Rotator Cuff Impingement Syndrome in Sports

Activities such as pitching, swimming, and serving a tennis ball, which involve overhead movement of the arm, can cause pain around the shoulder. Rotator cuff impingement syndrome is confusing for physicians to diagnose, so the physical examination must be done systematically. Young athletes with the syndrome usually have an insidious onset of soreness in the shoulder that becomes more severe if they continue the offending activity. Treatment revolves around decreasing inflammation, increasing shoulder function, and correcting the cause of the problem. With proper diagnosis and treatment, nonsurgical treatment is successful and allows most patients to return to their previous level of activity.     

A practical approach for the differential diagnosis of chronic leg pain in the athlete

Chronic lower leg pain results from various conditions, most commonly, medial tibial stress syndrome, stress fracture, chronic exertional compartment syndrome, nerve entrapment, and popliteal artery entrapment syndrome. Symptoms associated with these conditions often overlap, making a definitive diagnosis difficult. As a result, an algorithmic approach was created to aid in the evaluation of patients with complaints of lower leg pain and to assist in defining a diagnosis by providing recommended diagnostic studies for each condition. A comprehensive physical examination is imperative to confirm a diagnosis and should begin with an inquiry regarding the location and onset of the patient's pain and tenderness. Confirmation of the diagnosis requires performing the appropriate diagnostic studies, including radiographs, bone scans, magnetic resonance imaging, magnetic resonance angiography, compartmental pressure measurements, and arteriograms. Although most conditions causing lower leg pain are treated successfully with nonsurgical management, some syndromes, such as popliteal artery entrapment syndrome, may require surgical intervention. Regardless of the form of treatment, return to activity must be gradual and individualized for each patient to prevent future athletic injury.     

Painful Shoulder in Swimmers: A Diagnostic Challenge

In brief: Painful shoulder can cause significant disability in swimmers, and in elite swimmers it may even force premature retirement. Treatment of this problem has been difficult, and surgery has been perceived as generally unsuccessful. The author asserts that “swimmer's shoulder” is not an anatomically based diagnosis and that the frequent lack of a specific diagnosis probably has hindered treatment. New investigative tools, such as arthrography and NMR imaging, have improved the chances of reaching an accurate diagnosis. The author lists the many regional problems that can cause shoulder pain, describes physical, clinical, and laboratory tests for use in diagnosis, and outlines approaches to management of the problem.     

Posterior Shoulder Pain and Arthroscopic Decompression of the Suprascapular Nerve at the Transverse Scapular Ligament

The etiology of posterior shoulder pain can be elusive for the treating physician. Compression of the suprascapular nerve at either the transverse scapular ligament or the spinoglenoid ligament can lead to resultant posterior shoulder pain, muscle weakness, and permanent muscle atrophy. Compression at the transverse scapular ligament, the more common finding than realized in the past in patients, can often result in weakness and atrophy of both the supraspinatus and infraspinatus muscles as compression occurs at the suprascapular notch prior to the nerve giving off motor branches to each of these muscles. Patients with this pathology often have a long-standing disease course of missed diagnoses and even wrong surgical procedures. This paper will discuss the anatomy, pathophysiology, and presentation of symptoms in patients. A thorough discussion of the physical examination as well as appropriate adjunct diagnostic procedures will follow to aid the clinician in making a correct diagnosis with detailed recommendations for appropriate arthroscopic decompression allowing the athlete and patient to return to activities of daily living with a short recuperation period.     

Physical examination of the overhead athlete's shoulder

Overhead athletes seek the services of an orthopedic surgeon because of pain and/or dysfunction. It is important to address the cause of the symptoms more so than the source of the patient's pain, so that treatment will eliminate the problem rather than merely ameliorate symptoms temporarily. In order to accomplish a thorough assessment of shoulder function, the examiner must expand his/her view from isolated assessment of the glenohumeral joint range of motion, stability, assessment of rotator cuff strength, palpation and provocative maneuvers, and add assessment of the shoulder in the context of the kinetic chain. The examination of the thrower's shoulder, coupled with a thorough history, will usually provide a solid functional diagnosis and provide a good idea as to the presence of structural damage. As a result, the value of rehabilitation and the benefit of surgical intervention are made more predictable.     

