination, there is noticeable restriction in both active and passive range of motion of her left shoulder, particularly in external rotation and abduction. There is no apparent joint instability or muscle weakness, and the neurovascular examination is normal. No history of trauma or prior shoulder pathology is reported. Based on these findings, a diagnosis of adhesive capsulitis, also known as frozen shoulder, is considered. The patient is advised to begin a regimen of physical therapy focusing on shoulder mobilization exercises and stretching. She is also prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management. The importance of diabetes control and regular follow-up is emphasized to monitor her progress and modify the treatment plan as necessary.
Frozen shoulder, also called adhesive capsulitis, is a painful condition in which the movement of the shoulder becomes limited. A frozen shoulder occurs when the strong connective tissue surrounding the shoulder joint (called the shoulder joint capsule) becomes thick, stiff, and inflamed

  • Characterized by a severely limited range of motion
  • Insidious onset of shoulder stiffness and pain at rest and with movement. Decreased active and passive range of motion
  • Often post fracture - it looks like a rotator cuff injury
  • Common in patients with diabetes and people who've kept their arm immobilized for a long period of time
  • Apley scratch test: the patient tries to bring hands together on the back while one hand comes from above and the other from below. Positive test - restriction with movement (watch video)

DX: Frozen shoulder is a clinical diagnosis made on the basis of medical history and physical examination

  • Plain radiographs, ultrasound, and MRI can rule out other conditions and confirm the likelihood of the correct diagnosis

TX: NSAIDs, physical therapy, and intra-articular steroid injections

  • Surgery if failure to respond to conservative treatments -  arthroscopic surgical release, manipulation under anesthesia (MUA)
MRI. Suspicion of frozen shoulder due to minor intraarticularly injectable contrast agent. No contrast agent at the bursa subacromialis and subdeltoidea. Major articular-sided partial tear of the supraspinatus tendon.

MRI with suspicion of frozen shoulder due to minor intraarticularly injectable contrast agent. No contrast agent at the bursa subacromialis and subdeltoidea.

References: UpToDate

Impingement

Shoulder impingement syndrome

Patient will present as → a 70-year-old male with an insidious onset of left shoulder pain that is exacerbated by overhead activities and while lifting objects away from his body. He is a retired mechanic of 35 years. The patient reports that over the last several months, he has been having difficulty sleeping because of the pain. On physical examination, there is notable tenderness over the left anterolateral shoulder, and passive forward flexion >90° causes severe pain. An x-ray reveals proximal migration of the humeral head and calcification of the coracoacromial ligament. Based on these findings, a diagnosis of shoulder impingement syndrome is considered. Conservative management is initiated with NSAIDs for pain relief, rest, and modification of activities to avoid overhead motions. The patient is referred to physical therapy for rotator cuff and scapular stabilizer strengthening exercises, and postural correction. Instructions are given on the importance of gradual return to sports and the potential need for further intervention, such as a subacromial injection or, rarely, surgical decompression, if symptoms do not improve with conservative management. A follow-up appointment is scheduled to assess progress and response to treatment.
Subacromial impingement syndrome (SAIS) refers to the inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space

  • Patients will present with  pain with reaching or lifting and pain with overhead motions
  • Will have positive impingement tests: check the subscapular nerve and the supraspinatus
  • Crepitus with range of motion

DX: X-ray may show tendonc calcification or a subacromial spur

  • Ultrasound and MRI may be helpful if the diagnosis remains unclear or rotator cuff or labral tear is suspected

TX: Treatment involves rest, ice, activity modification, NSAIDs, and corticosteroid injections

Radiographs showing subacromial spur in the anterior region of acromion. Note: the presence of this spur doesn ’ t affect the visualization of the lower aspect of the acromion and the top of humerus greater tuberosity for the SII

Image: Radiographs showing subacromial spur in the anterior region of the acromion

References: UpToDate

Shoulder Bursitis

Subacromial Bursitis

Patient will present as → a 45-year-old male, an avid tennis player, presents with a three-month history of right shoulder pain. He describes the pain as a constant, dull ache, worsening with overhead activities and at night, especially when lying on the affected side. He denies any history of trauma but mentions that his pain began after intensifying his tennis training. On physical examination, there is tenderness to palpation over the lateral aspect of the right shoulder, and pain is exacerbated by abduction and internal rotation of the arm. The Neer and Hawkins tests elicit pain, while the rotator cuff strength remains intact. There is no evidence of joint instability or neurological deficits. Based on the clinical presentation, a diagnosis of subacromial bursitis is suspected. The patient is advised to modify his activities, especially reducing overhead movements. He is prescribed a course of nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation, and referred for physical therapy focusing on shoulder strengthening and range of motion exercises. A follow-up appointment is scheduled to reassess his condition and consider further interventions, such as corticosteroid injections, if there is no improvement with conservative management.
Subacromial bursitis is a common etiology of shoulder pain. It results from inflammation of the bursa, a sac of tissue present under the acromion process of the shoulder

  • The inflammation is usually brought about by repetitive overhead activities or trauma
  • Pain in motion and at rest can cause fluid to accumulate. The presentation is very similar to what you would see with subacromial impingement

DX: Diagnosis is by history and physical examination, including provocative maneuvers

  • Suspected rotator cuff injury can be further evaluated with MRI or ultrasound
  • Aspirate if fever, diabetic or immunocompromised

TX: Includes prevention of the precipitating factors, rest, and NSAIDs. Cortisone injections can be helpful

Image by Adobe Stock

The subacromial bursa sits in a tight space under the acromion process of the shoulder, making it susceptible to overuse injury.

