Acquired abnormalities

Acquired abnormalities

History Patients usually associate the onset of their symptoms with an unusual event (trauma or excessive activity) even though the causation may not be as clear as the patient thinks. Even so, the onset (sudden or gradual) and duration are important details to establish, as is the age, occupation and hand dominance of the patient. Pain presenting in the shoulder (or anywhere in the upper limb) can arise from the nerves of the neck, so the history should enquire about neck problems. Examination If the patient can localise the pain to an exact point around or within the shoulder, then the problem is unlikely to be referred from the neck. Tests for inflammation and impingement involve trying to reproduce the pain by loading the limb in the position that creates the problem (e.g. Hawkins’ test for impingement; Figure 38.3 ). Tests for tears in structures such as the rotator cu ff look specifically for weakness, while appre hension tests check for instability (such as may predispose to recurrent shoulder dislocation). Richard J Hawkins , contemporary , Canadian orthopaedic surgeon. Investigations Radiographs are often of limited value because most shoulder pain arises from soft-tissue structures. However, a reduced subacromial space may be clearly visible in full-thickness rotator cu ff tears ( Figure 38.4a ). The appearance of a typical subacromial spur can be seen on the radiograph in Figure 38.4b and morphological variants of the acromion are shown in Figure 38.5 . Patients with impingement pain and rotator cu ff tears are much more likely to have a hooked acro - mion. The appearance of a spur, which produces the hook, is usually due to calcification within the coracoacromial ligament - (CAL) insertion and it may be a secondary consequence of degenerative cu ff disease rather than a causative lesion.

Figure 38.2 Sprengel’s shoulder (right) of a 4-year-old girl. (a) Figure 38.4 (a) Radio- graph showing sclerosis on the undersurface of the acromion and the greater tuberosity, with reduced subacromial space. (b) Radiograph showing an acromial spur and arthritis of the acromioclavicular joint. Figure 38.3 Hawkins’ impingement test. Impingement pain is repro

duced when the shoulder is internally rotated with 90° of forward /f_l exion, thereby locating the greater tuberosity and anterior rotator cuff underneath the acromion and coracoacromial ligament. (b) Acromioclavicular arthritis Spur

Both ultrasound and magnetic resonance imaging (MRI) allow the integrity and health of the rotator cu ff to be checked whereas magnetic resonance (MR) arthrography also gives information on the integrity of the labrum of the glenohu meral joint ( Figure 38.6 ). Local anaesthetic injections may help to localise the source of pain. For example, a painful arc on forward elevation (Neer’s sign) may be completely relieved by injecting local anaesthetic into the subacromial b ursa in cases of subacromial impinge ment (Neer’s test positive). Rotator cuff degeneration and impingement The rotator cu ff moves in a confined space between the humeral head, the acromion and the CAL. Blood vessels cannot cross the glenohumeral joint cavity below the supraspinatus tendon or through the subacromial space above it, and vessels that enter Charles Sumner Neer II , 1917–2011, orthopedic surgeon, Columbia University , New Y ork, NY , USA, developed the first widely used shoulder arthroplasty . from the insertional and muscle belly ends become constricted when the tendon is tensioned around the curved humeral head when the cu ff is active. Blood flow is therefore limited, the - tendon is exposed to external forces as it operates in a confined space and its capacity for self-repair is limited. More than any other tendon, therefore, it is prone to age-related degeneration, leading to tendinosis and partial- and full-thickness tearing; the rate of this is at least partly genetically determined. Even a - trivial injury can inhibit rotator cu ff function, so that it does not glide so easily in its subacromial space, starting a progression of inflammation, swelling and pain in the subacromial region. This subacromial pain may be termed impingement, which is felt to be attributable to abrasion of the cu ff and bursa on the undersurface of the acromion. The impingement itself causes further bursal inflammation and pain, which further inhibits rotator cu ff function, and a vicious circle is set up. The likelihood of subacromial pain developing is increased in patients with a spur beneath the acromion, which is seen increasingly commonly with age ( Figure 38.5 ) and may be an e ff ect rather than a cause of painful subacromial degeneration, as described earlier in this paragraph. The result is a painful arc of movement for the patient, which corresponds to the position where the inflamed segment of the supraspinatus tendon passes under the anterior acromial spur. The examiner may find that, although the patient cannot actively lift their arm through this segment (because of the pain), passively lifting the arm for the patient enables them to continue with pain-free movement once the area of impingement is passed ( Figure 38.7 ). Treatment Injection of steroid into the inflamed subacromial bursa may break the cycle of inflammation and impingement ( Figure 38.8 ), allowing rotator cu ff function to resume without impingement. Physiotherapy promotes normal cu ff activity once the pain has been relieved in this way . A commonly performed procedure is arthroscopic removal of the subacromial spur, anteroinferior acromion and the CAL, which has been shown to give good relief of symptoms ( Figure 38.9 ), but there is no evidence that it either improves the long-term prognosis or reduces the risk of rotator cu ff tears developing.

