David E. Kern
Shoulder Pain
Shoulder pain is common. Point prevalence ranges from 7% to >26% in the population aged 18 years and older. Lifetime prevalence ranges from 7% to 67%, with the greatest prevalence in individuals of middle and older age (1,2). It is a common reason why patients consult their primary care givers, and often is associated with impairment of function (1,3,4). Persistent and recurrent symptoms are common (4, 5, 6).
Usually the primary care practitioner can establish the correct diagnosis and direct appropriate therapy without orthopedic or rheumatologic consultation. This section reviews the major causes of shoulder pain and provides a basis for diagnosis and treatment of these conditions.
Anatomy and Function
To enable accurate diagnosis and treatment of disorders of the shoulder, it is necessary to understand the anatomy and function of the shoulder structures (Figs. 69.1 and 69.2, and Table 69.1). Normal shoulder motion depends on the smooth, integrated movement of the glenohumeral, acromioclavicular, and sternoclavicular joints and the scapulothoracic articulation.
The shoulder structures themselves are organized in four layers (Fig. 69.1).
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Abduction of the shoulder is accomplished by the coordinated action of the deltoid (which initially elevates, or shrugs, the glenohumeral joint, then abducts the arm at the glenohumeral joint) and the rotator cuff muscles, especially the supraspinatus (which hold the humeral head in the glenoid fossa while abducting). In addition, the rotator cuff muscles assist in internal and external rotation of the shoulder. Repetitive impingement of these structures between the acromion or coracoacromial ligament and the greater tuberosity of the humerus during abduction is thought to lead to inflammatory and degenerative changes within the cuff that are the most common cause of nontraumatic shoulder pain.
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FIGURE 69.1. Structures of the shoulder and their relationships. Note that the subdeltoid or subacromial bursa lies next to the supraspinatus tendon but separate from the shoulder joint. Note the acromion and coracoacromial ligaments, which may impinge on the supraspinatus tendon on abduction of the arm. Note the location for subacromial injection into the bursa and about the rotator cuff tendons. (Sagittal section adapted from Pansky B. Review of gross anatomy. New York: Macmillan, 1979 , with permission.) |
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FIGURE 69.2. Humerus and scapula showing attachments of muscles. The distal attachments of the triceps and biceps onto the ulna and radius, respectively, can be seen in Figure 69.5. (Adapted from Agur AMR, Lee MJ, eds. Grant's atlas of anatomy. Baltimore: Williams & Wilkins, 1991 , with permission.) |
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TABLE 69.1 Muscles Acting on the Shoulder Joint |
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The joint is formed by the articulation of the humeral head with the shallow glenoid fossa of the scapula, the diameter and depth of which are increased by the fibrocartilaginous glenoid labrum. The shallowness of the fossa enables nearly hemispheric motion of the arm, but this wide range of motion (ROM) is achieved at the price of joint stability. Stability of the shoulder joint depends primarily not on bony structures but on the integrity of supporting soft-tissue structures, including the labrum, capsule, and rotator cuff.
Diagnostic Approach
Pain about the shoulder usually originates from one of three sites: periarticular structures (e.g., rotator cuff), glenohumeral joint, or sites distant from the shoulder. Table 69.2 lists the causes of shoulder pain arranged by their relative frequencies.
History and Physical Examination
The history and physical examination usually are sufficient to establish a working diagnosis and direct effective treatment. The history is less useful than the physical examination in establishing the anatomic problem, but it is nevertheless helpful. Perceived location of the pain usually is not helpful, because most sources of pain (e.g., rotator cuff tendon, subdeltoid bursa, glenohumeral joint space) share a fifth (or sixth) cervical derivation and cause pain in the upper arm only. More severe lesions tend to cause pain
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radiating down the arm and forearm, usually along the anterolateral aspect. Pain confined to the point of the shoulder suggests a lesion of the acromioclavicular joint, which has a fourth cervical derivation. Involvement of other joints suggests a generalized arthritic process.
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TABLE 69.2 Differential Diagnosis of Shoulder Pain in Primary Care Adult Patients |
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Asking about recent trauma and briefly reviewing the patient's problem list, medication list, and past medical history may be helpful in raising the suspicion for less common causes of shoulder pain, such as dislocation (e.g., from trauma), neoplasm (e.g., history of breast or lung cancer), or osteonecrosis (e.g., from corticosteroid use). Dislocation of the glenohumeral joint should be suspected with major injuries to the arm, especially if the shoulder is abducted and externally rotated at impact, whereas injury to, or separation of, the acromioclavicular joint usually results from a direct blow to the acromion. Asking what precipitates or makes the pain worse also is helpful. Pain referred to the shoulder from a distant site should not be exacerbated by movement of the shoulder. In contrast, pain with active or passive movement of the shoulder suggests a shoulder or periarticular problem. A history of occupational (6) and sports activities, such as working with hands elevated, lifting heavy objects, carrying loads supported by the shoulders, hand–arm vibration, pitching baseballs, swimming, or serving tennis balls, can identify exacerbating factors that may both suggest a cause and direct the attention of the clinician to a patient activity that should be modified as part of the treatment plan, especially in a patient with chronic or recurrent shoulder pain.
The physical examination usually is successful in identifying the source of pain. The uninvolved shoulder should be used as a control to confirm any questionable abnormality found on examination of the symptomatic shoulder. Inspection is the least helpful part of the examination, but it may reveal evidence of atrophy or displacement of bony landmarks. A popular approach that is most useful and widely accepted for the rest of the examination is given in Cyriax (see http://www.hopkinsbayview.org/PAMreferences). Excellent interrater reliability has been reported in one study (7). First, the location of pain origin is surveyed through a brief examination of the neck, scapula, shoulder, elbow, and wrist, usually involving a combination of active and resisted movements. The suspected abnormal site then is examined in depth. If the shoulder appears normal but another site is abnormal on the survey, the shoulder pain probably is referred from the abnormal site. If the survey reveals no abnormalities, the pain may be referred, or an abnormality in the shoulder may still be present. The shoulder is examined in the following way:
Active motion is studied by having the patient perform a few simple maneuvers. The patient is asked to elevate the arm as far as possible (normal is 180 degrees). External (lateral) and internal (medial) rotation is assessed with the elbow at the patient's side and the forearm held at a right angle in the anteroposterior (AP) plane (normal values are 40–45 degrees and 55–60 degrees, respectively). Internal rotation usually is limited by the patient's body and can be further evaluated by having the patient touch his or her back from below. Alternatively, external and internal rotation can be assessed with the patient's arm in 90-degree abduction. Adduction is assessed by placement of the patient's hands on the opposite shoulders.
Passive ROM then is examined and compared with the active range. Approximately 90 degrees of arm elevation is accomplished through abduction at the glenohumeral joint, 60 degrees by rotation of the scapula by the serratus anterior and upper half of the trapezoid, and 30 degrees by adduction and external rotation, which increases the articulating surface of the humeral head and turns the surgical neck away from the tip of the acromion. Glenohumeral abduction can be isolated by immobilizing the scapula or observing for scapular movement with one's fingers on the inferior angle of the scapula.
Resisted movements are examined next because they help elicit pain from the deep muscles of the rotator cuff. These tests are accomplished without movement of the shoulder joint, with the elbow at the patient's side, and with the forearm at a right angle in the AP plane. Abduction is tested by having the patient press outward at the elbow against the examiner's braced hand so that movement does not occur. Adduction is tested by having the patient press in, flexion forward, and extension backward at the elbow against the examiner's hand. External rotation is tested by having the patient press laterally and internal rotation medially at the wrist against the examiner's braced hand, again without movement and with the elbow kept at the side. Resisted flexion and supination of the elbow are assessed with the arm in the same position in order to test for a lesion of the biceps tendon. Strength and the elicitation of pain are noted.
Palpation is performed last. Palpation is less useful than the combination of active movements, passive ROM, and resisted movements because pain from palpation is common and nonspecific and because some structures are difficult or impossible to palpate. However, differential tenderness, compared with the control side, can help confirm disorders at the acromioclavicular joint, the bursa, or the biceps tendon in the bicipital groove.
Table 69.3 addresses interpretation of the physical examination. Both articular and periarticular disorders can cause pain and limitation of active movements. If both active and passive ROMs of the shoulder are limited, a disorder of the glenohumeral joint, adhesive capsulitis, or bursitis should be suspected. Limited ROM with a capsular pattern (lateral rotation more impaired than abduction, internal least impaired) suggests adhesive capsulitis or glenohumeral arthritis. A noncapsular pattern (abduction limited with little limitation to either rotation) suggests subdeltoid bursitis. If passive ROM is normal or exceeds the active range and passive movements are not painful
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or are less painful than active movements, a periarticular cause is likely. Pain on resisted movements identifies the anatomic location of the disorder (i.e., some element of the muscle or adjacent tissue, such as a bursa, that is being tensed). Weakness on resisted movements suggests a muscle or tendon tear or neurologic compromise. Sometimes strength cannot be accurately assessed because of pain, unless the shoulder is examined after the appropriately placed injection of a local anesthetic.
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TABLE 69.3 Interpretation of the Physical Examination |
Additional Diagnostic Tests
Additional diagnostic tests should be used selectively to confirm or further define, for therapeutic purposes, a diagnosis suspected on the basis of history and physical examination. Depending on the circumstances, additional diagnostic tests include a complete blood cell count, erythrocyte sedimentation rate, serologic tests for rheumatologic disorders, diagnostic arthrocentesis, plain radiographs of the shoulder or neck, and other imaging modalities. All have important roles in selected patients. Acute episodes of shoulder pain caused by rotator cuff tendinitis, bursitis, or biceps tendinitis usually should be managed without any additional testing.
