CLINICAL REVIEWS Painful Shoulder Syndromes: Diagnosis and Management DAVID L. SMITH, MD, STEPHEN M. CAMPBELL, MD SHOULDER PAIN is the third most c o m m o n complaint of patients consulting primary care physicians.t Although cervical, intrathoracic, or subdiaphragmatic disorders may cause referred pain in the shoulder region, painful motion of the shoulder usually signifies periarticular abnormality or inflammation, most c o m m o n l y supraspinatus tendinitis/subacromial bursitis, rotator cuff tendon tears and rupture, bicipital tendinitis, and adhesive capsulitis. While these disorders are sometimes difficult to differentiate, a knowledge of shoulder anato m y and essential topographic landmarks permits a careful clinical assessment that directs further diagnostic and therapeutic decisions.

down in the glenohumeral fossa, minimizing impingement on the inferior acromial shelf during 6 0 - 120 ° of abduction (Fig. 4).4, 5 Consequently, c o m p l e t e abduction requires both contraction of the overlying large deltoid muscle and functional integrity of the supraspinatus muscle. Although numerous bursae are present in the shoulder region, most investigators agree that the subacromial bursa, situated d e e p to the deltoid muscle belly and superficial to the insertional point of the supraspinatus tendon at the greater tuberosity, accounts for most "bursitis" syndromes. 6"8 The normal bursa's synovial fluid lining provides lubrication and maximizes gliding 9 for the deltoid muscle and the supraspi-

ANATOMY OF THE SHOULDER Although the glenohumeral articulation is the principal joint for shoulder motion, the sternoclavicular (SC) and acromioclavicular (AC) joints facilitate c o m p l e t e abduction to 180°. 2 A c o m p l e t e painless shoulder arc depends u p o n normal functioning of these joints, p r o p e r positioning o f the humeral head in the glenohumeral fossa, and a normal functional relationship of surrounding shoulder muscles and structures (Figs. 1 and 2).3 The glenohumeral joint is a synovialfluid-lined articulation surrounded by a fibrous joint capsule. The shallowness of the glenohumeral fossa maximizes humeral head mobility but reduces shoulder stability. The rotator cuff, a descriptive term applied to a group of scapulohumeral rotator muscles, consists of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles. These muscles originate on either the superior or the inferior aspect of the posterior scapula; their tendons blend i m p e r c e p t i b l y with the shoulder joint capsule and insert on either the greater or lesser humeral head tuberosity (Fig. 3).3 The primary function of these muscles is to maintain traction on the humeral head during abduction or to produce rotation. Contraction and resultant tendon stress of the supraspinatus muscle hold the humeral head

Receivedfrom the Oregon Health SciencesUniversity,Sections of General Medicine (DLS)and Rheumatology(DLS,SMC), Portland Veterans AffairsMedical Center, Portland, Oregon. Address correspondence and reprint requests to Dr. Smith: VA Outpatient Clinic (111-OPC), 8909 SWBarburBoulevard,P.O. Box 1036, Portland, OR 97207. 328

Supraspinatus

Subacromial Bursa

- Subscapularis

FIGURE 1. Anterior drawing of the right shoulder highlighting the normal relationship of the rotator cuff muscles, the insertional point of the supraspinatus muscle's tendon on the humeral head greater tuberosity. and the location of the subacromial bursa deep to the deltoid muscle belly and just superficial to the supraspinatus tendon.

JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (May/June), 1992 natus tendon, especially during the middle phase (60 120 o ) of shoulder abduction. Supraspinatus muscle tendon and bursal inflammation or calcification can impede this gliding ability, resulting in painful active abduction. Figure 5 depicts the readily palpable landmarks of the shoulder region. The shoulder region may be the site of referred pain originating from other areas of the body. A comm o n cause is C5 cervical root radicular pain, usually perceived over the superior shoulder and lateral arm. 1o Another neurologic cause is compression or entrapment of a peripheral nerve such as the median nerve, causing carpal tunnel s y n d r o m e ) ~ Other examples of referred shoulder pain are intrathoracic conditions such as an apical lung tumor, pleural disease, or myocardial ischemia, and subdiaphragmatic or diaphragmatic irritation from gallbladder disease, tumor, abscess, or p n e u m o p e r i t o n e u m . The neurovascular supply to the shoulder is complex. The neural fibers of the shoulder capsule, tendons, and subacromial bursa derive from embryonic C5 elements; irritation o f these fibers triggers pain that frequently radiates to the C5 dermatomal distribution (superior shoulder and lateral arm). 12 Impaired blood flow to a hypovascular "critical z o n e " of the distal su-

Acro

S u.b /J~c r o~j

Infraspinatus~

inor

.s~lrBU~aatus

~

~

me eS sobs,

Te~esr

Subscapularis

FIGURE 3. Sagittal view of the right shoulder.Noticethe position of the rotator cuff musclesand their tendons surroundingand blending with the joint capsule.Also notice the relationshipof the supraspinatus tendon and the subacromialbursawith the acromion.

Acromion

Supraspinatus tendon

Subacromial~

Deltoid ~ / / ' / / ~ /

is

329

" °i:!~!

FIGURE4. Anterior view of the right shoulderat 60 ° of abduction. Noticethat the supraspinatustendon and the subacromialbursa beginto approach the inferior aspect of the acromial shelf; when edematous, inflamed, or calcified,tissue can be compressedbetweenthe tuberosity and the anterior acromion. praspinatus t e n d o n at or near its insertional area may cause degeneration of the supraspinatus tendon, leading to either chronic tendinitis or t e n d o n tear/ rupture. ] 3

DIAGNOSTIC APPROACH TO PAINFUL SHOULDER SYNDROMES

FIGURE Z. Posteriorview of the right shoulderdepictingthe normal position of the supraspinatusmusclebelly, its tendon blendingwith the superioraspectof thejoint capsuleto insert;on the greatertuberosity. Noticethe darkenedcircle,which depictsthe landmarkfor posterior injection of the shoulderjoint (shoulderinternally rotated: middle of lateral third of scapularspinejust beneathspine: needledirected anteriorly).

The prime aim o f the history and shoulder region examination is to recognize referred causes of shoulder pain, clinically assess the integrity of the supraspinatus and bicipital tendon and joint capsule, identify corresponding periarticular tender points, and recognize malalignment or malfunction of the glenohumeral and AC joints. The clinician should elicit any history of trauma and a careful description of the pain, including m o d e of onset, precipitating or aggravating factors, du-

Smith, Campbell, PAINFULSHOULDERSYNDROMES

330

Inspection. The e x a m i n e r should inspect the AC and SC joints, noting swelling or asymmetry, w h i c h usually signifies an effusion, degenerative arthritis, or separation. Localized subacromial swelling indicates a c c u m u l a t i o n of subacromial bursal cavity fluid, w h i l e p r o m i n e n t anterior shoulder swelling suggests a glenohumeral joint effusion or malalignment (e.g., dislocation). Deltoid m u s c l e a t r o p h y indicates disuse f r o m a prior rotator cuff (supraspinatus) tendon r u p t u r e or joint i m m o b i l i t y from adhesive shoulder capsulitis.

