GC236 Common Shoulder Problems
Common shoulder problems encompass a group of frequently encountered musculoskeletal conditions—including rotator cuff injuries, impingement syndrome, adhesive capsulitis, and instability—that cause pain, stiffness, and functional limitation of the shoulder joint.
Common Shoulder Problems
This lecture (GC 236, updated 2025, Prof. Tak Man Wong) covers three bread-and-butter shoulder conditions that appear repeatedly in HKUMed Fourth Summative papers and OSCEs. The deck is explicitly divided into three modules [1]:
| Module | Topic | Core Issue |
|---|---|---|
| 1 | Anterior Shoulder Instability | Dislocation → recurrence → when to operate |
| 2 | Rotator Cuff Pathology | Degenerative tear → impingement → repair |
| 3 | Frozen Shoulder (Adhesive Capsulitis) | Capsular fibrosis → stiffness → release |
The big idea: The glenohumeral (GH) joint trades bony stability for the widest range of motion (ROM) of any human joint. That trade-off explains why the shoulder is the most commonly dislocated joint, why the rotator cuff is uniquely vulnerable, and why the capsule can stiffen catastrophically when inflamed.
How this fits into exams: The 2025 Fourth Summative MCQ Q44 directly tested rotator cuff tear vs frozen shoulder vs impingement [5]. Past papers also test shoulder examination (goniometer MCQ, 2020 Q13) [6]. Expect MCQs on classification of instability, indications for surgery, and clinical differentiation of these three entities.
Functional Anatomy – Why the Shoulder Is Special
The shoulder has the ability to precisely stabilise the humeral head at the centre of the glenoid but also allow a vast range of motion. [1]
| Structure | Role | Clinical Relevance |
|---|---|---|
| Glenoid | Shallow socket ("no deep socket") → avoids neck-to-rim contact → allows wide arc of motion | Loss of glenoid bone ("inverted pear deformity") → recurrent instability |
| Labrum | Fibrocartilaginous rim that deepens glenoid ~50% | Bankart lesion = labral avulsion → anterior instability |
| GH ligaments (superior, middle, inferior) | "Check-reins" at extremes of motion where muscle forces fail; elastic "countervailing" behaviour within arc of motion | Inferior GH ligament complex (IGHLC) torn in 100% of anterior dislocations |
| Capsule (coracohumeral ligament, rotator interval) | Restrains rotation at rest | Contracture → frozen shoulder |
GH ligaments act as check-reins at positions where the muscle forces begin to fail, and provide countervailing elastic behaviour within the arc of motion. [1]
| Structure | Function |
|---|---|
| Rotator cuff (Supraspinatus, Infraspinatus, Teres minor, Subscapularis – mnemonic: SITS) | Compresses humeral head into glenoid ("concavity compression"); fine-tunes joint reaction force vector |
| Deltoid | Prime mover for abduction; force-couple with cuff |
| Periscapular muscles (serratus anterior, trapezius, rhomboids) | Control scapular position → maintain optimal glenoid version |
A stable shoulder requires: Static articulation (bony + GH ligaments) and Dynamic muscle (rotator cuff + deltoid balancing joint reaction force). [1]
Why this matters from first principles: Compare the shoulder to the hip. The hip has a deep acetabulum with nearly 180° coverage and a strong labrum – it virtually never dislocates without massive trauma. The shoulder glenoid covers only ~25-30% of the humeral head surface. This means stability depends overwhelmingly on soft tissue (ligaments, labrum, cuff muscles). When any of these fail, the clinical consequences are immediate and dramatic.
Module 1 – Anterior Shoulder Instability
When the arm is in abduction + external rotation and a force is applied, the humeral head levers anteriorly over the glenoid rim. The inferior GH ligament complex acts like a hammock; when this hammock fails, the head dislocates anteriorly.