Plain shoulder radiographs usually should be ordered in the presence of significant trauma, suspected arthritis (limited ROM in the capsular pattern on physical examination), suspicion of neoplasm, suspicion of osteonecrosis, or chronic, recurrent, or unexplained symptoms. Standard views consist of AP films in external and internal rotation. In external rotation, the humeral head is club shaped and overlaps the glenoid; its greater tuberosity is seen in profile. In internal rotation, the humeral head is rounded. Failure to see this distinction, in the absence of anatomic abnormality, suggests significant limitation in rotational movement. Additional views can be helpful in specific circumstances. An axillary lateral view (which permits accurate evaluation of the glenohumeral articulation but requires
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that the arm be held in abduction) or a scapular “Y” view (a lateral view that displays the scapula on end) can detect a posterior dislocation, which may not be noticed on routine AP views. A caudal tilt view can help identify subacromial spurs, which may contribute to a chronic impingement or rotator cuff syndrome. A true AP view, in which the patient is turned 40 to 45 degrees toward the symptomatic shoulder, provides a tangential view for evaluation of the glenohumeral joint space in a patient with arthritis. Plain radiographs, although useful in detecting fracture, dislocation, bone destruction, advanced osteonecrosis, calcific tendinitis, and arthritis, are insensitive in the diagnosis of early osteonecrosis and are, at best, only suggestive in the diagnosis of rotator cuff tear and other soft-tissue disorders. For all of these reasons, a detailed explanation of the reason for the radiograph will guide the radiologist to obtain the appropriate views.
Further imaging studies are best ordered in consultation with a specialist when referral or the possibility of surgery is being considered.Ultrasonography (approximately 1.2–4 times more expensive than plain radiographs) can be used to evaluate rotator cuff muscles and tendons, the biceps tenon, and the subacromial bursa. Pooled sensitivity and specificity for full thickness rotator cuff tears are 87% and 96%, but ultrasound is less sensitive in detecting partial-thickness tears (sensitivity 67%) (8). Skilled interpretation is required.Arthrography (three to eight times more expensive than plain radiographs) is both sensitive (approximately 92%) and specific (approximately 98%) for detecting rotator cuff tears (9), but it causes discomfort and may miss partial tears, particularly those on the bursal side. Communication of dye between the glenohumeral joint and the subacromial space unequivocally confirms a full-thickness tear. Arthrography can also confirm a diagnosis of adhesive capsulitis when clinical findings are equivocal. Arthrography combined with computed tomography (arthro-CT) is of value in detecting soft-tissue lesions (e.g., partial tendon tears) and intra-articular pathology (e.g., labral tears, capsular tears, loose bodies, chondral defects), especially in cases of recurrent subluxation/dislocation. CT (four to eight times as expensive as plain radiographs) and magnetic resonance imaging (MRI) (seven to 17 times as expensive) are noninvasive but costly techniques for evaluation of soft-tissue lesions. MRI better defines capsule anatomy, supraspinatus tendon integrity, site of impingement, and bursal anatomy than does CT. MRI is equal to arthrography and equal or superior to ultrasonography in detecting rotator cuff tears (sensitivity 75%–100%, specificity 84%–100%) (9,10). A systematic review found a pooled sensitivity and specificity of 89% and 93%, respectively, for full-thickness tears, but 44% and 90%, respectively, for partial-thickness tears (8). MRI is the imaging technique of choice in the diagnosis of early osteonecrosis. MRI arthrography with gadolinium (modestly more expensive than plain MRI) is more sensitive than plain MRI for detecting partial-thickness tears and labral tears (11) and is emerging as the imaging study of choice for glenohumeral instability and labral tears.
Management Strategies
Specific management varies depending on the disorder responsible for the pain. However, some management strategies are broadly applicable.
Physical Activity/Physical Therapy/Acupuncture
In the treatment of acute pain, the patient may benefit from a brief period (2–3 days) of rest with the arm in a sling. Many patients can begin ROM movements immediately to maintain mobility, while avoiding aggressive exercise or overuse. Prolonged immobilization of the shoulder should be avoided whenever possible, because contracture of the shoulder capsule and periarticular structures, known as adhesive capsulitis or frozen shoulder, may result. When glenohumeral ROM remains restricted after the acute pain has diminished, specific exercises, such as pendular and wall-climbing exercises (Fig. 69.3), should be prescribed for 5 to 10 minutes two to four times per day to maintain joint mobility. Patients with impingement disorders (e.g., rotator cuff lesions, subdeltoid bursitis) should avoid repetitive tasks with their arms overhead or their elbows above midtorso height, especially if the condition is recurrent or chronic. A program of balanced isometric or isotonic exercise of the shoulder abductors, adductors, flexors, extensors, and internal and external rotators, to strengthen the rotator cuff musculature, may help prevent recurrences. Balanced isotonic exercise can be approximated by having the patient loop a long rubber tube around the foot, on the same side as the shoulder being exercised, and do repetitions of shoulder abduction, adduction, flexion, and extension. Repetitions of external rotations can be performed with the tube held in the opposite hand and of internal rotation with the tube looped around an external stationary object. Exercise is beneficial for both short-term recovery and long-term function (12). Manual therapy (manually and/or mechanically applied movement techniques to improve joint motion) may be effective (13).
The efficacy of adjunctive physical therapy measures, such as heat or ultrasound, has not been adequately demonstrated (12,14,15). Nevertheless, on empiric and theoretical grounds, local cooling is generally recommended after acute injury to relieve pain and limit hemorrhage and edema. Similarly, local superficial heat often is recommended to decrease pain and promote tissue extensibility in the subacute and chronic stages, respectively. Some evidence indicates that laser therapy is more effective than placebo for adhesive capsulitis (12).
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FIGURE 69.3. Range-of-motion exercises of the shoulder. A: Pendular exercise can be done with a weight, which facilitates the pendular movement. The arm is moved back and forth in the sagittal and frontal planes, then circumducted in the clockwise and counterclockwise directions in increasingly large circles. B, C: Wall-climbing exercise done correctly. The wall climb can be started facing the wall. The body then is turned until the patient is at a right angle to the wall. The shoulder movement is at the glenohumeral joint. D: Wall-climbing exercise done incorrectly, with shrugging of the scapula. (Redrawn from Cailliet R. Shoulder pain. Philadelphia: FA Davis, 1981 , with permission.) |
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Referral to a physical therapist is recommended for patients who require a supervised exercise program after surgery or when satisfactory understanding of prescribed exercises or improvements in ROM have not been achieved after counseling by the health care practitioner.
Evidence supporting or refuting the use of acupuncture for shoulder pain is insufficient (16).
Medication
Nonsteroidal anti-inflammatory drugs (NSAIDs) (see Chapter 77) appear to be more effective than placebo but somewhat less effective than steroid injections in decreasing pain and restoring function in periarticular disorders (17, 18, 19, 20). Generally, a 2-week course of one of these agents is prescribed for acute disorders (see Chapter 77 for a full discussion of NSAIDs). The effectiveness of NSAIDs for this purpose, compared with analgesics such as acetaminophen, has not been adequately studied (20), although NSAIDs have a theoretical advantage because of their anti-inflammatory properties. Concern has been expressed regarding possible gastrointestinal (peptic disease with bleeding or perforation) or renal (proteinuria and failure) toxicity, particularly in the elderly. The efficacy of topical treatments has been insufficiently studied in patients with shoulder pain.
Injection Therapy
Based on studies using injections of lidocaine only, placebo oral drugs, NSAIDs/analgesics, heat, ultrasound, exercise, and acupuncture, injections of depo corticosteroid appear
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to reduce pain and speed functional recovery in patients with rotator cuff tendinitis/bursitis and may be more effective than NSAIDs/analgesics (18,19,21,22). A second or even third injection is sometimes required. Based on controlled (22, 23, 24, 25, 26) and uncontrolled studies (27), steroid injections (often several), combined with an exercise program designed to increase ROM, may be more effective than analgesic or no therapy (28) in reducing pain and speeding the recovery of patients with adhesive capsulitis. A meta-analysis of the controlled trials of corticosteroid injections for shoulder pain concluded that subacromial steroid injection appears to have a benefit over placebo for rotator cuff tendonitis, but a benefit over NSAIDs could not be demonstrated. It concluded that intra-articular steroid injections may provide early benefit over placebo or physiotherapy alone for adhesive capsulitis (29).
A 60% to 90% success rate can be expected after steroid injections for treatment of bursitis and tendinitis of the shoulder. In one study, after diagnosis by the physical examination strategies described earlier, injection was shown to be much more effective than tender or trigger point injections (20% success rate) (30). Serious complications of treatment (infection, degenerative changes after multiple injections, weakening or rupture of tendons) are rare (<0.1%) (31). They can be minimized by using sterile technique, observing contraindications to intra-articular injection (Table 69.4), following the procedures for injection described in Chapter 74, limiting the number of injections into an area over a given period, and avoiding injection directly into tendons. Instead, the diluted steroid can be injected around the length of the affected tendon. Subcutaneous tissue atrophy occasionally occurs and may be caused by inappropriately superficial injections. Postinjection flares of pain are uncommon (approximately 2% of injections), begin 6 to 12 hours after injection, last up to 72 hours, and can be treated with local cooling and analgesics or NSAIDs. Systemic absorption of locally injected steroid does occur and may cause transient suppression of the hypothalamic–pituitary–adrenal axis. This possibility must be considered in certain situations, as in a diabetic patient in whom the blood sugar concentration could become unusually elevated.
