1. Shoulder pain

2. 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

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

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

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

6. 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 ,……

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

8. 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

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

10. 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

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

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

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

14. 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

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

16. 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

17. Rotator cuff Tendinitis
Treatment :
Rest
NSAIDs
Strengthening Exercises

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

19. 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)

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

21. 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

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

23. 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 )

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

25. 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 : % 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

26. 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)

27. Calcific Tendinitis

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

29. 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

30. 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

31. 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

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

33. 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

34. 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

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

36. 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 …….

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

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

39. 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

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

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

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

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

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

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

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

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

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