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A. Bicipital Tendinitisnavigator

  1. Symptoms
    1. Pain, usually in anterior portion of shoulder
    2. Patients can usually point to point of maximal focal tenderness
    3. Either (or both) heads of the biceps may be involved
    4. Probably due to impingement of biceps tendon by acromion
  2. May be coincident with rotator cuff tendinitis
  3. Treatment
    1. Rest
    2. Hot packs
    3. Physical Therapy
    4. Ultrasound Therapy
    5. Passive then active range of motion (ROM) exercises
    6. Non-steroidal antiinflammatory drugs (NSAIDs)
    7. Good acute response to lidocaine + DepoMedrol® followed by 1-2 months of NSAIDs

B. Rotator Cuff Tendinitis [6]navigator

  1. Typically associated with calcification of tendons in rotator cuff
    1. This causes calcific tendonitis which is probably most common final step in pathology
    2. Also called Impingement Syndrome: supraspinatus tendon impinged on by acromion
    3. Osteophyte development, especially inferior aspect of acromioclavicular joint
  2. Characteristics
    1. Most common cause of shoulder pain
    2. Pain worse when arm is moved forward with elbow flexed
    3. Active motion worse than passive motion
  3. Underlying Causes
    1. Probably multifactorial
    2. Overuse most common contributing factor, usually with overhead reaching
    3. Acute shoulder trauma
    4. History of inflammatory joint disease, usually with shoulder symptoms
    5. Joint diseases include rheumatoid arthritis (RA), pseudogout, gout
  4. Diagnosis with shoulder magnetic resonance imaging (MRI)
  5. Treatment
    1. Conservative care with rest, hot or cold packs, ± NSAIDs
    2. Physical therapy
    3. Manipulative therapy for shoulder girdle symtoms can accelerate recovery [4]
    4. Resistant cases can be treated with glucocorticoids or ultrasound therapies
    5. Lidocaine injection usually into subacromial bursa can be diagnostic and therapeutic
    6. If lidocaine improves symptoms, then ~20mg of Depo-Medrol can be infused as well
    7. Ultrasound - 24 x 15 minute treatments improves pain and reduces calcification [1]
    8. Low or high dose ultrasound (electrocorporeal shock wave therapy) highly effective [2]
    9. NSAIDs

C. Rotator Cuff Tear [2,6]navigator

  1. Roator-cuff tendon failure due to either tear or wear is most common clinical shoulder problem
  2. Anatomy of the Rotator Cuff [6]
    1. Rotator cuff is the integration of the capsule of the glenohumeral joint with tendons derived from four different muscles
    2. Tendons arise from supraspinatus, infraspinatus, teres minor, and subscapularis ("SITS")
    3. Biceps tendons (two heads, medial and lateral) run just under the rotator cuff
    4. The individual muscles of the cuff help provide strength in arm movement
    5. Subscapularis aides in internal rotation
    6. Supraspinatus muscle aides in elevation
    7. Infraspinatus and teres minor muscles aid in external rotation
  3. Classification of Tear
    1. Acute or Chronic
    2. Partial or Complete
  4. Causes
    1. <50% are associated with trauma
    2. The majority of the remainder are due to age-related attrition of the tendons
    3. Any disease process which weakens the tendons can contribute to dysfunction
    4. Chronic inflammatory diseases: especially RA (rheumatoid arthritis), pseudogout (CPPD)
    5. Cuff defects more common in obese persons
    6. Glucocorticoid injections do not increase risk of cuff failure, but may alter tendon composition
    7. Smoking (nicotine) may reduce ability of tendons to heal and attach to bones
  5. Symptoms
    1. Shoulder pain ± crepitus on active movement
    2. Weakness on abduction
    3. Inability to maintain 90° of passive abduction indicates large tear in 98% of cases [3]
    4. Patients with complete tear may have superiorly migrated shoulders
    5. Radiograph should generally be done to rule out fractures
  6. High Clinical Suspicion for Tear
    1. Supraspinatus weakness
    2. Weakness in external rotation
    3. Impingement sign (pain)
    4. Presence of all three signs: 98% probability of tear
    5. Presence of two of the three signs AND age >60: 98% probability of tear
    6. Absence of any of the signs: <5% chance of tear
  7. Diagnosis
    1. Shoulder films usually not helpful except to show fractures, RA changes or chondrocalcinosis
    2. MRI and ultrasound are similarly accurate, 97% positive predictive values, >67% specificity [6]
    3. Definitive diagnosis by arthrogram with computerized tomography (CT) or open surgery
    4. This should show communication between glenohumeral joint and subacromial bursa
    5. Small ulcer-like crater in rotator cuff may be seen in incomplete tears
  8. Treatment
    1. Large tears, especially in young persons, should be surgically repaired
    2. Acute cuff failure should be treated rapidly (as with any rupture of major tendon)
    3. Prolonged observation / non-surgical management allow tendon to retract and muscle atrophy
    4. Chronic, full-thikcness degenerative tendon defects best managed without surgery
    5. Small complete and larger incomplete tears are treated conservatively
    6. This includes NSAIDs, rest, and physical therapy (stretching and muscle strengthening)
    7. Subacromial injections of lidocaine/steroids are usually no better than NSAIDS at relieving pain
    8. Local injection is reasonable for NSAID failures or intolerance
    9. Repeated glucocorticoid injections are not recommended
  9. Surgical Repair
    1. For acute, full tendon ruptures, surgery is indicated
    2. For more chronic situations, surgery is considered if symptoms persist
    3. Surgery goal is to reattached the detached cuff tendon
    4. Surgery more likely to be effective if age <60 years, traumatic onset of weekness, symptoms for <2 months, <4 glucocorticoid injections, no previous shoulder surgery or muscle atrophy
    5. Surgical risks include infection, postsurgical adhesions with loss of motion, deltoid injury
    6. Injury to axillary nerve, roughness in humeroscapular motion, damage to coaracoacromial arch also occur