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TABLE 69.4 Contraindications to Arthrocentesis or Injection into the Shoulder or Periarticular Structures |
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Injection Techniques
Because of the frequency of shoulder pain and the apparent efficacy of steroid injections in treating a number of the most common causes, primary care practitioners may want to become proficient in these techniques. Depending on the number and type of sites to be injected, 1 to 5 mL of a short-acting local anesthetic (e.g., 1% lidocaine) is mixed in a syringe with a variable amount (usually 0.5–1.0 mL) of long-acting (depo) corticosteroid preparation (20–40 mg triamcinolone hexacetonide [Aristopan 20 mg/mL] or triamcinolone acetonide [Kenalog 10 or 40 mg/mL], 3–6 mg betamethasone [Celestone 6 mg/mL], or 20–40 mg methylprednisolone acetate [Depo-Medrol 20, 40, and 80 mg/mL]). Injection then is accomplished, observing sterile technique and universal precautions, with a 1.5- to 2-inch, 22- or 25-gauge needle; an 18- or 20-gauge needle is used if joint aspiration is required. For patient comfort, the steroid injection may be preceded by superficial and deep infiltration of a local anesthetic using a 25- to 30-gauge needle. Patients should be told that pain may return 1 to 4 hours after injection, when the effect of the short-acting local anesthetic wears off, but that the pain should improve again as the anti-inflammatory actions of the corticosteroid take effect (several hours or longer after injection).
Rotator cuff lesions and subdeltoid bursitis usually are treated with a subacromial injection (Fig. 69.1) of 20 to 40 mg triamcinolone or its equivalent (italics for clarity) in 4 to 6 mL of local anesthetic. The local anesthetic provides an adequate volume for the medication to diffuse through the bursa or along the rotator cuff tendons. The needle is inserted medially along the groove between the midpoint of the lateral acromion and the head of the humerus until grittiness and resistance to depression of the plunger are appreciated as the needle enters the rotator cuff tendon. The needle then is slowly withdrawn while the plunger is depressed lightly, until resistance lessens and some of the solution can be injected. The needle is partially withdrawn and redirected anteriorly and then posteriorly to deposit the remaining solution. This technique probably results in deposition of solution both in the subacromial portion of the bursa and along the rotator cuff tendon. If bursitis is the predominant finding and there is marked tenderness over the lower portion of the bursa, the injection should be directed toward this area as well. Cyriax (see http://www.hopkinsbayview.org/PAMreferences) has described techniques for injecting around the insertion of the specifically involved tendons, but the therapeutic trials described previously generally used the subacromial fan distribution for injection.
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Adhesive capsulitis is treated with intra-articular injection of 20 to 40 mg triamcinolone, or its equivalent, in local anesthetic. A posterior or anterior approach can be used (Fig. 69.2). If the posterior approach is used, the patient should rotate the shoulder medially, which turns the articular surface posteriorly and presents a larger target. This position can be fixed, if necessary, by having the patient lie prone, with the forearm under the upper abdomen. The practitioner places an index finger on the point of the coracoid process and the thumb on the point where the acromion and spine of the scapula meet at right angles, punctures the skin just inferior to the thumb, and directs the needle along the line joining the fingers, which crosses the glenoid cavity. Once impingement against cartilage and resistance to depression of the plunger are felt, the syringe is minutely withdrawn and the injection accomplished. A 2-inch needle usually is required. If the anterior approach is used, the patient is asked to sit with the shoulder externally rotated. The needle is inserted at a point just medial to the head of the humerus and slightly inferiorly and laterally to the coracoid process. It is directed posteriorly and slightly superiorly and laterally. Passage into joint space should be unobstructed. If bone is hit, the needle should be withdrawn and directed at a slightly different angle.
If bicipital tendinitis is the diagnosis, the bicipital tendon is identified by palpating it in its groove as the arm is rotated internally and externally with the elbow held in 90 degrees flexion. Then 20 mg triamcinolone or its equivalent in local anesthetic is injected along the length of the affected tendon.
The acromioclavicular joint (Fig. 69.1) can be palpated as a groove at the lateral end of the clavicle just medial to the shoulder. A 5/8- to 1-inch needle is directed inferiorly from the superior aspect of the joint. If the needle hits bone at a depth <1 cm or 3/8 inch, the tip probably does not lie intra-articularly, and slightly different spots should be tried until the needle slips in to approximately 2-cm length. Triamcinolone 4 to 10 mg, or its equivalent, in a small volume of local anesthetic is then injected about the joint space. Alternatively, the needle can be inserted from an anterior approach, with the tip of the needle slightly inferior to the joint.
Because the glenohumeral joint capsule juxtaposes the rotator cuff tendons and rotator cuff tendon disorders may accompany adhesive capsulitis, subacromial and intra-articular injections often are combined at the same time. This is particularly true for treatment of adhesive capsulitis. Because intra-articular injections are not consistently successful in entering the joint space, the posterior and anterior approaches are sometimes used sequentially at the same or separate sessions.
Use of a short-acting local anesthetic with or without steroid allows the practitioner to assess immediately after injection the accuracy of the injection by asking the patient whether the pain is gone and by repeating the examination. If the injection was effective, strength and ROM, now uninhibited by pain, can be assessed more accurately.
Because pain may be completely relieved, patients may be tempted to resume full activity of their shoulder immediately after injection. Common sense suggests that the patient should rest the arm for a few days after injection in the case of periarticular disorders, avoid heavy use (or use of the type that may have precipitated the disorder) for several weeks while healing occurs, and take appropriate precautions to prevent recurrence.
Referral
Occasionally, a patient needs to be referred to an orthopedist, rheumatologist, or physical medicine and rehabilitation specialist. Indications for referral include dislocation, fracture, functionally significant rotator cuff tear or rupture, suspected neoplasm, inability to perform indicated steroid injection therapy, nonresponsiveness to therapy, chronic or recurrent symptoms despite appropriate management, and uncertainty regarding the diagnosis or treatment.
Periarticular Disorders
Rotator Cuff Tendinitis
Rotator cuff tendinitis is the most common cause of shoulder pain (30,32,33). The tendinous fibers of the rotator cuff muscles undergo degenerative changes with advancing age. The tendons, particularly the supraspinatus, which is the most superior, are thought to be worn down by repetitive excursion between the greater tuberosity of the humerus and the acromion and acromioclavicular ligament. Edema, hemorrhage, and inflammation associated with repeated trauma cause pain that may lead the patient to seek medical attention. Inflammation of the subacromial bursa also may occur in this manner. The impingement syndrome and pericapsulitis are less specific terms that are applied to these degenerative and inflammatory disorders of the tendons and bursa. Risk factors for rotator cuff tendinitis include repetitive overhead work or activities and increasing age.
In addition to the history noted previously (see Diagnostic Approach), patients often complain of night pain and difficulty sleeping on the involved side. The physical examination is characterized by pain on resisted abduction (supraspinatus, most common), lateral rotation (infraspinatus), and/or medial rotation (subscapularis, least common). In the most common lesions, which involve the superficial distal end of the tendons, there is a painful arc. Pain occurs between 60 and 120 degrees of shoulder abduction (or 60–90 degrees glenohumeral abduction), where the impingement occurs. However, the pain resolves
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with further elevation as the shoulder is flexed, externally rotated, and adducted, and the impingement is relieved. An impingement sign (pain) also can be elicited by forcibly flexing/elevating the arm to 130 degrees while depressing the scapula (Neer impingement sign) or by elevating the shoulder to 90 degrees, flexing the elbow to 90 degrees, and internally rotating the humerus (Hawkins impingement sign). The tests, however, have only modest sensitivity and poor specificity (34). In isolated rotator cuff tendinitis, muscle strength is normal; passive ROM is normal or exceeds active ROM, which may or may not be limited by pain.
The indications for obtaining radiographs were stated (see Additional Diagnostic Tests). If rotator cuff tendinitis is the only problem, the radiographs are normal. However, periarticular calcification in the supraspinatus tendon or subacromial bursa is occasionally seen. Its clinical significance is uncertain because the majority of patients with this radiographic finding do not have symptoms; calcium deposits may disappear spontaneously and usually require no specific treatment (35). In one study, however, ultrasound decreased calcium deposits and relieved pain more effectively than placebo in patients with calcific tendonitis (12). A systematic review found moderate evidence that high-energy extracorporeal shock wave therapy is effective in treating calcific tendinitis (36). If calcium deposits are associated with chronic or recurrent symptoms and do not respond to conservative treatment, removal of the deposit by lavage and aspiration or surgery may be successful. An orthopedist should be consulted in this situation for consideration of the performance of these procedures.
Treatment of most patients with rotator cuff tendinitis was described previously (see Management Strategies). Most patients improve over the course of a few weeks. Relief usually occurs immediately after injection therapy. However, recurrences and eventually the development of chronic symptoms are common (5,37), underscoring the importance of a preventive exercise program and of preventive counseling based on a careful history of occupational and other activities (see History and Physical Examination). Persistent symptoms despite appropriate treatment suggest the possibility of a continued impingement, a tear, or instability (see Rotator Cuff Tear, and Glenohumeral Disorders,Trauma and Instability).
Subdeltoid (Subacromial) Bursitis
Bursitis may involve the subacromial or subdeltoid portion of the bursa and may accompany rotator cuff tendinitis. Its onset often is abrupt. The disorder is characterized by pain, often severe, with a noncapsular limitation (described earlier in History and Physical Examination) of both active and passive ROMs. Active ROM usually is more limited than passive ROM. Abduction is significantly more limited than lateral or medial rotation. The bursa is tender to palpation; the area of tenderness may be used to direct the injection of corticosteroids. A painful arc may not be demonstrable until the patient recovers sufficient ROM. Treatment was described earlier (see Management Strategies).
Rotator Cuff Tear
By the sixth decade, degenerative changes in the rotator cuff are seen almost universally and are thought to be secondary to diminished blood flow. Tears and ruptures of the cuff may then occur even in the absence of significant trauma. In younger patients, trauma (e.g., falling on an outstretched hand), injuries with subluxation or dislocation, and overuse usually are involved.
Most tears occur just proximal to the distal attachment of the supraspinatus tendon. A small tear may be indistinguishable from rotator cuff tendinitis on physical examination. Larger tears are characterized by weakness on resisted abduction. In complete tears (ruptures), the patient may be unable to initiate abduction or to lower the arm to the side smoothly (drop arm test) because the supraspinatus is necessary to stabilize the humeral head and to assist the deltoid in the initial phase of abduction. In one study, the drop arm test had low sensitivity but good specificity for complete tears (34).