Figure 38.5 The three commonest acromial morphologies seen in adults. Children almost always have the /f_l at morphology. Cuff tear Figure 38.6 Magnetic resonance imaging scan showing a retracted cuff tear.

Summary box 38.1 Rotator cuff degeneration and impingement /uni25CF /uni25CF /uni25CF Summary box 38.2 Treatment of subacromial impingement /uni25CF /uni25CF /uni25CF Rotator cuff tears The rotator cu ff has a relatively poor blood supply in the segment that glides between the humeral head and acromion, as described in Rotator cu ff degeneration and impinge ment . The cu ff thins with age and eventually develops defects that are termed tears, whether or not there has been any trauma involved in their appearance. This means that tears are more common in older adults, and at any age they do not heal spontaneously . Tears usually begin at the anterolateral edge of the supraspinatus, and progress posteriorly to involve the infraspinatus and teres minor tendons. This creates a bare area over the greater tuberosity , as the torn cu ff retracts medially ( Figure 38.10 ). History In the younger patient with a healthier cu ff the onset often requires relatively major trauma, e.g. breaking a fall from a motorcycle or significant height with the outstretched hand, but in older adults the onset may follow a simple fall, a painful period of tendinitis or the condition may apparently occur spontaneously . Examination The patient may have a mixed picture of subacromial pain and a tear, but if the pain is removed by injection of local - anaesthetic the weakness will persist. Symptomatic tears are

o 180 170 o 60 o 0 Figure 38.7 Arcs of shoulder girdle motion with subacromial impinge ment pain between 60° and 120° of abduction, and acromioclavicular joint pain between 170° and 180°. Tendinosis and bursitis produce weakness secondary to pain (often a painful arc) A tendon tear produces weakness that is only secondarily painful Injection of local anaesthetic and retesting can distinguish those who do from those who do not have a tear – weakness persists if there is a signi /f_i cant tear Non-operative treatment includes injections and rotator cuff rehabilitation Surgery may be indicated if symptoms persist beyond 3–6 months of non-surgical management Surgery restores a /f_l at acromion and makes more room for rotator cuff gliding but there is no evidence that it improves the long-term outlook o 120 Figure 38.8 Technique of administering an injection into the subacro

mial bursa. (b) (a)

Figure 38.9 (a) Arthroscopic view of an acromial spur. (b) Arthroscopic view after the acromial spur has been removed and the cuff decom

pressed.

associated with pain, weakness, limited active abduction, cu ff muscle wasting and hunching of the shoulder when attempting abduction ( Figure 38.11 ). Specific tests can localise the tear by identifying which muscles are a ff ected, e.g. the ‘empty can test’ for supraspinatus. Investigation Both ultrasound scanning, in the hands of an experienced operator, and MRI are excellent tools for detecting rotator cu ff tears and assessing the tissue quality . Tears are classified as small (less than 1 /uni00A0 cm), intermediate (2–4 /uni00A0 cm) and large (more than 5 /uni00A0 cm). Treatment Treatment depends on the patient’s age, lifestyle and severity of symptoms. Three to six months of rehabilitation are required after surgical repair before resuming full overhead loading, so this is not an operation to be carried out in those who cannot rest the shoulder, including those who need it for weight-bearing through bilateral crutches. Arthroscopic or mini-open repair with subacromial decompression can be considered for all tears, but is likely to give a better outcome in the y oung than in the old. It may not be possible to repair large tears owing to their size, or the attempt at repair may be fruitless because of fatty atrophy of the rotator cu ff and loss of muscle contractility , in which case complex surgery , e.g. tendon transfers, patch grafts or reverse joint replacement ( Figure 38.12 ), will need to be considered. Summary box 38.3 Rotator cuff tears /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Frozen shoulder (adhesive capsulitis) This is an idiopathic condition causing sti ff ness and pain, most commonly a ff ecting females in their fifties. It is also associated with diabetes, heart and thyroid disease. History and examination Frozen shoulder is characterised by the onset of severe pain that is often spontaneous, though patients may recall an episode of minor trauma, which is of unknown relevance. It may also complicate surgery or other painful shoulder condi - tions. The di ff erential diagnosis includes infection, fractures and rotator cu ff tear, though if the sti ff ness is global and there is no redness or temperature then osteoarthritis is the main