 

References: Merck Manual · UpToDate

Glenohumeral Joint Osteoarthritis

Glenohumeral Joint Osteoarthritis

Patient will present as → a 67-year-old female with a history of type 2 diabetes and hypertension presents complaining of progressive right shoulder pain over the past year. She describes the pain as a deep, aching sensation, worsening with movement and at night, leading to disturbed sleep. She notes decreased range of motion and difficulty in performing daily activities, such as reaching overhead and behind her back. She denies any history of injury to the shoulder. On examination, there is noticeable crepitus with passive movement of the right shoulder, tenderness to palpation over the glenohumeral joint, and a limited range of motion, particularly in external rotation and abduction. There are no signs of acute inflammation or systemic illness. Radiographic imaging of the shoulder reveals joint space narrowing, osteophyte formation, and subchondral sclerosis, consistent with osteoarthritis. Based on these findings, a diagnosis of primary glenohumeral joint osteoarthritis is made. The patient is advised on activity modification, provided with a prescription for NSAIDs for pain management, and referred to physical therapy for strengthening and range of motion exercises. Intra-articular corticosteroid injections are discussed as a potential option for pain relief. The patient is also educated about the possibility of future surgical interventions, such as shoulder arthroplasty, should conservative measures fail to provide adequate relief. Regular follow-up is scheduled to monitor her symptoms and functional status.
Degenerative shoulder (glenohumeral) osteoarthritis is characterized by degeneration of articular cartilage and subchondral bone with narrowing of the glenohumeral joint

  • Worse with activity => the more the patient does, the more pain he/she will have
  • More common in the elderly, it may be associated with throwing athletes at a younger age
  • Presents with pain at night and pain with activities involving shoulder motion
  • On physical exam, will have tenderness at the GH joint, flattening of the anterior shoulder contour due to posterior subluxation of the humeral head, functional limitations at the GH joint - decreased external rotation and painful shoulder range of motion

DX: Radiographs demonstrate joint space narrowing,  subchondral sclerosis, and osteophytes at the inferior aspect of the humeral head

  • MRI may be indicated to evaluate rotator cuff

TX: NSAIDs, physical therapy, corticosteroid injections

  • Total shoulder arthroplasty if unresponsive to nonoperative treatment
ShoulderOsteoarthritis

Right shoulder osteoarthritis in a 78-year-old woman.

References: Merck Manual · UpToDate

Question 1
A 33-year-old man complains of left anterior shoulder pain for 4 weeks. The pain is made worse with overhead activities. On examination, you note maximal pain in the shoulder with palpation between the greater and lesser tubercle. Pain in the shoulder is exacerbated when the arm is held at the side, elbow flexed to 90 ° and the patient is asked to supinate and flex the forearm against your resistance. On the basis of this presentation, what is the most likely diagnosis?  
A
rotator cuff tendonitis
B
myocardial infarction
C
anterior shoulder dislocation
D
rotator cuff tear
E
bicipital tendonitis
Question 1 Explanation: 
Bicipital tendonitis is an inflammation of the long head of the biceps tendon and the tendon sheath causes anterior shoulder pain that resembles and often accompanies coexisting rotator cuff tendonitis. Tenderness with bicipital tendonitis is reproduced with Yergason test. During Yergason test, the shoulder pain is exacerbated when the arm is held at the side, elbow flexed to 90 °, and the patient asked to supinate and flex the forearm against your resistance. Rotator cuff injuries often accompany bicipital tendonitis, and bicipital tendonitis can occur secondary to compensation for rotator cuff disorders or labral tears. In this case, the pain is clearly reproduced in a pattern suggestive of bicipital tendonitis. Myocardial infarction can present as shoulder pain and should always be considered in patients, especially those with known cardiac risk factors.
Question 2
A 62-year-old man presents complaining of progressively worse right shoulder pain for 5 weeks. The pain is located anterolaterally and is aggravated by overhead activities. The patient notes significant pain when trying to sleep with his arm in a forward-flexed position and his hand behind his head. The patient notes weakness of the right arm and states that he has noticed that he uses the arm less because of the pain. On physical examination, you elevate the patient's arms to 90 °, abduct to 30 °, and internally rotate the arms with the thumbs pointing downward. You note weakness and drooping of the right arm with this maneuver that is exacerbated when you apply downward pressure to the right arm. On the basis of this presentation, what is the most likely injured structure?
A
infraspinatus tendon
B
supraspinatus tendon
C
teres minor tendon
D
subscapularis tendon
E
bicipital tendon
Question 2 Explanation: 
The maneuver described is commonly referred to as the supraspinatus strength test or the “empty the can” test. Weakness in this maneuver is suggestive of injury to supraspinatus tendon. The teres minor and infraspinatus tendons are external rotators and are often tested with the arm at 90 ° of elbow flexion with the patient attempting to externally rotate against resistance. The subscapularis is also tested at 90 ° of elbow flexion with resistance applied as the patient attempts to internally rotate against resistance.
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