Radiographs are indicated when symptoms are recurrent or persistent despite treatment (see Diagnostic Approach). An uncommonly seen radiologic sign, narrowing of the space between the acromion and humerus (≤5 mm is abnormal), suggests a tear, as does proximal subluxation of the humeral head and erosive changes in the anterior aspect of the acromion. The techniques of arthrography, CT, ultrasonography, and MRI are more useful than radiography in confirming partial or complete tears (see Diagnostic Approach). An orthopedic surgeon or radiologist may be consulted, to discuss the approach to establishing the diagnosis.
In general, minor tears can be treated conservatively in the manner described for rotator cuff tendinitis. ROM movements, followed by strengthening exercises, usually are part of the rehabilitation program. The decision to treat a patient with a large tear medically or surgically depends on the severity of symptoms, the functional disability, and the functional demands of each patient. Optimally, the patient, the family, the primary care practitioner, and an orthopedist are involved in making decisions. Indications for surgery remain somewhat unclear because of uncertainty about short- and long-term benefits versus risks in the absence of well-designed controlled trials, but they generally include acute posttraumatic weakness, particularly in younger patients and athletes, as well as persistent pain, weakness, and/or dysfunction despite conservative therapy. The traditional surgical approach involves removal of part of the acromion (acromioplasty) and repair
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of the rotator cuff tendon. The recovery period is more protracted after surgery (6–9 months of painful or restricted movement) than after conservative therapy (typically 8 weeks of painful or restricted movement). Arthroscopic and open repair have similar results; however, with arthroscopic repair, the incision is smaller, there is no need to detach the deltoid for inspection and treatment of intra-articular lesions, the procedure can be performed in the outpatient setting, and return to work and normal activities is shorter (38). One meta-analysis indicated very weak evidence for a long-term superiority of open repair (39). Because immobilization of the shoulder joint after surgery can lead to adhesive capsulitis, early and regular postoperative passive ROM exercises under orthopedic or physical therapy supervision are necessary. Complete pain relief and return to full function are uncommon after surgery.
Bicipital Tendinitis
With aging, the biceps tendon, like the rotator cuff tendons, is subject to inflammation, erosion, and rupture. Because the biceps tendon runs through the joint space and next to the rotator cuff and subacromial bursa, bicipital tendinitis can coexist with inflammation of these structures. However, attrition or chronic subluxation of the tendon in the bicipital groove of the humerus is more often responsible for symptoms.
Pain on resisted supination (Yergason test or sign) and flexion of the elbow are the characteristic findings on physical examination. A Speed test (pain at the bicipital groove on resisted forward elevation of the humerus with the elbow fully extended and forearm supinated) reportedly is more sensitive but less specific than the Yergason test (34), but it can also be positive in superior labral tears. If the glenoid origin is involved, the pain may be felt purely under the acromion. More often, pain is elicited in the upper arm, and the biceps tendon of the involved arm is tender to palpation in the bicipital groove. If bicipital tendinitis is isolated, active and passive ROM movements of the shoulder are painless and full. Radiographs are not necessary or diagnostic; however, if obtained for other reasons, they may show degenerative changes in the wall of the bicipital groove on tangential views.
Treatment was described earlier (see Management Strategies). Subacromial or intra-articular injection should suffice when this portion of the tendon is involved; otherwise, injection is directed along (but not into) the tendon in the bicipital groove. To reduce the chance of rupture, injections should be repeated no more than once or twice and separated by an interval of at least 4 to 6 weeks. For the same reason, injection usually is followed by a few days to 1 week of resting the tendon and avoidance of fully loading the tendon for a few weeks.
Rupture of the biceps tendon, which occurs rarely, is evident on physical examination as a mass of contracted muscle midway between the shoulder and elbow (Popeye sign). Rupture is accompanied by a sudden painful popping sensation, usually during a lifting effort. The upper arm remains painful and tender for several days after the rupture. Surgical repair, if desired (e.g., in an athlete, if an occupation demands maximal biceps function), is best accomplished within 7 days; otherwise, the tendon is likely to be contracted or fibrosed, precluding effective repair. Conservative management is an acceptable alternative. With regular exercise, the strength of forearm flexion and supination gradually returns; however, a 5% to 10% deficit in these movements usually persists.
Acromioclavicular Disorders
The acromioclavicular joint is formed by the articulation of the distal part of the clavicle with the acromion. Osteoarthritis is common in this joint during middle age and later life. Subluxation or dislocation may result from trauma, such as a fall on or a direct blow to the shoulder or acromion, which forces the scapula down and applies stress to the acromioclavicular and coracoclavicular ligaments. Laborers who lift heavy objects overhead or carry weights on their shoulders and athletes who compete in contact sports or weight lifting often sustain repetitive trauma to this joint. Injuries are classified as grade I—injury without subluxation, grade II—subluxation, and grades III to VI—complete dislocation. In grade III separation, there is modest superior displacement of the clavicle relative to the acromion. Types IV through VI are less common; they are characterized by posterior as well as superior, severe superior, and inferior dislocation of the clavicle, respectively.
Pain usually is localized to the exact site of the acromioclavicular joint or to the point of the shoulder (acromial area). There is little or no radiation of pain into the upper deltoid area. On physical examination, active and passive ROM usually are normal. Pain may be felt at the extreme limits of passive motion. Full passive adduction of the arm across the front of the upper thorax is often the most painful movement. Local tenderness is present when the superior ligament is involved. In grades III through VI dislocation, the acromion is displaced on palpation. Routine plain radiographs are indicated in situations of severe trauma. A 15-degree caudal tilt view of the acromioclavicular joint at 50% penetrance may be helpful in defining joint anatomy and pathology. Osteoarthritic changes are commonly seen on radiographs, but they also are often present in asymptomatic patients. Osteolysis of the distal clavicle may be seen as a posttraumatic change or in association with diseases such as rheumatoid arthritis, hyperparathyroidism, or sarcoidosis. Alleviation of pain after injection of a short-acting anesthetic directly into the acromioclavicular joint may be helpful in confirming this site as the source of pain. If a severe injury is suspected,
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the radiologic technician can be asked to obtain AP radiographs with the patient holding weights in both hands to help reveal grade II and grade III separations. However, one study suggested that weighted radiographs may miss acromioclavicular separations (40). Ultrasound, CT, and MRI may also be used when defining acromioclavicular joint pathology is desirable. The choice of methods is best made in consultation with a radiologist, rheumatologist, or orthopedic specialist.
Treatment of pain caused by degenerative arthritis was discussed earlier (see Management Strategies) and includes the use of NSAIDs or nonnarcotic analgesics. Local injection of corticosteroid/anesthetic solution may relieve symptoms in arthritic or low-grade traumatic conditions. If subluxation or complete dislocation is suspected after acute trauma and pain cannot be controlled with conservative measures over a few days, referral to an orthopedist should be obtained for consideration of surgery. However, one caveat should be considered before surgery is contemplated: Several prospective studies of grade III injuries that compared conservative management with strapping or a sling versus open reduction and internal fixation failed to demonstrate improved results from surgical treatment. Therefore, conservative treatment of shoulder separations of grade I, II, or III lesions currently is recommended by most orthopedists (41, 42, 43). Conservative management consists of treatment with an analgesic and a sling until the acute pain subsides. The patient should be aware that there will be a permanent prominence of the distal clavicle in grade III separations and a 5% to 10% loss of shoulder strength, which for most people is functionally insignificant. Surgery may be considered in the rare person whose occupation depends on continuous overhead activity (e.g., painters, some athletes) and in whom conservative treatment has failed to control pain. Type IV through VI lesions usually are evaluated for operative repair (42,43).
Glenohumeral Disorders
Adhesive Capsulitis
Adhesive capsulitis, or frozen shoulder, is a condition of unknown (but likely multiple) causes in which progressive restriction of shoulder motion occurs. It is commonly seen in diabetic patients. Often, an underlying painful condition of the shoulder, such as rotator cuff tendinitis or subdeltoid bursitis, precedes the development of adhesive capsulitis. However, this disorder also may occur in association with a cerebrovascular accident (especially hemiparesis, in which case it affects the paretic side), myocardial infarction, cervical radiculopathy, thyroid disorders, local or lung tumors, or Parkinson disease. A common underlying factor in most of these diverse conditions appears to be immobility of the arm. Eventually, the adhesive capsulitis may represent a greater disability than the initial cause of immobilization. Thickening of the joint capsule and capsular adhesions to the underlying humeral head develop. However, inflammatory findings in the capsule or synovial lining of the joint are not constant findings. Therefore, whether contracture of the shoulder capsule is a passive process related to lack of motion or an active process caused by inflammation remains unclear.
Adhesive capsulitis is somewhat more common in women than in men, and it most frequently occurs between the ages of 40 and 60 years. The patient characteristically complains of the insidious onset of diffuse pain and limitation of motion in the shoulder. In particular, the patient notes difficulty in performing tasks that require overhead arm motion, such as combing the hair and grasping objects from high shelves. Physical examination reveals pain at the extremes of motion and markedly reduced active and passive ROMs of the glenohumeral joint, usually in a capsular pattern (see Diagnostic Approach). Injection of an anesthetic agent into the glenohumeral joint may reduce the pain, but it does not result in an improved ROM. If adhesive capsulitis is the only problem, a plain radiograph (see Additional Diagnostic Tests) usually is normal and can help rule out arthritis, osteonecrosis, loose bodies, and other local pathology. Additional studies are rarely indicated. MRI with gadolinium, if done, may reveal thickening of the capsule and synovium. Arthrography, if performed, usually reveals a markedly reduced joint capacity, increased filling pressure, intact tendons, and an absence of inflammatory arthritic changes. If an arthrogram is done, corticosteroid injection and capsular distention by the orthopedist or radiologist can be accomplished at the same time, with accurate placement of solution.
