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Managing shoulder pain

In the second of our six-part series on the latest in orthopaedics, upper limb orthopaedic surgeon Mr Brian Cohen offers tips on managing shoulder pain

In the second of our six-part series on the latest in orthopaedics, upper limb orthopaedic surgeon Mr Brian Cohen offers tips on managing shoulder pain

There are many causes of shoulder pain and these conditions often overlap in their clinical presentation. It may be difficult or even impossible to distinguish clinically between, for example, subacromial impingement, rotator cuff tear, degenerative change in the acromioclavicular (AC) joint and the early stages of an adhesive capsulitis.

It is clearly important to exclude causes unrelated to shoulder pathology such as referred pain from the cervical spine or upper back. As always, an accurate history is the first step in establishing the diagnosis.

A detailed history of any injury to the shoulder should be sought. The mechanism of injury is often helpful. For example, a fall onto the point of the shoulder may cause an injury to the acromioclavicular joint or a fracture of the greater tuberosity of the proximal humerus, whereas an injury that forces the arm into abduction and extension is more likely to result in subluxation – or even dislocation – of the shoulder.

Tips and tricks for specific conditions

Subacromial impingement

As the rotator cuff passes beneath the coracoacromial arch, it is covered by the subacomial bursa. This facilitates its smooth passage beneath the arch during overhead activities. Subacromial impingement refers to inflammation or abrasion by bone spurs of the surface of the tendon.

Typical features include gradual spontaneous onset of pain over the lateral aspect of the shoulder and upper arm – although it may follow a relatively minor injury. There is discomfort in the shoulder when laying on the affected side in bed, so sleep may be disturbed. There is often pain and limitation of movement for overhead tasks such as reaching up to a shelf or combing hair.

Clinical signs of subacromial impingement include:

• a painful arc of movement in the mid range of abduction

• a positive Hawkins-Kennedy test (internal rotation of the arm with the arm at 90° of abduction on the scapula plane producing pain)

• the Neer impingement sign (passive forward flexion with internal rotation of the arm similarly resulting in pain in the upper arm).

Note that although these tests are quite sensitive, they are not particularly specific.

Treatment is with anti-inflammatories, steroid injection into the subacromial space and physiotherapy. If conservative measures fail then an arthroscopic subacromial decompression may be performed.

Rotator cuff tears

A rotator cuff tear may result from chronic abrasion of the tendon or an acute injury – such as a when trying to lift or catch a heavy object, or a fall onto the outstretched arm. Tears may be partial or full thickness.

Patients often describe persistent, unremitting ‘toothache-like' pain deep within the shoulder. Sleep disturbance is the norm, and the shoulder feels weak and fatigues easily when using the arm above shoulder height. Examination may show a limited range of shoulder movement.

If the suprasinatus portion of the rotator cuff is torn then there is pain and weakness on resistance to abduction at 90° of elevation. There is also pain on lowering the arm from an elevated position, such that the patient may simply have to let the arm fall, a so-called positive drop arm sign.

If the infraspinatus is torn, there is weakness on resisted external rotation of the shoulder.

It is much rarer for subscapularis to tear but this results in weakness of internal rotation producing a positive ‘belly press' or Napoleon's sign – where patients cannot internally rotate, so when pushing on their belly with the flat of the palm the elbow will drop backwards.

An ultrasound scan will confirm the diagnosis and whether the tear is partial or full thickness. MRI scanning has a sensitivity of 91% for full thickness tears.

Full thickness rotator cuff tears do not heal and 40% will enlarge over a five-year period. Treatment depends on many factors including the age of the patient, the duration of symptoms, patient expectations and sporting aspirations, and the response to conservative treatment – including analgesia, anti-inflammatory medication and physiotherapy.

Rotator cuff repair is undertaken either by open, mini-open or arthroscopic techniques. Recovery from surgery is often slow and may take six to nine months.

Adhesive capsulitis

The early stages of an adhesive capsulitis may be clinically indistinguishable from the development of subacromial impingement or an acute calcific tendonitis, all presenting with pain and some degree of limitation of movement. In this condition, the normally thin and patulous capsule of the shoulder becomes thickened, inflamed and indistensible. This accounts for the cardinal sign of loss of external rotation of the shoulder in the presence of a normal X-ray.

Treatment in the early phase of the condition is directed towards pain management with analgesia, anti-inflammatory medication and steroid injection or suprascapular nerve block. Once the inflammatory phase of the condition has settled – usually after four to six months – arthroscopic capsular release or manipulation under anaesthetic can be considered. But it should be noted that the natural history is normally one of slow resolution over a period of 12 to 18 months in most cases.

Acute calcific tendonitis

This often presents with the onset of extremely severe pain over the course of a few hours. There is marked limitation of shoulder movement. Radiographs should be performed and will confirm a calcific deposit within the subacromial space of the shoulder. Treatment is with anti-inflammatory medication, analgesia and ultrasound-guided steroid injections into the subacromial space. If such treatments are unsuccessful, surgical excision of the calcific deposit by arthroscopic or open technique can be performed. Chronic calcific tendonitis may lead to subacromial impingement.

Rupture of the long head of biceps

This may occur suddenly after heavy lifting, with pain and bruising in the upper arm and a typical ‘Popeye' appearance to the muscle on elbow flexion. There is normally no significant loss of function or power and generally no treatment required, although tenodesis (fixation of the biceps tendon into its groove in the proximal humerus) may be considered for cosmetic reasons.

Degenerative change in the AC joint

This presents with progressive pain, swelling and localised tenderness over the AC joint. There may be subtle loss of full abduction of the shoulder and pain at the end of range in addition to pain on adducting the arm across the body and on extension of the shoulder. Diagnosis is confirmed on plain radiographs with joint space narrowing and osteophyte formation. Treatment is by steroid injection into the AC joint or surgical excision.

Degenerative change in the glenohumeral joint

This is relatively rare compared with osteoarthritis affecting the hip or knee. It presents with pain often over the posterior aspect of the shoulder, global limitation of movement and restriction of shoulder function. Diagnosis is confirmed on radiographs and if conservative management fails, treatment is by joint replacement.

Mr Brian Cohen is a founding partner of The London Orthopaedic Clinic and is an upper limb surgeon at the nearby Princess Grace Hospital

The London Orthopaedic Clinic hold free monthly Education sessions aimed at GPs, physiotherapists and allied health professionals. For more information about Brian Cohen and The London Orthopaedic Clinic visit www.londonorthopaedic.com or call 0207 1861000. Details of the Education Programme and the clinic's 'after hours emergency service' can also be found on the website.

Arthrtitis in shoulder joint Related Seminar: Musculoskeletal Medicine

Clinical Seminar: Musculoskeletal Medicine

What: A one day refresher to update GPs on the hot issues and trickiest dilemmas in rheumatology and orthopaedics.

When: Thursday 5 November 2009

Where: Raddison Hotel, Manchester

Next steps: Find out more and book

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