The painful shoulder: when to inject and when to refer

Physicians can usually diagnose the cause of shoulder pain by performing a focused history and physical examination and ordering anteroposterior and lateral radiographs. Treatment depends on the cause and can include physical therapy, injections of corticosteroids into the joint space or bursa, and surgery. This paper reviews the diagnosis and treatment of impingement syndrome, adhesive capsulitis, rotator cuff tears, and arthritis of the glenohumeral joint and acromioclavicular (AC) joint.     

Rotator cuff pathology and subacromial impingement

Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain. Subacromial impingement with subsequent tendinitis and bursitis is frequently found in young adult patients. Rotator cuff tears are a common cause of shoulder pain in patients over age 40. The majority of subacromial impingement and incomplete rotator cuff tears may be successfully managed with conservative treatment. This article discusses anatomic function of the glenohumeral joint and subacromial space, etiology of subacromial impingement and rotator cuff disorders, examination of the shoulder, diagnostic testing, and treatment of subacromial impingement and rotator cuff disorders in the primary care setting.     

徒手治疗联合运动疗法对慢性肩袖损伤患者肩关节功能及疼痛程度的影响

目的探讨慢性肩袖损伤患者应用徒手治疗联合运动疗法对肩关节功能及疼痛程度的影响。方法选择2018年5月至2019年5月某院接收的62例慢性肩袖损伤患者,根据盲抽法分为观察组31例,对照组31例。对照组实施物理治疗,观察组采用徒手治疗联合运动疗法,比较两组患者肩关节功能、疼痛程度。结果治疗后,两组肩关节功能评分较治疗前高,且与对照组相比,观察组肌力、肢体活动度、日常生活活动能力及疼痛评分均较高,差异有统计学意义(P<0.05);治疗后较治疗前两组疼痛评分降低,且观察组较对照组低,差异有统计学意义(P<0.05)。结论慢性肩袖损伤患者应用徒手治疗联合运动疗法,可有效改善肩关节功能,减轻疼痛程度。     

Rotator cuff tendonitis in lymphedema: a retrospective case series

OBJECTIVES: To report rotator cuff tendonitis as a complication of lymphedema and to discuss the possible etiology and treatment options. DESIGN: Retrospective review of 8 cases. SETTING: University hospital outpatient clinic. PARTICIPANTS: A total of 8 breast cancer patients with a history of lymphedema and ipsilateral shoulder pain. INTERVENTION: Patients with lymphedema and ipsilateral shoulder pain were diagnosed with rotator cuff tendonitis if all of the following 3 tests were positive: supraspinatus test, Neers impingement test, and Hawkins impingement test. Patients diagnosed with rotator cuff tendonitis were prescribed a nonsteroidal anti-inflammatory drug (NSAID) and physical therapy (PT). MAIN OUTCOME MEASURES: Improvement in symptoms of shoulder pain at a 4- to 6-week follow-up, as measured by visual analog scale (VAS). RESULTS: Seven of 8 patients reported a subjective decrease in their symptoms of shoulder pain at a 4- to 6-week follow-up. The average improvement in shoulder pain as measured by VAS was a 4.5-point decrease from the original pain score given. One of 8 patients had a full-thickness supraspinatus tendon tear and required additional decongestive therapy and PT to obtain relief of symptoms. CONCLUSIONS: Rotator cuff tendonitis is a complication of lymphedema caused by internal derangement of tendon fibers, which may be subject to impingement, functional overload, and intrinsic tendinopathy. Conservative treatment with NSAIDs and PT is a safe and effective treatment.     

The management of shoulder impingement and related disorders: A systematic review on diagnostic accuracy of physical tests and manual therapy efficacy

BackgroundDiagnostic accuracy of physical tests and effectiveness of musculoskeletal rehabilitation of shoulder disorders are still debated.ObjectivesTo investigate diagnostic accuracy of physical tests, efficacy of physiotherapy and coherence between target of assessment and intervention for shoulder impingement and related disorders like bursitis, rotator cuff and long head biceps tendinopathy and labral lesions.MethodsA systematic search of four databases was conducted, including RCTs and cross-sectional studies. Cochrane Risk of Bias and QUADAS-2 were adopted for critical appraisal and a narrative synthesis was undertaken.Results6 RCTs and 2 cross-sectional studies were appraised. Studies presented low to moderate risk of bias. There is a lack of evidence to support the mechanical construct guiding the choice of physical tests for diagnosis of impingement. Manual techniques appear to yield better results than placebo and ultrasounds, but not better than exercise therapy alone. Discrepancy between the goal of assessment strategies and the relative proposed treatments were present together with high heterogeneity in terms of selection of patients, type of endpoints and follow-ups.ConclusionsMusculoskeletal physiotherapy seems to be an effective treatment for patients with shoulder pain although it is still based on weak diagnostic clinical instruments. The adoption of more functional and prognostic assessment strategies is advisable to improve coherence between evaluation and treatment.     