The primary aims of treatment of adhesive capsulitis are pain relief, restoration of motion, and correction of any contributing cause. Treated only with analgesics, most patients recover within 2 to 3 years, but residual slight restriction of movement is common, and severe restriction occasionally is present at 3 to 4 years (28). In controlled (22, 23, 24, 25, 26) and uncontrolled (27) trials, intra-articular and periarticular corticosteroid injection, usually combined with a progressive exercise program designed to increase ROM, has been associated with shortened recovery periods of 3 to 8 weeks (22, 23, 24, 25, 26, 27). Typically, injections are repeated weekly for several weeks until the patient's pain is controlled and progress in mobility is being made. Capsular distention or rupture with 10 to 90 mL of fluid may actually speed recovery (25,44). An exercise program should be started as soon as the acute pain subsides. This may be limited initially to passive ROM exercises, performed at home with a trained family member. Active ROM often can begin fter injection, with pendular and then wall-climbing exercises (Fig. 69.3). Too aggressive mobilization may actually be associated with less satisfactory outcomes. Referral to a physical therapist usually is indicated to increase motivation, to ensure patient understanding of the
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exercise program, and to train family members. If pain is a limiting factor, consideration may be given to suprascapular nerve block. Two studies have provided some evidence of the effectiveness of suprascapular nerve block in reducing pain in patients with frozen shoulder (45,46). In the past, referral to an orthopedist for manipulation of the shoulder under anesthesia to free capsular adhesions was recommended for patients who did not improve with conservative management. The efficacy of this treatment has not been studied in a controlled fashion. It is no longer generally recommended and should be considered only in recalcitrant cases.
Trauma and Instability
Dislocation
Because of its instability, the shoulder is the joint most commonly dislocated. Dislocation occurs most often in active young to middle-aged adults. Anterior dislocation (95% of shoulder dislocations) usually results from a fall on an outstretched hand with forceful abduction, extension, and external rotation of the shoulder. On physical examination, the arm is held in the neutral position, and movement is avoided because of pain. The contour of the shoulder, which normally is convex below the acromion because of the humeral head, is flattened. The tip of the acromion is now the most lateral point of the shoulder region, and a noticeable prominence, caused by the displaced humeral head, is seen and felt inferior to the clavicle. Standard AP radiographs confirm the diagnosis.
Posterior dislocation (5% of shoulder dislocations) is less obvious and more likely to be overlooked on examination and radiography. It results from direct or indirect trauma that forces the humeral head posteriorly out of the glenoid fossa, and it may occur after an electrical shock or convulsion. On physical examination, the arm is held adducted and fixed in internal rotation. Anteriorly, there is flattening of the shoulder contour and prominence of the coracoid process. Posteriorly, there is prominence and rounding of the shoulder. The findings on standard AP radiographs are subtle (slight increase in space between the anterior glenoid rim and the medial humeral head; failure on the external rotation view [see Additional Diagnostic Tests] to see the normal club-shaped humeral head, with its greater tuberosity prominent at the superolateral margin, because the shoulder is locked in internal rotation). An axillary lateral or scapular “Y” view reveals the posterior displacement of the humeral head relative to the glenoid fossa.
Treatment of dislocations requires prompt reduction and usually involves immediate referral to an orthopedist or emergency department. Postreduction management includes a 2- to 6-week period of immobilization in a sling (less time for older patients), with removal a few times per day to extend the elbow, followed by an intensive physical therapy program to restore ROM and strengthen the appropriate anterior or posterior muscle groups in the hope of preventing recurrence. Dislocations may be accompanied by rotator cuff injury, neurovascular compromise (commonly the axillary nerve in anterior dislocation), or fracture, so pretreatment and posttreatment physical examination and radiographic studies should be done to evaluate these complications and to ensure the adequacy of the reduction.
Recurrent dislocation may follow the acute dislocation. It is especially common in younger patients (>50% incidence in patients 25 years of age or younger) (47,48). Each subsequent dislocation may require less force; eventually dislocation may occur even during routine tasks such as combing the hair. A variety of surgical procedures are available to treat this condition. Limited evidence now supports primary surgical intervention for young adults, primarily male, engaged in highly demanding physical activities, who have sustained their first acute traumatic shoulder dislocation (49).
Instability
A syndrome of glenohumeral instability, with subluxation with or without recurrent dislocation, is often seen in athletes, particularly in the dominant arm of baseball pitchers, racket sport players, and swimmers. Instability can be anterior, multidirectional, posterior, or inferior; the first two are most common. Patients with multidirectional instability are more likely to have joint laxity, shoulder muscle deconditioning, a history of repetitive injuries, or a previous large rotator cuff tear. Anterior instability with subluxation and secondary impingement can be an additional cause of rotator cuff tendinitis.
In addition to pain, patients may describe a sense of instability, weakness, or even radicular symptoms. They may voluntarily reduce their ROM. This syndrome can be difficult to diagnose. Physical examination should include an apprehension test, for anterior instability. The arm is placed in 90-degree abduction and full external rotation; patients with a positive test experience apprehension and a sense of impending dislocation. Subsequent application of pressure over the anterior aspect of the proximal humerus may alleviate the apprehension (relocation sign), whereas sudden release of this pressure may cause a return of apprehension, pain, or sense of impending dislocation (anterior release sign). The relocation and anterior release signs have similar sensitivity (~85%) but higher specificity (~87%) than the apprehension test (~50%), giving them better positive predictive values and likelihood ratios (50) (see Chapter 2). Inferior instability may be detected by inferior traction on the patient's arm, revealing a sulcus sign, or subacromial indentation, which has low sensitivity (31%) but reasonably high specificity (89%) (50). Posterior instability is tested with a jerk test. With the shoulder and elbow
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in 90 degrees flexion and the shoulder in full internal rotation, the arm is adducted across the body while pushing the humerus posteriorly. A positive test is characterized by posterior subluxation or dislocation. In the case of dislocation, the humeral head can be felt to clunk back into the joint as the arm is abducted. This is not to be confused with the clunk test, a test of low sensitivity (35%) and high specificity (98%) used to both assess joint instability and labral tears. With the arm abducted, forward pressure is placed on head of the humerus from behind as the shoulder is externally rotated; a clunk or grinding sensation represents a positive test. Joint laxity is tested by having the patient try to touch a thumb to the volar surface of the forearm and by having the patient bend back the fingers at the metacarpophalangeal joints. Plain radiographs usually are normal, but they may show subluxation with the patient holding a weight while relaxing the shoulder musculature.
Special radiographs may demonstrate a Bankart lesion (avulsion of the anterior inferior glenoid rim) or a Hill-Sachs lesion (compression fracture of the posterior humeral head) apparently caused by recurrent subluxation of the humeral head in front of the anterior glenoid rim. MRI, MRI arthrography, or arthro–CT may demonstrate a glenoid labral tear, laxity of the glenohumeral ligaments, or a Hill-Sachs lesion.
Treatment for anterior instability often requires surgery. The mnemonic TUBS applies to anterior instability: Trauma, Unidirectional, Bankart lesion, Surgery. Treatment of multidirectional instability involves a program of shoulder strengthening exercises, with a good to excellent response to treatment in approximately 80% of patients (51). The mnemonic AMBRI applies to multidirectional instability: Atraumatic,Multidirectional, Bilateral signs of laxity, Rehabilitation as the preferred treatment, and Inferior capsule tightening if surgery becomes necessary. If conservative treatment fails or if help is needed in making the diagnosis, referral to an orthopedist is appropriate. Surgery is directed toward tightening the capsular structures and stabilizing the joint.
Labral Tears
The labrum is a ring of fibrocartilage that runs around and deepens the glenoid fossa. Glenoid labral tears most commonly result from a fall on an outstretched arm with the shoulder in abduction and forward flexion. They also occur in people involved in throwing sports, racket sports, and swimming. The torn labral fragment can catch between the glenoid and humeral head, causing a sensation of catching, locking, and slipping that has been called “functional glenohumeral instability.” Tears can be classified as Bankart tears, which are anterior and inferior and predispose the shoulder to recurrent dislocation, or SLAP (superior labrum anterior and posterior) tears, which commonly occur after a fall on an outstretched arm or in overhead athletes. The diagnosis may be confused with rotator cuff tendinitis or bicipital tendinitis. Physical examination tests for labral tears are being studied. The most common is the O’Brien test. With the arm flexed 90 degrees and the elbow extended, downward pressure is applied; pain is felt in full pronation but not full supination. The test, although initially promising, has been found in subsequent studies to have disappointing sensitivity and specificity (50). Labral tears can be confirmed by MRI arthrography, arthro-CT, double-contrast arthrotomography, or arthroscopy. If the diagnosis is suspected, referral to an orthopedist is indicated. Conservative management, usually prior to radiographic confirmation, includes analgesics and/or NSAIDs and a program of stretching and strengthening exercises. Symptomatic tears generally require surgery, which usually is performed arthroscopically.
Fractures
Fractures of the proximal humerus occur most commonly in elderly persons, usually after a fall, although they may accompany traumatic dislocation in patients of any age. The neck and the greater tuberosity are most often involved. Pain, swelling, and deformity are characteristic of displaced fractures. Extensive bruising of the upper and middle arm may appear 1 to 2 days after fracture of the neck. Plain radiography establishes the diagnosis. If fracture is suspected, true AP and axillary lateral (or scapular “Y”) views, in addition to standard AP views, are recommended. Because radial nerve injuries are often associated, the practitioner should assess nerve as well as vascular function distal to the fracture site.