FIGURE 5. Anterior view of a radiograph superimposed upon a photograph of the left shoulder. Normal-joint/bony anatomic relationships and topographical landmarks are demonstrated. The arrow above the acromioclavicular joint articulation depicts a readily palpable bony prominence. The arrow inferiorly directed 30 ° over the lateral subacromial area depicts the classic tender point for subacromial bursitis, supraspinatus tendinitis, or tendon tear/rupture. The arrow over the anterior glenohumeral articulation ( 1 cm inferior and 1 cm lateral to the palpable coracoid beak) depicts the area of tenderness seen with capsulitis and the point for anterior joint intraarticular aspiration or injection.

ration, progression, and the type of shoulder m o t i o n that elicits it. The examination includes c o m p a r i n g the a p p e a r a n c e s of the two shoulders, assessing passive (examiner-assisted) motion, and testing muscle strength, active range of motion, and m o v e m e n t against resistance.

~o

Motion Testing. Passive abduction is typically less painful than active m o t i o n b e t w e e n 60 ° and 120 ° for supraspinatus tendinitis or subacromial bursitis, since examiner-assisted m o v e m e n t p r e c l u d e s muscle contraction and tendon stress. In cases w i t h o u t trauma, unless severe pain or muscle spasm prevents motion, passive limitation in all planes indicates shoulder joint adhesive capsulitis. 14, 13 Pain beginning at 60 o to 70 o of abduction, or forward flexion, strongly suggests compression of subacromial tissue (e.g., bursal or tendon calcification) b e t w e e n the anterior acromial shelf and the humeral head greater tuberosity. 16 W h e n severe pain and guarding interfere w i t h passive m o v e m e n t , infiltrating the subacromial bursa area w i t h 5 mL of 1% lidocaine affords t e m p o r a r y anesthesia and facilitates testing the range of m o t i o n (Fig. 6). Active range of m o t i o n and resisted a b d u c t i o n testing at 90 ° permits evaluation of the supraspinatus tendon integrity. 17 W h e n the strength of resisted abduction at 90 ° is equivalent to that in the u n i n v o l v e d shoulder, the tendon is intact. On the other hand, weakness with active or examiner-resisted a b d u c t i o n at 90 ° strongly suggests a supraspinatus tendon partial or c o m p l e t e tear (rupture). Anesthetic subacromial infiltration diminishes pain, but a b d u c t i o n weakness per-

160° (forward)]

/

J

50° adduction

extension

ha'

~"70 o internal rotation

FIGURE 6. Normal shoulder motion in typically described planes. Note that forward flexion may be described as forward elevation.

JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (May/June), 1992 TABLE 1 Frequencies (%)* of Specific Painful Shoulder Conditions Subacromial bursitis/supraspinatus tendinitis Bicipital tendinitis Supraspinatus tendon tear or rupture Adhesive shoulder capsulitis Acromiodavicularjoint osteoarthritis Other/undear

60 4 10 12 7 7

*Frequencies of specific painful shoulder conditions are based on a computation of 160 evaluable unselected casesdescribed in three reports (Symonds MB. J lnt Med Res. 1975;3:261-6; Kessel L, Watson M. J Bone Joint Surg 1977;59:166-72; Chard M, Hazleman B. Ann Rheum Dis. 1987;46:684-7) where a distinctive painful shoulder disorder was diagnosed. Duration of symptoms was not addressed; impingement syndrome (see the text) may also have been present in the tendinitis/bursitis groups.

sists. Isolated bicipital t e n d o n inflammation is p r e s e n t w h e n t h u m b r o l l i n g o v e r the t e n d o n sheath elicits tenderness w i t h 90 ° o f e l b o w flexion c o m b i n e d w i t h resisted f o r e a r m supination. 18-21

Palpation. Palpable tenderness o v e r the d e l t o i d region, just lateral to t h e a c r o m i a l shelf, is nonspecific, since it m a y o c c u r w i t h s u b a c r o m i a l bursitis and supraspinatus t e n d o n inflammation tear or r u p t u r e , x7,22 W h e n p a l p a t i n g the anterior s h o u l d e r region, the examiner s h o u l d distinguish bicipital t e n d o n s h e a t h tenderness f r o m a n t e r i o r s h o u l d e r joint line ( c a p s u l e ) tenderness, o r AC joint tenderness.

Salient Features of Common Painful Shoulder Syndromes Subacromial

Bursitis/Supraspinatus

Tendin-

r e g i o n is tender, c o m p a r e d w i t h that o n the u n i n v o l v e d side. I m p i n g e m e n t o f s u b a c r o m i a l tissue ( s u c h as an e d e m a t o u s , inflamed, or calcified supraspinatus tend o n or bursa) o n the inferior aspect o f the a c r o m i o n f r e q u e n t l y a c c o m p a n i e s these disorders. 4 I m p i n g e ment, b y definition, is c a u s e d b y repetitive t r a u m a or v i g o r o u s o v e r h e a d activities, p r o d u c e s r e c u r r e n t o r

TABLE 2 Helpful Distinguishing Clinical Features of Common Painful Shoulder Conditions Referred shoulder pain from cervical area (e.g., C5 radicuiar pain from nerve root encroachment)

Subacromiai bursitis and noncalcificsupraspinatus tendinitis

Bicipital tendinitis

Shoulder motion shows painless complete arc; no specific periarticular shoulder tender point, but muscle spasm may be present. Neck rotation or neck compression testing

typicallytriggers radicular pain distally in C5 dermatomal distribution. Painful shoulder motion, especially between 60 ° and 120 ° of active abduction, tender subacromial region; pain may partially radiate in C5 dermatomal distribution. Anesthetic subacromial infiltration can minimize pain during movement. Localizedanterior shoulder pain over long head of biceps tendon; with forearm supination, tendon sheath is tender with thumb rolling. Shoulder motion normal.

Supraspinatus tendon tear or rupture

Followingtrauma in younger patients, abrupt pain and

Adhesive capsulitis (frozen shoulder)

Gradual onset of diffusely painful shoulder, markedly restricted passive and active motion in all planes.

Acromioclavicular(AC)joint disorder

Shoulder arc painful but limited only during last 20 ° of abduction. ACjoint tender and prominent compared with contralateral side if separation or osteophytes are present. Impingementtypicallybegins at 60 ° to 70 o and is maximum between 100 ° and 120" of abduction. Recurrent pain from compression of subacromial tissue also occurs at 9 0 - 1O0° of forward flexion.

itis.