zone Normal Full-thickness tear Figure 38.10 Various stages of rotator cuff tear. Initial partial-thickness tears progress to full–thickness and retracted tears but this process may be asymptomatic. Figure 38.11 A 75-year-old man with a >5 cm retracted cuff tear attempting to abduct his shoulder; the lack of a stable fulcrum pro vided by the rotator cuff means that the deltoid is less effective and can only abduct to 60°. Partial-thickness tears Chronic tear Retracted chronic tear Occur more commonly in older age groups 4–20% of 40- to 50-year-olds have asymptomatic rotator cuff

tears Up to 30% of 70-year-olds have an asymptomatic full- thickness tear Acute tears may present with little pain but profound weakness Earlier repair after traumatic onset with acute loss of function gives better results

alternative diagnosis. Initially there is severe pain but this improves with time. However, there is global loss of active and passive movement, limited by pain. The pathognomonic sign is loss of active external rotation. Radiographs are normal and distinguish it from osteoarthritis. Treatment The clinical course typically lasts 1–2 years, often consider ably longer in individuals with diabetes, and is divided into painful, sti ff ening (freezing and frozen) and thawing phases. If untreated, frozen shoulder will resolve, and the majority of oblems. In the first phase patients are left with no functional pr of the condition, treatment is pain relief. Corticosteroids can also be injected into the subacromial space or glenohumeral joint, although this is more often considered in the second phase. The latter can also be combined with a large volume (20–30 /uni00A0 mL) of local anaesthetic to produce a distension injec tion. Despite the pain, the patient should be encouraged to perform as much active and passive movement as they can, and distension injections facilitate this. Operative options include manipulation under anaesthesia or arthroscopic release of the tight capsule, w hich usually produce pain relief and are indicated for prolonged sti ff ness. Summary box 38.4 Frozen shoulder (adhesive capsulitis) /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Calcium salt deposition within the supraspinatus tendon is believed to be part of a degenerative process, possibly linked to the processes producing partial degenerative tears of the tendon. However, large deposits can occur in relatively young individuals with acute calcific tendinitis. Calcific deposits can be found coincidentally on radiographs taken for other purposes, but acute calcific tendinitis is agonisingly painful and associated with florid opaque lesions on radiographs. There is a spectrum of presentations between these two extremes History and examination In acute calcific tendinitis there is a rapid onset of severe shoul - der pain with painful, restricted motion. However, in contrast to adhesive capsulitis, external rotation is usually possible. Subacromial calcific deposits can be seen on plain radiographs , ( Figure 38.13 ) and are well delineated on ultrasound scanning with the calcifications casting acoustic shadows. Treatment Subacromial corticosteroid injections may help and can be accompanied by needling, aspiration or flushing of the deposits (barbotage). The condition is often self-limiting, with resorption of the calcium deposits. Surgery for resistant cases includes arthroscopic or open subacromial decompression and release or excision of the calcific deposits if they are prominent.

Figure 38.12 Reverse geometry total shoulder replacement. Most commonly occurs in females in their /f_i fties Spontaneous onset Produces severe pain with reduced glenohumeral motion Spontaneous resolution can occur over 1–2 years Differential diagnoses: calci /f_i c tendinitis and rotator cuff tear Injections, distension with saline, manipulation and surgical release may all help

Acquired abnormalities

History Patients usually associate the onset of their symptoms with an unusual event (trauma or excessive activity) even though the causation may not be as clear as the patient thinks. Even so, the onset (sudden or gradual) and duration are important details to establish, as is the age, occupation and hand dominance of the patient. Pain presenting in the shoulder (or anywhere in the upper limb) can arise from the nerves of the neck, so the history should enquire about neck problems. Examination If the patient can localise the pain to an exact point around or within the shoulder, then the problem is unlikely to be referred from the neck. Tests for inflammation and impingement involve trying to reproduce the pain by loading the limb in the position that creates the problem (e.g. Hawkins’ test for impingement; Figure 38.3 ). Tests for tears in structures such as the rotator cu ff look specifically for weakness, while appre hension tests check for instability (such as may predispose to recurrent shoulder dislocation). Richard J Hawkins , contemporary , Canadian orthopaedic surgeon. Investigations Radiographs are often of limited value because most shoulder pain arises from soft-tissue structures. However, a reduced subacromial space may be clearly visible in full-thickness rotator cu ff tears ( Figure 38.4a ). The appearance of a typical subacromial spur can be seen on the radiograph in Figure 38.4b and morphological variants of the acromion are shown in Figure 38.5 . Patients with impingement pain and rotator cu ff tears are much more likely to have a hooked acro - mion. The appearance of a spur, which produces the hook, is usually due to calcification within the coracoacromial ligament - (CAL) insertion and it may be a secondary consequence of degenerative cu ff disease rather than a causative lesion.

