Managing sports injuries in the GP surgery: arm and shoulder

Sports medicine specialist Dr Ralph Mitchell explains how to diagnose and treat some common arm
and shoulder injuries in primary care

Case 1 Medial epicondylitis (golfer’s elbow)

A 22-year-old female attends your clinic. A keen squash player, she complains of pain in her inner elbow region radiating down into her forearm. She has tried taking paracetamol for it, but the day after a squash game she is struggling to use her arm and finds gripping things painful.

Elbow pain is a common presentation in young racquet sports players.^1,2 It can be difficult to diagnose and to manage as it affects a complex anatomical structure, with tendon, bone and neural structures all contributing to pain. This type of injury also requires careful management of patient expectations as it can be difficult to improve.

There are several differentials to consider, which a thorough history and examination can help to clarify.

Key history
As with all musculoskeletal conditions, the history is vital in establishing the diagnosis.

It is important first to differentiate between acute and chronic injuries. Acute pathologies associated with this type of presentation include avulsion fracture, ulnar collateral ligament injury and ulnar nerve neuritis.³

Once it has been established there is a chronic injury, it is important to work out the underlying mechanism. Medial epicondylitis, also called golfer’s elbow, is tendinopathy of the medial common flexor tendon of the elbow due to overload or overuse.⁴ The medial epicondyle is the common origin of the flexor and pronator muscles of the forearm. The patient will usually describe heavy use in gripping, or valgus stress in throwing or hitting a ball, which entails repetitive loading, causing tendon stress and pain. They may find the pain is worse when they start to use their arm in sport, or first thing in the morning, after which the arm ‘warms up’ and the pain settles, before becoming stiff and sore again after exercise. It is important to recognise there may be some non-sporting provoking factors too, particularly
if the patient has a job involving repetitive elbow movements.⁵

Examination
Classic medial epicondylitis is often found on palpation as slight swelling on the medial epicondyle; a ‘bogginess’ may also be felt. Palpation of the common flexor origin on the forearm will often reproduce the pain, but the patient may also report referred pain down the forearm.

The most common test for the condition is the rather unimaginatively named golfer’s elbow test. The examiner places one hand on the medial epicondyle or common flexor tendon, then uses the other hand to passively supinate the arm and extend the elbow and wrist. A positive test is pain or discomfort along the medial epicondyle or common flexor tendon.⁶ Note that resisted flexion of the wrist is not as useful, as it fails to load the flexor origin alone.

Management
The management of medial epicondylitis is often straightforward in primary care. In many cases rest, reassurance and activity modification, along with a cock-up wrist splint, will be enough to settle it down permanently and allow the patient to return to usual sporting or other physical activity. For others, a suitable tendon rehabilitation programme may be needed to resolve symptoms. This can be carried out by a physiotherapist or through an online programme, but often proves difficult for patients as it requires patience and dedication.

If this management fails, referral to a dedicated extra-corporeal shockwave therapy service is warranted.⁷ This treatment uses high-energy soundwaves, which can alter both regulation of the pain stimuli and localised metabolism, reducing pain and promoting the healing process.

Steroids have a role, but plasma-rich protein injections are increasingly being used, with evidence they reduce pain and improve function.⁴ These treatments are primarily offered in sports medicine departments.

Case 2: Subacromial impingement

A 30-year-old amateur cricketer comes to see you with pain in his bowling arm. The pain is exacerbated by his fast bowling and can ache for several hours after a game. He wants to know what’s wrong and what he can do to make it heal quickly.

Shoulder pain in the throwing athlete can be one of the most challenging sports medicine scenarios to deal with. Often the patient is reluctant to stop their sport; due to the lack of an acute injury, they tend to ‘push through’ the pain, which in turn results in a late and potentially more worrisome presentation. There are many reasons why overhead athletes develop shoulder pain and it is essential to conduct a good history and examination to ensure the best approach to management.

Throwing injury often involves a narrowing of the subacromial space, which results in ‘impingement’ of the subacromial structures (supraspinatus tendon and subacromial bursa) and causes pain that is often felt within or down the lateral aspect of the arm.

History
The history with subacromial impingement commonly involves insidious onset of pain in the shoulder and arm. Classically the patient reports pain in the ‘cocking phase’ and early acceleration of throwing.⁸ A detailed history to elicit the provoking factors is essential. Take particular note of: changes in throwing volume, intensity, technique adaptations; other nearby chronic musculoskeletal injuries; and competition schedules.⁸ Other differentials include: superior labral anterior to posterior (SLAP) tears, which may produce pain as well as instability symptoms; rotator cuff tears, which may have associated loss of function and weakness; and cervical nerve-root irritation, which may present as pain or paraesthesia in the shoulder.