These t w o d i s o r d e r s , g r o u p e d t o g e t h e r since their clinical findings are virtually indistinguishable, r e p r e s e n t t h e m o s t c o m m o n clinical diagnoses (Table 1) .23 Both p r o d u c e gradually progressive, dull, subdeltoid area pain or a c h i n g that f r e q u e n t l y radiates d o w n the lateral arm. Abrupt, sharp, localized, s u b d e l t o i d p a i n a c c o m p a n i e d b y a history o f s h o u l d e r o v e r u s e m a y signify a m o r e a c u t e f o r m o f bursitis/tendinitis. O t h e r characteristic features are n o c t u r n a l w o r s e n i n g w h e n lying o n the i n v o l v e d side and aggravation o f p a i n w i t h the s h o u l d e r a b d u c t e d . Differentiating features o f this a n d o t h e r c o m m o n s h o u l d e r p a i n s y n d r o m e s are summ a r i z e d in Table 2. Examination findings d e p e n d o n the e x t e n t o f inflammation. I n s p e c t i o n u s u a l l y yields n o r m a l results unless c h r o n i c o r r e c u r r e n t s y m p t o m s lead to disuse and p r o d u c e p e r i a r t i c u l a r (e.g., d e l t o i d ) m u s c l e atrophy. In cases o f r e c e n t onset, passive r o t a t i o n and abd u c t i o n are n o r m a l unless pain and g u a r d i n g limit passing t h r o u g h 6 0 - 120 o o f a b d u c t i o n . Active a b d u c t i o n and examiner-resisted a b d u c t i o n at 9 0 ° t r i g g e r increased s u b d e l t o i d pain, b u t m u s c l e s t r e n g t h against resistance at 9 0 ° a b d u c t i o n is normal. The s u b a c r o m i a l

331

Impingement syndrome

weak or absent active abduction. More gradual onset of pain and weakness with tears in older patients. Anesthetic subacromial infiltration will reduce pain but absent or weak resisted abduction at 90 ° persists. Small tears may mimic tendinitis symptoms.

Smith, Campbell, PAINFULSHOULDERSYNDROMES

332 TABLE 3

PredisposingFactors or ClinicalConditionsAssociatedwith Adhesive ShoulderCapsulitis* Shouldertrauma, fracture, immobilization, or inflammation Avascular necrosis of humeral head Systemic inflammatory arthritis with shoulder involvement Scleroderma Intrathoracic abnormality/coronary artery disease Cervicaldegenerativedisc disease Reflexsympathetic dystrophy syndrome~ Central nervous system vascularevent or tumor Impaired state of consciousness Diabetesmellitus Thyroid disease *Adapted from: Risk TE, PinalsRS. Frozenshoulder.SeminArthritis Rheum. 1982; 11:440-52. tSome investigatorsbelieveadhesivecapsulitisis a variant or partial presentation of reflex sympathetic dystrophy syndrome.

chronic symptoms, and causes either a " c a t c h " or aggravation of pain from 6 0 - 70 o of abduction or forward flexion to 100 °.4, ~6, 24-27It is due to compression of the supraspinatus tendon or subacromial bursa between the anterior acromial arch and humeral head below. Impingement is more c o m m o n in internal rotation than in external rotation w h e n abducting or flexing since the tuberosity is more prominent.

Supraspinatus Tendon Tear or Rupture. In patients older than 50 years, diminished b l o o d flow to the supraspinatus tendon may cause t e n d o n degeneration and ultimately a tear or r u p t u r e ) 3, 22, 2s, z9 In younger patients with rotator cuff tendon damage, indirect shoulder trauma (e.g., falling on an outstretched arm), blunt direct shoulder trauma, and repetitive use are typical causes.22 The majority of tendon tears o c c u r just proximal to the insertional site. A supraspinatus tendon tear or rupture produces a range of findings reflecting the type of injury and the extent of tendon damage. Inspection reveals deltoid (and possibly supraspinatus) muscle atrophy if a large tear or rupture is undiagnosed for weeks or months. While a small tear is indistinguishable from supraspinatus tendinitis, a large tear or rupture produces marked weakness with attempted active or resisted abduction of the arm.3° A " d r o p a r m " sign, w h e n the arm drops toward the patient's side after the examiner abducts the arm to 90 ° and then releases it, is virtually diagnostic of a large tear or rupture. Palpation reveals subacromial region tenderness with either a tear or a rupture. Bicipital Tendinitis. Anterior shoulder bicipital tendon pain predominates, especially with biceps muscle contraction. Shoulder inspection, rotation, and abduction are normal, but palpation with t h u m b rolling over the bicipital t e n d o n and surrounding sheath with resisted forearm supination and e l b o w flexion causes exquisitely tenderness. 31 Palpating the contralateral t e n d o n allows a more precise estimate of the extent of

tenderness. The anterior leading edge o f the subacromial bursa can join with the bicipital sheath; subacromial bursitis and bicipital tendinitis findings can coexist and may even overlap.

Adhesive Capsulitis. Frozen shoulder, periarthritis, 32 and pericapsulitis 33 are other terms emp l o y e d to describe this only partially understood condition. Table 3 includes the important associated risk factors. Prospective studies show that an extensive period of impaired consciousness or a degree of hemiparesis are two important prognosticators of a p o o r outcome. 34 Capsule and synovial fluid histology demonstrate only scant inflammation, minimal synovial lining hyperplasia, and subsynovial tissue and capsule fibrosis. 33. 35 Adhesive capsulitis may be an incomplete or variant form of reflex sympathetic dystrophy syndrome. 36 Adhesive capsulitis is clinically defined by a progressive painful restriction of all shoulder joint motion. Early findings include diffuse shoulder stiffness coup l e d with painful, restricted passive and active movement. Over several months, stiffness and muscle guarding progress, both active and passive shoulder motion b e c o m e markedly restricted, but, with the attendant disuse, shoulder pain diminishes. Physical findings d e p e n d on the timing of patient presentation. Early findings are spasms of the scapular, pectoralis, and deltoid muscles c o m b i n e d with diffuse lateral and anterior glenohumeral joint capsule tenderness. 32 Anesthetic infiltration of periarticular tender points may diminish pain but does not improve passive shoulder motion; hence the term "frozen s h o u l d e r . " This condition varies over months or years; periods o f increasing and decreasing mobility are characteristic. A prospective study of 5 0 patients over a ten-year period demonstrated that spontaneous increased mobility, beginning with rotation and progressing to abduction, typically occurred; the mean recovery time was 30 months. 37 Pain d e v e l o p e d with the extremes o f shoulder motion, permanent motion impairment and disability were rare, and the m o d e of onset did not correlate with eventual motion limitation. Twenty-five of 41 patients had mild residual impairment, but only three patients had significant functional disability.

Imaging Modalities Employed to Detect Various Shoulder Conditions The majority of painful shoulder conditions can be identified on clinical grounds alone. The diagnosis o f a rotator cuff tear or rupture, however, is problematic. No study has prospectively evaluated the usefulness or the predictive value of the drop arm sign, motion weakness, or impaired abduction against resistance. A retrospective analysis suggests that physical signs o f a rotator cuff complete tear may not correlate well with the ex-

JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (May/June), 1992

333

tent of surgical findings. 3° An imaging modality, therefore, is warranted if a supraspinatus tendon tear is clinically suspected. Although contrast shoulder arthrography is the conventional study for evaluating tendon integrity, magnetic resonance imaging (MRI) accurately defines both tendon rupture and tendon tear and differentiates tendon injury from i m p i n g e m e n t syndrome.38 Arthrography or MR1 is occasionally indicated to confirm adhesive capsulitis.

