Ecase #9 Feb 26 - Mar 2, 2001

Karen Wang, M.D.

Case Presentation

Hx: 67 y.o. woman comes in with 4 months right shoulder and arm pain.She denies any specific known injury, but notices pain radiating from the shoulder down to the mid forearm.  Pain and weakness in the arm is especially notable when she tries to open car doors. Pain with overhead activities is present.  She denies symptoms of the shoulder "popping out",denies numbness or tingling down either arm or legs.

PMH: significant for Diabetes (diet controlled), HTN, Bell's palsy

PE:

Observation: Pleasant woman, who appears to be guarding her right shoulder.  

Inspection: no obvious atrophy.  Muscle tone is poor. No masses or swelling seen.

Palpation:  Tenderness over the rotator cuff with passive extension of the shoulder  Also pain with palpation of biceps tendon.  No AC joint tenderness. 

Active ROM: reduced IR,ER and AB (internal/external rotation,abduction).

Passive ROM: reduced as well due to pain. No fixed end points felt.

Strength testing: IR 5/5 bilat., ER slightly weaker on right side.AB 5/5 bilat

Sensory testing: intact bilat. C4-T2 dermatomes.

Special Tests: Impingement sign positive.

Drop test negative.

Apprehension Test negative.

Relocation test negative.

Yergason's test positive.

X-rays: 3 views (IR, ER, and axillary), show no dislocation. Calcification of the rotator cuff tendon.

Impression:  Calcific Tendonitis from Chronic Rotator cuff tendonitis.

Plan: 6 week trial of physical therapy for

1. Rotator cuff protection

2. Rotator cuff strengthening

3. restoration of flexibility

4. work/sport modification.

Key questions

1. What are the most common causes of shoulder pain in adults?

2. What are key features of these disorders? (symptoms, and physical exam findings)

3. What useful diagnostic imaging techniques can you use?

4. How do you appropriately use physical therapy, injections,and referral to orthopedics?

E-case #9

Discussion

Common Shoulder Problems in Primary Care

1. The most common causes are subacromial bursitis/ rotator cuff tendonitis, adhesive capsulitis, AC arthritis/sprains, biceps tendonitis/rupture, glenohumeral instability, and rotator cuff tears.   Less common causes are calcific tendonitis, cervical radiculopathy, glenohumeral DJD, and referred pain (cardiac, gallbladder, Pancoast tumors.)
2. Distinguishing features:
   1. Subacromial bursitis: More in younger people, pain intensifies with overhead activity, can radiate into the biceps area anteriorly.  Normal strength tests, Positive Impingement sign.
   2. Rotator cuff tendonitis: More in mid-age to older people, pain usually more severe than bursitis. Pain often at night when lying on the affected side, with overhead activity, and with IR(putting on shirt, scratching back). Palpation of rotator cuff (shoulder passively extended) elicits pain. Positive Impingement sign,  both active and passive ROM usually reduced.  Pain with resisted ER and AB.
   3. "Impingement Syndrome" is just a spectrum of conditions (bursitis, rotator cuff tendonitis, cuff tears) that prevent normal shoulder motion from soft tissue compromise in the subacromial space. People thus have pronounced pain in the arc from 60-120 degrees of active abduction or flexion.  This goes along with the Impingement sign (pain with passive flexion of the arm in pronated position), and that is why the above conditions usually get great relief from subacromial steroid/lidocaine injections.
   4. Biceps tendonitis: Usually anterior shoulder pain, radiating towards biceps/anterior elbow.  Tenderness over the biceps tendon (felt by ER of shoulder about 30 degrees), and positive Yergason's test (patient flexes elbow, tries to supinate as examiner hold elbow and wrist for resistance).  Rupture long head of biceps tendon causes appearance of"Popeye" muscle.
   5. Adhesive capsulitis: Gradual onset pain and stiffness, older pts., risk factors: diabetes, CVA, immobility. Loss of passive AND active IR, ER, AB. Stiff end-points felt.
   6. Rotator cuff tear: small tears present like rotator cuff tendonitis. Larger tears present with weakness. Active ROM usually decreased, while passive ROM usually normal. With large tears, loss of ER strength and positive drop test (have patient AB arm then slowly lower it, if arm drops at 90 degrees, test is positive).
   7. Glenohumeral Instability: history of trauma,laxity, or recurrent dislocation/subluxations from sports or overuse. " Arm going dead or popping out" when in an ER or AB position. Positive Apprehension Sign, (patient unhappy when you put their shoulder in abducted,ext. rotated position), impingement sign may be positive, and Relocation test can differentiate anterior instability from primary impingement(Patient supine, shoulder 90 degrees AB and ER, then examiner applies gentle, firm posterior pressure on affected shoulder, allowing further ER that is painless).
   8. Acromioclavicular strains, separations and DJD: sprains/separations result from direct falls to the shoulder. DJD here common in weight lifters, esp. excessive bench presses.
   9. Calcific Tendonitis: can be acute, sub acute or chronic. More common in mid-age women. Mostly supraspinatus involved. Due to local ischemia/overuse? Unclear. People usually in severe pain in acute phase, so exam is difficult. Calcifications on x-ray of tendon insertions.