Lesion of the inferior glenohumeral ligament complex (IGHLC) occurs in 100% of anterior dislocations. [1]
Key Pathological Lesions
| Lesion | Definition | Frequency |
|---|---|---|
| Bankart lesion | Avulsion of anterior-inferior labrum (+/- labral-capsular complex) from glenoid | 97% of IGHLC injuries |
| Mid-substance tear | Tear within the ligament body itself | 1.5% |
| HAGL lesion (Humeral Avulsion of GH Ligaments) | Avulsion at humeral attachment of IGHLC | 1.5% |
| Hill-Sachs lesion | Posterolateral impaction fracture of humeral head from resting against anterior glenoid rim | 50% after first dislocation; 38-88% in recurrent instability |
| Bony Bankart / Inverted pear | Fracture of anterior-inferior glenoid (bone loss) | 20% after first dislocation; 50-73% in chronic/recurrent instability |
| ALPSA lesion (Anterior Labroligamentous Periosteal Sleeve Avulsion) | Labrum avulses with intact periosteum that displaces medially and heals in non-anatomic position | Variant of Bankart; associated with chronic instability |
High Yield – Bankart Lesion
"The only rational treatment is to reattach the glenoid ligament to the bone from which it has been torn." – Bankart, 1923/1939 [1]. This is the intellectual foundation for surgical Bankart repair and is quotable in SAQs.
This classification is directly from the lecture slides and is high yield. [1]
| Feature | TUBS (96%) | AMBRII (4%) |
|---|---|---|
| Aetiology | Traumatic | Atraumatic |
| Direction | Unidirectional (anterior) | Multidirectional |
| Laterality | Usually unilateral | Bilateral laxity |
| Pathology | Bankart lesion | Capsular redundancy |
| Treatment | Surgery (if recurrent) | Rehabilitation, Inferior capsular shift, Interval closure (surgery if fails) |
20% incidence of recurrent instability after a first-time anterior dislocation (Leroux et al., 2014). [1]
Dislocation < 20 years old → > 80% will re-dislocate. Dislocation < 35 years old → 55.7% recurrence within 2 years, 66.8% at 5 years (Robinson et al., 2006). Younger male patients are most at risk. [1]
Why age matters: Younger patients have more elastic tissue that doesn't scar down tightly, higher activity levels, and often participate in contact sports. The Bankart lesion in a young person is less likely to heal in an anatomic position because the labrum doesn't fibrose as effectively.
Risk factors for recurrence [1]:
- Age (single most important factor – younger = higher recurrence)
- Trauma severity
- Contact/competitive sports
- Associated fractures (glenoid bone loss, large Hill-Sachs)
Assessment
- Mechanism (arm position at time of dislocation – typically abduction + ER)
- Number of previous dislocations
- Position that provokes apprehension
- Sport/activity demands
- Previous treatment
Look → Feel → Move (active/passive) → Generalised laxity → Translation test → Provocative tests → SLAP tests → Rotator cuff strength → Neurology/Cervical [1]
| Test | Technique | What It Tests |
|---|---|---|
| Load and shift | Stabilise scapula, load humeral head into glenoid, then shift anteriorly/posteriorly | Glenoid concavity/labral competence |
| Sulcus sign | Downward traction on arm in adduction; gap appears below acromion | Inferior laxity (multidirectional instability) |
| Anterior apprehension test | Shoulder abducted 90°, maximally externally rotated and hyperextended | Patient feels "about to dislocate" → positive |
| Relocation test | Posterior-directed force on humeral head during apprehension → relief of symptoms | Confirms anterior instability |
| Jerk test (posterior) | Axial load + horizontal adduction → posterior subluxation/clunk | Posterior instability |
| Kim test | Sitting, abduct 90°, further elevate 45°, axial load + posteroinferior force → pain and clunk | Posteroinferior labral lesion |
OSCE Tip
For the anterior apprehension-relocation test: The key positive finding is apprehension (fear of dislocation), not just pain. If a posterior force (relocation) relieves the apprehension, this confirms anterior instability. Examiners will deduct marks if you say "pain positive" without mentioning apprehension.