Routine Radiography. Obtaining routine shoulder films ( $ 1 0 0 ) (imaging modality costs are c o m p u t e d as averages obtained from three Portland, Oregon, area medical centers plus professional fee) is a basic ancillary test. Periarticular calcification in the supraspinatus tendon or subacromial bursal region can be readily identified, but the clinical significance of calcification is unclear, since radiographic evidence of calcification does not necessarily i m p l y a s y m p t o m a t i c shoulder condition. 39 On the other hand, subacromial or supraspinatus tendon calcification may p r o d u c e acute or chronic shoulder pain; w i t h a p p r o p r i a t e clinical findings (e.g., i m p i n g e m e n t ) , radiographic evidence is virtually diagnostic.24, 3~Although noted infrequently, humeral head elevation in the g l e n o h u m e r a l fossa encroaching on the inferior a c r o m i o n signifies longstanding supraspinatus tendon dysfunction. A routine radiographic series will also depict the glenohumetal relationship for inflammatory or degenerative arthritis. W h e n the history indicates that trauma p r e c e d e d shoulder pain or loss of motion, x-rays of the shoulder a n d / o r the AC joint are warranted to e x c l u d e a shoulder dislocation, an AC joint separation, or a humeral head fracture with avulsion of the supraspinatus tendon. Arthrography. Arthrography ($320) is the "gold standard" for assessing supraspinatus tendon integrity (Fig. 7). With e x p e r i e n c e d interpreters, the use of arthrograms is very accurate (92% sensitivity, 98% specificity) for detecting partial or c o m p l e t e tears of the supraspinatus tendon. 4°-43 The test relies on intraarticular contrast injection (or double contrast w h e n air is also injected)44.45 and indirect visualization of the rotator cuff. Infrequently, i n c o m p l e t e supraspinatus tendon tears are f o u n d at surgery or p o s t m o r t e m despite a normal arthrogram; the bursal m e m b r a n e can seal off a small full-thickness tear or arthrography can fail to demonstrate partial tears involving only the bursal side. 43, 46, 47 In addition, a false-positive arthrogram for a tendon tear can lead to a t t e m p t e d surgical repair, but in such cases only a concavity in the tendon is found. 4s Several investigators also advocate arthrography to confirm adhesive capsulitis, since other shoulder conditions such as longstanding rotator cuff tears, recurrent calcific tendinitis, or r h e u m a t o i d arthritis actively

FIGURE 7. Anterior view of contrast arthrogram of the left shoutder. Dye in the subacromia[bursa (indicated by arrow) is pat~ognomonicfor a supraspinatustendon rupture: normallythe subacromialbursa cavity does not communicatewith the glenohumeraljoint articulation.

involving only the shoulder joint can m i m i c capsulitis.49, s0 In adhesive capsulitis, unlike these other disorders, arthrography demonstrates intact tendons and an adherent capsule with marked v o l u m e loss. 5~, 32 Arthrography causes discomfort, requires the expertise of radiologists or orthopedists, and is a p p r o p r i a t e w h e n clinical findings strongly suggest a tendon tear or, infrequently, w h e n clinical findings for adhesive capsulitis are equivocal.

Ultrasonography. This noninvasive t e c h n i q u e ( $ 1 2 0 ) can demonstrate rotator cuff tears, but it requires skilled interpretation. Small, c o m p l e t e tendon tears may not be seen with ultrasonography. 48 In one study c o m p a r i n g MRI and ultrasonography for rotator cuffs tears, ultrasonography was m u c h less accurate (63% sensitivity, 50% specificity). 43 The test is most useful for evaluating patients with large or i n c o m p l e t e tears on the bursal side .47. 53 Absent tendon m o t i o n w i t h passive abduction provides strong evidence of a complete tear. 54 In over 150 cases in three recent reports, the diagnostic accuracy of ultrasonography for tendon tears c o m p a r e d with that of arthrography or direct visualization ranged from 77% to 95%. 46. 53, 55 Computed Tomography and Magnetic Resonance Imaging. Currently, MRI p r o d u c e s m o r e detailed images than does CT in evaluating soft-tissue shoulder abnormality (Fig. 8). Although s h o u l d e r CT is less expensive and p r o b a b l y m o r e readily available ( $ 6 7 0 ) , MRI ( $ 9 0 0 ) better defines the shoulder cap-

Smith, Campbell PAINFULSHOULDERSYNDROMES

334

FIGURE 8. Anterior-view magnetic resonance imaging of the right shoulder. A 69-year-old patient with a two-month history of shoulder pain had tenderness in the subacromial area: marked weakness with attempted abduction was noticed on examination. The arrow indicates a supraspinatus tendon tear and a contracted muscle belly.

sule anatomy, the supraspinatous tendon integrity, the impingement syndrome, and the anatomy o f the subacromial bursa. 38, 43, ~6-62 Several reports, totalling more than 100 patients, indicate excellent correlation b e t w e e n the results of MRI of t e n d o n tears and the surgical findings. 38, 43, 6o MRI has a sensitivity of 92% and a specificity of 88 - 100% in identifying both i n c o m p l e t e and c o m p l e t e tears. Detection of inferior and subacromial-side partial tears is more difficult. 62 Other. Radionuclide isotope imaging (scintigraphy) lacks specificity for c o m m o n painful shoulder syndromes; its diagnostic usefulness is confined to infectious or neoplastic bone disease and reflex sympathetic dystrophy syndrome. 63, 64 As more radionuclide isotopes are developed and tested, scintigraphic imaging for c o m m o n shoulder pain syndromes may b e c o m e more useful. Arthroscopy, n o w available only by orthopedists with shoulder arthroscopy training, may become more widely applied since it provides direct visualization of the shoulder capsule joint and surrounding structures. Preliminary results of arthroscopy-assisted repair of c o m p l e t e rotator cuff tears are encouraging. 65

MANAGEMENT Therapy for painful shoulder syndromes should reduce pain, inflammation, or mechanical dysfunction and improve shoulder motion. Numerous case reports and retrospective trials endorse various treatments, but prospective, blinded, placebo-controlled comparative trials are limited. These studies indicate benefit (1) for tendinitis/bursitis with an intrabursal steroid injection or an oral nonsteroidal anti-inflammatory drug (NSAID), (2) conservative management for incomplete

tears of the supraspinatus tendon, (3) early surgical repair for m e d i u m or large supraspinatus tendon tears or ruptures, and (4) intraarticular steroid injection, c o m b i n e d with physical therapy, for adhesive capsulids. Overall, the management of c o m m o n painful shoulder disorders is optimal w h e n patients undergo treatment specifically tailored for a clearly diagnosed condition early in its course, receive a different therapy if the first option fails, and prevent recurrences by avoiding precipitating, aggravating, or associated risk factors.

