REGIONAL DISORDERS OF THE NECK
A 45-year-old healthy woman presented with neck pain with gradual onset over 3 to 4 weeks. Pain was described as worse in the lower neck and around the shoulders, and achy in nature. She described a headache intermittently associated with the pain, especially at the end of the day. She had recently begun a job as a receptionist and was spending 7 hours each day working at a computer and using the telephone. Acetaminophen provided minimal relief.
Cervical spine was normal to inspection, but with slightly diminished flexion associated with pain; extension was normal. Mild tenderness was present over the inferior cervical spine and at the scapulae, and there was moderate tenderness at the paraspinal musculature including trapezius as well as the sternocleidomastoids. The neurologic examination was normal.
A 62-year-old woman with a history of rheumatoid arthritis, fibromyalgia, and depression presented with neck pain localized to the posterior neck and occasionally the base of the skull. The pain was worse in the evenings and interfered with the patient’s sleep. Ibuprofen provided only minimal relief. There were no paresthesias or symptoms of neuropathy.
The cervical spine was normal to inspection. However, there was diminished flexion and extension and these motions reproduced the pain. There was tenderness over the inferior cervical vertebral bodies. A test for radiculopathy, by neck extension with rotation of the head (Spurling’s maneuver), was negative. The neurologic examination was normal, and there were normal deep tendon reflexes in the upper extremities.
Imaging: Lateral radiography of the cervical spine ( Fig. 25-1 ) revealed anterior spondylolisthesis of C3 on C4, and grade 1 spondylosis of the mid and upper cervical spine; odontoid radiographs were normal.
A 37-year-old previously healthy man presented with neck and arm pain of 2 months’ duration, which had progressed to a sensation of numbness in the right hand and resulted in him dropping objects occasionally. The pain was constant during the day, worse on the right side, and especially in the right shoulder. There were associated paresthesias of the thumb and second finger, which were exacerbated by active motion of the arm. Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs), as well as massage and acupuncture, had not provided symptomatic relief. There was no history of trauma or injury, and there were no other neuromuscular complaints.
The cervical spine was normal to inspection, but there was slightly decreased flexion and extension, with reproduction of pain at the extremes of both flexion and extension. Paravertebral muscle spasm was noted. Spurling’s maneuver reproduced the pain with the head tilted to the right. Shoulder examination was normal without evidence of impingement. Neurologic examination revealed weakness of the right biceps and wrist extensors (4/5), diminished brachioradialis and biceps reflexes on the right, and diminished sensation to pin prick of the right thumb and index finger.
Imaging: T-2 weighted magnetic resonance imaging (MRI) scan of the cervical spine ( Fig. 25-2 ) revealed posterior bulging and herniation of the intervertebral disc at the C5-C6 and C6-C7 levels, causing mild spinal cord impingement.
A 44-year-old woman with a history of depression and hypothyroidism presented with diffuse neck and shoulder pain. The pain had been intermittent for approximately one year, and was described as a chronic ache across the upper back and neck and radiating to both shoulders. The pain had affected the patient’s sleep as well as her ability to care for her children and to participate in sports. She reported lack of energy, extreme fatigue, and stiffness of the neck and back in the mornings. There was no history of trauma or injury.
The neck and back were normal to inspection and examination except for tender points suboccipitally, as well as at the trapezius, supraspinatus, and paraspinal muscles. Shoulders and upper extremities were normal, and the neurologic examination was unremarkable. There were additional tender points noted at the second costochondral junction, lateral epicondyles, and at the greater trochanters.
Laboratory evaluation, including blood count, comprehensive metabolic profile, and thyroid function, was normal.
Neck pain affects individuals of all ages. An understanding of neck anatomy is essential to evaluate the etiology of neck pain. The seven vertebrae of the cervical spine constitute the axial skeleton of the neck and support the neck through its arc of motion. The natural lordosis of the neck, assumed during infancy, enhances the compliance of the vertebral column during weight bearing. The first and second cervical vertebrae, the atlas and axis, respectively, differ anatomically from the other cervical vertebrae and account for approximately half of the ability to rotate the head on the neck; the lower cervical levels contribute the rest. Although the total range of motion of each cervical segment varies from individual to individual, the axis of rotation of each vertebral level may be more constant and has been used as a semiobjective measure of disturbed cervical function. The spinal musculature of the neck consists of the posterior cervical paraspinal muscles, which provide cervical extension; the lateral cervical spine muscles, which rotate and laterally flex the neck; and the anterior cervical spinal muscles, which flex the neck. The trapezius muscles comprise the primary posterior muscles of the neck, whereas the most important lateral cervical muscle is the sternocleidomastoid.