| Modality | View/Technique | Findings |
|---|---|---|
| X-ray AP | Standard | Dislocation, glenoid fracture |
| Axillary view | Arm abducted, beam shoots superiorly through axilla | Confirm direction of dislocation |
| Stryker Notch view | Arm over head | Hill-Sachs lesion |
| West Point view | Prone, beam angled tangential to anterior glenoid | Glenoid defect |
| CT | 3D reconstruction | Quantify bone loss (glenoid & humeral head) |
| MRI +/- arthrogram | Labral tears (Bankart, ALPSA, HAGL), cuff tears, cartilage damage |
After the first anterior dislocation: 1/2 of patients have Hill-Sachs notch visible on XR; 1/6 have visible glenoid defects; 1/6 have persistent subluxation. [1]
Management
Simple immobilisation has no role in conservative treatment other than for comfort. (Andrews, CONA 2002) [1]
- Immobilisation: 3-4 weeks, mainly for pain management
- Itoi et al. (2003) suggested immobilisation in external rotation may reduce recurrence (pushes Bankart lesion back against glenoid) – but this remains controversial [1]
- Rehabilitation for supervised strengthening has conflicting evidence:
- Naval Academy: useful – 25% recurrence after 4 months rehab
- West Point: not useful – 80-92% recurrence on similar programme [1]
- Physiotherapy focus: Periscapular strengthening, cuff strengthening, power movers (pectoralis, deltoid, latissimus dorsi), proprioceptive neuromuscular facilitation (PNF), taping
- Return-to-play criteria: Pain free, full ROM, normal strength [1]
In-season athletes: Regain muscle control, brace to limit abduction and ER. [1]
Who, When, How? – Lecture slide heading [1]
Indications for surgery:
- Recurrent instability (especially young, active patients)
- Significant bone loss
- Failed conservative management
- First-time dislocation in young competitive/contact sport athlete (controversial but increasingly favoured given > 80% recurrence in < 20-year-olds)
Surgical Options Based on Bone Loss [1]:
| Bone Loss | Procedure |
|---|---|
| Glenoid bone loss < 25% | Standard arthroscopic Bankart repair ("create a new bumper") |
| Glenoid bone loss > 25% | Open or arthroscopic Latarjet procedure (coracoid bone block transfer) |
| Engaging Hill-Sachs (5-7 mm depth, engages glenoid in abd + ER) | Remplissage (arthroscopic posterior capsulodesis + infraspinatus tenodesis to fill defect), or glenoid-based bone augmentation, or humeral head options |
Arthroscopic Bankart repair: low recurrence rate (5.2%), good ROM, low morbidity (CUHK data). [1]
Early operation → easier operation, less bone loss, early recovery, few complications, good functional outcome, low recurrence. [1]
Accelerated Rehabilitation After Bankart Repair [1]:
| Time | Activity |
|---|---|
| Day 1 | Pendulum exercises |
| Day 3 | IR & forward elevation as tolerated |
| Week 1 | ER as tolerated |
| Week 4 | ER with 90° abduction |
| Week 6 | Full ROM + strengthening |
"We go slower as you get older!" [1]
- Avulsion of anterior IGHLC (with or without bone)
- Glenoid fracture
- Rotator cuff tears (especially in older patients – > 40 years)
- Neurovascular injury (axillary nerve – test deltoid and "regimental badge" area sensation)
- Cartilage damage
Don't Forget the Axillary Nerve!
After any shoulder dislocation, ALWAYS test axillary nerve function: sensation over "regimental badge" area (lateral deltoid) and deltoid power. This is commonly examined in OSCEs and missed by students. Inferior dislocation has the highest incidence of axillary nerve injury [2].
Module 2 – Rotator Cuff Pathology
| Muscle | Origin | Action | Nerve |
|---|---|---|---|
| Supraspinatus | Supraspinous fossa | Abduction (initiates first 15-30°) | Suprascapular |
| Infraspinatus | Infraspinous fossa | External rotation | Suprascapular |
| Teres minor | Lateral scapular border | External rotation | Axillary |
| Subscapularis | Subscapular fossa | Internal rotation | Upper & lower subscapular |
The deltoid is the prime mover for abduction but requires the cuff to centre the humeral head. Without a functioning cuff, the deltoid pulls the humeral head superiorly rather than abducting the arm (loss of force couple).