Muscle load in reaching movements performed by a wheelchair user: a case study

Abstract

Purpose: The aim of this study was to analyse the load on the shoulder muscles during reaching movements that are specific to wheelchair users in relation to the risk of impingement. Method: Three activities of daily living were performed: putting a book on a shelf in front and at the side and putting a pack of water bottles on a table. The AnyBody shoulder model was used to calculate the activity and forces of the shoulder muscles. Results: Handling the pack of bottles caused the highest forces in the deltoideus, trapezius, serratus anterior and rotator cuff muscles. For handling the book, the highest forces were found in the deltoideus (scapular part) and the serratus anterior, especially during the put phase. Conclusions: Handling heavy objects such as a pack of bottles or a wheelchair produces high forces on the rotator cuff muscles and can lead to early fatigue. Therefore, these activities seem to be associated with a high risk of developing impingement syndrome.

• Implications for Rehabilitation

• In a single patient, this study demonstrates that the load on the rotator cuff is high during reaching movements.

• Handling a pack of water bottles, which resembles wheelchair handling, represents an activity associated with a high risk of developing impingement syndrome.

• Shoulder muscles must be trained in a balanced way to provide stabilization at the shoulder joint and prevent fatigue.

     

GUIDED EXERCISES WITH OR WITHOUT JOINT MOBILIZATION OR NO TREATMENT IN PATIENTS WITH SUBACROMIAL PAIN SYNDROME: A CLINICAL TRIAL

BackgroundGraded resistance training is the recommended treatment for patients with subacromial pain syndrome. It is debated whether adding joint mobilization will improve the outcome. The aim of this study was to evaluate the clinical outcome of guided exercises with or without joint mobilization, compared with controls who did not receive any treatment.MethodsA 3-armed controlled trial in a primary care setting. A total of 120 patients, with clinically diagnosed subacromial pain syndrome, were randomized into guided exercise groups with and without additional joint mobilization, and a control group that did not receive any treatment. Data were analysed at baseline, 6 weeks, 12 weeks and 6 months. Primary outcome was the Constant-Murley score, and secondary outcomes were pain and active range of motion.ResultsShoulder function improved in all groups, as measured with the Constant-Murley score. At 12 weeks and 6 months the exercise groups improved significantly compared with the control group (p ≤ 0.05). Add-on joint mobilization resulted in decreased pain in active range of motion at 6 and 12 weeks compared with guided exercise or no treatment (p ≤ 0.05). Range of motion increased over time in all 3 groups.ConclusionIn patients with subacromial pain syndrome guided exercises improved shoulder function compared with no treatment. Add-on joint mobilization decreased pain in the short-term compared with exercise alone or no treatment.LAY ABSTRACTTo determine treatment efficacy in patients with shoulder pain treated with a combination of joint mobilization and guided training or guided training alone, and compare this with a control group who received no treatment. The study was a randomized controlled trial in Swedish primary care. A total of 120 patients aged between 20 and 59 years were recruited from general practice in Stockholm. Guided exercises, with or without joint mobilization, improved shoulder function compared with no treatment. In the short term, add-on joint mobilization decreased pain, and may thus serve as a substitute for non-steroidal anti-inflammatory drugs (NSAIDs) or other painkillers at the start of a treatment period.Key words: Constant-Murley score, manual therapy, resistance training, shoulder pain