The evaluation of neck pain begins by determining its source; potential sources of neck pain may be categorized as intra-articular, periarticular, age-related degenerative disease, or referred pain from neurovascular processes. Table 25-1 provides a brief differential diagnosis of regional neck pain syndromes. A thorough clinical history, including occupational and recreational activities and a comprehensive physical examination are necessary to distinguish among the various causes of neck pain.
Articular etiologies of neck pain include degenerative spine disease due to osteoarthritis, any of the inflammatory arthritides, including rheumatoid arthritis and the spondylitides, and infection. These presentations are discussed in detail in separate chapters. In addition, severe neck pain may be a feature of systemic inflammatory conditions, such as polymyositis, dermatomyositis, and polymyalgia rheumatic; however in these cases, neck pain is generally not an isolated finding and often reflects involvement of the muscles rather than the joints.
Neck pain emanating from periarticular structures, the focus of this section, can be organized into relatively distinct groups: acute injury, chronic overuse disorders, age-related degenerative changes, and myofascial syndromes. The majority of minor neck pain is nonspecific, and results from muscular strain related to posture, stress, or occupational or sporting activities. As in many periarticular conditions discussed in this Chapter, repetitive activities, overuse, and lifestyle factors greatly contribute. The term cervical strain describes injuries to the musculotendonous portions of the neck and cervical sprain describes pain related to injury of the ligaments of the neck. Case Study 1 is an example of cervical strain. Neck strain or sprain can result acutely from sports injuries or can develop chronically due to lifestyle factors. A related acute cervical injury is so-called whiplash, which refers to neck strain that results from an acceleration-deceleration injury involving the abrupt extension of the neck during acute trauma, typically during a motor vehicle accident. Although the pathology of this injury is poorly understood, clinical, animal, and cadaveric investigations suggest that mechanical overload injury of the zygoapophyseal joints, with concomitant injury to the articular pillars or the joint capsule, may be a significant source of whiplash pain. The clinical syndrome of whiplash-associated disorders consists of neck pain, neck stiffness, arm pain and paresthesias; in addition, associated temperomandibular joint pain, headache, visual and memory disturbances, and psychological dysfunction are sometimes ascribed to the whiplash injury. FLOAT NOT FOUND
Spondylosis refers to age-related degenerative changes of the spinal column that impinge on the adjacent neurological structures. Cervical spondylosis, as described in Case Study 2 , is a common cause of axial neck pain, whereby vertebral osteophytes, or degenerative intervertebral discs, compress nerve roots or the spinal cord. It is important to remember, however, that during normal aging, the intervertebral discs lose much of their viscoelasticity, which causes them to lose height and to bulge posteriorly into the spinal canal ; thus, radiographic evidence of cervical spondylosis is common, even in asymptomatic individuals, especially among the elderly, and the distinction between normal aging and disease is usually made on clinical grounds. In addition to neck pain, spondylosis can cause radiculopathy and myelopathy through extrinsic compression of the nerve roots or spinal cord by posteriorly bulging discs or by vertebral osteophytes. In cervical radiculopathy, there is pain, hyperesthesia, or neurologic dysfunction in the distribution of one or more cervical nerve roots, whereas in cervical myelopathy, there are varied neurologic deficits and signs in both the upper and lower extremities due to spinal cord compression. Cervical radiculopathy in young adults typically results from herniation of a cervical disc or by acute trauma damaging a nerve root at the foramen; in contrast, cervical radiculopathy in older patients is more frequently a result of foraminal narrowing from osteophytes, osteoarthritis of the uncovertebral joints anteriorly or of the facet joints posteriorly, or degenerative disc disease with decreased disc height. FLOAT NOT FOUND
Myofascial pain refers to regional pain of soft tissue origin characterized by painful muscles with increased tone and stiffness and with trigger points, and is a common source of muscular pain in the shoulder-neck region ; the fibromyalgia syndrome refers to generalized myofascial pain. It has been reported that 72% of patients with fibromyalgia have active trigger points and 20% of patients with myofascial pain syndrome have fibromyalgia. Case Study 4 represents a case of fibromyalgia with myofascial pain of the neck. FLOAT NOT FOUND
Clinical History and Symptoms
The clinical history of patients suffering from neck strain ( Case Study 1 ) includes acute neck pain and stiffness, often with inability to perform daily tasks. There may be an inciting injury or recreational activity that has caused or aggravated the pain; however, strain may result simply from awkward positioning of the neck during the night or while cradling a phone. Patients suffering from neck strain often report only incomplete relief with rest and anti-inflammatory medications.