| Factor | Mechanism |
|---|---|
| Age | Progressive degeneration |
| Hand dominance | Greater loading on dominant side |
| Contralateral shoulder | Bilateral tear likelihood after 60 is as high as 50% |
| Smoking | Affects vascularity of tendon |
| Family history | Genetic predisposition to tendon degeneration |
| Trauma | Acute tear on degenerative tendon |
| Occupational heavy labour | Chronic overload |
| Mechanism | Details |
|---|---|
| Extrinsic | Acromion morphology (hooked Type III acromion causes mechanical impingement), spur over coracoacromial ligament, coracoid morphology, bursitis |
| Intrinsic | Chronic microtrauma (repeated overhead activities – swimming, lifting, painting), poor vascularity: a critical hypovascular zone exists 10-15 mm proximal to the RC insertion on the humeral head |
Why the "critical zone" matters: The supraspinatus tendon's blood supply comes from both the osseous side (humeral head vessels) and the musculotendinous side. Near the insertion, these two vascular territories barely overlap, creating a watershed zone. This is why tears almost always start here – it's the weakest link biomechanically AND biologically.
- Bursal side vs Articular side (partial tears)
- Partial thickness vs Full thickness
- Full thickness tear sizes [2]: Small ( < 1 cm), Medium (1-3 cm), Large (3-5 cm), Massive ( > 5 cm or multiple tendons)
Shoulder pain: anterolateral and lateral margin. Night pain – cannot sleep on affected side. Sometimes radiates to elbow. Weakness. Can present as impingement syndrome or frozen shoulder.
Key differentiator (exam favourite): In a rotator cuff tear, active ROM is limited but passive ROM is preserved (the tendon can't pull but the joint isn't blocked). In frozen shoulder, both active AND passive ROM are limited (the capsule is contracted). In impingement, there is a painful arc (60-120°) with preserved ROM beyond that.
- ROM (active vs passive)
- Tenderness over rotator cuff
- Weakness testing
| Special Test | What It Tests | Technique |
|---|---|---|
| Jobe test (Empty can) | Supraspinatus | Arm 90° abduction, 30° forward flexion, thumb down; resist downward force |
| Lift-off test (Gerber) | Subscapularis | Hand behind back (IR), lift hand away from back; weakness = positive |
| Impingement tests (Neer, Hawkins) | Subacromial impingement | Neer: passive forward flexion with scapula stabilised; Hawkins: 90° flexion + IR |
| Drop arm test | Large rotator cuff tear | Slowly lower arm from full abduction; sudden drop = positive |
| Modality | Sensitivity/Specificity | Notes |
|---|---|---|
| USG | PTT: sensitivity 84%, specificity 89%; FTT: sensitivity 96%, specificity 93% | Operator dependent; good screening tool |
| MRI | 92.5% and 87.5% accuracy for fatty infiltration in SSP, ISP, SS respectively | Gold standard for surgical planning; shows fatty infiltration (irreparability marker), retraction, muscle atrophy |
| X-ray | N/A | Acromiohumeral distance (normal > 7 mm; reduced = proximal humeral migration from massive cuff tear), acromion morphology, calcification |
Management [1]
- Medication (NSAIDs, subacromial steroid injection)
- Physiotherapy: muscle strengthening, ROM exercises, pain relief
Tear size > 1 cm, recurrent symptoms, weakness, lack of healing, tendon retraction, muscle atrophy.
| Procedure | When |
|---|---|
| Debridement | Partial tears, elderly/low demand |
| Repair (open or arthroscopic) | Reparable full-thickness tears |
| Reconstruction | Failed repair, massive irreparable tears |
| Replacement (reverse shoulder arthroplasty) | Cuff tear arthropathy (massive tear + secondary OA) |
Rehabilitation after surgery [1]:
- Debridement: Free mobilisation as tolerated
- Repair/Reconstruction: Immobilisation → passive mobilisation → assisted active mobilisation (gradual progression to protect repair)
Healing rate depends on comorbidities: DM, hypercholesterolaemia, smoking – all may affect healing.
| Tear Size | Healing Rate |
|---|---|
| Small to medium | 87% |
| Large to massive | 62% |
| Multi-tendon tears | 36% (vs 67% single tendon) |
No evidence supports bio-augmentation (e.g. PRP, stem cells). [1]
Module 3 – Frozen Shoulder (Adhesive Capsulitis)
Loss of both active AND passive ROM, with symptom of true shoulder pain and night pain of insidious onset. Painful restriction of active and passive movement, with passive movement limited to ≤ 100° elevation, ER < 30°, and IR limited to L5 or less.