Figure 38.2 Sprengel’s shoulder (right) of a 4-year-old girl. (a) Figure 38.4 (a) Radio- graph showing sclerosis on the undersurface of the acromion and the greater tuberosity, with reduced subacromial space. (b) Radiograph showing an acromial spur and arthritis of the acromioclavicular joint. Figure 38.3 Hawkins’ impingement test. Impingement pain is repro

duced when the shoulder is internally rotated with 90° of forward /f_l exion, thereby locating the greater tuberosity and anterior rotator cuff underneath the acromion and coracoacromial ligament. (b) Acromioclavicular arthritis Spur

Both ultrasound and magnetic resonance imaging (MRI) allow the integrity and health of the rotator cu ff to be checked whereas magnetic resonance (MR) arthrography also gives information on the integrity of the labrum of the glenohu meral joint ( Figure 38.6 ). Local anaesthetic injections may help to localise the source of pain. For example, a painful arc on forward elevation (Neer’s sign) may be completely relieved by injecting local anaesthetic into the subacromial b ursa in cases of subacromial impinge ment (Neer’s test positive). Rotator cuff degeneration and impingement The rotator cu ff moves in a confined space between the humeral head, the acromion and the CAL. Blood vessels cannot cross the glenohumeral joint cavity below the supraspinatus tendon or through the subacromial space above it, and vessels that enter Charles Sumner Neer II , 1917–2011, orthopedic surgeon, Columbia University , New Y ork, NY , USA, developed the first widely used shoulder arthroplasty . from the insertional and muscle belly ends become constricted when the tendon is tensioned around the curved humeral head when the cu ff is active. Blood flow is therefore limited, the - tendon is exposed to external forces as it operates in a confined space and its capacity for self-repair is limited. More than any other tendon, therefore, it is prone to age-related degeneration, leading to tendinosis and partial- and full-thickness tearing; the rate of this is at least partly genetically determined. Even a - trivial injury can inhibit rotator cu ff function, so that it does not glide so easily in its subacromial space, starting a progression of inflammation, swelling and pain in the subacromial region. This subacromial pain may be termed impingement, which is felt to be attributable to abrasion of the cu ff and bursa on the undersurface of the acromion. The impingement itself causes further bursal inflammation and pain, which further inhibits rotator cu ff function, and a vicious circle is set up. The likelihood of subacromial pain developing is increased in patients with a spur beneath the acromion, which is seen increasingly commonly with age ( Figure 38.5 ) and may be an e ff ect rather than a cause of painful subacromial degeneration, as described earlier in this paragraph. The result is a painful arc of movement for the patient, which corresponds to the position where the inflamed segment of the supraspinatus tendon passes under the anterior acromial spur. The examiner may find that, although the patient cannot actively lift their arm through this segment (because of the pain), passively lifting the arm for the patient enables them to continue with pain-free movement once the area of impingement is passed ( Figure 38.7 ). Treatment Injection of steroid into the inflamed subacromial bursa may break the cycle of inflammation and impingement ( Figure 38.8 ), allowing rotator cu ff function to resume without impingement. Physiotherapy promotes normal cu ff activity once the pain has been relieved in this way . A commonly performed procedure is arthroscopic removal of the subacromial spur, anteroinferior acromion and the CAL, which has been shown to give good relief of symptoms ( Figure 38.9 ), but there is no evidence that it either improves the long-term prognosis or reduces the risk of rotator cu ff tears developing.

Figure 38.5 The three commonest acromial morphologies seen in adults. Children almost always have the /f_l at morphology. Cuff tear Figure 38.6 Magnetic resonance imaging scan showing a retracted cuff tear.

Summary box 38.1 Rotator cuff degeneration and impingement /uni25CF /uni25CF /uni25CF Summary box 38.2 Treatment of subacromial impingement /uni25CF /uni25CF /uni25CF Rotator cuff tears The rotator cu ff has a relatively poor blood supply in the segment that glides between the humeral head and acromion, as described in Rotator cu ff degeneration and impinge ment . The cu ff thins with age and eventually develops defects that are termed tears, whether or not there has been any trauma involved in their appearance. This means that tears are more common in older adults, and at any age they do not heal spontaneously . Tears usually begin at the anterolateral edge of the supraspinatus, and progress posteriorly to involve the infraspinatus and teres minor tendons. This creates a bare area over the greater tuberosity , as the torn cu ff retracts medially ( Figure 38.10 ). History In the younger patient with a healthier cu ff the onset often requires relatively major trauma, e.g. breaking a fall from a motorcycle or significant height with the outstretched hand, but in older adults the onset may follow a simple fall, a painful period of tendinitis or the condition may apparently occur spontaneously . Examination The patient may have a mixed picture of subacromial pain and a tear, but if the pain is removed by injection of local - anaesthetic the weakness will persist. Symptomatic tears are