In contrast to the acute pain of neck strain, cervical spondylosis ( Case Study 2 ) has a more insidious onset, with axial neck pain often referred to the lower part of the head, the shoulder blades or the upper limbs, and which is aggravated by movement. This may be accompanied by paresthesias of the upper limbs and vertigo, which would suggest the presence of radiculopathy or myelopathy. Cervical radiculopathy ( Case Study 3 ) most commonly involves nerve root compression at the C5 to C7 levels, with segmental distribution of shooting pain, hyperesthesia, and numbness. Cervical myelopathy presents with symptoms similar to radiculopathy, but in addition, there are often reports of clumsiness of the hands, gait ataxia, and motor weakness with muscle wasting in the upper and lower extremities; bladder/bowel dysfunction may be present in severe cases. FLOAT NOT FOUND
The presentation of myofascial neck pain tends to be nonspecific with complaints of varied symptoms; however, there is usually a complaint of deep pain of the neck musculature which may fluctuate in severity. The onset is characteristically insidious but can sometimes be traced by the patient to a specific injury. There are often subjective reports of imbalance, dizziness, or tinnitus ; however, if these are clearly evident in an objective examination, then an alternative etiology would need to be sought. Finally, it must be remembered that certain symptoms such as nonmechanical neck pain, unintended weight loss, fever, or worsening neurologic deficits may be markers of possible neoplastic or infectious pathology, and urgent evaluation would be warranted.
The physical examination is primarily directed at excluding structural or mechanical etiologies, because the examination would be expected to be essentially normal with most causes of regional neck pain that are not associated with lateralizing neurologic symptoms. Inspection may reveal obvious bony deformities or soft tissue swelling. Next, palpation starts at the occiput and proceeds inferiorly to include the cervical vertebrae and paraspinal musculature, cervical lymph nodes, as well as the larynx and thyroid. In patients with cervical strain, whiplash, and myofascial neck pain, palpation of the cervical and paraspinal musculature will reproduce pain in varying degrees. Each of the classic cervical trigger points should be assessed, especially if myofascial pain is suspected.
Cervical motion is assessed with active and passive range of motion in extension, flexion, lateral flexion, and rotation. Most patients with regional neck pain have some restriction in range of motion; however, the significance of this is uncertain as studies have shown that there is great variation in range of neck movement even among normal individuals ; substantial global loss of motion is suggestive of significant articular disease, as seen in the inflammatory arthritides.
A thorough neurologic evaluation is warranted, especially when there are specific neurologic complaints. In cervical radiculopathy and myelopathy, neurologic examination alone often pinpoints the level of nerve root or spinal cord involvement, and the commonly involved nerve roots result in typical deficits. Radiculopathy of the third cervical root, between the second and third cervical vertebrae, which innervates the suboccipital region, causes pain to the posterior region of the head often extending to the ear. Radiculopathy of the fourth cervical root causes numbness and pain to the neck and superior shoulder; involvement of the fifth cervical root presents with numbness and pain at the superior shoulder to the lateral arm, which often presents as shoulder pain but with normal range of motion. Motor deficits are also common: the deltoid muscle is innervated by the fifth nerve root; the diaphragm is innervated by the third, fourth, and fifth nerve roots; hence, radiculopathy of these roots may result in paradoxical breathing patterns ; and the fifth and sixth nerve roots innervate the biceps, thus affecting the biceps reflex when they are involved. Radiculopathy of the sixth cervical nerve root results in pain and numbness from the lateral neck to the lateral arm and to the dorsal web space between the thumb and index finger, and may involve weakness of the wrist extensors and supinators; thus, the brachioradialis and biceps reflexes may both be diminished, as illustrated by Case 3.
The seventh cervical nerve root is the most commonly involved level in cervical radiculopathy. With involvement at this level, radicular symptoms and pain are felt from the posterior shoulder along the triceps and dorsum of the forearm to the dorsum of the index finger. The triceps, wrist flexors, and finger extensors may be weak, and the triceps reflex may be diminished. The Spurling test is a test for nerve root compression ( Fig. 25-3 ). With the patient seated, downward pressure is uniformly applied by the examiner to the patient’s cranium while the head is gently rotated toward the side of the suspected lesion. The test is positive if there is immediate pain or paresthesias radiating to the upper limb.