This is the definition the examiner will expect. The hallmark is global restriction of both active and passive ROM – this separates frozen shoulder from rotator cuff pathology (where passive ROM is preserved).
| Type | Cause |
|---|---|
| Primary (idiopathic) | No identifiable cause |
| Secondary | Post-traumatic (e.g. fracture greater tuberosity), post-operative, associated with systemic disease (DM, thyroid disease) |
Primary: 3-5% of population, age 40-60, more common in females, 10-20% of patients with diabetes (Manske et al., 2008). Post-operative/post-traumatic: 11%.
Why diabetes predisposes: Glycosylation of collagen in the capsule leads to crosslinking, thickening, and stiffening. Diabetic patients also have impaired microvascular flow, which delays healing and promotes fibrosis.
Anterosuperior capsule (rotator interval, SGHL, CHL) → limits ER in adducted shoulder. Anteroinferior capsule → limits ER in abducted shoulder. Posterior capsule → limits IR.
Understanding which capsular region is affected predicts which motion is limited – this is a common exam question stem.
40% of patients have persistent symptoms (Hazleman 1972). 50% have mild pain after several years, 60% have residual stiffness (Shaffer 1992). 7-15% have persistent functional disability (Binder 1984).
Myth Buster
Many textbooks say frozen shoulder is "self-limiting" and fully resolves in 1-3 years. The lecture emphasises that a significant proportion (40-60%) have persistent symptoms or residual stiffness. Don't state in an exam that "frozen shoulder always resolves spontaneously" – the data does not support this.
| Phase | Description | Duration |
|---|---|---|
| Freezing | Pain onset → progressive loss of ROM | 2-9 months |
| Frozen | Pain decreases but stiffness persists | 4-12 months |
| Thawing | Pain improving, ROM gradually improving | 12-24 months |
| Structure Involved | Motion Limited |
|---|---|
| Rotator interval | ER in adducted arm |
| Anteroinferior capsule | ER in abducted arm |
| Posterior capsule | Adduction and IR |
| Extra-articular structures | Global stiffness |
Special tests should be done to rule out other pathologies (rotator cuff tear, instability, cervical radiculopathy) [1].
| Finding | Frozen Shoulder | Normal |
|---|---|---|
| CHL thickness | > 4 mm (mean 4.1 mm) | 2.7 mm |
| Capsule thickness | > 7 mm (mean 7.1 mm) | 4.5 mm |
| Axillary recess | Smaller/obliterated | Normal |
Management [1]
Goals: Pain relief + Restore ROM and function. [1]
| Treatment | Details |
|---|---|
| Physiotherapy | First-line; stretching, mobilisation |
| Steroid injection | Intra-articular; reduces inflammation in freezing phase |
| MUA (Manipulation Under Anaesthesia) | Forceful breaking of adhesions; risk of fracture, nerve injury |
| Arthroscopic capsular release | Systematic release of contracted capsule sections |
| Combined (ACR + MUA) | Prof. Wong's preferred approach when conservative Tx fails at 3 months |
- Anterosuperior capsule (rotator interval, SGHL, CHL)
- Anteroinferior capsule
- Posterior capsule
- Be cautious about inferior release because of the axillary nerve [1]
Surgical Safety
The axillary nerve runs along the inferior capsule approximately 12 mm from the glenoid rim. Excessive inferior release risks axillary nerve injury (incidence 0.6%). [1] This is a favourite SAQ/viva point.
