Shoulder pain

EPIDEMIOLOGY Prevalence in General Population 70 _ 260 per 1000 Common in Female Common in > 40 y Risk increases on activities that need raising the arms or working with hand tools

Causes of Shoulder pain Intrinsic Cause:  Periarticular Disorders  Glenohumeral Disorders Extrinsic Cause:

Causes of Shoulder pain Periarticular Disorders:  Rotator cuff tendinitis or Impingement syndrome  Rotator cuff tears  Calcific tendinitis  Bicipital tendinitis  Acromioclavicular arthritis

Causes of Shoulder pain Glenohumeral Disorders:  Inflammatory Arthritis  Osteoarthritis  Osteonecrosis  Cuff Arthropathy  Septic Arthritis  Adhesive Capsulitis  Glenohumeral Instability  Glenoid Lebral Tears

Causes of Shoulder pain Extrinsic Cause:  Cervical radiculopathy  Brachial neuritis  Nerve entrapment syndromes  Sternoclavicular arthritis  Reflex sympathetic dystrophy  Fibrositis  Neoplasms  Miscellaneous Gallbladder disease , Splenic trauma , Subphrenic abscess , MI ,……

Rotator cuff Tendinitis Rotator cuff is composed of 4 musculotendinous unit :  Supraspinatus  Infraspinatus  Teres Minor  Subscapularis

Rotator cuff Tendinitis The most common cause of shoulder pain (70%) Rotator cuff tendinitis is clinically defined as shoulder pain exacerbated by movement against resistance when Shoulder is : A) abducted (Supraspinatus tendinitis) B) Externally Rotated (Infraspinatus tendinitis) C) Internally Rotated (Subscapularis tendinitis) B C

Causes of Rotator cuff Tendinitis Intrinsic: Poor vascular supply of the critical zone  Degenerative changes associated with aging  Local calcium deposits Extrinsic:  Impingement

Causes of Rotator cuff Tendinitis Impingement:  In the volume the tendons  In the volume of bursa  Enclosed space secondary to:  acromial shape  Osteophytes  Superior migration of the humeral head

Rotator cuff Tendinitis Potential shapes of acromion A) Flat B) Curved C) Hooked A B C

Rotator cuff Tendinitis Epidemiology Middle age & Elderly Impingement :  Stage 1 : < 25y Swimmer, Tennis player  Stage 2 : 25 _ 40y Workers, Athletes  Stage 3 : > 40y

Rotator cuff Tendinitis Clinical Feature : Painful Arch in Abduction & Flexion (60 _ 120 degree ) Limitation in active movement , but not in passive

Rotator cuff Tendinitis Clinical Examination : Neer Test (non specific) The patient’s scapula is immobilized and the painful arm is passively flexed as far as it will go

Rotator cuff Tendinitis Clinical Examination : Impingement Test injection of lidocaine into the subacromial bursa

Rotator cuff Tendinitis Radiography Normal in early stages Narrowing of the acromiohumeral gap Erosive changes of the anterior acromion Sclerosis of anterior 1/3 acromion

Rotator cuff Tendinitis Treatment : Rest NSAIDs Strengthening Exercises

Rotator cuff Tears Before 40y is rare unless: Significant acute trauma (Fall on an outstretched arm) Acute ( 8%) Chronic

Rotator cuff Tears Clinical Manifestation : No clinical sign is pathognomonic Pain & weakness in abduction and external rotation Symptoms of chronic impingement Supra & Infraspinatus atrophy (in long-standing tears)

Rotator cuff Tears Clinical Examination : Drop arm test Sensitivity 98% Specificity 10% The arm is passively abducted to 90 degrees then released

Clinical Examination of Rotator cuff Tears Three positive test or two if the patient is aged > 60y are diagnostic for a rotator cuff tear (98%) A) Supraspinatus weakness B) Infraspinatus weakness C) Hawkins impingement sign in abduction & external rotation D) Hawkins impingement internal rotation A B D C

Rotator cuff Tears Cuff Arthropathy should be suspected if:  Acromial humeral distance less than 7mm  Cyst formation within the greater tuberosity  Humeral head osteopenia

Diagnostic tests in Rotator cuff Tears Arthrography (with sensitivity & specificity > 90%) Ultrasonography (a good screening tools) with favorable sensitivity & specificity MRI ( very helpful in diagnosis of tears )

Treatment in Rotator cuff Tears Young adult : Surgical treatment Elderly person : Conservative treatment for 6 to 12 months if failed  surgery