Shoulder injuries may result in fractures of the clavicle or of the scapula. Clavicular fractures usually result from a fall or direct impact to the clavicle. The patient experiences pain at the fracture site on attempted raising of the arm. Scapular fractures usually result from high-impact trauma, such as falls from a height or motor vehicle crashes. They may involve the glenoid, acromion, or coracoid process or the scapula proper. Often there are associated injuries, such as rib fractures, lung contusion, pneumothorax, and brachial plexus or spine injuries. The patient characteristically holds the arm at the side and experiences pain with any attempted movement of the arm. Referral to an emergency department or orthopedist is generally advised for definitive treatment, which varies depending on the type of fracture and the presence or absence of displacement of the segments.
Arthritis and Osteonecrosis
Arthritis
Arthritic conditions are distinguished by pain and limitation in a capsular pattern on active and passive ROM
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(see Diagnostic Approach). Plain radiographs may show chronic arthritic changes, but they may be normal in early or acute arthritis. Radiologic changes must always be interpreted with the clinical information on hand. Monoarticular arthritis uncommonly is the cause of shoulder pain. Primary osteoarthritis of the shoulder is uncommon, although secondary osteoarthritis may occur as a result of recurrent dislocation or instability, complete rotator cuff tear (cuff tear arthropathy), fracture, neuropathy (Charcot joint), osteonecrosis, hemoglobinopathy, or inflammation (see Chapter 75). In chronic inflammatory arthritides, such as rheumatoid arthritis, the shoulder usually is involved as part of a constellation of articular complaints (see Chapter 77). A septic (usually gonococcal or staphylococcal, less commonly streptococcal or gram-negative) or microcrystalline (see Chapter 76) process should be suspected if the shoulder is the site of monoarticular arthritis of acute onset. Joint aspiration should be performed promptly to obtain fluid for culture and fluid analysis, including cell count and examination for crystals by polarization microscopy (see Table 74.2, Table 76.1 and Fig. 76.1). The patient with a septic arthritis should be hospitalized and treated with intravenous antibiotics and drainage, usually by percutaneous but occasionally by surgical means.
Osteonecrosis
Osteonecrosis (also called avascular or aseptic necrosis) of the humeral head should be suspected in the patient with a history of fracture of the humeral head or neck, prolonged corticosteroid therapy, or sickle cell disease. Its incidence is also increased in patients with diabetes, alcohol abuse, or a variety of less common disorders. Diagnosis is confirmed by plain radiography or, if necessary, by bone scan or MRI (most sensitive, see Diagnostic Approach). Patients are staged from 0 to 4: 0—with all imaging studies normal, diagnosis by histology; 1—plain radiographs and CT normal, MRI and biopsy positive; 2—radiographs positive, no collapse; 3—subchondral radiolucency and early flattening of the dome; 4—flattening of the head with joint space narrowing. The disease often is progressive. Treatment includes ROM exercises, analgesics or NSAIDs, and limitation of stress, as discussed previously (see Management Strategies). Evidence from uncontrolled studies indicates that core decompression, which appears to be of benefit in hip osteonecrosis, may be of assistance for grade 1, 2, or 3 disease of the humeral head (52,53); it is a reasonable option in patients with no response after a few months of conservative therapy. Arthroscopic débridement and removal of loose bodies are sometimes used as an alternative or adjunct to core decompression (53). Patients with significant loss of function or severe pain whose condition does not respond to conservative management should be referred to an orthopedist for consideration of core compression, humeral head replacement, or total joint replacement. Total joint replacement is the treatment of choice for stage 4 lesions.
Referred Pain
Occasionally, pain in the shoulder area is referred from other regions of the body. Referred pain should be suspected when (a) the initial physical examination reveals another source for the pain; (b) active, passive, and resisted movements and palpation of the shoulder fail to elicit or exacerbate pain; or (c) the pain is in an atypical distribution (see Diagnostic Approach). The common causes of referred pain are discussed here.
Visceral sources of referred pain may be suggested by a review of the patient's problem list or medical history and the absence of another cause for the referred pain. Irritation of the phrenic nerve or diaphragm may arise from pathologic processes abutting these structures, such as subdiaphragmatic abscess, ruptured viscus, or disease involving the mediastinum, pericardium, liver, spleen, or gallbladder. In addition, ischemic heart disease, apical or superior sulcus tumor of the lung (Pancoast tumor; see Chapter 61), and dissecting aortic aneurysms all may be causes of referred pain (usually acute) to the shoulder.
Reflex sympathetic dystrophy, or shoulder–hand syndrome, now designated complex regional pain syndrome, is a poorly understood condition that may be a cause of referred shoulder pain. It is characterized by stiffness, swelling without pitting edema, warmth and erythema, vasomotor instability, and patchy bone demineralization of the hand. The syndrome may occur in association with trauma or surgery of the involved extremity, acute myocardial infarction, or cerebrovascular accident (see Chapter 91).
Nerve compression or irritation that is manifested clinically by shoulder pain may originate at the level of the cervical spine, wrist, or shoulder. In addition to pain, the patient may complain of paresthesias, numbness, muscular weakness, or atrophy. Neurologic examination often delineates the nerves or nerve roots affected. Cervical nerve root irritation is a common cause of shoulder pain. The pain often is felt above the shoulder, rather than in the upper arm, and it may be accompanied by neck pain. Characteristically the pain is exacerbated by movement of the neck but not of the shoulder. Chapter 70 discusses the diagnosis and management. Compression of the median nerve in the carpal tunnel of the wrist, known as carpal tunnel syndrome, occasionally is associated with pain about the shoulder. Usually, the pain originates in the wrist and radiates to the upper arm or shoulder. Chapter 92 discusses this condition. Irritation or compression of thesuprascapular nerve at the suprascapular or spinoglenoid notch can occur as a result of direct compression from a space-occupying lesion such as a ganglion or lipoma or from nerve
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entrapment, often seen in athletes involved in excessive overhead activity, often volleyball players (54). Patients experience deep posterior shoulder pain without sensory loss, weakness on external rotation (infraspinatus) with or without weakness on abduction (supraspinatus), and, occasionally, supraspinatus or infraspinatus atrophy. Full adduction of the arm across the chest may increase the pain. MRI, nerve conduction studies, and electromyography can help confirm the diagnosis. Six to 12 months of conservative treatment is recommended, which includes avoidance of repetitive overhead activities, a balanced muscle-strengthening program, and use of NSAIDs and/or gabapentin or a tricyclic antidepressant. Surgery may be required for a space-occupying lesion or to decompress the nerve if conservative treatment fails. Damage to the axillary nerve, usually resulting from shoulder dislocation, humeral fracture, or blunt trauma, is characterized predominantly by deltoid weakness but may be accompanied by a patch of sensory loss and pain over the outer shoulder. Other muscles innervated by C5 are not affected. Axillary nerve entrapment, termed the quadrilateral space syndrome, can cause similar symptoms. Shoulder pain may result from irritation, compression, or injury of the long thoracic nerve, which supplies the serratus anterior and results in winging of the scapula, or of the spinal accessory nerve, which supplies the trapezius muscle and results in weakness of shoulder shrugging and abduction, associated with abnormal movement of the scapula.
Thoracic outlet syndrome is an uncommon but serious condition in which pain in the shoulder is a common complaint. Neck pain may be present. The thoracic outlet consists of a series of three narrow, fixed passages within which the neurovascular supply of the upper extremity (brachial plexus and subclavian vessels) can become compressed as it exits the neck and thorax to enter the axilla. These three channels are (a) the space between the scalene muscles and first rib; (b) the costoclavicular space, bordered by the clavicle, first rib, and scapula; and (c) the space under the pectoralis minor where it inserts on the coracoid process (Fig. 69.4). Compression of the neural or vascular structures results most often from mechanical traction caused by muscle weakness, obesity, heavy breasts or arms, poor posture, or the carrying of backpacks or heavy loads on the shoulders. Symptoms may develop from periods of prolonged overhead work or sleeping with the arms hyperabducted. Only a minority of cases are caused by anatomic abnormalities such as a cervical rib (enlargement of the transverse process of C7), anomalies of the clavicle or first rib, cervical bands, hypertrophy of the omohyoid or scalene muscles, or subclavian artery aneurysms. The presenting complaint depends on the predominant structure that is compressed. If it is neural in origin, the patient complains of pain, often extending from the neck or shoulder area to the forearm or hand and accompanied by paresthesias or numbness, usually along an ulnar distribution. Muscle weakness and atrophy may be noted on physical examination. If it is vascular in origin, the patient may complain of an alteration in color or temperature, swelling of the affected hand, or a Raynaudlike phenomenon. Neurologic complaints usually predominate.
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FIGURE 69.4. Points of neurovascular compression in the thoracic outlet syndrome. (From Steinberg GC, Akins CM, Baran DT, eds. Ramamurti's orthopaedics in primary care. Baltimore: Williams & Wilkins, 1992 , with permission.) |
On physical examination, the force of the patient's radial pulse is palpated during the following maneuvers:
Unfortunately, the sensitivity and specificity of these tests are low, which seriously limits their usefulness. Because a substantial percentage of normal patients manifest a decrease or obliteration of their radial pulse with these maneuvers (55), reproduction of symptoms in parallel with the change in arterial pulse at the wrist is necessary to properly interpret these physical findings. Only a minority of
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patients have discoloration, temperature changes, or edema as a result of arterial or venous compression.
Plain films of the neck, chest, and shoulder should be obtained if referred pain is suspected. Noninvasive Doppler studies of the vascular structures of the upper extremity can be performed at rest and during the maneuvers listed if a vascular impingement is considered likely. Subclavian arteriography occasionally is needed to confirm stenosis, to identify an anatomic abnormality such as an aneurysm, or as a prelude to surgical intervention. Magnetic resonance angiography may be an acceptable less invasive alternative approach to vascular diagnosis. Nerve conduction velocity and electromyography can be used to help distinguish between thoracic outlet syndrome and other pathology.