In contrast to radiculopathy, the presentation of cervical myelopathy can be variable. Motor weakness and wasting of the upper and lower extremities is common. Sensory deficits may include diminished pain, temperature, proprioception, and vibration perception. The combination of muscle weakness and sensory loss often results in a broad-based unsteady gait. The confirmatory signs of upper motor neuron lesions include brisk reflexes, clonus, and the presence of pathologic reflexes such as the extensor plantar response and the Hoffman reflex, wherein tapping of the terminal phalanx of the third or fourth finger results in reflex flexion of the terminal phalanx of thumb.
When evaluating pain radiating from the neck to the arm, alternate diagnoses always need to be kept in mind. For example, a suspected case of radiculopathy with reported severe shoulder pain may in fact be due to rotator cuff or glenohumeral joint disease; similarly, peripheral nerve entrapments often mimic radiculopathy. In cases of severe pain radiating down the arm, myocardial infarction, of course, needs to be considered in an at-risk population.
Individuals presenting with “red flag” symptoms associated with neck pain including trauma, a history of cancer with night neck pain, fever, chills, unexplained weight loss, a history of recent systemic infection or of a recent invasive procedure, progressive neurologic dysfunction, or bowel or bladder dysfunction, require imaging without delay ; for other patients with neck pain, especially those with myofascial neck pain, imaging studies are often not a part of the initial diagnostic evaluation. When imaging is deemed necessary, plain radiographs are often the first modality obtained. However, as mentioned earlier, degenerative changes including intervertebral disc space narrowing, osteoarthrosis of facet joints and osteophytes are common in individuals without cervical pain, and therefore, their presence does not necessarily imply a source of pain. The diagnosis of whiplash is made on clinical grounds; imaging studies are not helpful as they are normal in most cases.
Magnetic resonance imaging (MRI) is the test of choice when cervical radiculopathy or myelopathy is a concern; however, there are no objective guidelines defining when such imaging is warranted ; reasonable indications for prompt MRI testing include the presence of any “red flag” symptoms, suspicion of cancer or infectious process, or progressive neurologic decline. As is the case with standard radiography, the detection by MRI of abnormalities such as disk herniation and spinal cord impingement and compression are common incidental findings even in asymptomatic patients, and thus do not alone assign a structural etiology to neck pain.
Computed tomography (CT) is useful to evaluate bony conduits through which the neural structures pass and can distinguish the magnitude of bony spurs, foraminal encroachment, or ossification of the posterior longitudinal ligament. CT myelography, the addition of intrathecal contrast material to CT, provides accuracy that is at least comparable to MRI in distinguishing osseous from soft tissue etiologies of impingement and in identifying foraminal stenosis.
Treatment of cervical strain or sprain and of myofascial neck pain is directed at palliating symptoms. Local modalities include electrotherapy, cold or heat application, and local anesthetics. Conventional pharmacologic therapy for musculoskeletal pain includes nonsteroidal anti-inflammatory drugs (NSAIDs), muscle spasmolytics, antidepressants, and opioid and nonopioid analgesics. NSAIDs have been found to be useful for the treatment of neck pain; however, long-term use for this indication may entail the risk of renal and gastrointestinal adverse effects. There is no evidence that any particular NSAID is superior to others with regard to pain relief, however, patients who are refractory to one NSAID may obtain relief after switching to another NSAID class. Finally, attention to behavioral issues, though often overlooked, may provide important adjunctive relief. For example, lifestyle factors may contribute to a chronic cycle of cervical strain and myofascial pain. Postural and ergonomic modifications, both at home and at work, and stress reduction through biofeedback, meditation or progressive relaxation techniques may be helpful, though there are few controlled studies to support these approaches. There is evidence that stretching exercises, supervised by a physical therapist, may improve pain and function in the myofascial pain syndromes, and have become a primary therapeutic modality for addressing myofascial pain.
Injections of trigger points with lidocaine, or occasionally with glucocorticoids, have been used as second line therapy in conjunction with stretching exercises to augment their effect, though their long-term efficacy is unproven. Most practitioners who employ this modality suggest that their efficacy may be optimized if the injections are preceded and immediately followed by manual muscle trigger point release techniques and stretching exercises. 14 Other less conventional therapies for myofascial pain that have been advocated include botulinum toxin type A injection, which may reduce pain and palpable muscle firmness in individuals with chronic pain, although the literature is conflicting regarding its efficacy, and acupuncture, which has been evaluated in myofascial pain and fibromyalgia, but less extensively in nonspecific neck pain.