Subacromial pain syndrome (SAPS) is a clinical diagnosis and one of the most common reasons for seeking physical therapy in primary care (1). The aetiology is known to be multi-factorial and includes several rotator cuff pathologies, such as increased tendon thickness (e.g. tendinopathies), bursitis, and tears affecting the rotator cuff or the long head of the bicepstendon (2). No single examination test has the specificity and sensitivity to alone set the diagnosis. A combination of different tests has been suggested (3). There is little knowledge about the natural history and treatment of patients with SAPS. This syndrome is believed to consist of inflammatory cells, and therefore patients with SAPS are often treated with non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroid injection (4). Even if current evidence suggests that the inflammatory response is a key component, the presence of inflammation has not been confirmed in those with tendinopathy (5).A consensus on physical therapy treatment for patients with SAPS was reached in 2015 (6). This was after the start of the current clinical trial. However, the current trial followed the guiding principles for implementing exercise therapy for shoulder pain recommended by the consensus. Namely, a limited number of exercises, performed with appropriate scapulo-humeral coordination and humeral head alignment, in a gradually progressed manner.A common reason for using joint mobilization is to reduce hypomobility and improve shoulder function, but it has also been used to decrease pain (7, 8). The main mechanism for joint mobilization discussed is neurophysiological, and includes stimulating mechanoreceptors, releasing endorphins, and reducing the cytokine concentration (9). Whether joint mobilization evokes pain relief, which then provides suitable conditions for resisted exercises, is inconclusive (10, 11). However, the joint mobilization according to Kaltenborn used in the current study is a theory, and was used in order to decrease pain and increase relaxation (8).The aim of the current study was to evaluate the clinical outcome, in terms of shoulder function and pain, of guided exercises with or without the addition of joint mobilization compared with no treatment, in patients diagnosed with SAPS. The hypothesis was that the addition of joint mobilization of the gleno-humeral joint would be superior to guided exercises alone or no treatment in patients with SAPS.     

Axillary mononeuropathy after herpes zoster infection mimicking subacromial impingement syndrome

Subacromial impingement syndrome is a frequent cause of shoulder pain and it is readily confused with other shoulder problems. We present a patient with herpes zoster infection associated with axillary mononeuropathy that was initially misdiagnosed as subacromial impingement syndrome. A 75-yr-old female patient was admitted to the internal medicine clinic because of pain and weakness in her right shoulder. As she did not respond to medical treatment and local injection therapy, magnetic resonance imaging of the right shoulder was ordered. As the magnetic resonance imaging revealed subacromial impingement of the supraspinatus tendon, the patient was referred to the physical medicine and rehabilitation department for rehabilitation. In our initial physical examination, her shoulder abductor muscle strength was 2/5 and her shoulder external rotator muscle strength was 3/5. A subacromial injection test with 10 ml of 1% lidocain was negative and the magnetic resonance imaging did not show a complete rotator tendon rupture that could explain such a muscle strength loss. So, an electrodiagnostic evaluation was performed and the patient was diagnosed to have a right axillary neuropathy. A more detailed questioning of the patient disclosed a history of herpes zoster approximately 3 mos ago. Herpes zoster-associated axillary neuropathy can mimic subacromial impingement syndrome, and magnetic resonance imaging examination alone may lead to a misdiagnosis. Therefore, we imply that clinical and electrophysiological evaluations would be of great importance in relevant patients with shoulder problems.     

The influence of simulated rotator cuff tears on the risk for impingement in handbike and handrim wheelchair propulsion

BackgroundRotator cuff tears strongly affect the biomechanics of the shoulder joint in their role to regulate the joint contact force needed to prevent the joint from dislocation. The aim of this study was to investigate the influence of simulated progressed rotator cuff tears on the (in)stability of the glenohumeral joint and the risk for impingement during wheelchair and handbike propulsion.MethodsThe Delft Shoulder and Elbow Model was used to calculate the magnitude of the glenohumeral joint reaction force and the objective function J, which is an indication of the effort needed to complete the task. Full-thickness tears were simulated by virtually removing muscles from the model.FindingsWith larger cuff tears the joint reaction force was higher and more superiorly directed. Also extra muscle force was necessary to balance the external force such that the glenohumeral joint did not dislocate.InterpretationA tear of only the supraspinatus leads only to a minor increase in muscle forces and a minor shift of the force on the glenoid, indicating that it is possible to function well with a torn supraspinatus muscle. A massive tear shifts the direction of the joint reaction force to the superior border of the glenoid, increasing the risk for impingement.     

Adhesive capsulitis: a review

Adhesive capsulitis is a common, yet poorly understood, condition causing pain and loss of range of motion in the shoulder. It can occur in isolation or concomitantly with other shoulder conditions (e.g., rotator cuff tendinopathy, bursitis) or diabetes mellitus. It is often self-limited, but can persist for years and may never fully resolve. The diagnosis is usually clinical, although imaging can help rule out other conditions. The differential diagnosis includes acromioclavicular arthropathy, autoimmune disease (e.g., systemic lupus erythematosus, rheumatoid arthritis), biceps tendinopathy, glenohumeral osteoarthritis, neoplasm, rotator cuff tendinopathy or tear (with or without impingement), and subacromial and subdeltoid bursitis. Several treatment options are commonly used, but few have high-level evidence to support them. Because the condition is often self-limited, observation and reassurance may be considered; however, this may not be acceptable to many patients because of the painful and debilitating nature of the condition. Nonsurgical treatments include analgesics (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs), oral prednisone, and intra-articular corticosteroid injections. Home exercise regimens and physical therapy are often prescribed. Surgical treatments include manipulation of the joint under anesthesia and capsular release.     