Management of the thoracic outlet syndrome depends on the underlying cause. For most conditions, conservative management is beneficial. This involves the identification and elimination (or reduction) of aggravating factors and the implementation of an appropriate exercise and postural program. Such conservative measures provide relief in 50% to 90% of patients according to Sheon et al. (seehttp://www.hopkinsbayview.org/PAMreferences). An occupational therapist (if functional guidance is necessary) or a physical therapist (if exercise guidance is necessary) should be consulted when initiating the exercise program. Occasionally, patients with severe or refractory pain may be helped by surgical intervention, which can involve resection of the first rib, a portion of the scalene muscles, and/or an abnormal constricting structure such as a cervical rib. Consultation with a surgeon should be considered in such situations.
Elbow Pain
Elbow pain, although less common than shoulder pain, is a problem not infrequently encountered by the primary care practitioner. It has a prevalence of a few percent in the adult population (1).
Anatomy and Function
The elbow includes the distal humerus, the proximal ulna, and the proximal radius (Fig. 69.5). The elbow joint consists of two articulations. The articulation between the trochlea of the humerus and the olecranon of the ulna, sometimes called the humeroulnar joint, enables flexion and extension. The articulation between the capitulum of the humerus and the head of the radius, sometimes called the humeroradial orradiocapitellar joint, enables pronation and supination.
Movements at the elbow joint include flexion, extension, pronation, and supination. Flexion at the elbow is powered predominantly by the biceps and brachialis muscles, extension primarily by the triceps, supination primarily by the supinator and biceps, and pronation primarily by the pronators quadratus and teres. Importantly, the wrist and finger extensors originate from the lateral epicondyle of the humerus, the most common site of clinical symptoms, and the wrist and finger flexors originate from the medial epicondyle of the humerus, the second most common site of clinical symptoms at the elbow. Table 69.5 lists the function and innervation of the major muscles working across the elbow.
The olecranon bursa, a common site of bursitis, overlies the olecranon of the ulna and does not connect with the joint space.
Unlike the shoulder, the elbow has considerable articular congruency, and joint instability is much less a problem with the elbow than with the shoulder. Stability is aided by various ligaments shown in Figure 69.5.
Diagnostic Approach
Causes of Elbow Pain
Table 69.6 lists some causes of elbow pain. Lateral epicondylitis (tennis elbow) and medial epicondylitis (golfer's elbow) are discussed in detail in this chapter. General approaches to arthritis and traumatic injuries involving the elbow also are discussed. Chapter 74 discusses olecranon bursitis. Chapter 92 discusses compression and entrapment neuropathies.
History and Physical Examination
History
The history should include questions about the onset and duration of symptoms; location and radiation of the pain and associated symptoms; precipitating, exacerbating, and relieving factors; and the patient's activities. Acute onset suggests significant injury, whereas subacute or gradual onset over days to weeks suggests an overuse syndrome. Pain well localized to the lateral or medial epicondyles suggests lateral and medial epicondylitis, respectively, whereas less well-localized pain posterior to the lateral epicondyle is more suggestive of arthritis. Paresthesias or weakness distal to the elbow suggests nerve entrapment. Pain on flexion and extension of the elbow is characteristic of arthritis.
Activities that place individuals at risk include throwing, power gripping, using the elbow as a weight-bearing joint (e.g., gymnasts), and pronation–supination of the forearm, especially with an extended wrist. Particularly important are repetitive movements of these types, such as repetitive wrist turning, hand gripping or shaking, tool use, or twisting movements, and movements that exceed capacity or normal ROM. Individuals at particular risk
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include carpenters, gardeners, dentists, politicians, weight lifters, gymnasts, golfers, fly-casting fishers, and racquet and throwing athletes, particularly novices.
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FIGURE 69.5. The elbow: bones, ligaments, arteries, nerves, and attachments of muscles acting on the elbow joint. The proximal attachments of the biceps brachii are shown in Figure 69.2. (Adapted from Agur AMR, Lee MJ, eds. Grant's atlas of anatomy. 9th ed. Baltimore, MD: Williams & Wilkins 1991; and Agur AMR, Lee MJ, eds. Grant's atlas of anatomy. 10th ed. Philadelphia: Lippincott Williams & Wilkins, 1999 , with permission.) |
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TABLE 69.5 Muscles About the Elbow: Actions and Nerve Supply |
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TABLE 69.6 Differential Diagnosis of Elbow Pain in Adult Primary Care Patients |
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Physical Examination
Physical examination includes inspection and palpation, ROM, and resisted movements.
Inspection
With the patient standing and facing the examiner, the carrying angle (the angle made by the axis of the humerus and forearm), which normally is 5 to 10 degrees valgus, can be assessed. An abnormal angle suggests previous or current injury. The presence of ecchymosissuggests trauma, whereas swelling (using the other elbow for comparison) may be seen in arthritis, bursitis, or trauma. Swelling over the posterior olecranon process is characteristic of olecranon bursitis; associated erythema suggests infection or gout, with overlying cellulitis.
Palpation
In 1 degrees flexion the lateral epicondyle, medial epicondyle, and olecranon form a triangle, which becomes a straight line as the elbow is fully extended. Loss of this relationship suggests dislocation or displaced fracture. Small joint effusions may be detected by noting bulging in the triangular area that connects the lateral epicondyle, radial head, and olecranon in an area posterior and distal to the lateral epicondyle. Lateral and medial epicondylitis are characterized by tenderness over the respective epicondyles. Tenderness 4 to 5 cm distal to the lateral epicondyle suggests radial tunnel syndrome (posterior interosseus compression) (see Chapter 92). A cystic swelling
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over the olecranon suggests olecranon bursitis; associated warmth and tenderness suggest infection or gout, with overlying cellulitis.
Range of Motion
Normal ulnohumeral ROM (flexion–extension) is 0 to 135 or 145 degrees, with at least 30 to 130 degrees required for most normal activities of daily living. Radiohumeral ROM (pronation–supination) is tested with the elbow flexed at 90 degrees; findings of 0 to 150 degrees or 180 degrees total motion, and 70 to 90 degrees each of pronation and supination from the sagittal plane, are normal. Most activities of daily living are accomplished with 50 degrees each of pronation and supination. A limitation in ROM suggests arthritis, joint effusion, or previous or current injury involving the joint. Locking suggests a loose body. Bursitis and epicondylitis rarely affect ROM, except when there is overlying cellulitis or the epicondylitis is severe.
Resisted Movements
With the elbow at 90 degrees flexion, the following six isometric movements are tested against counterpressure with no actual movement of the associated joint: elbow flexion, elbow extension, supination, pronation, wrist extension, and wrist flexion. Testing of wrist extension and flexion is indicated because, as noted previously, (see Anatomy and Function) the wrist and finger extensors originate from the lateral epicondyle of the humerus and the wrist and finger flexors originate from the medial epicondyle. Pain on resisted movement that is localized to the tendon or other area of a muscle suggests an injury in the area of pain, such as tendinitis of the common extensor muscles of the wrists and fingers, commonly called lateral epicondylitis or tennis elbow. True weakness, rather than decreased resistance secondary to pain, suggests muscle or tendon rupture or tear. Soft-tissue injuries (e.g., tendinitis) are characterized by normal, nonpainful ROM with pain, weakness, or both on resisted movements.
Check for Referred Pain
If referred pain is suspected, the physical examination should include the neck (e.g., nerve root impingement, described in Chapter 70), shoulder (discussed previously in this chapter), and/or wrist (e.g., carpal tunnel syndrome, covered in Chapter 92). In the case of referred pain, pain typically is not increased by testing ROM or resisted movements.
Additional Diagnostic Tests
The history and physical examination usually are sufficient to make a diagnosis in the patient with nontraumatic elbow symptoms.Radiographs are necessary in the presence of acute trauma to confirm a diagnosis of fracture or dislocation, and they may be useful in confirming and characterizing the type and severity of arthritis. Basic radiologic assessment includes an AP view of the extended elbow and a lateral view with the elbow flexed at 90 degrees and the forearm supinated. Oblique views are used to help diagnose subtle fractures and when the elbow cannot be fully extended. MRI can help identify stress fractures; serious ligament, muscle, and tendon injuries; and nerve entrapment. Neuroelectrodiagnostic studies are helpful in diagnosing nerve entrapment syndromes (see Chapter 92). Bursal or joint aspiration is useful in distinguishing traumatic from infectious or other inflammatory etiologies and in diagnosing crystal-induced disease (see Tables 74.2, 76.1, and Fig. 76.1).
Lateral Epicondylitis (Tennis Elbow)
Definition, Epidemiology, and Etiology
The terms tennis elbow and lateral epicondylitis refer to injury in the region of the lateral epicondyle of the humerus at the origin of the common extensor muscles (see Fig. 69.5). The syndrome is the most common cause of elbow pain. It is associated with activities that involve excessive pronation and supination of the forearm, especially with an extended wrist, or with use of the common extensor muscles that exceeds capacity. Tennis, squash, and badminton players (especially novices), as well as throwers, bowlers, carpenters, gardeners, dentists, and politicians, are at risk. Case reports suggest a relationship with fluoroquinolone use (56). Some studies have shown the pathogenesis of lateral epicondylitis involves collagen degeneration and inflammation and injury (microtearing or microavulsion) of the common extensor muscles and tendons. Whether the anconeus muscle, radial collateral ligament, periosteum, radiohumeral synovium, or bursa is involved is unclear.
Diagnosis
The history is characterized by pain and tenderness localized in the lateral epicondylar area. It is more likely seen in the dominant arm. Sometimes the pain radiates proximally into the arm or distally into the forearm. The onset usually is gradual but can be acute or subacute. Sometimes the patient complains of intermittent pain or weakness. The pain may be aggravated by lifting (especially with the palm down), by repetitive use of the forearm or wrist, or by shaking hands. On careful questioning, there often is a history of activities that predisposed the patient to this condition.