Treatment for acute whiplash is focused on palliating symptoms, improving function and preventing chronicity. Conservative measures such as a cervical soft collar, passive physical therapy, and rest have been shown to be inferior to programs that reinforce return to normal activities and active mobilization exercises. There is no consensus regarding whether chronic whiplash exists as a discrete syndrome, nor what the source of chronic pain is in this condition ; hence, there is a paucity of controlled studies that evaluate treatment approaches. Nevertheless, there is some evidence that neurotomy of the facet innervation may provide effective pain relief in chronic whiplash, whereas intra-articular injections have been found to be ineffective. There are no data confirming the use of exercise regimens in chronic whiplash, although it is believed to be of significant clinical value.
Initial management of cervical spondylosis is generally conservative, with the goal of reducing pain and inflammation. NSAIDs, opiates, muscle relaxants, and antidepressants have been used empirically, as have soft cervical collars, although clinical studies are lacking. Nonetheless, 45% to 60% of patients with cervical spondylosis and symptoms of neck pain or radiculopathy will have resolution of symptoms with conservative therapy alone. Additional modalities that may be helpful include epidural corticosteroid injections and physical therapy regimens that include isometric exercises and active range of motion maneuvers. In contrast, systematic reviews suggest that cervical traction and acupuncture may be ineffective in cervical spondylosis.
Indications for surgical intervention in spondylosis are often specific to the clinical situation. Patients with progressive or disabling neurologic dysfunction are typically considered for early surgery, whereas uncomplicated disease is usually treated conservatively. In general, operative intervention is appropriate for these patients if they have severe persistent pain that has a significant adverse effect on function or lifestyle and that has failed a reasonable trial of conservative management. The duration of conservative management prior to considering surgery depends on the patient’s situation; 12 months may be reasonable in uncomplicated cervical degenerative disease, whereas 3 months may be more appropriate for persistent cervical radiculopathy. It is important to correlate the clinical history and examination with diagnostic imaging when contemplating surgical intervention for neck pain, because the risk-benefit analysis must include the possibility of structural anomalies that are unrelated to symptoms. Finally, damage to the spinal cord, as in myelopathy, is often permanent despite surgical intervention, whereas symptoms may progress after surgery.
Neurovascular and Referred Neck Pain
Syringomyelia and thoracic outlet obstruction are neurovascular conditions in which neck pain may be a prominent feature. Syringomyelia refers to the development of a fluid filled cyst in the spinal cord, and may result from a congenital cerebellar defect, the so-called Chiari I malformation, or from acquired etiologies such as tissue damage from trauma, infection, or tumor. Over time, the syrinx may expand and compromise neurological function. Neck pain and stiffness may be early symptoms of the process, but neurologic deficits become manifest with progression. Diagnostically, MRI is highly sensitive for detecting the presence of a syrinx. Thoracic outlet syndrome occurs when nerves, vessels, or both are compressed due to anatomic abnormalities, trauma, or major changes of body habitus such as weight gain. Neck pain associated with numbness, paresthesias, and occasionally discoloration of the skin of the hands and fingers is frequently associated with thoracic outlet syndrome; this can be differentiated from intra-articular or periarticular etiologies of neck pain because they do not cause vascular changes.
In light of its central location, the neck can be a site of pain referred from the anterior neck, thorax, heart, stomach, and diaphragm. Thyroid disorders, laryngitis, tracheitis, esophageal obstruction or dysmotility, cardiogenic pain from acute coronary syndrome or pericarditis, and carotid artery disorders such as carotidynia or dissection can each be a source of neck pain, and should be considered when the clinical presentation is appropriate.
REGIONAL DISORDERS OF THE SHOULDER
Shoulder pain is a malady that affects all ages and occupations. As with all musculoskeletal disorders, the approach to diagnosis and treatment depends on an understanding of the underlying anatomy and on identifying the source of the pain. The shoulder region consists of the glenohumeral and acromioclavicular joints, as well as the scapulothoracic and even the sternoclavicular joints, along with the surrounding musculature and tendons. The shoulder is commonly involved in inflammatory polyarthropathies, and intra-articular structural derangement is common; nonetheless, periarticular disorders represent a much more common source of shoulder pain in adults. Periarticular syndromes, the focus of this discussion, may emanate from the structures that comprise the rotator cuff, from the bursae, or may be manifestations of referred pain from peripheral nerve, plexus, nerve roots, or the spinal cord. Table 25-2 is a brief list of differential diagnoses to consider in patients presenting with shoulder pain.