Initial evaluation of the athletewith anterior knee pain

Anterior knee pain is a common complaint among athletes and active, young individuals. Its causes are broad, butthe correct diagnosis can usually be made after a thorough history and physical examination. The history should include a complete investigation of the nature and onset of the athlete's symptoms, past medical history, and the nature of any previous treatment he or she may have received for the problem. The physical examination includes a general lower extremity musculoskeletal examination with determinations of flexibility and limb alignment. The spine and hips are also evaluated to rule out radicular or referred pain to the knee. The knee examination must include assessment of the peripatellar tissues as well as the patellofemoral joint. Although patients often perceive their pain as being poorly localized, the pain source can usually be precisely localized on examination. The information presented here should enable the clinician to make an accurate diagnosis on which to base initial treatment.     

Clinical evaluation of nonarthritic shoulder pain: Diagnosis and treatment

Shoulder pain and dysfunction is a complex problem frequently encountered by primary care physicians. Common nonarthritic conditions seen in the primary care setting include rotator cuff syndrome, impingement, posttraumatic stiffness, adhesive capsulitis, and instability. A thorough history and physical examination can aid in the diagnosis of many common shoulder complaints. Pain and instability are the most common shoulder complaints. Pain that is sharp or burning is commonly radicular in origin, whereas pain caused by tendinitis is often dull, diffuse, and aching. Instability is frequently found in patients with a history of dislocation, but also may occur with no prior history. Imaging modalities such as magnetic resonance imaging can be helpful for more advanced pathology. However, many common shoulder conditions can be diagnosed without imaging, and may be initially treated with a short course of rest, ice, topical analgesics, nonsteroidal anti-inflammatory drugs, directed and supervised physical therapy, and occasionally subacromial corticosteroid injections. As always, a detailed history and a thorough physical exam by a primary care physician are vital for diagnosis. When conservative measures fail, referral to an orthopaedic surgeon may be necessary for further patient management.     

Bone stress injuries

Bone stress injuries are due to cyclical overuse of the bone. They are relatively common in athletes and military recruits but also among otherwise healthy people who have recently started new or intensive physical activity. Diagnosis of bone stress injuries is based on the patient's history of increased physical activity and on imaging findings. The general symptom of a bone stress injury is stress-related pain. Bone stress injuries are difficult to diagnose based only on a clinical examination because the clinical symptoms may vary depending on the phase of the pathophysiological spectrum in the bone stress injury. Imaging studies are needed to ensure an early and exact diagnosis, because if the diagnosis is not delayed most bone stress injuries heal well without complications.     

Computed tomography in the imaging of colonic diverticulitis

Colonic diverticulitis occurs when diverticula within the colon become infected or inflamed. It is becoming an increasingly common cause for hospital admission, particularly in western society, where it is linked to a low fibre diet. Symptoms of diverticulitis include abdominal pain, diarrhoea and pyrexia, however, symptoms are often non-specific and the clinical diagnosis may be difficult. In addition, elderly patients and those taking corticosteroids may have limited findings on physical examination, even in the presence of severe diverticulitis. A high index of suspicion is required in such patients in order to avoid a significant delay in arriving at the correct diagnosis. Imaging plays an important role in establishing an early and correct diagnosis. In the past, contrast enema studies were the principal imaging test used to make the diagnosis. However, such studies lack sensitivity and have limited success in identifying abscesses that may require drainage. Conversely computed tomography (CT) is both sensitive and specific in making a diagnosis of diverticulitis. In addition, it is the imaging technique of choice in depicting complications such as perforation, abscess formation and fistulae. CT-guided drainage of diverticular abscesses helps to reduce sepsis and to permit a one-stage, rather than two-stage, surgical operation. The purpose of this review article is to discuss the role of CT in the imaging of diverticulitis, describe the CT imaging features and complications of this disease, as well as review the impact and rationale of CT imaging and intervention in the overall management of patients with diverticulitis.     

Laxity testing of the shoulder: a review

Laxity testing is an important part of the examination of any joint. In the shoulder, it presents unique challenges because of the complexity of the interactions of the glenohumeral and scapulothoracic joints. Many practitioners believe that laxity testing of the shoulder is difficult, and they are unclear about its role in evaluation of patients. The objectives of the various laxity and instability tests differ, but the clinical signs of such tests can provide helpful information about joint stability. This article summarizes the principles of shoulder laxity testing, reviews techniques for measuring shoulder laxity, and evaluates the clinical usefulness of the shoulder laxity tests. Shoulder laxity evaluation can be a valuable element of the shoulder examination in patients with shoulder pain and instability.     