The physical examination characteristically reveals tenderness localized to the region of the lateral epicondyle and pain, similarly localized, on resisted extension of the wrist. Pain also can be elicited by stretching the wrist extensors
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through maximal palmar flexion of the wrist with the elbow fully extended and the forearm pronated. A tight handshake may elicit pain. Sometimes there is pain on resisted radial deviation, supination, or pronation. ROM is normal.
The differential diagnosis, which includes arthritis, radial or posterior interosseus nerve entrapment (radial tunnel syndrome), trauma, osteochondral loose body, and referred pain, usually can be distinguished based upon the history and physical examination. In some cases, additional diagnostic tests are required to distinguish among potential causes (see Diagnostic Approach).
Management
A short course of immobilization with a sling or long arm splint with the wrist held in dorsiflexion may help to rest the tendons, although evidence supporting this approach is lacking (57). At least temporary abstention (usually a few weeks) from the type of overuse that may have precipitated the condition seems wise. Analgesics, topical or oral NSAIDs, ultrasound, iontophoresis with a steroid gel, acupuncture, or ice may provide relief, with the current evidence strongest for NSAIDs, ultrasound, and acupuncture (58, 59, 60). The weight of current evidence suggests that extracorporeal shock wave therapy is not effective.
Corticosteroid injections are more efficacious than placebo and other conservative treatments in reducing symptoms during the first few weeks after treatment (approximately 80%–90% efficacy, compared with 50%–60% efficacy for placebo or NSAIDs) (61,62). However, long-term outcomes (e.g., at 12 months) are similar; one study suggests that they may be better with physiotherapy (exercises, ultrasound, and deep friction massage) (62). A long-acting corticosteroid preparation (e.g., 10–20 mg triamcinolone) with approximately 1 mL short-acting local anesthetic (e.g., 1% lidocaine) is injected, using a 22- or 25-gauge needle and sterile technique, in the area of maximal tenderness just superficial to the tendon. A painful reaction or resistance to injection suggests that the needle is at bone or within the tendon and should be withdrawn slightly. Contraindications and precautions are similar to those discussed for shoulder disorders (see Injection Therapy). The elbow should be rested for a few days after injection, and consideration should be given to having the patient wear a hook and loop (Velcro) wrist brace for a few weeks.
Recurrence and prolonged minor discomfort that affects some activities are common. Prevention of recurrence may be aided by instituting an exercise program after the acute symptoms have subsided. These include grip exercises with a compressible ball or putty and stretch and isometric strengthening/toning exercises of the wrist extensors and flexors. Adjustment in activities that may precipitate or exacerbate symptoms probably is important. For example, changes in technique, racket handle, or frequency of use, combined with an exercise program, may help prevent recurrence in a novice tennis player. Alternating use of the left and right arms may be helpful for others. Referral to a physical therapist may be helpful in motivating patients, teaching them exercises, and analyzing and adjusting precipitating or exacerbating activities. Forearm bands, which theoretically reduce stress on the tendons, appear to help some patients during potentially exacerbating activities, although evidence of their efficacy is lacking (57).
If symptoms fail to respond to conservative treatment, orthopedic consultation should be considered. Surgery occasionally is required, in which case MRI can be helpful in surgical planning by defining the degree of tendon degeneration and tear. No randomized controlled trials have evaluated the efficacy of surgery.
Medial Epicondylitis (Golfer's Elbow)
Definition, Epidemiology, and Etiology
Medial epicondylitis (golfer's elbow) is caused by inflammation of the tissues in the area of the medial epicondyle, where the muscles that flex and pronate the wrist originate (Fig. 69.5). It is caused by overuse of these muscles and is seen most commonly in persons who engage in such activities, including throwing athletes, golfers, swimmers, tennis players who pronate and flex during their serve, and individuals who engage in repetitive lifting, tooling, hammering, or tight gripping. Although medial epicondylitis is not uncommon, it is less common than lateral epicondylitis.
Diagnosis
The history is characterized by pain and tenderness localized in the medial epicondylar area. It is more likely seen in the dominant arm. Sometimes the pain radiates proximally into the arm or distally into the forearm. The onset usually is gradual but can be acute or subacute. Sometimes the patient complains of intermittent pain or weakness. The pain may be aggravated by lifting (especially with the palm up), by repetitive use of the forearm or wrist, or by shaking hands. On careful questioning, there often is a history of activities that predisposed the patient to this condition.
The physical examination characteristically reveals tenderness localized to the region of the medial epicondyle and pain, similarly localized, on resisted flexion of the wrist. Pain may be elicited by stretching the wrist flexors through maximal extension of the wrist with the elbow fully extended and the forearm supinated. A tight handshake may elicit pain. Sometimes there is pain on resisted radial deviation, supination, or pronation. ROM is normal. The
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status of the ulnar nerve, which runs immediately posterior to the medial epicondyle, should be assessed (see Chapter 92). The differential diagnosis, which includes arthritis, ulnar nerve injury or compression (cubital tunnel syndrome), trauma, osteochondral loose body, and referred pain, usually can be distinguished based upon the history and physical examination. In some cases, additional diagnostic tests are required to distinguish among potential causes (see Diagnostic Approach).
Management
Management is similar to management for lateral epicondylitis, except that caution should be taken when injecting corticosteroids to avoid the ulnar nerve (Fig. 69.5). As in lateral epicondylitis, steroid injection appears to have benefit in the short term (several weeks) but not in the long term (3–12 months) (63). Surgical outcomes are worse in patients who have concomitant ulnar neuropathy (64,65).
Arthritis
Definition, Epidemiology, and Etiology
Arthritis refers to disease involving the synovium, cartilage, or bone of the joint space. In the elbow, the most common types are rheumatoid arthritis (see Chapter 77), posttraumatic arthritis, and crystal-induced arthritides (gout, pseudogout, or other; see Chapter 76). Osteoarthritis (see Chapter 75) is relatively uncommon and is seen most often in patients with a history of overuse (e.g., manual laborers, overhead throwing athletes). Infectious causes (e.g., due to local trauma or systemic infection) are seen occasionally.
Diagnosis
On history, the pain of arthritis is not as well localized as that of epicondylitis. Early in the course, it often is lateral, but posterior to the epicondyle. Later, it may be more diffuse. On questioning, the practitioner may discover patterns of pain and joint distributions characteristic of rheumatoid, degenerative, or crystal-induced arthritis (see Chapters 75, 76 and 77).
On physical examination, there usually is a limitation in ROM. Early on, there is a lack of full extension, which maximally reduces joint volume. Extension usually is more limited than flexion. Limitation of pronation and supination usually comes later, unless the arthritis was caused by injury to the radiohumeral area. Often there is end-point stiffness or pain. Lack of smooth motion, catching, or locking suggests the presence of a loose body, often seen in osteonecrosis. Soft-tissue swelling or rheumatoid nodules suggest an inflammatory arthritis. Physical examination of other joints may reveal findings of degenerative arthritis (see Chapter 75), inflammatory arthritis (see Chapter 77), or crystal-induced arthritis (see Chapter 76).
The differential diagnosis includes fracture of the radial head or distal humerus (including stress fractures), loose bodies, and osteonecrosis (avascular or aseptic necrosis or osteochondritis dissecans, most often seen in adolescent athletes with a repetitive overuse history), which often produces loose bodies.
AP and lateral radiographs (see Diagnostic Approach) can demonstrate patterns and characteristics of the various types of arthritides and reveal fractures or loose bodies. MRI may be required to reveal subtle fractures or loose bodies. If a septic effusion is suspected, joint aspiration is required for diagnosis. With the elbow resting at 90 degrees flexion, the elbow joint is entered in the center of the triangle connecting the lateral epicondyle, radial head, and olecranon (i.e., inferior and posterior to the lateral epicondyle). Preparation is the same as for shoulder disorders (see Injection Therapy); fluid analysis is described in Tables 74.2 and 76.1.
Management
Chapters 75, 76 and 77 discuss management of the various types of arthritis. Management usually involves a combination of specific medications, joint rest, and physical therapy. Occasionally intra-articular steroid injections are used in the management of rheumatoid arthritis, but this probably is best done in consultation with a rheumatologist. In the presence of disabling deformity or symptoms unresponsive to conservative treatment, the patient can be referred to an orthopedic surgeon for consideration of open or arthroscopic débridement or total joint replacement.
Traumatic Disorders of The Elbow
Traumatic injuries to the elbow include dislocation (posterior in >80% of the cases), fracture of the olecranon or coronoid process of the ulna, fracture of the radial head, and distal fracture of the humerus. Although patients usually present to the emergency room, they occasionally present to their primary care practitioner. The practitioner should, therefore, be aware of these injuries and have an approach to diagnosis and referral.
Dislocations and fractures of the radial head commonly result from falls on an outstretched hand with the arm in extension and adduction. Fractures of the olecranon usually result from a direct blow to or fall on the olecranon. Fractures of the coronoid process usually are preceded by sudden, strong resisted contraction of the brachialis muscle or occur in association with dislocation. Humeral
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fractures are relatively rare. Stress fractures of the olecranon usually are associated with overuse.
The diagnosis is suggested by acute and severe pain, swelling, ecchymosis, limited ROM, crepitus, and/or joint deformity. Physical examination should include palpation of the brachial, radial, and ulnar pulses and assessment of the distal vascular supply (warmth, color, and capillary refill). Median, radial, and ulnar nerve function should be assessed distal to the elbow. Radiographs of the elbow are always indicated and usually reveal the diagnosis. Dislocation is not infrequently accompanied by fracture (usually of the radial head or coronoid process of the proximal ulna). Stress fractures, usually of the olecranon, are characterized by a less dramatic history and physical examination and may require a bone scan or MRI for diagnosis.
Once a diagnosis has been made or seriously entertained, referral usually is made to an emergency department or orthopedic physician for treatment. In the case of vascular or neurologic compromise, dislocation, or displaced, open, or comminuted fractures, communication and transfer of care are urgent.
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.
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