May get dramatic benefit from steroid injection.

Diagnostic Imaging:

All patients with persistent pain should have plain x-rays to rule out fracture, calcification, dislocation, arthritic changes, congenital problems, and tumors.  Standard views are "AP" in which the shoulder is internally and externally rotated. An AXILLARY view is important in patients with instability (can detect Hill-Sachs lesion, humeral head fractures).  AP films with and without 10 lb. hanging weights are used to distinguish between complete and incomplete AC separations.

Ultrasound: good for assessment of rotator cuff and long head of biceps tendons. However, sensitivities for detection of tears range from 60-90%,due to operator dependence. Better at the UW.

Arthrogram: Good for visualizing joint capsule, labrum, rotator cuff full and partial tears. Invasive, painful. May be therapeutic as well as diagnostic for those with adhesive capsulitis.

MRI: Most detailed and comprehensive imaging. Can visualize tendonitis, bone marrow, soft tissue, and rotator cuff. 

MRI/Arthrogram: more sensitive than MRI alone for labral tears, partial thickness cuff tears.

CT: good for assessing bone tumors, osteomyelitis, fractures, calcified loose bodies.

Physical Therapy: Mantra is STRENGTH and FLEXIBILITY prevents re-injury. The mainstay of treatment for most shoulder problems. For Rotator cuff tendonitis/small tears, biceps tendonitis, subacromial bursitis treatment focuses on

REST/activity modification to avoid repeated injury

ANTI-INFLAMMATORIES (local injection or pills)

ROTATOR CUFF STRENGHTHENING - must be taught by good therapist. (progression from isometric to isotonic exercises, followed by strengthening rest of shoulder stabilizers)

GENTLE STRETCHING to maintain flexibility.

INJECTIONS:Very effective for any cause of impingement syndrome, as the subacromial space gets bathed by the medication. Technically, should not receive more than 3 per year, as risk of tendon rupture increases.  Try diagnostic injection first with 5 cc of Lidocaine via posterior/lateral approach.  If this alleviates pain, do repeat exam to detect any weakness that could be from rotator cuff tear before using steroids. BE SURE TO KEEP PATIENTINVOLVED IN PT, AS THE STEROID JUST HELPS WITH PAIN/INFLAMMATION.

REFERRAL to ORTHO 

1. Problems persist beyond 3-6 months despite physical therapy

2. Young person with acute post traumatic rotator cuff tear

3. Full thickness tear not responding to 6 weeks of PT

4. Young patients with biceps tendon rupture

5. Recurrent, chronic instability

6. Chronic calcific tendonitis.

References

The painful shoulder. Postgraduate Medicine vol 106 no.7 Dec 1999Imaging the painful shoulder: An update . Hospital Medicine 59(10) Oct. 1998

Primary care orthopedics. Steven Brier, Mosby 1999

Practical orthopedics. Lonnie Mercier, Mosby 1995