Shoulder: what the orthopaedic doctor needs to know

Diagnosing shoulder pathology accurately requires both clinical expertise and the ability to interpret and correlate radiographic studies. Variational anatomy of the shoulder combined with the complexity of physical examination makes this difficult. Physical examination of the shoulder often leaves the surgeon with more than one working diagnosis. Imaging studies of the shoulder are more valuable if used to confirm a working diagnosis as opposed to reading the study in a vacuum. Clinical correlation should also be considered for any and all findings on an imaging study. Collaboration of the surgeon and the radiologist is essential in reducing the number of over-reported findings that are clinically insignificant. The surgeon should directly communicate with the radiologist as to his or her working diagnosis and the goal of the study. In this way the surgeon and radiologist become superior diagnosticians.     

Diseases of the shoulder joint from the orthopedic viewpoint

The cardinal symptom in all shoulder disorders is shoulder pain. We have to differentiate between genuine shoulder pain originating from the glenohumeral joint and its periarticular structures and referred pain originating at a site distant from the shoulder joint, e.g., the cervical spine or the internal organs. The differential diagnosis of genuine shoulder pain is discussed. The options open to the radiologist for reaching a correct diagnosis in different sorts of shoulder pain are shown.     

Acromioclavicular joint injuries and reconstructions: a review of expected imaging findings and potential complications

Shoulder injuries, including acromioclavicular (AC) joint separations, remain a common reason for presentation to the emergency room. Although the diagnosis can be made apparent through proper history and physical examination by the emergency medicine physician, ascertaining the degree of injury can be difficult on the basis of clinical evaluation alone. While there is consensus in the literature that low-grade AC joint injuries can be treated with conservative management, high-grade injuries will generally require surgical intervention. Furthermore, the treatment of grade 3 injuries remains controversial, making it incumbent upon the radiologist to become comfortable with distinguishing this diagnosis from lower or higher grade injuries. Imaging of AC joint injuries after clinical evaluation is generally initiated in the emergency room setting with plain film radiography; however, on occasion, an alternative modality may be presented to the emergency room radiologist for interpretation. As such, it remains important to be familiar with the appearance of AC joint separations on a variety of modalities. Another possible patient presentation in both the emergent and nonemergent setting includes new onset of pain or instability in the postsurgical shoulder. In this scenario, the onus is often placed on the radiologist to determine whether the pain or instability represents the sequelae of reinjury versus a complication of surgery. The purpose of this review is to present an anatomically based discussion of imaging findings associated with AC joint separations as seen on multiple modalities, as well as to describe and elucidate a variety of potential complications which may present to the emergency room radiologist.     

Clinical evaluation of the elbow in throwers

The elbow is a vital part of the complicated and intricate mechanism known as throwing. The athlete that participates in a throwing sport walks a fine line between success and injury. It is this line that the clinician must monitor. When an athlete admits that an injury has occurred, it is up to the physician to listen, observe, and examine the player in great detail. Injuries that involve the elbow are complex and difficult to evaluate; therefore, it is essential that a thorough, complete, and reproducible evaluation be performed every time. Not only is this important initially, but is invaluable when following up on the athlete over the course of the injury. The patient's history is the initial tool used to narrow the differential diagnoses. Questioning is concise, structured, and not leading. The result is a workable list of possible diagnosis that will aid the examiner when the physical examination is performed. The physical, like the history, is well outlined and defined. This methodology allows the clinician to be structured when evaluating the results. In the end, a complete history and physical examination may not be enough to draw a final conclusion to the etiology of the athlete's elbow injury. Ancillary studies should then be evaluated for their value and effectiveness in aiding the examiner to achieve a correct diagnosis. The purpose of this report is to provide the clinician a template that will give consistent results and aid in the diagnosis of elbow injuries.     

History and physical examination ofthe patellofemoral joint with patellar instability

Patellar instability is a common source of anterior knee pain among young, active individuals, and is morecommon in females than in males. There is usually an underlying malalignment of the lower extremity, which may contribute to the patient's complaints of “giving way.” A careful, deliberate history and physical examination are instrumental in the diagnosis of a patient with anterior knee pain secondary to instability. The history should include the initial onset of the patient's symptoms, the exacerbating and relieving maneuvers, as well as any treatment-relieving measures the patient has had in the past. The physical examination is directed toward the identification of predisposing factors contributing to the patient's instability.     