肩部撞击综合征的发生机制和影像学表现

肩部撞击综合征是临床上常见的引起肩关节疼痛和活动障碍的一组疾病,以肩袖、肱二头肌肌腱等结构的炎症及损伤为主要病理改变.广义的肩部撞击综合征包括肩峰下撞击、喙突下撞击和内撞击三型,对其发生机制尚存在争议,本文就肩部撞击的发生机制和影像学表现进行综述.     

肩袖损伤合并肩峰下撞击综合征的MRI表现

目的探讨肩袖损伤合并肩峰下撞击综合征的MRI影像表现。材料与方法对33例X线片无骨折但临床怀疑肩袖损伤或肩峰下撞击综合征的患者,用1.5 T MRI机检查,观察肩袖损伤及肩峰下撞击综合征在MR上的影像特征,分析两者的相关性,并与手术结果对比,计算准确率。结果 33例中肩袖损伤20例(合并肩峰下撞击综合征10例),肩峰下撞击综合征15例(合并肩袖损伤10例)。肩袖损伤和肩峰下撞击综合征术前MR诊断准确率分别约为95.0%、71.3%。结论肩关节MRI扫描对肩袖损伤及肩峰下撞击综合征的诊断有较高的临床应用价值,肩袖损伤者中至少半数合并肩峰下撞击综合征,临床和影像应予重视。     

Abstracts: AAOMPT Conference, 2006

Abstract

This case report describes the effectiveness of mechanical diagnosis and therapy (MDT) in the management of a patient referred with a diagnosis of shoulder tendonitis. The patient was a 56-year-old male with a 3-month history of left anterior shoulder pain. Upon initial assessment, he presented with a positive open-can test, lift-off test, and Hawkins–Kennedy impingement test. A MDT assessment quickly ruled out cervical involvement and identified a loss of end-range shoulder mobility and pain during active shoulder movement. After the patient underwent a repeated movement examination and treatment based on responses to end-range movements over three visits, his shoulder pain was abolished and motion was fully restored. Despite having positive rotator cuff and impingement signs, this patient was effectively treated with repeated end-range movements over a short period of 2 weeks. This case demonstrates that treatment based on MDT sub-classification principles may be an effective way to manage shoulder pain as it is in the spine.     

Strain on the repaired supraspinatus tendon during manual traction and translational glide mobilization on the glenohumeral joint: a cadaveric biomechanics study

There has been no report on the mechanical effects of joint mobilization on rotator cuffs. The purpose of this study was to determine whether it is safe to use grade 3 joint mobilization techniques after rotator cuff repair. Nine fresh frozen cadaveric shoulders were used in this study. The strains on the artificially repaired supraspinatus tendon during joint mobilization were measured at 0 degrees and 30 degrees of shoulder abduction and were compared with those at the maximal stretching position and relaxing position. Additionally, gap distances were measured during this experiment. The strain at 30 degrees of abduction of the repaired tendon during each joint mobilization was significantly smaller than that at 0 degrees abduction (P<0.05). At 30 degrees of abduction, the strain during joint mobilization was not statistically different from that of the shoulder in the relaxing position, except during the inferior glide technique. Gap distances were 0mm at 30 degrees , while the distances were 1.06-1.46 mm at 0 degrees. Our findings suggest that joint mobilization techniques, except inferior glide, can be performed safely without significantly straining the repaired tendon at 30 degrees of abduction, if rotator cuff repair is performed at 0 degrees of abduction.     

A case of opiate-insensitive pain: malignant treatment of benign pain.

OBJECTIVE: We report the case of a woman with presumed cancer pain treated with escalating doses of opiates despite no evident improvement in her pain and several deleterious side effects. PATIENT: A 62-year-old woman with cervical myelopathy and a diagnosis of a spinal cord tumor was referred to the University of Washington Medical Center complaining of chest tightness, multiple joint pains, nausea, constipation, seizures and a deteriorating memory. At the time of admission she was confined to her bed with a full-time attendant and was receiving 240 milligrams of intravenous morphine per hour for her pain. INTERVENTION: Diagnostic studies failed to find any evidence of neoplasm and revealed only an old hemorrhage within the cervical spinal cord. A program of increasing physical and occupational therapy and decreasing opiate intake was initiated. RESULTS: Within a month the patient's pain complaints decreased, as did the rest of her presenting complaints. Her activities of daily living greatly increased making attendant care no longer necessary. CONCLUSIONS: This case report illustrates some of the hazards of opioid therapy in the management of patients with chronic pain. Our patient's opiate therapy was expensive, gave her undesirable side effects, and did not reduce her pain complaints or improve her function. In the treatment of chronic pain, of noncancerous or cancerous origin, a) systemic opioids may not be effective in reducing pain complaints in every patient, b) treatment efficacy evaluation should always include functional endpoints, and c) nonefficacious treatments should not be continued indefinitely.     