- Extended inferior and posterior release → more rapid ROM improvement at 3 months; no significant difference at 6 months
- Systematic review (498 MUA vs 521 capsular release): minimal differences in outcomes
- RCT (503 patients, MUA vs ACR vs early structured physiotherapy): None was clinically superior; ACR had more adverse effects; MUA was most cost-effective [1]
- Dislocation
- Axillary nerve injury (0.6%)
- Superficial wound infection
PREVENTION is the best treatment for post-traumatic shoulder stiffness: Early mobilisation + Adequate pain relief. NO CONSENSUS in management of adhesive capsulitis. Arthroscopic capsular release: AVOID releasing too much; Consider when conservative treatment fails at 3 months; Beware of surgical complications. [1]
Clinical Approach – Shoulder Pain (Integrative)
| Condition | Key Discriminator |
|---|---|
| Rotator cuff tear | Active ROM limited, passive ROM preserved; weakness; positive Jobe/lift-off |
| Frozen shoulder | Both active AND passive ROM globally limited |
| Impingement syndrome | Painful arc (60-120°), positive Neer/Hawkins |
| Anterior instability | History of dislocation, positive apprehension/relocation |
| AC joint pathology | Pain at top of shoulder, positive cross-body adduction test |
| Cervical radiculopathy | Dermatomal numbness, Spurling positive, neck movements reproduce arm symptoms |
| Calcific tendinitis | Acute severe pain, calcification on XR |
| GH OA | Progressive pain, crepitus, joint space narrowing on XR |
- Site: Where exactly? (anterolateral = cuff; top = AC joint; posterior = posterior instability)
- Onset: Acute (trauma/dislocation) vs insidious (degenerative/frozen shoulder)
- Character: Catching/clicking (labral tear); grinding (OA); deep ache (cuff)
- Radiation: To elbow (cuff); to hand (cervical)
- Aggravating: Overhead (cuff/impingement); specific positions (instability)
- Night pain: Very common in cuff tears and freezing phase
- Function: Dressing, hair washing, reaching behind back
- Red flags: Weight loss, fever (infection/tumour), bilateral (inflammatory arthritis)
- Co-morbidities: DM (frozen shoulder risk ×5), thyroid, smoking
| Step | What to Look For |
|---|---|
| Look | Muscle wasting (supraspinatus/infraspinatus fossa), asymmetry, scars |
| Feel | Tenderness (greater tuberosity, AC joint, bicipital groove) |
| Move | Active ROM → passive ROM → document difference |
| Special tests | Apprehension/relocation, Jobe, lift-off, Neer, Hawkins, Speed's, O'Brien |
| Neurovascular | Axillary nerve, cervical spine screen |
- X-ray (AP, lateral, axillary +/- Stryker notch/West Point for instability)
- USG (first-line for suspected cuff tear – cheap, dynamic, no radiation)
- MRI (definitive for surgical planning – cuff, labrum, bone)
- CT (quantify bone loss for instability surgery planning)
Past Paper Questions
Stem: "A 60-year-old female reported a 3-month history of right shoulder pain. She reported pain with overhead activities which was relieved with rest. Active range of motion in elevation was 110 degrees, while passive range of motion was 160 degrees. Which of the following is the MOST LIKELY diagnosis?"
A. Frozen shoulder B. Impingement syndrome C. Rotator cuff tear ✓ D. Shoulder osteoarthritis
Rationale: The key discriminator is that active ROM (110°) is significantly less than passive ROM (160°). This discrepancy indicates a motor/tendon problem (cuff tear) rather than a mechanical block. In frozen shoulder, both active and passive would be equally limited. Impingement typically shows a painful arc (60-120°) but full active ROM beyond the arc. OA would show crepitus and progressive global loss.
Stem: "A 51-year-old woman was referred to an orthopaedic surgeon for a 2-month history of shoulder pain. When you are performing physical examination on her, which of the following equipment would be the MOST USEFUL?"
A. 2-point discriminator B. Goniometer ✓ C. Measuring tape D. Tendon hammer
Rationale: Shoulder examination relies critically on measuring ROM (active vs passive). A goniometer quantifies joint angles accurately. This is the single most useful instrument for differentiating cuff tear (active < passive) from frozen shoulder (both reduced). A tendon hammer tests reflexes (not the primary concern). Measuring tape measures limb length (hip/lower limb). A 2-point discriminator tests fine sensory discrimination (hand surgery).