Examination
The examination is crucial in arriving at a diagnosis. An initial inspection of the shoulder may reveal some muscle wasting in chronic cases. Posterior inspection with the patient demonstrating abduction and adduction may reveal scapular dyskinesis – essentially abnormal scapular movement in relation to the chest wall on the affected side. The clinical characteristics may include prominence of the medial or inferomedial scapular border, early scapular elevation or shrugging on arm elevation, or rapid downward rotation on lowering of the arm.⁹ This plays an important role in the development of impingement.

There are also certain easily elicited tests¹⁰ that have a higher sensitivity for impingement and aid the overall diagnosis:

Neers test – with the arm in pronation, passive flexion of the shoulder results in pain as the subacromial space is narrowed through flexion.
Hawkins-Kennedy test – with the shoulder in 90˚ abduction and elbow flexed at 90˚, the patient’s arm is taken into internal rotation. A positive test is pain elicited on this movement.
Empty can test – shoulder flexed to 90˚ and then brought in anteriorly 30˚; downward pressure is then applied to the shoulders and reproduction of the pain is a positive sign.

Management
Management is often difficult in athletes, who struggle to accept rest from the throwing activity. However, a simple rest period and modification of activities can often be enough to reduce the pain and allow the injury to settle on its own. If this doesn’t work, a course of physiotherapy may be needed, which will involve correcting movements of the scapula, improving core stability, postural rehabilitation and addressing rotator-cuff imbalances and posterior capsular tightness.¹¹

If pain inhibits physiotherapy, a steroid injection may be warranted to settle the pain so interventions can be continued. A small number of cases may require referral to a shoulder surgeon. Surgery for
a younger patient involves a capsular labral repair with or without a subacromial decompression.
For an older athlete, a subacromial decompression is the most common procedure.¹¹

Case 3. Lateral epicondylitis

A 44-year-old tennis player presents with a six-month history of elbow pain, which is worse on backhand shots. They also note it when they are in work using a mouse or typing.

Lateral epicondylitis is a common condition of the elbow that can affect up to three in 100 adults annually.¹² It is commonly a result of overuse of the common extensor origin, resulting in pain on movement and after exercise. It is more common than its neighbouring pathology medial epicondylitis.¹³

History
It is important to ascertain the chronicity of the injury and differentiate from acute injuries, such as avulsion tears of the tendon, or acute cervical disc prolapse causing referred pain into the arm and fractures. Once this has been established, it is important to understand any provoking activities and sports. In this case the tennis backhand is key although it is important to know that only 5% of lateral epicondylitis is caused by tennis.¹³ The pain can be classic tendon pain, which can be worse during or after exercise or on gripping objects.¹⁴ The patient may report the pain as referring down the forearm and as far as the wrist. It is important to screen for cervical pain with specific questioning about weakness and dermatomal type of pain in the hand.

Examination
Initial inspection may show a swelling to the lateral epicondyle, or muscle wasting if there is a long history to the disease pattern. Furthermore, patients who have had multiple corticosteroid injections in the area may show dimpling of the skin and skin changes.¹⁵ On palpation there is often pain over the lateral epicondyle or when the patient extends their wrist or fingers. There are certain special tests that can be done to add clinical weight to the diagnosis:

Cozen’s test – commonly used, with the patient in a sitting position. The patient’s arm is in extension, the forearm in pronation, and the wrist in slight radial deviation. The examiner palpates the lateral epicondyle of the humerus and then asks to make a fist and to perform resisted wrist extension against pressure.¹⁶

Mill’s test – performed with the elbow in flexion. One hand is used to stabilise the forearm while palpating the lateral humeral epicondyle with the thumb. Then, passively pronate the forearm, flex the patient’s wrist and extend the elbow maximally. This will place tension on the extensor carpi radialis brevis, with the aim to exacerbate symptoms.

Maudsley’s test – the examiner resists extension of the third digit of the hand, stressing the extensor digitorum muscle and tendon, while palpating the patient’s lateral epicondyle.¹³

Management
Most cases of lateral epicondylitis do not require imaging, although ultrasound or MRI can help in some cases where the diagnosis is uncertain.¹⁵ Ultrasound may show thickening and neovascularisation of the tendon, whereas MRI may show much greater detail including oedema, small tears and bone pathology.

In many patients, the condition is self-limiting and simple rest and activity modification can be enough to resolve symptoms. In cases that are refractory to this basic management, then pain relief, bracing (with common elbow braces) and an appropriate tendon loading programme through a physiotherapist can help. There is some evidence in favour of corticosteroid injection, but the benefits are short term and have complications. As a result, steroid injections are not recommended as a mainstay of treatment.¹⁵ In refractory cases, referral to a dedicated sports medicine department can be warranted for adjuvant therapies such as plasma-rich protein or autologous blood injections. However, these are only suitable when a dedicated rehabilitation programme has failed.

Dr Ralph Mitchell is a GPSI in musculoskeletal medicine in Leicestershire and team doctor at Wasps Rugby FC

References

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