D. Adhesive Capsulitisnavigator

  1. Introduction
    1. Also called "frozen shoulder" or pericapsulitis
    2. Rare prior to age 40
    3. May occur secondary to any type of shoulder problem and is usually chronic
    4. Diabetes and inflammatory shoulder arthritis may predispose
    5. Failure to use shoulder and/or low pain threshhold may exacerbate disease
  2. Symptoms
    1. Generalized pain and tenderness with severe loss of active and passive motion
    2. Muscle atrophy may occur early in the course
  3. Pathology
    1. Formation of fibrous adhesions between joint capsule and humeral neck
    2. Axillary fold binds to itself causing restriction of joint motion
    3. Capsule becomes thickened and contracted
  4. Diagnosis
    1. Clinical symptoms with physical findings are fairly accurate
    2. In severe cases, arthrography can be used
    3. Arthrogram shows decrease in infusible dye (<10mL; normal ~30mL)
  5. Treatment
    1. NSAIDs are usually suboptimal
    2. Subacromial ± glenohumeral lidocaine+DepoMedrol (20-40mg) injections
    3. Physical therapy with ice packs, ultrasound, TENS, gentle ROM exercises
    4. ROM exercises include pendulum (arm swinging) and wall climbing (with fingers) motions

E. Shoulder Instability and Dislocation [5]navigator

  1. Instability of the glenohumeral joint occurs when shoulder structures provide too little stability when humerus moves on the glenoid; pain is the usual result
  2. Result is that head of the humerus fails to stay in the glenoid fossa on motion
  3. Tears in the labrum (cartilage rim of glenoid) can contribute to pain
  4. Subluxation is symptomatic translation of the humeral head without complete separation
  5. Dislocation: humeral head has no attachment to glenoid fossa (complete separation)
  6. Three Causes of Instability
    1. Anterior luxation occurs with sudden fall with an outstreched arm (skiers) or with blocked throwing motion, usually reduced in the field
    2. Chronic luxation due to chronic gradual overhead stretching, without obvious trauma
    3. Hyperlaxicity of glenohumeral capsule, usually congenital without trauma, less common
  7. Shoulder Dislocation
    1. Very painful condition
    2. Patient will hold arm in fixed position
  8. Shoulder Instability (without Dislocation)
    1. More subtle presentation than dislocation
    2. Dead arm feeling
    3. Pain and functional disability nonspecific for presence of instability
    4. Physical exam should attempt to evoke symptoms
    5. Evaluate for presence of glenohumeral joint laxity
    6. Relocation test and anterior release test are best for establishing diagnosis of instability or intra-articular pathology
    7. Relocation test performed to relieve symptoms (pain and apprehension) of instability
    8. Relocation test conducted with patient supine and the arm aaabducted to 90° and extrenally rotated to 90°; apply downward pressure to humeral head
    9. Anterior release test conduct similar to relocation test, then examiner's hand is removed suddenly releaseing pressure on the humeral head

References navigator

  1. Eisenbichler GR, Erdogmus CB, Resch KL, et al. 1999. NEJM. 340(2):1533
  2. Gerdesmeyer L, Wagenpfeil S, haake M, et al. 2003. JAMA. 290(19):2573 abstract
  3. Murrell GAC and Walton JR. 2001. Lancet. 357(9258):769 abstract
  4. Bergman GJD, Winters JC, Groenier KH, et al. 2004. Ann Intern Med. 141(6):432 abstract
  5. Luime JJ, Verhagen AP, Miedema HS, et al. 2004. JAMA. 292(16):1989 abstract
  6. Matsen FA III. 2008. NEJM. 358(20):2138 abstract