Calcific Tendinitis Definition : A painful condition about the rotator cuff , association with deposition of calcium salts Etiology : Unknown . but, degeneration of tendon is the commonly accepted cause incidence : 2.7-20 % in asymptomatic individuals in Diabetic patient , Uremia , Hypervitaminosis D Average age : 40 _ 50y Common in the right shoulder , 6% bilateral More than 50% occurs in Supraspinatus tendon Up to ¾ of patients are Female

Clinical Manifestation of Calcific Tendinitis Three clinical pictures occur :  Silent (discovered incidentally, never cause symptoms)  Chronic Calcific Tendinitis ( chronic aching , increased pain on flexion & abduction)  Acute Calcific Tendinitis (sudden excruciating shoulder pain , radiates toward deltoid insertion & base of the neck , guarding the afflicted arm , supporting with good hand , unable to move the arm , can not sleep at night)

Calcific Tendinitis

Treatment of Calcific Tendinitis Depends on the clinical presentation and the presence of impingement  Local Glucocorticoid injection  NSAIDs  Colchicine  Lithotripsy

Bicipital Tendinitis Chief Complaint : Anterior Shoulder pain , which 95% is associated with Rotator cuff disease and impingement Chief Complaint : Anterior Shoulder pain , which may extend to biceps muscle belly Dose not radiate to the neck Pain worsens with lifting , carrying and may worsen at night

Clinical Examination of Bicipital Tendinitis Point tenderness (5-7 cm below the acromion) Speed’s Test : Flexion against resistance with the elbow extended and forearm supinated causes pain over the biceps tendon

Clinical Examination of Bicipital Tendinitis Yergason’s Sign : Supination of the forearm against resistance when the elbow is flexed causes pain over proximal anteromedial arm

Treatment of Bicipital Tendinitis Rest the arm and discontinuation of activities that cause pain NSAIDs Subacromial steroid injection (no more than once )

Rupture of Biceps Tendon Uncommon in young Occurs when the muscle contracts forcefully unexpectedly In middle aged & elderly with a history of chronic shoulder pain Local steroid injection

Clinical Examination in Rupture of Biceps Tendon Ludington Test : Patient puts both hands behind his head and flexes the biceps , rupture causes a distal bulging

Rupture of Biceps Tendon Imaging :  Plain radiography  Ultrasonography  MRI & CT arthrography Treatment :  Surgery in young adult  Conservative in elderly

Adhesive capsulitis Limitation of motion of shoulder joint Pain at the extremes of motion The exact cause is unknown Conditions associated with :  Trauma  Diabetes mellitus  Parkinsonism  Thyroid disorders  Cardiovascular disease  TB …….

Adhesive capsulitis Epidemiology :  2-3 % of general population  11-19 % of diabetes  slightly more common in female  common in 50-70 y (rare < 40y)  5-25 % bilateral

Adhesive capsulitis Clinical manifestation :  Diffuse shoulder pain  Night pain  Loss of mobility (active & passive mobility is limited , even by using Xylocaine injection)

Adhesive capsulitis Three Clinical Stage :  Freezing (a few weeks or months) severe pain  Frozen (4 to 12 months) marked stiffness , less pain  Thawing (5 to 26 months) resolution

Adhesive capsulitis Diagnosis : A diagnosis of exclusion  Chronic posterior dislocation  Rotator cuff disease  Septic arthritis  Avascular necrosis  Fracture  Bony or Pulmonary neoplasm  Osteoarthritis , …….

Adhesive capsulitis Para clinic :  CBC , ESR , TFT , Serum chemistry  Radiography (PA & axillary view)  Arthrogram

Treatment :  Moist heat Adhesive capsulitis Treatment :  Moist heat  NSAIDs  Analgesics  Oral steroids  Exercise

Reflex Sympathetic Dystrophy Algodystrophy , Sudeck’s atrophy Shoulder-hand syndrome Complex Regional Pain Syndrome Extremity pain Swelling Stiffness Discoloration

Reflex Sympathetic Dystrophy Cause is unknown Prevalence is not known Associated conditions :  Trauma  Ischemic heart Disease  Cerebrovascular Disease  Fractures  Herpes zoster  Epilepsy  Brain Tumors , ……….

Reflex Sympathetic Dystrophy Clinical Features :  Severe Pain (aggravated by motion)  Swelling  Diffusely tender  Limited shoulder motion  Allodynia

Reflex Sympathetic Dystrophy Clinical Finding :  Swelling (pitting or non pitting)  Discoloration  Increased Sweating  Shiny skin  Weakness  Tremor

Reflex Sympathetic Dystrophy Diagnosis is made clinically Radiography show patchy or spotty osteopenia Bone scanning with technetium

Reflex Sympathetic Dystrophy Prevention : Early mobilization after MI , trauma and strokes Early treatment lead to a better outcome Treatment : Corticosteroids Calcitonin Sympathetic blockade