Subacromial Bursitis/Supraspinatus Tendinitis/Bicipital Tendinitis The optimal medical management for these clinical syndromes is unclear, in part because they may be difficult to distinguish from each other or overlap with other shoulder disorders (e.g., small rotator cuff tear or early adhesive capsulitis), and because the natural histories of bursitis and tendinitis are uncertain. General e x p e r i e n c e suggests that they are usually self-limited but occasionally recurrent (perhaps associated with work or sports), and only a minority of patients develop long-term disability or the chronic impingement syndrome.2.4.66 A recent study, however, reexamined 137 patients with rotator cuff tendinitis a mean of 19 months after treatment with exercise, physical therapy, and local injection. 67 Only 39% were asymptomatic, 29% had mild residual pain, and 26% had active tendinitis. Thus the course of rotator cuff tendinitis and its response to therapy may not be as good as previously thought. Patients are usually advised to rest the shoulder and to avoid movement that aggravates or triggers severe pain. However, gentle range o f motion exercises

JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (May/June), 1992

such as C o d m a n ' s classic " p e n d u l u m " exercises are suggested to maintain range of motion and avoid adhesive capsulitis. P e n d u l u m exercises consist of flexing 90 ° at the waist, relaxing the u p p e r b o d y on a cushioned low table, and, using gravity and b o d y m o m e n tum, loosely swinging the arm like a p e n d u l u m . An arc of only a f e w degrees in abduction and abduction can b e gradually increased to a full circle. 6, x7 Fifteen to 30 minutes of exercise three to five times a w e e k is sufficient. There is no controlled study s u p p o r t i n g this, but, certainly, very aggressive exercise may worsen some kinds of shoulder lesions. 68 Moreover, no blinded controlled study has evaluated adjunctive physiotherapy measures (e.g., heat or ultrasound); several studies have suggested no additional benefit f r o m physiotherapy c o m p a r e d with steroid injections or NSAIDs alone.6S The mainstays of the medical m a n a g e m e n t of the bursitis and tendinitis syndromes have b e e n NSAIDs a n d / o r local corticosteroid injections. 2, 23, 69-72 Three recent p l a c e b o - c o n t r o l l e d double-blind studies have c o m p a r e d these modalities. The first, using a doubleblind d o u b l e - d u m m y protocol, s h o w e d no difference in efficacy at six weeks for indomethacin, 100 mg/day, c o m p a r e d with an intrabursal injection of triamcinolone acetonide, 40 mg; r o u g h l y two thirds of the evaluable patients in each g r o u p improved. 73 A r a n d o m i z e d second trial s h o w e d that b o t h naproxen, 1,000 m g / day, and an intrabursal injection of triamcinolone, 40 mg, w e r e superior to p l a c e b o at four weeks, that the intrabursal triamcinolone may be s o m e w h a t better than naproxen, and that the c o m b i n a t i o n of the two modalities was no better than either alone.74 Finally, b o t h diclofenac, 150 m g / d a y (30% response rate), and an intrabursal injection of triamcinolone, 80 m g (70% response rate), at four w e e k s w e r e superior to p l a c e b o (0% response rate).75 Toxicity in these controlled studies was minimal. The adverse effects of NSAIDs are well known. Potential complications of an intrabursal steroid injection include infection, postinjection flares of pain, softtissue atrophy, and damage to the collagen of tendons. 76 The incidences of these complications are u n k n o w n but p r o b a b l y very low. In the absence of definitive studies addressing the f r e q u e n c y and safety of repetitive steroid injections, a m a x i m u m of two or three injections spaced over one to two years is p r u d e n t advice. Clearly, no single " c o r r e c t " treatment of these syndromes exists. It seems reasonable to have the patient avoid activities that aggravate shoulder pain, primarily those that involve repetitive a b d u c t i o n or forward flexion, particularly u n d e r loaded conditions (e.g., carrying heavy loads, overhead throwing). Pendulum-type range-of-motion exercises also s e e m reasonable. Some form of physiotherapy (e.g., heat or cold) may afford s o m e s y m p t o m a t i c relief. O t h e r su-

33S

pervised modalities (e.g., ultrasound) are not recomm e n d e d because of their cost and the uncertainty about their additional benefit. The decision to use NSAIDs or injection therapy rests on clinical judgment. NSAIDs m a y be the first choice in treating a y o u n g p e r s o n w i t h mild or moderate s y m p t o m s and no contraindication to these drugs. An intrabursal steroid injection is appropriate for patients w h o have severe symptoms, w h o have had unsuccessful therapy w i t h NSAIDs, or w h o have contraindications to their use. W h e n there are s y m p t o m s of chronic i m p i n g e m e n t (e.g., f r o m intrabursal tendon calcification or osteophyte formation on the inferior a c r o m i o n ) , o r t h o p e d i c referral is suggested, especially in the m a n a g e m e n t of y o u n g e r patients w h o have s y m p t o m s that severely limit vocational performance. 4, t6 Many t e c h n i q u e s for intrabursal injection exist. The goal is to inject the subacromial bursa, n o t the underlying tendon. Because it may b e quite difficult to enter the true bursa, the t e r m " p e r i b u r s a l " injection is m o r e appropriate.77 One a p p r o a c h uses 20 mg of methylprednisolone acetate or triamcinolone acetonide m i x e d w i t h 4 - 6 mL of 1% lidocaine in a 10-mL syringe attached to a 1.5-inch 27-gauge needle. The lidocaine provides an adequate v o l u m e for the medication to diffuse through the bursa, the use of a small-gauge needle is less painful than the use of a larger one, and a clinically gratifying response usually occurs (though this may not predict g o o d long-term response). After thoroughly cleaning the skin, the clinician inserts the needle at a 30 ° angle into the groove b e t w e e n the m i d p o i n t of the lateral a c r o m i o n and the greater tuberosity of the h u m e r u s (Fig. 9). "Grittiness" is appreciated, and resistance to depression of the syringe p l u n g e r occurs at a d e p t h of a b o u t 3/4 inch to 1 inch, w h e n the needle enters the rotator cuff tendon. On feeling grittiness, the clinician should slightly and gradually w i t h d r a w the syringe and needle while lightly depressing the plunger, w h i c h will suddenly "give w a y " w h e n the needle leaves the tendon and enters the subacromial bursa. After injecting a p p r o x i m a t e l y 2 - 3 mL at this site, the clinician should partially w i t h d r a w the n e e d l e and redirect it anteriorly and posteriorly in a " f a n " distribution to inject the remaining material at the same depth. If the injection is too superficial, a small s u b c u t a n e o u s b u l g e will i m m e d i a t e l y appear; a p r o p e r l y p l a c e d injection may visibly distend the w h o l e bursa. C o m m o n sense dictates that the patient rest the arm after an injection and certainly avoid heavy use of the s h o u l d e r (especially u n d e r loaded conditions) for several weeks. Because the bicipital tendon runs t h r o u g h the rotator cuff and subacromial bursa, bicipital tendinitis can coexist w i t h inflammation of these structures. No study has addressed the medical m a n a g e m e n t of isolated bicipital tendinitis, although m a n y have considered this condition s o m e w h a t m o r e resistant to treatment. Injection may be m o r e difficult; the n e e d l e

Smith, Campbell, PAINFUL SHOULDER SYNDROMES

336

Supraspinatus

Subacromial Bursa

- Subscapularis

RGURE 9. Anterior view of the right shoulder indicating the injection landmarks (indicated by the black dots): the subacromial bursa region, the bicipital peritendinous area, and the anterior glenohumecaljoint articulation. After shoulder landmarks are identified, skin point-of-needle entry can be indented with a retracted ballpoint pen. After thorough skin cleaning, the authors recommend a 1 .S-inch 27-gauge needle on a 10-mL syringe for bursal or peritendinous injection (e.g., 20 mg oftriamcinolone acetonide mixed in 4 - 6 mL of 1% lidocaine), lntraarticular injection usually is performed with a 21 -gauge 2-inch needle; after anesthetic inl~ltration, 40 mg of triamcinolone hexacetonide is mixed with 2 - 5 mL of saline in a 10-mL syringe. The posterior approach is depicted in Figure 2.

should be inserted into the anterior shoulder area b e l o w the greater tuberosity of the humerus and directed along the sheath or side of (but n o t into) the bicipital tendon. Because the tendon is quite long and slender and takes a sharp angle around the head of humerus, rupture with overuse after injection may be a risk. 7a