A 27-year-old woman with no past medical history presented with right lateral shoulder pain. She stated that the pain began three weeks previously and did not resolve with rest and anti-inflammatory medications. The patient assumed that this was a muscle strain and treated herself with a heating pad but without relief. There was no history of injury or sports participation, but the patient had recently painted her apartment. She denied any history of swelling, loss of function or numbness in the arm or shoulder.
The right shoulder was normal to inspection. Palpation of the greater tuberosity elicited tenderness. There was no apparent effusion, warmth or erythema of the shoulder. Passive range of motion was full and pain free; active range of motion elicited shoulder pain at abduction above 90 degrees but the patient was able to raise her arm to 160 degrees. Tests of shoulder impingement (Hawkin’s and Neer’s) were positive, but the drop arm test was negative.
No imaging was performed.
A healthy 64-year-old man presented with left shoulder pain of 7 months’ duration. The patient recalled traveling at the time of onset but denied trauma or any precipitating event. Approximately 4 months previously, radiography of the painful shoulder was reportedly normal. The pain progressed, and at the time of the visit was present at rest, worse at the end of the day, and was waking him at night. He denied symptoms of numbness or swelling. He was substantially limited in his ability to lift heavy objects and to comb his hair with the right hand. Shoulder exercises and ibuprofen provided only mild pain relief.
Inspection of the left shoulder revealed mild atrophy posteriorly. Passive flexion yielded audible grating and palpable crepitus. There was no swelling or erythema of the glenohumeral joint. Passive range of motion was mildly limited at the extremes and painful; active range of motion was more limited, with abduction to 90 degrees and external rotation to 60 degrees. Tests of shoulder impingement (Hawkin’s and Neer’s) and the drop arm test were positive.
Radiography ( Fig. 25-4 ) revealed normal glenohumoral joint space, a subacromial osteophyte, and no apparent soft tissue swelling.
MRI was remarkable for a full-thickness tear of the rotator cuff at the supraspinatus, with impingement of the acromial osteophyte on the supraspinatus.
A 63-year-old woman with a history of ovarian cancer 10 years previously and of diabetes presented with left shoulder pain that had been present for 6 months and was described as diffuse throughout the shoulder region and radiating to the upper back. She could not lie on the left side because of pain in the shoulder. There was a sensation of increasing “stiffness” during the past 2 months, and she was no longer able to lift the left arm as high as her right arm. She had no history of arthritis or trauma.
The left shoulder was normal to inspection. There was mild diffuse tenderness throughout the shoulder, but no palpable effusion. Significant reduction in active and passive range of motion of the left shoulder was appreciated: passive abduction was 40 degrees, passive external rotation was 10 degrees, and passive internal rotation was 15 degrees.
Radiography of the left shoulder was normal.
A 55-year-old woman with a history of osteoporosis and diabetes presented with anterior left shoulder pain of two months’ duration. The pain was described as a chronic, aching pain that was aggravated with minor lifting but was not present at rest. While describing the pain, the patient pointed to one area of the anterior shoulder where the pain was the worst. There was no history of arthritis or trauma, nor had the patient noticed swelling or redness of the shoulder. Ibuprofen provided incomplete relief.
Inspection of the left shoulder was normal. There was focal tenderness at the bicipital groove, which was exacerbated by resisted flexion of the elbow. Pain was also present with passive and active shoulder extension, but there was little limitation to motion. Speed’s and Yergason’s tests were positive.
No imaging was performed.
The shoulder may be involved in virtually all of the inflammatory polyarthropathies, and the etiology of the shoulder pain itself is usually obvious from systemic findings; isolated shoulder pain without associated disease is unusual. In all patients who are older, as well as those with a history of inflammatory or degenerative arthritis, articular disease of the glenohumeral and acromioclavicular joints should be considered in the differential diagnosis of shoulder pain. Whereas shoulder involvement in patients with systemic inflammatory disease is not usually subtle, osteoarthritis of the shoulder may be neglected because osteoarthritis is often assumed not to have a predisposition for the shoulder. Nonetheless, glenohumeral osteoarthritis is common, especially in the elderly and in individuals with a prior history of significant shoulder trauma. Osteophytes that develop in acromioclavicular osteoarthritis may be a source of chronic friction to the overlying rotator cuff, and may be especially common in degenerative rotator cuff disease in the elderly. In cases of osteoarthritis of the shoulder, the presenting history typically includes an insidious course with gradual worsening of pain over time and with limitation in range of motion and in function. Palpable effusion may be present at the glenohumeral joint, and radiography reveals typical signs of osteoarthritis. Other intra-articular pathologies that must be considered in the differential diagnosis include crystalline arthropathy, avascular necrosis, neuropathic arthropathy, and damage to the articular cartilage such as a torn labrum.