o 180 170 o 60 o 0 Figure 38.7 Arcs of shoulder girdle motion with subacromial impinge ment pain between 60° and 120° of abduction, and acromioclavicular joint pain between 170° and 180°. Tendinosis and bursitis produce weakness secondary to pain (often a painful arc) A tendon tear produces weakness that is only secondarily painful Injection of local anaesthetic and retesting can distinguish those who do from those who do not have a tear – weakness persists if there is a signi /f_i cant tear Non-operative treatment includes injections and rotator cuff rehabilitation Surgery may be indicated if symptoms persist beyond 3–6 months of non-surgical management Surgery restores a /f_l at acromion and makes more room for rotator cuff gliding but there is no evidence that it improves the long-term outlook o 120 Figure 38.8 Technique of administering an injection into the subacro

mial bursa. (b) (a)

Figure 38.9 (a) Arthroscopic view of an acromial spur. (b) Arthroscopic view after the acromial spur has been removed and the cuff decom

pressed.

associated with pain, weakness, limited active abduction, cu ff muscle wasting and hunching of the shoulder when attempting abduction ( Figure 38.11 ). Specific tests can localise the tear by identifying which muscles are a ff ected, e.g. the ‘empty can test’ for supraspinatus. Investigation Both ultrasound scanning, in the hands of an experienced operator, and MRI are excellent tools for detecting rotator cu ff tears and assessing the tissue quality . Tears are classified as small (less than 1 /uni00A0 cm), intermediate (2–4 /uni00A0 cm) and large (more than 5 /uni00A0 cm). Treatment Treatment depends on the patient’s age, lifestyle and severity of symptoms. Three to six months of rehabilitation are required after surgical repair before resuming full overhead loading, so this is not an operation to be carried out in those who cannot rest the shoulder, including those who need it for weight-bearing through bilateral crutches. Arthroscopic or mini-open repair with subacromial decompression can be considered for all tears, but is likely to give a better outcome in the y oung than in the old. It may not be possible to repair large tears owing to their size, or the attempt at repair may be fruitless because of fatty atrophy of the rotator cu ff and loss of muscle contractility , in which case complex surgery , e.g. tendon transfers, patch grafts or reverse joint replacement ( Figure 38.12 ), will need to be considered. Summary box 38.3 Rotator cuff tears /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Frozen shoulder (adhesive capsulitis) This is an idiopathic condition causing sti ff ness and pain, most commonly a ff ecting females in their fifties. It is also associated with diabetes, heart and thyroid disease. History and examination Frozen shoulder is characterised by the onset of severe pain that is often spontaneous, though patients may recall an episode of minor trauma, which is of unknown relevance. It may also complicate surgery or other painful shoulder condi - tions. The di ff erential diagnosis includes infection, fractures and rotator cu ff tear, though if the sti ff ness is global and there is no redness or temperature then osteoarthritis is the main

zone Normal Full-thickness tear Figure 38.10 Various stages of rotator cuff tear. Initial partial-thickness tears progress to full–thickness and retracted tears but this process may be asymptomatic. Figure 38.11 A 75-year-old man with a >5 cm retracted cuff tear attempting to abduct his shoulder; the lack of a stable fulcrum pro vided by the rotator cuff means that the deltoid is less effective and can only abduct to 60°. Partial-thickness tears Chronic tear Retracted chronic tear Occur more commonly in older age groups 4–20% of 40- to 50-year-olds have asymptomatic rotator cuff

tears Up to 30% of 70-year-olds have an asymptomatic full- thickness tear Acute tears may present with little pain but profound weakness Earlier repair after traumatic onset with acute loss of function gives better results