Rotator Cuff ($upraspinatus Tendon) Tendon Tear Rupture Reports addressing the effectiveness of steroid injections for supraspinatus tendon tears are difficult to interpret, since they include a mixture of incomplete small tears, c o m p l e t e tears, and large tears without clear discrimination. Since small i n c o m p l e t e o r complete t e n d o n tears are difficult to distinguish clinically from the tendinitis/bursitis syndrome, earlier reports of o u t c o m e of local soft-tissue periarticular or subacromial steroid injection are uninterpretable. 23, 32,70,79 One study 71 attempted greater precision b y arthogra-

phically identifying supraspinatus "tears," but it failed to describe the extent o f the tear ( c o m p l e t e or incomplete). Moreover, the trial was not randomized and the location of the steroid injection was ill-defined. An uncontrolled, unblinded trial studied 15 patients w h o had arthrographically proven supraspinatus tendon tears of similar size, without actual rupture. 72 Each patient received during fluoroscopy a 40-mg intraarticular injection o f triamcinolone acetonide, w h i c h was repeated, w i t h o u t fluoroscopy, one w e e k later in patients w h o had only partial improvement in motion or pain. At one month, 13 of the 1 5 patients (86%) showed improvement, but six of the 1 5 (40%) required at least two steroid injections. These results contrast with those o f previous reports, which showed m u c h less efficacy. 7~ These data suggest that small supraspinatus t e n d o n tears may respond to intraarticular steroids. Moreover, none of the steroid injection trials indicate any deleterious local effects. 22,8° Although long-term controlled trials are lacking, judicious steroid injection for small tendon tears may be reasonable. Nevertheless, we remain hesitant to use an intraarticular or a periarticular steroid injection w h e n an imaging study demonstrates a tendon tear. Prudent management consists of o r t h o p e d i c referral and physical therapy, c o m b i n e d with motion exercises. An eight-week recovery period is typical. 22 Therapy of m e d i u m or large full-thickness tendon tears or tendon rupture is less controversial: early operative repair is warranted once the defect is confirmed by an imaging technique. 48, 65 Local steroid infiltration is not advised, sl The postoperative recuperative phase is protracted: painful or restricted motion typically persists for six to nine months. However, arthroscopic repair should shorten the recovery period. Since shoulder joint immobilization can lead to adhesive capsulitis, early postoperative passive shoulder motion exercises under o r t h o p e d i c supervision and guidance of a physical therapist are indicated to minimize this risk.

Adhesive Capsulitis The many treatments advocated for this condition reflect the lack of knowledge about its pathogenesis and only a paucity of information about the natural history. 37 Earlier reports suggested that the efficacy of a regimen o f heat, massage, and stretching exercises s2, s3 was superior to that of the use of analgesics alone.S4 Other conservative therapies include NSAIDs, s5 oral steroids, 2 and local ice application. 6s More aggressive treatments, such as manipulation u n d e r anesthesia, are rarely needed. Periarticular or intraarticular corticosteroid injections, w h i c h many advocate as the best treatment available, have b e e n extensively studied. Earlier reports compared hydrocortisone acetate with physical ther-

JOURNALOFGENERALINTERNALMEDICINE,Volume 7 (May/June). I992

apy alone or with lidocaine and placebo injection, a6 Periarticular injection in the subacromial or bicipital tendon sheath area provided only marginal, short-lived benefit in open trials lasting less than three months. 7a, aS, sT, 88 Other prospective studies using longer-acting, more potent intraarticular s t e r o i d s prednisolone, methylprednisolone, and triamcinolone ( 2 5 - 4 0 mg) - - demonstrated better success. 6a,89-91 These trials totalled 130 patients, and the investigators either ensured intraarticular injection during arthrography or used randomization and blinded methodology. Since the natural recovery for adhesive capsulitis is slow, future prospective trials of steroid injections should assess the long-term benefit. One study 92 assessed 40 patients for a mean period of 44 months in an open, case-controlled series. No significant functional impairment o c c u r r e d in either those patients receiving a steroid injection or those doing pendular exercises. Other studies suggest that early treatment shortens recovery time, 79 which, however, is not influenced by the precipitating cause (e.g., trauma, immobilization). Dominant arm involvement, manual labor, and increasing age are associated with protracted recovery.34, 79, 91 Definitive recommendations cannot be made until results are available from well-designed long-term clinical trials, but a p r u d e n t approach to managing adhesive capsulitis includes intraarticular injection of a potent longer-acting steroid preparation (e.g., triamcinolone hexacetonide, 40 mg) mixed in 2 - 5 mL of saline (to help reduce pain and diffuse the steroid throughout the joint space) in patients w h o present early. After local anesthetic injection, we prefer, among the several techniques possible, either an anterior or a posterior approach using a 2-inch 21-gauge n e e d l e attached to a lO-mL syringe (Figs. 2 and 9). Physical therapy, especially exercise training, is r e c o m m e n d e d to gradually increase shoulder mobility. Early motion should be passive or the pendular type, graduating to more active motion, with the patient exercising once severe pain no longer restricts mobility. One or several pain treatments, including ice application, oral analgesics, transcutaneous nerve stimulators, and NSAIDs, may help r e d u c e pain and facilitate motion exercising. Shoulder manipulation with the patient u n d e r anesthesia can be considered in recalcitrant cases. Long-term functional disability occurs only in a minority of cases.

SUMMARY Painful shoulder conditions are c o m m o n primary care problems. Providers should learn the topographical landmarks about the shoulder and understand shoulder mechanics. A careful clinical evaluation will usually provide a likely diagnosis. In unclear cases with

337

marked pain, weakness, and r e d u c e d mobility, or with a suspected rotator cuff tear or rupture, arthrography or MRI wiIl usually establish a diagnosis. Therapy of bursitis/tendinitis consists of a steroid injection into the inflamed subacromial area or a 14-day trial of an NSAID. Therapy of bicipital tendinitis, largely empiric because definitive studies are unavailable for any specific treatment, includes judicious peritendinous steroid injections and avoiding aggravating activities. In the management of patients with suspected tendon tears or rupture, primary care practitioners can confirm the diagnosis by ordering MRI or arthrography before referring these patients to an orthopedist for definitive surgical therapy. Optimal management of adhesive capsulitis remains unclear, but an intraarticular steroid injection appears beneficial at least in temporarily diminishing pain. Pendular motion exercising is also an integral part of therapy. Deleterious effects o f peribursal or intraarticular steroid infiltration appear minimal; but injections into the tendon or frequent, repetitive injections are contraindicated. Each shoulder condition has a variable course, depending on the structure(s) and extent of involvement.