A Systematic Comparison on Postoperative Analgesia Effect Between Subacromial and Intravenous Analgesia Pumps for Arthroscopic Rotator Cuff Repair

PurposeArthroscopic rotator cuff repair is often associated with severe postoperative pain. Various agents, routes, and modes are used for the treatment of postoperative pain with a minimum of side effects. This systematic work was conducted to compare the postoperative effect of subacromial patient-controlled analgesia with intravenous patient-controlled analgesia after an arthroscopic rotator cuff repair surgery.DesignA systematic review of relevant studies were retrieved from electronic databases and included based on criteria and eligibility.MethodsThe articles were retrieved from 1997 to 2018 by computerized searches of Scopus, PubMed, and EMBASE using different combinations of search terms, such as shoulder, rotator cuff, analgesic, analgesia, arthroscopic, pain, cuff repair, rotator cuff repair, acromion, and intravenous.FindingsA total of 10 articles were included in this study from the initial search of 778 records. Compared with subacromial procedure, the intravenous procedure helps in reducing the postoperative pain but with more side effects.ConclusionsThis study described that the direct continuous infusion of anesthetic under subacromial analgesic pump showed a greater pain relief with less side effects compared with intravenous infusion for arthroscopic rotator cuff repair.     

Effect of sternoclavicular joint mobilization on pain and function in a patient with massive supraspinatus tear

Massive irreparable rotator cuff tears can be difficult to treat conservatively, especially when the patient has multiple comorbidities. Although there is evidence to support interventions aimed at the spine, there is paucity in the literature describing interventions to the sternoclavicular joint (SCJ) in individuals with rotator cuff pathology. A 57-year-old female with multiple comorbidities and a body mass index of 59 was referred to physical therapy with a 4-month history of right shoulder pain, significant functional limitations, and magnetic resonance imaging (MRI), demonstrating a full-thickness supraspinatus tear. She presented initially with active shoulder flexion range of motion (ROM) 0–80°, numeric pain rating scale (NPRS) 7/10, and QuickDASH 65.9%. After six physical therapy sessions, the patient had plateaued with improvements in pain and ROM. SCJ mobilizations at visit 7 immediately improved pain, active ROM, and subjective reports of function. The patient was discharged after 13 visits with increased active shoulder flexion ROM to 0–170°, NPRS 1/10, QuickDASH 31.8%, and Global Rating of Change (GROC) +5. This case highlights the successful conservative treatment of an individual with an irreparable rotator cuff tear and numerous comorbidities by using a multimodal approach including SCJ mobilizations.     

In vivo dynamic acromiohumeral distance in shoulders with rotator cuff tears

BackgroundThere are no previous studies on the acromiohumeral distance in shoulders with large-to-massive full-thickness rotator cuff tears. In this study, the acromiohumeral distance in rotator cuff tear and healthy shoulders was measured using 3D-to-2D model-to-image registration techniques.MethodsThe dynamic glenohumeral kinematics during scapular plane abduction and axial rotation were analyzed in 11 rotator cuff tear patients and 10 healthy control subjects. Periodic radiographic images of scapular plane abduction and axial rotation were taken using a flat-panel radiograph image detector. Movements of the shoulder joint were assessed using radiographic images and computed tomography-derived digitally reconstructed radiographs. The acromiohumeral distance was defined as the shortest 3D distance between the acromion and the proximal humerus.FindingsFor scapular plane abduction, the rotator cuff tear group had significantly smaller acromiohumeral distance than the control group at 15°, 30°, 45°, 60°, 75°, 135°, and 150° of humeral abduction (P < 0.05 at each measured angle). For axial rotation in the adducted position, the rotator cuff tear group had significantly smaller acromiohumeral distance than the control group at each point between −20° and 40° of glenohumeral external rotation (P < 0.05 at each measured angle).InterpretationThe minimum measured acromiohumeral distance was 0.9 mm in the rotator cuff tear shoulders and 2.1 mm in the healthy shoulders at 90° of scapular plane abduction. The findings are of clinical relevance because quantitative evaluation of the dynamic acromiohumeral distances in rotator cuff tear and healthy shoulders might provide important insight into subacromial impingement.