alternative diagnosis. Initially there is severe pain but this improves with time. However, there is global loss of active and passive movement, limited by pain. The pathognomonic sign is loss of active external rotation. Radiographs are normal and distinguish it from osteoarthritis. Treatment The clinical course typically lasts 1–2 years, often consider ably longer in individuals with diabetes, and is divided into painful, sti ff ening (freezing and frozen) and thawing phases. If untreated, frozen shoulder will resolve, and the majority of oblems. In the first phase patients are left with no functional pr of the condition, treatment is pain relief. Corticosteroids can also be injected into the subacromial space or glenohumeral joint, although this is more often considered in the second phase. The latter can also be combined with a large volume (20–30 /uni00A0 mL) of local anaesthetic to produce a distension injec tion. Despite the pain, the patient should be encouraged to perform as much active and passive movement as they can, and distension injections facilitate this. Operative options include manipulation under anaesthesia or arthroscopic release of the tight capsule, w hich usually produce pain relief and are indicated for prolonged sti ff ness. Summary box 38.4 Frozen shoulder (adhesive capsulitis) /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Calcium salt deposition within the supraspinatus tendon is believed to be part of a degenerative process, possibly linked to the processes producing partial degenerative tears of the tendon. However, large deposits can occur in relatively young individuals with acute calcific tendinitis. Calcific deposits can be found coincidentally on radiographs taken for other purposes, but acute calcific tendinitis is agonisingly painful and associated with florid opaque lesions on radiographs. There is a spectrum of presentations between these two extremes History and examination In acute calcific tendinitis there is a rapid onset of severe shoul - der pain with painful, restricted motion. However, in contrast to adhesive capsulitis, external rotation is usually possible. Subacromial calcific deposits can be seen on plain radiographs , ( Figure 38.13 ) and are well delineated on ultrasound scanning with the calcifications casting acoustic shadows. Treatment Subacromial corticosteroid injections may help and can be accompanied by needling, aspiration or flushing of the deposits (barbotage). The condition is often self-limiting, with resorption of the calcium deposits. Surgery for resistant cases includes arthroscopic or open subacromial decompression and release or excision of the calcific deposits if they are prominent.

Figure 38.12 Reverse geometry total shoulder replacement. Most commonly occurs in females in their /f_i fties Spontaneous onset Produces severe pain with reduced glenohumeral motion Spontaneous resolution can occur over 1–2 years Differential diagnoses: calci /f_i c tendinitis and rotator cuff tear Injections, distension with saline, manipulation and surgical release may all help

Acquired abnormalities

History Patients usually associate the onset of their symptoms with an unusual event (trauma or excessive activity) even though the causation may not be as clear as the patient thinks. Even so, the onset (sudden or gradual) and duration are important details to establish, as is the age, occupation and hand dominance of the patient. Pain presenting in the shoulder (or anywhere in the upper limb) can arise from the nerves of the neck, so the history should enquire about neck problems. Examination If the patient can localise the pain to an exact point around or within the shoulder, then the problem is unlikely to be referred from the neck. Tests for inflammation and impingement involve trying to reproduce the pain by loading the limb in the position that creates the problem (e.g. Hawkins’ test for impingement; Figure 38.3 ). Tests for tears in structures such as the rotator cu ff look specifically for weakness, while appre hension tests check for instability (such as may predispose to recurrent shoulder dislocation). Richard J Hawkins , contemporary , Canadian orthopaedic surgeon. Investigations Radiographs are often of limited value because most shoulder pain arises from soft-tissue structures. However, a reduced subacromial space may be clearly visible in full-thickness rotator cu ff tears ( Figure 38.4a ). The appearance of a typical subacromial spur can be seen on the radiograph in Figure 38.4b and morphological variants of the acromion are shown in Figure 38.5 . Patients with impingement pain and rotator cu ff tears are much more likely to have a hooked acro - mion. The appearance of a spur, which produces the hook, is usually due to calcification within the coracoacromial ligament - (CAL) insertion and it may be a secondary consequence of degenerative cu ff disease rather than a causative lesion.

Figure 38.2 Sprengel’s shoulder (right) of a 4-year-old girl. (a) Figure 38.4 (a) Radio- graph showing sclerosis on the undersurface of the acromion and the greater tuberosity, with reduced subacromial space. (b) Radiograph showing an acromial spur and arthritis of the acromioclavicular joint. Figure 38.3 Hawkins’ impingement test. Impingement pain is repro

duced when the shoulder is internally rotated with 90° of forward /f_l exion, thereby locating the greater tuberosity and anterior rotator cuff underneath the acromion and coracoacromial ligament. (b) Acromioclavicular arthritis Spur