REFERENCES 1. Bonafede PR, Bennett RM. Shoulder pain. Guidelines to diagnosis and management. Postgrad Med. 1987;82:185-93. 2. Bland JH, Merrit JA, Boushey DR. The painful shoulder. Semin Arthritis Rheum. 1977; 7:21-47. 3. Inman VT, SaundersJB, Abbott LC. Observations on the function of the shoulder joint. J Bone Joint Surg. 1944;26:1-30. 4. Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder. J Bone Joint Surg. 1972;54:41-50. 5. Tullos HS, KingJW. Throwing mechanism in sports. Orthop Clin North Am. 1973;4:709-20. 6. Codman EA. The shoulder. Boston: Todd, 1934. 7. Bywaters EG. Lesions of bursae, tendons and tendon sheaths. Clin Rheum Dis. 1979;5:883-925. 8. Sarkar K, Uhthoff HK. Ultrastructure of the subacromial bursa in painful shoulder syndromes. Virchows Arch [A]. 1983; 400:107-17. 9. Canoso JJ. Bursae, tendons and ligaments. Clin Rheum Dis. 1981;7:189-221. 10. Hoppenfeld S. Orthop Neurol. Philadelphia: J. B. Lippincott, 1977;32. 11. Campbell SM. Referred shoulder pain. Postgrad Med. 1983;73:193-203. 12. Mayfield FH. Neural and vascular compression syndromes of the shoulder girdle and arm. Clin Neurosurg. 1968; 15:384-93. 13. Rothman RH, Parke WW. The vascular anatomy of the rotary cuff. Clin Orthop. 1965;41:176-86. 14. DePalmaAF. Loss of scapulobumeral motion (frozen shoulder). Ann Surg. 1952;135:193-204. 15. Risk TE, Pinals RS. Frozen shoulder. Semin Arthritis Rheum. 1982;11:440-52. 16. Neer CS, Welsh RP. The shoulder in sports. Orthop Clin North Am. 1977;8:583-91. 17. Cogen L, Anderson LG, Phelps P. Medical management of the painful shoulder. Bull Rheum Dis. 1982; 32: 54-8. 18. Meyer AW. Spontaneous dislocation and destruction of the tendon of long head of biceps brachii. Arch Surg. 1928; 1 7 : 4 9 3 - 506. 19. Gilcreest EL. Rupture of muscles and tendons, particularly subcutaneous rupture of the biceps flexor brachii. JAMA. 1925;84:1819-22. 20. Gilcreest EL. Dislocation and elongation of the long head of the

3,38

21. 22. 23. 24. 25. 26.

27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41.

42. 43. 44. 45. 46. 47. 48. 49. 50.

Smith, Campbell. PAINFULSHOULDERSYNDROMES

biceps brachii. Analysis of six cases. Ann Surg. 1936; 104:118-38. Bateman JE. The shoulder and neck. Philadelphia: W. B. Saunders, 1972;254. Neviaser RJ. Ruptures of the rotator cuff. Orthop Clin North Am. 1987;18:387-94. Symonds MB. Accurate diagnosis and treatment in painful shoulder conditions. J Int Med Res. 1975;3:261-6. Faure G, Daculsi G. Calcified tendinitis: a review. Ann Rheum Dis. 1983;42:49-53. Simkin PA.Tendinitisandbursitisoftheshoulder. PostgradMed. 1983;73:177-90. Mavrikakis ME, Drimis J, Kontoyannis DA, Rasidakis A, Moulopoulou ES, Kontoyannis S. Calcific shoulder periarthritis (tendinitis) in adult onset diabetes mellitus: a controlled study. Ann Rheum Dis. 1989;48:211-4. Uhthoff HK, Sarkar K, Maynard JA. Calcifying tendinitis: a new concept of its pathogenesis. Clin Orthop. 1976; 118:164-8. RathburnJB, MacNab I. The microvascular patrern of the rotator cuff. J Bone Joint Surg [Br]. 1970;52:540-53. Cotton RE, Rideout DF. Tears of the humeral rotator cuff. J Bone Joint Surg [Br]. 1964;46:314-28. Norwood LA, Barrack R, Jacobson KE. Clinical presentation of complete tears of the rotator cuff. J Bone Joint Surg [Am]. 1989;71:499-505. Simon WH. Soft tissue disorders of the shoulder. Frozen shoulder, calcific tendinitis and bicipital tendinitis. Orthop Clin North Am. 1975;6:521-39. Lloyd-Roberts GC, French PR. Periarthritis of the shoulder. Br MedJ. 1959;1:569-71. Neviaser JS. Adhesive capsulitis of the shoulder: a study of the pathologic findings in periarthritis of the shoulder. J Bone Joint Surg. 1945;27:211-22. Bruckner FE, Nye CJS.A prospective study of adhesive capsulitis of the shoulder (frozen shoulder) in a high risk population. Q J Med. 1981;198:191-204. Neviascr JS. Adhesive capsulitis of the shoulder. Med Times. 1962;90:783-807. Kozin F. Painful shoulder and the reflex sympathetic dystrophy syndrome. In: McCarty DJ, ed. Arthritis and allied conditions, lOth ed. Philadelphia: Lea and Febiger, 1982;1091-120. Reeves B. The natural history of frozen shoulder syndrome. ScandJ Rheumatol. 1975;4:193-6. Seeger LL, Gold RH, Bassett LW, Ellman H. Shoulder impingement syndrome. MR findings in 53 shoulders. AJR Am J Roentgenol. 1988;150:343-8. Boyle AC. Joints and their diseases. Disorders of the shoulder joint. Br MedJ. 1969;3:283-5. Neviaser RJ. Tears of the rotator cuff. Orthop Clin North Am. 1980; 11:295-306. Neviascr RJ, Neviaser TJ. Lesions of the musculotendinous cuff and capsule of the shoulder--diagnosis and management, part I: Tears of the rotator cuff. St. Louis, MO: C. V. Mosby, 1981; 239-50. Stiles RG, Resnick D, Sartoris DJ, Andre MP. Rotator cuffdisruption: diagnosis with digital arthrography. Radiology. 1988; 168:705-8. Burk DL, Karasick D, Kurtz AB, et al. Rotator cuff t e a r s - prospective comparison of MR imaging with arthrography, sonography and surgery. AJR Am J Roentgenol. 1989;153:87-92. Resnick D. Shoulder arthrography. Radiol Clin North Am. 1981;19:243-53. Kaplan PA, Walker CW. Contrast radiology. Curr Opin Rheum. 1990;2:355-60. HodlerJ, Fretz CJ, Terrier F, Gerber C. Rotator cufftears: correlation of sonographic and surgical findings. Radiology. 1988; 169:791-4. Fukuda H, Mikasa M, Yamanaka K. Incomplete thickness rotator cuff tears diagnosed by subacromial bursography. Clin Orthop. 1987;223:51-6. Adebajo A, Hazleman B. Shoulder pain and reflex sympathetic dystrophy. Curr Opin Rheum. 1990;2:270-5. Neviaser RJ, Neviaser JS. The frozen shoulder: diagnosis and management. Clin Orthop. 1987;223:59-64. LoydJA, Loyd HM. Adhesive capsulitis of the shoulder: arthrographic diagnosis and treatment. South Med J. 1983;76:879-83.