Periarticular processes are a major cause of shoulder pain and are the focus of this section. The etiology of periarticular pain may be related to derangement of the soft tissues surrounding the joint, including the bursae, tendons, or muscles, or alternatively it may be of distant origin, with pain referred to the shoulder. The tendons and muscles surrounding the shoulder, in combination with the glenohumeral synovium, form the rotator cuff and the shoulder capsule. The rotator cuff is composed of the interconnecting tendons of four muscles, the supraspinatus, infraspinatus, subscapularis, and teres minor. These muscles surround and stabilize the humeral head against the glenoid fossa, while also functioning to provide rotation and abduction of the arm. Owing to their stabilizing function, these muscles and tendons sustain repetitive action and high loading, and injuries to these structures represent a common source of shoulder pain. Although trauma or overuse cause injury, shoulder pain from apparently spontaneous rotator cuff dysfunction is common. Rotator cuff tendonitis occurs when there is disruption or inflammation of the rotator cuff tendons. Clinically, tendonitis is difficult to distinguish from incomplete tears of the rotator cuff, whereas complete rupture has specific clinical findings (see later). In light of the similarity of presentation, the entire spectrum of subacromial space lesions, including partial thickness rotator cuff tears, rotator cuff tendonitis, calcific tendonitis, and subacromial bursitis is sometimes considered as a single syndrome, the chronic impingement syndrome or painful arc syndrome .
Case Study 5 is a case of rotator cuff tendonitis, and Case Study 6 illustrates a rotator cuff tear. Younger, athletically active individuals may suffer traumatic or acute tears of the rotator cuff, often accompanied by acute pain and local swelling. In contrast, among middle-aged and elderly patients rotator cuff tears most frequently result from age-related tendon degeneration and chronic mechanical impingement. As is the case with all tendons, the rotator cuff tendons are poorly vascularized, which renders them especially susceptible to minor injuries; moreover, during the degenerative processes of aging, the tensile strength of the collagen fibers is diminished, and the tendons may be further impaired by chronic traction over osteophytes at the acromioclavicular joint. Degenerative tears begin as partial thickness and generally originate in the supraspinatus tendon. As they progress anteriorly or posteriorly, they may transform to full-thickness tears, especially among individuals over 60 years of age. FLOAT NOT FOUND FLOAT NOT FOUND
The bursae of the shoulder that are frequently painful and develop bursitis include the subacromial bursa, subdeltoid bursa, and less commonly the scapulothoracic bursa. Bursitis may be diagnosed by exquisite pain elicited by pressure exerted directly over the involved bursa and by pain on active motion across the bursa. Bursitis in the shoulder region is usually idiopathic, and the association between rotator cuff tendonitis and subacromial bursitis is sufficiently strong that the two are often considered to be clinically synonymous; in contrast, secondary bursitis in the shoulder due to trauma, infection, crystalline arthropathy, or rheumatoid arthritis is not as frequently encountered.
