Standards plea for GP commissioners
and arm pain
A 40-year-old carpenter has shoulder pain that is worse when reaching out and during overhead activities. It also occurs at night. The pain is aggravated when he tries to wash his back. There is minimal wasting of the rotator cuff and mild tenderness over the greater tuberosity.
On active elevation, the patient winces and there is soft crepitus and scapulothoracic rhythm disturbance. This pain is aggravated by internal rotation of the arm when it is held at 90 degrees elevation. External rotation is symmetrical and power is normal.
This middle-aged man gives a typical history of impingement. This accounts for more than a third of all the patients coming to GP clinics with shoulder pain. It is caused by compression of the rotator cuff tendons and the subacromial bursa between the greater tubercle of the humeral head and the lateral edge of the acromion process.
Management is generally conservative with physiotherapy and simple analgesics. If it does not improve, steroid can be injected into the subacromial space. If this fails, a referral to the shoulder team is warranted.
Patient 2 crescendo pain
A 45-year-old painter goes to A&E with a history of crescendo pain in the shoulder. This starts as an acute toothache-like pain that builds over a few hours into agonising pain.
The patient resists any attempt to move the shoulder and holds it in adduction and internal rotation. The shoulder is generally tender and warm to touch. The pain is dramatically relieved by injection of local anaesthetic into the subacromial bursa.
Acute calcifying tendonitis is a form of impingement, and is one of the few shoulder emergencies. Periarticular calcification is frequently an incidental radiographic finding in asymptomatic patients. The acute phase is usually very painful and associated with resorption of the deposits.
The clinical picture in many ways resembles septic arthritis or acute gout. The main priority in acute cases is pain relief. Needling of the calcific deposit or decompressing it to relieve pressure, accompanied by lavage of the subacromial space, is sometimes done.
A labourer, aged over 40 and with a previously normal shoulder, injures his shoulder and has an immediate but brief pain followed by severe pain that night. There is loss of power in elevating the arm and a faulty scapulohumeral rhythm. There is a tender point, sulcus and eminence at the insertion of supraspinatus, which causes a wince and crepitus as the tuberosity disappears under the acromion as the arm is passively elevated, and which reappears on descent of the arm. The radiograph is normal.
This is a typical presentation for a rotator cuff tear. There is a spectrum of rotator cuff disease starting with impingement and progressing to small, moderate, large or massive tears. Most occur in the tendon of insertion of supraspinatus.
Tears can cause both pain and weakness, and the surgical management depends on the age of the patient, the state of the
cuff and the size of the tear, as well as whether the presenting problem is pain or weakness.
An acute traumatic tear in the young is different and should be referred for repair.
A 70-year-old woman keeps coming to her surgery with shoulder pain that started a year ago. Her pain is aggravated by activities and relieved when she takes rest. Recently she is having difficulty in personal care activities such as getting dressed, combing her hair and so on.
She is not able to lie flat due to pain, and finds she is more comfortable sleeping in a chair. No other relevant medical history is noted there is no suggestion of rheumatoid arthritis or other joint involvement. However, in the past she used to have recurrent dislocations of her shoulder, and this was treated conservatively.
On examination there is generalised muscle wasting and the shoulder looks swollen. Movement is restricted because it aggravates pain, and crepitus can be felt. However, despite all this, power in the arm is actually good.
Radiographs show narrowing of the cartilage space, the joint outlines are clear-cut and often show some sclerosis, and there is spurring from osteophyte formation at the joint margins.
This patient presents with symptomatic secondary osteoarthritis. Glenohumeral arthritis can be primary (rare), secondary (following trauma, dislocations or previous surg- eries), cuff tear arthropathy and avascular necrosis of the humeral head. In rheumatoid arthritis the shoulder is commonly involved.
In most cases conservative measures should be relied upon and an operation is not justified. If there is a large effusion, it should be aspirated.
Patient 5 grinding sensation
A 66-year-old man presents to his GP with anterior shoulder pain. He describes a grinding sensation when reaching overhead or across the chest. He tries to keep his arm close to his chest and resists rotation and elevation. On questioning, he points to his AC joint while describing his symptoms. On examination there is no soft-tissue thickening or swelling and no increase of skin temperature.
The total range of shoulder movements is well preserved, but pain in the region of the AC joint is exacerbated at the extremes of movement, especially at the end of abduction. Crossing his arms across his chest also causes pain. Radiographs show narrowing of cartilage space and marginal osteophytes.
Primary osteoarthritis is much more common in the AC joint than in the glenohumeral joint.
Often treatment is not needed. Overhead work should be avoided. If persistent, an injection of steroid may be beneficial, and an ultrasound-guided injection may be requested. In severe cases an operation to excise the lateral end of the clavicle is justified.