Suprascapular nerve injuries with isolated paralysis of the infraspinatus

Nerve lesions are frequently overlooked in the differential diagnosis of shoulder pain, and there have been few reports in the literature of injuries of the supracapsular nerve that involve only the infraspinatus. We report four cases of suprascapular nerve injuries which involve solely the infraspinatus in which each patient presented with shoulder pain and weakness. The diagnosis can be suspected by careful history and physical examination, but must be confirmed by the appropriate electrical studies. Our patients required 6 months to 1 year to regain full function, and isokinetic testing revealed near normal return of strength. Further diagnostic work-up and surgery may be necessary for those cases which fail to demonstrate satisfactory improvement in the expected time period.     

Computed tomographic diagnosis of splenic trauma presenting with kehr's sign (referred left shoulder pain)

Acute, posttraumatic shoulder pain is most often due to direct injury to the shoulder girdle. Occasionally, it can be due to pain referred from injury elsewhere, such as in the diaphragmatic region. In the setting of left-sided thoracoabdominal trauma, left upper quadrant tenderness, and left shoulder pain, splenic injury should be strongly suspected. Kehr's sign, or referred left shoulder pain from splenic injury, is well described in the surgery literature but has not received similar attention in the radiology literature. This communication describes a patient injured in a bicycling accident whose chief complaint was severe left shoulder pain. Negative shoulder radiographs and an unremarkable shoulder physical examination sparked concern for a splenic injury referring pain to the left shoulder, and this was confirmed on abdominopelvic computed tomography.     

Evaluation and treatment of rotator cuff tears

Rotator cuff injuries are common problems and a frequent reason for patients to present to primary care physicians. These injuries are seen more frequently now with the aging population. These muscles allow for movement of the arm in overhead activities and controlled movements through space. A thorough physical examination can lead to the diagnosis of rotator cuff pathology. Radiographic imaging may offer some insight into the underlying pathology, and magnetic resonance imaging provides for excellent visualization of the rotator cuff. Many rotator cuff tears, especially partial tears, will symptomatically improve with conservative management. Surgical treatment may offer improved pain relief and function in those patients for whom nonoperative care is insufficient. In cases in which rotator cuff repair is not possible, the reverse total shoulder arthroplasty is a possibility. New technologies are also under investigation that allow for biological augmentation of rotator cuff tears.     

MR imaging of the shoulder. Impingement and instability-related abnormalities

In addition to the case history and the clinical examination, MR imaging has an important role in the diagnosis and differential diagnosis of numerous shoulder abnormalities and in the investigation of chronic shoulder pain. Important indications for MR imaging are any conditions or symptoms making assessment of the rotator cuff and the labrocapsular complex necessary. Assessment of the rotator cuff muscles, in particular, is crucial. The value of MR arthrography, which is still controversial, is discussed. The greatest potential benefit of MR arthrography is the accurate evaluation of subtle rotator cuff abnormalities and shoulder instability-related lesions, and the assessment of pathologic conditions of the long biceps tendon. This paper describes the most common pathologic findings of the shoulder joint and describes how the relevant findings are reported and quantified for the orthopaedic shoulder surgeon.     

Meniscal injuries in the young, athletically active patient

Meniscal injuries are common in young physically active individuals, particularly those who are involved in contact level 1 sports that involve frequent pivoting, such as soccer and American football. This is a unique population because of their high physical activity at a young age, and it is important that correct diagnosis and appropriate treatment are provided, as the medial and lateral menisci are essential for normal knee function. In this article, we review the anatomy and function of the meniscus, the epidemiology of meniscal tears, and mechanism(s) of injury. Important concomitant injuries are also discussed. When making a diagnosis, relevant patient history, physical examination, and appropriate imaging studies are required. Nonoperative treatment is rarely successful for treating meniscal tears in young athletes, and therefore repair of the torn menisci is often required. We also discuss partial resection (which should only be performed when repair is not possible), as well as rehabilitation protocols after repair has been performed. All of these factors associated with meniscal injuries are important for a physician when diagnosing and treating these often complex injuries.