Both ultrasound and magnetic resonance imaging (MRI) allow the integrity and health of the rotator cu ff to be checked whereas magnetic resonance (MR) arthrography also gives information on the integrity of the labrum of the glenohu meral joint ( Figure 38.6 ). Local anaesthetic injections may help to localise the source of pain. For example, a painful arc on forward elevation (Neer’s sign) may be completely relieved by injecting local anaesthetic into the subacromial b ursa in cases of subacromial impinge ment (Neer’s test positive). Rotator cuff degeneration and impingement The rotator cu ff moves in a confined space between the humeral head, the acromion and the CAL. Blood vessels cannot cross the glenohumeral joint cavity below the supraspinatus tendon or through the subacromial space above it, and vessels that enter Charles Sumner Neer II , 1917–2011, orthopedic surgeon, Columbia University , New Y ork, NY , USA, developed the first widely used shoulder arthroplasty . from the insertional and muscle belly ends become constricted when the tendon is tensioned around the curved humeral head when the cu ff is active. Blood flow is therefore limited, the - tendon is exposed to external forces as it operates in a confined space and its capacity for self-repair is limited. More than any other tendon, therefore, it is prone to age-related degeneration, leading to tendinosis and partial- and full-thickness tearing; the rate of this is at least partly genetically determined. Even a - trivial injury can inhibit rotator cu ff function, so that it does not glide so easily in its subacromial space, starting a progression of inflammation, swelling and pain in the subacromial region. This subacromial pain may be termed impingement, which is felt to be attributable to abrasion of the cu ff and bursa on the undersurface of the acromion. The impingement itself causes further bursal inflammation and pain, which further inhibits rotator cu ff function, and a vicious circle is set up. The likelihood of subacromial pain developing is increased in patients with a spur beneath the acromion, which is seen increasingly commonly with age ( Figure 38.5 ) and may be an e ff ect rather than a cause of painful subacromial degeneration, as described earlier in this paragraph. The result is a painful arc of movement for the patient, which corresponds to the position where the inflamed segment of the supraspinatus tendon passes under the anterior acromial spur. The examiner may find that, although the patient cannot actively lift their arm through this segment (because of the pain), passively lifting the arm for the patient enables them to continue with pain-free movement once the area of impingement is passed ( Figure 38.7 ). Treatment Injection of steroid into the inflamed subacromial bursa may break the cycle of inflammation and impingement ( Figure 38.8 ), allowing rotator cu ff function to resume without impingement. Physiotherapy promotes normal cu ff activity once the pain has been relieved in this way . A commonly performed procedure is arthroscopic removal of the subacromial spur, anteroinferior acromion and the CAL, which has been shown to give good relief of symptoms ( Figure 38.9 ), but there is no evidence that it either improves the long-term prognosis or reduces the risk of rotator cu ff tears developing.

Figure 38.5 The three commonest acromial morphologies seen in adults. Children almost always have the /f_l at morphology. Cuff tear Figure 38.6 Magnetic resonance imaging scan showing a retracted cuff tear.

Summary box 38.1 Rotator cuff degeneration and impingement /uni25CF /uni25CF /uni25CF Summary box 38.2 Treatment of subacromial impingement /uni25CF /uni25CF /uni25CF Rotator cuff tears The rotator cu ff has a relatively poor blood supply in the segment that glides between the humeral head and acromion, as described in Rotator cu ff degeneration and impinge ment . The cu ff thins with age and eventually develops defects that are termed tears, whether or not there has been any trauma involved in their appearance. This means that tears are more common in older adults, and at any age they do not heal spontaneously . Tears usually begin at the anterolateral edge of the supraspinatus, and progress posteriorly to involve the infraspinatus and teres minor tendons. This creates a bare area over the greater tuberosity , as the torn cu ff retracts medially ( Figure 38.10 ). History In the younger patient with a healthier cu ff the onset often requires relatively major trauma, e.g. breaking a fall from a motorcycle or significant height with the outstretched hand, but in older adults the onset may follow a simple fall, a painful period of tendinitis or the condition may apparently occur spontaneously . Examination The patient may have a mixed picture of subacromial pain and a tear, but if the pain is removed by injection of local - anaesthetic the weakness will persist. Symptomatic tears are

o 180 170 o 60 o 0 Figure 38.7 Arcs of shoulder girdle motion with subacromial impinge ment pain between 60° and 120° of abduction, and acromioclavicular joint pain between 170° and 180°. Tendinosis and bursitis produce weakness secondary to pain (often a painful arc) A tendon tear produces weakness that is only secondarily painful Injection of local anaesthetic and retesting can distinguish those who do from those who do not have a tear – weakness persists if there is a signi /f_i cant tear Non-operative treatment includes injections and rotator cuff rehabilitation Surgery may be indicated if symptoms persist beyond 3–6 months of non-surgical management Surgery restores a /f_l at acromion and makes more room for rotator cuff gliding but there is no evidence that it improves the long-term outlook o 120 Figure 38.8 Technique of administering an injection into the subacro

mial bursa. (b) (a)

Figure 38.9 (a) Arthroscopic view of an acromial spur. (b) Arthroscopic view after the acromial spur has been removed and the cuff decom

pressed.