Exam Intelligence
| Trap | Correct Thinking |
|---|---|
| "Frozen shoulder always resolves spontaneously" | 40-60% have residual symptoms; 7-15% persistent disability [1] |
| Confusing frozen shoulder with cuff tear | Frozen = both active + passive limited; Cuff tear = only active limited |
| Forgetting axillary nerve after dislocation | ALWAYS test – regimental badge sensation + deltoid power |
| Saying "immobilise for 6 weeks" after dislocation | Lecture says 3-4 weeks; prolonged immobilisation has no proven benefit and may worsen stiffness [1] |
| Bankart repair for > 25% glenoid bone loss | > 25% bone loss → Bankart repair will fail; need Latarjet [1] |
| Ordering MRI first for cuff tear | USG is a reasonable first-line; MRI for surgical planning |
| "All cuff tears need surgery" | Many are asymptomatic; surgery is for symptomatic tears > 1 cm that fail conservative Rx |
| Missing DM as risk factor for frozen shoulder | 10-20% of diabetic patients develop frozen shoulder [1] |
- MCQ: "Which is the most likely diagnosis?" given active/passive ROM discrepancy (as in 2025 Q44)
- SAQ: "List the pathological lesions associated with anterior shoulder dislocation" → Bankart, Hill-Sachs, ALPSA, HAGL, glenoid fracture
- SAQ: "Name risk factors for rotator cuff tear" → Age, smoking, DM, occupation, dominance, contralateral tear, family Hx
- OSCE: Demonstrate shoulder examination – Look/Feel/Move/Special tests
- SAQ: "Describe the 3 phases of frozen shoulder" with durations
High Yield Summary
- The GH joint sacrifices bony stability for ROM – stability depends on labrum, GH ligaments (static) and rotator cuff (dynamic).
- Anterior dislocation always tears the IGHLC (100%); Bankart lesion in 97%; Hill-Sachs in ~50%. Recurrence rate in < 20-year-olds is > 80%.
- TUBS (96%): Traumatic, Unidirectional, Bankart, Surgery. AMBRII (4%): Atraumatic, Multidirectional, Bilateral, Rehabilitation/Inferior capsular shift.
- Glenoid bone loss < 25% → arthroscopic Bankart repair. > 25% → Latarjet.
- Rotator cuff tear is age-related (20% in 60s, 40% in 70s). Critical hypovascular zone 10-15 mm proximal to insertion. Active ROM limited but passive ROM preserved.
- USG is first-line imaging for cuff tears (sensitivity 96% for FTT). MRI for surgical planning.
- Frozen shoulder = both active AND passive ROM limited. Three phases: Freezing (2-9 mo), Frozen (4-12 mo), Thawing (12-24 mo). NOT always self-limiting.
- DM increases frozen shoulder risk (10-20%); smoking impairs cuff tendon vascularity and healing.
- Arthroscopic capsular release: release anterosuperior → anteroinferior → posterior. Beware axillary nerve at inferior capsule (0.6% injury rate).
- Prevention (early mobilisation + pain relief) is the best treatment for post-traumatic stiffness.
Active Recall - Common Shoulder Problems
[1] Lecture slides: GC 236. Common Shoulder Problems [Updated in 2025].pdf [2] Senior notes: Maksim Surgery Notes.pdf (Shoulder section, pp. 231-235) [3] Lecture slides: MBBS IV History taking Ortho.pdf [4] Lecture slides: CFB Clinical skills Upper Limb RY 2025.pdf [5] Past papers: 2025 Fourth Summative MCQ.pdf (Q44) [6] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (Q13)
GC235 Osteoporotic Related Fractures
Fragility fractures occurring at sites such as the hip, vertebrae, and distal radius due to reduced bone mineral density and microarchitectural deterioration characteristic of osteoporosis.
GC237 Musculoskeletal Infection
Musculoskeletal infection refers to infectious processes affecting bones (osteomyelitis), joints (septic arthritis), or surrounding soft tissues, typically caused by bacterial pathogens and requiring prompt diagnosis and treatment to prevent tissue destruction and systemic complications.