Adhesive capsulitis or frozen shoulder , as illustrated by Case Study 7 , is a process that appears to occur only in the shoulder and involves the progressive restriction of passive and active range of motion in all planes, usually associated with significant pain. The pathogenesis of primary capsulitis remains unclear; however, it is known that synovial cytokine levels are elevated in the capsule of patients with adhesive capsulitis. Adhesive capsulitis associated with an identifiable intrinsic, extrinsic or systemic etiology is referred to as secondary capsulitis; examples of such conditions include trauma, the postsurgical state, prolonged shoulder immobilization, as well as metabolic diseases, such as diabetes and hypothyroidism. FLOAT NOT FOUND
In addition to the shoulder structures themselves, periarticular shoulder pain may stem from tendons that insert at the shoulder but function distally. Case Study 8 demonstrates a case of bicipital (biceps) tendonitis. This syndrome refers to inflammation of the long head of the biceps tendon, generally focused on its course in the bicipital groove of the anterior humerus. Primary isolated bicipital tendonitis typically results from overuse injuries such as repetitive lifting in weightlifting or overhead reaching as in pitching baseballs. These repetitive actions lead to inflammation and microtears. More commonly however, bicipital tendonitis results from chronic subacromial impingement occurring in association with rotator cuff tendonitis and glenohumeral instability. In the setting of a chronically inflamed tendon or in elderly patients, the tendon can rupture spontaneously. FLOAT NOT FOUND
Clinical History and Symptoms
Rotator cuff tendonitis ( Case Study 5 ) in young individuals is frequently a result of a sports-related injury. High-risk activities include those in which the arm is repeatedly held in an overhead position such as basketball, tennis, or swimming. In contrast, among older individuals, a history of repetitive motion above the shoulder level or of recent strenuous unaccustomed arm activity is common, although idiopathic rotator cuff tendonitis may be most common. In both cases, typical symptoms include aching pain in the lateral aspect of the upper arm that cannot be localized to a single site, but is exacerbated by raising the arm over the head or by lying on the affected side.
Individuals with rotator cuff tears ( Case Study 6 ) experience pain and stiffness that are exacerbated with extremes of motion; in addition, pain at night while lying on the affected side is characteristic. Difficulties with daily activities that involve rotation of the shoulder, such as combing one’s hair, hooking a bra strap, or reaching into a back pocket, are common. Patients with chronic rotator cuff tears may experience recurrent lateral shoulder pain of several months’ duration, usually without a history of trauma; symptoms typically are exacerbated with activity, though the clinical presentation is variable.
Adhesive capsulitis ( Case Study 7 ) typically presents with gradual onset of pain followed by loss of motion. Classic adhesive capsulitis has been classified into three stages, each of approximately 6 months duration: initially, the “freezing” stage is characterized by insidious pain onset and limitation of shoulder range of motion; this is followed by the “frozen” stage, wherein pain subsides but range of motion becomes markedly restricted; finally, during the “thawing” stage, range of motion slowly improves, often requiring 12 to 24 months for full resolution.
Bicipital tendonitis ( Case Study 8 ) presents with anterior shoulder pain that is exacerbated by activities that involve lifting and overhead reaching. The point of maximal tenderness follows the bicipital groove, in contrast to the pain of rotator cuff tendonitis or of tears, which is more laterally focused. However, because there is a strong association of bicipital tendonitis with rotator cuff tendonitis, there may be a great deal of overlap in the clinical history provided by patients with each condition.
Physical Examination of the Shoulder
Inspection of the shoulder begins with an evaluation for abnormal contours, asymmetry, and for the presence of bony prominences. Although no visual abnormalities are expected in cases of acute rotator cuff tendonitis or bicipital tendonitis, chronic rotator cuff tendonitis or tears may present with visible loss of muscle bulk posteriorly, indicating atrophy of the supraspinatus and infraspinatus muscles. Palpation of the clavicle determines whether there is tenderness, swelling, or instability of the acromioclavicular or sternoclavicular joints, as well as yield information about the glenohumeral joint. Palpation of the anterolateral portion of the acromion and of the greater tuberosity of the humerus may reveal tenderness of the subacromial bursa or of the rotator cuff; bursitis may be characterized by point tenderness over the bursa which is exacerbated by exertion of the overlying muscles. The glenohumeral joint should be palpated for evidence of effusion and for tenderness, and the bicipital groove, approximately 2 to 3 cm inferiorly from the anterolateral tip of the acromion, should be examined for tenderness of the bicipital tendon. Finally, the cervical vertebrae and the muscles of the neck should be examined for tenderness and for myofascial pain, as well as for evidence of primary pathology that may refer pain to the shoulder.
Range of motion of each shoulder is evaluated passively and actively for abduction, forward flexion and external and internal rotation ( Fig. 25-5A-C ). With the elbow placed at the side, the normal maximal external rotation may vary from 45 to 90 degrees and internal rotation from 55 to 80 degrees; with the shoulder abducted to 90 degrees and the elbow flexed at a right angle, both internal and external rotation should be 90 degrees. Typically, passive range of motion is not restricted by periarticular disorders unless there is adhesive capsulitis, whereas active motion is restricted either by pain or by injury to the soft tissues; in contrast, intra-articular pathology is associated with limitations of both passive and active motion. Impingement syndromes may be detected by the presence of a painful arc as the patient raises the arm in abduction; pain onset at abduction angles between 60 and 180 degrees is characteristic of impingement syndrome.