associated with pain, weakness, limited active abduction, cu ff muscle wasting and hunching of the shoulder when attempting abduction ( Figure 38.11 ). Specific tests can localise the tear by identifying which muscles are a ff ected, e.g. the ‘empty can test’ for supraspinatus. Investigation Both ultrasound scanning, in the hands of an experienced operator, and MRI are excellent tools for detecting rotator cu ff tears and assessing the tissue quality . Tears are classified as small (less than 1 /uni00A0 cm), intermediate (2–4 /uni00A0 cm) and large (more than 5 /uni00A0 cm). Treatment Treatment depends on the patient’s age, lifestyle and severity of symptoms. Three to six months of rehabilitation are required after surgical repair before resuming full overhead loading, so this is not an operation to be carried out in those who cannot rest the shoulder, including those who need it for weight-bearing through bilateral crutches. Arthroscopic or mini-open repair with subacromial decompression can be considered for all tears, but is likely to give a better outcome in the y oung than in the old. It may not be possible to repair large tears owing to their size, or the attempt at repair may be fruitless because of fatty atrophy of the rotator cu ff and loss of muscle contractility , in which case complex surgery , e.g. tendon transfers, patch grafts or reverse joint replacement ( Figure 38.12 ), will need to be considered. Summary box 38.3 Rotator cuff tears /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Frozen shoulder (adhesive capsulitis) This is an idiopathic condition causing sti ff ness and pain, most commonly a ff ecting females in their fifties. It is also associated with diabetes, heart and thyroid disease. History and examination Frozen shoulder is characterised by the onset of severe pain that is often spontaneous, though patients may recall an episode of minor trauma, which is of unknown relevance. It may also complicate surgery or other painful shoulder condi - tions. The di ff erential diagnosis includes infection, fractures and rotator cu ff tear, though if the sti ff ness is global and there is no redness or temperature then osteoarthritis is the main

zone Normal Full-thickness tear Figure 38.10 Various stages of rotator cuff tear. Initial partial-thickness tears progress to full–thickness and retracted tears but this process may be asymptomatic. Figure 38.11 A 75-year-old man with a >5 cm retracted cuff tear attempting to abduct his shoulder; the lack of a stable fulcrum pro vided by the rotator cuff means that the deltoid is less effective and can only abduct to 60°. Partial-thickness tears Chronic tear Retracted chronic tear Occur more commonly in older age groups 4–20% of 40- to 50-year-olds have asymptomatic rotator cuff

tears Up to 30% of 70-year-olds have an asymptomatic full- thickness tear Acute tears may present with little pain but profound weakness Earlier repair after traumatic onset with acute loss of function gives better results

alternative diagnosis. Initially there is severe pain but this improves with time. However, there is global loss of active and passive movement, limited by pain. The pathognomonic sign is loss of active external rotation. Radiographs are normal and distinguish it from osteoarthritis. Treatment The clinical course typically lasts 1–2 years, often consider ably longer in individuals with diabetes, and is divided into painful, sti ff ening (freezing and frozen) and thawing phases. If untreated, frozen shoulder will resolve, and the majority of oblems. In the first phase patients are left with no functional pr of the condition, treatment is pain relief. Corticosteroids can also be injected into the subacromial space or glenohumeral joint, although this is more often considered in the second phase. The latter can also be combined with a large volume (20–30 /uni00A0 mL) of local anaesthetic to produce a distension injec tion. Despite the pain, the patient should be encouraged to perform as much active and passive movement as they can, and distension injections facilitate this. Operative options include manipulation under anaesthesia or arthroscopic release of the tight capsule, w hich usually produce pain relief and are indicated for prolonged sti ff ness. Summary box 38.4 Frozen shoulder (adhesive capsulitis) /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Calcium salt deposition within the supraspinatus tendon is believed to be part of a degenerative process, possibly linked to the processes producing partial degenerative tears of the tendon. However, large deposits can occur in relatively young individuals with acute calcific tendinitis. Calcific deposits can be found coincidentally on radiographs taken for other purposes, but acute calcific tendinitis is agonisingly painful and associated with florid opaque lesions on radiographs. There is a spectrum of presentations between these two extremes History and examination In acute calcific tendinitis there is a rapid onset of severe shoul - der pain with painful, restricted motion. However, in contrast to adhesive capsulitis, external rotation is usually possible. Subacromial calcific deposits can be seen on plain radiographs , ( Figure 38.13 ) and are well delineated on ultrasound scanning with the calcifications casting acoustic shadows. Treatment Subacromial corticosteroid injections may help and can be accompanied by needling, aspiration or flushing of the deposits (barbotage). The condition is often self-limiting, with resorption of the calcium deposits. Surgery for resistant cases includes arthroscopic or open subacromial decompression and release or excision of the calcific deposits if they are prominent.

Figure 38.12 Reverse geometry total shoulder replacement. Most commonly occurs in females in their /f_i fties Spontaneous onset Produces severe pain with reduced glenohumeral motion Spontaneous resolution can occur over 1–2 years Differential diagnoses: calci /f_i c tendinitis and rotator cuff tear Injections, distension with saline, manipulation and surgical release may all help