51. Preston BJ, Jackson JP. Shoulder arthrography. Br J Radiol. 1976;49:288-91. 52. Reeves B. Arthrographic changes in frozen and post-traumatic stiff shoulder. Proc R Soc Med. 1966;59:827-30. 53. HodlerJ, Fretz CJ, Terrier F, Gerber C. Rotator cufftears: correlation of sonographic and surgical findings. Radiology. 1988; 169:791-4. 54. Kilcoyne RF. Ultrasonography and computed tomography. Curr Opin Rheum. 1990;2:361-4. 55. Miller CI, Karasick D, Kurtz AB, Fenlin JM. Limited sensitivity of ultrasound for the detection of rotator cuff tears. Skeletal Radiol. 1989; 18:179-83. 56. Evancho AM, Stiles RG, Fajman WA, et al. MR imaging diagnosis of rotator cuff tears. AJR Am J Roentgenol. 1988; 151:751-4. 57. Kieft GJ, Bloem JL, Rozing PM. MR imaging of recurrent anterior dislocation: comparison with CT arthrography. AJR Am J Roentgenol. 1988; 150:1083-7. 58. Kieft GJ, Bloem JL, Rozing PM, Oberman WR. Rotator cuff impingement syndrome: MR imaging. Radiology. 1988; 168:211-4. 59. Seeger LL, Gold RH, Bassett LW. Shoulder instability. Evaluation with MR imaging. Radiology. 1988; 168:695-7. 60. Zlatkin MB, Iannotti JP, Roberts MC, et al. Rotator cuff tears: diagnostic performance of MR imaging. Radiology. 1989; 172:223-9. 61. Zlatkin MB, Reicher MA, Kellerhouse LE, McDade W, Vetter L, Resnick D. The painful shoulder: MR imaging of the glenohumeral joint. J Comput Assist Tomogr. 1988;12:995-1001. 62. Brahme-Kursunoglu S, Resnick D. Magnetic resonance imaging of the shoulder. Radiol Clin North Am. 1990;28:941-54. 63. Schauwecker DS. Osteomyelitis: diagnosis with In-111 -labeled leukocytes. Radiology. 1989; 171:141-6. 64. Demangeat JL, Constantinesco A, Btunot B, Foucher G, Farcot JM. Three-phase bone scanning in reflex sympathetic dystrophy of the hand. J Nucl Med. 1988;29:26-32. 65. LevyHJ, UribeJW, DeLaneyLG.Arthroscopicassistedrotatorcuff repair: preliminary results. Arthroscopy. 1990;6:55-60. 66. Berry H, Fernandes L, Bloom B, Clark RJ, Hamilton EBD. Clinical study comparing acupuncture, physiotherapy, injection and oral antiirdtammatory therapy in shoulder-cuff lesions. Curr Med Res Opin. 1980;7:121-6. 67. Chard MD, Sattelle MD, Hazleman BL. The long-term outcome of rotator cuff t e n d i n i t i s - - a review study. Br J Rheumatol. 1988;27:385-9. 68. Bulgen DY, Binder A1, Hazleman BL, DuttonJ, Roberts S. Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens. Ann Rheum Dis. 1984;43:353-60. 69. Dacre JE, Beeney N, Scott DL. Injections and physiotherapy for the painful stiff shoulder. Ann Rheum Dis. 1989;48:322-5. 70. Fearnley ME, Vadasz I. Factors influencing the response of lesions of the rotator cuff of the shoulder to local steroid injections. Ann Phys Med. 1969;10:53-63. 71. Darlington LG, Coomes EN. The effects of local steroid injection for supraspinatus tears. Rheumatol Rehabil. 1977; 16:172-9. 72. Weiss JJ. Inwaa~icular steroids in the treatment of rotator cuff tears: reappraisal by arthrography. Arch Phys Med Rehabil. 1981;62:555-7. 73. White RH, Paull DM, Fleming KW. Rotator cuff tendinitis: comparison of subacromial injection of a long acting corticosteroid versus oral indomethacin therapy. J Rheumatol. 1986; 13:608-13. 74. Petri M, Dobrow R, Neiman R, Whiting-O'Keefe Q, Seaman WE. Randomized double-blind placebo-controlled study of the treatment of the painful shoulder. Arthritis Rheum. 1987; 30:1040-50. 75. Adebajo AO, Nash P, Hazleman BL. Prospective double-blind dummy placebo controlled study comparing triamcinolone hexacetonide injection with oral diclofenac 50mg TDS in patients with rotator cuff tendinitis. J Rheumatol. 1990; 17:1207-10. 76. Goldie I. Local steroid therapy in painful orthopaedic conditions. Scott MedJ. 1972;17:176-86. 77. Cone RO, Resnick D, Danzig LI. Shoulder improvement syndrome: radiographic evaluation. Radiology. 1984; 150:29- 33. 78. Halperu AA, Horowitz BG, Nagel DA. Tendon ruptures associated with corticosteroid therapy. WestJ Med. 1977;127:378-82. 79. Crisp EJ, Kendall PH. Treatment of periarthritis of the shoulder

JOURNALOFGENERALINTERNALMEDICINE, Volume 7 (May/June}, lgg2

with hydrocortisone. Br IViedJ. 1955; 1:1500-1. 80. ConnollyJ, Regen E, Evans OB. Management of the painful, stiff shoulder. Clin Orthop. 1972;84:97-103. 81. Bj6rkenheim J-M, Paavolainen P, Ahovuo J, Sllitis P. Surgical repair of the rotator cuff and surrounding tissues. Factors influencing results. Clin Orthop. 1988;236:148-53. 82. Leibolt FL. Frozen shoulder. Passive exercises for treatment. N Y State J Med. 1970;70:2085. 83. Lehman JF, Warren CG, Scham SM. Therapeutic heat and cold. Clin Orthop. 1974;99:207-45. 84. Lee PN, Haq AM, Wright V, Longton EB. Periarthritis of the shoulder, a controlled trial of physiotherapy. Physiotherapy. 1973;59:312-5. 85. Duke E, Zecler E, Grahame R. Anti-inflammatory drugs on periarthritis of the shoulder: a double-blind, between-patient study of naproxen versus indomethacin. Rheumatol Rehabil. 1981;20:54-9. 86. Murnaghan GF, Edin MB, Mclnitosh D. Hydrocortisone in painful shoulder. A controlled trial. Lancet. 1955;2:798-800. 87. Lee PN, Lee M, Haq AM, Longton EB, Wright V. Periarthritis of the shoulder. Ann Rheum Dis. 1974;33:116-9. 88. Quinn CE. "Frozen shoulder": evaluation of treatment with hydrocortisone injections and exercises. Ann Plays Med. 1965;8:22-5. 89. Richardson AT. The painful shoulder. Proc R Soc Med. 1975;68:731-6. 90. L°yd JA' L°yd HM"Adhesive capsulitis °f the sh°ulder: arthr°graphic diagnosis and treatment. South MedJ. 1983;76:879-83. 91. Weiss JJ. Arthrography-assisted intra-articular injection of steroids in treatment of adhesive capsulitis. Arch Phys Med Rehabil. 1978;59:285-7. 92. Binder AI, Bulgen D¥, Hazelman BL, Roberts S. Frozen shoulder: a long-term prospective study. Ann Rheum Dis. 1984;43: 361-4.

339

APPENDIX A

Record o f S h o u l d e r E x a m i n a t i o n Findings" Appearance A c r o m i o c l a v i c u l a r (AC) joint G l e n o h u m e r a l (GH) joint Subdeltoid area Supraspinatus/deltoid m u s c l e

Passive range of motion I n t e r n a l / e x t e r n a l rotation Forward flexion Abduction

Active range o f motion I n t e r n a l / e x t e r n a l rotation Forward flexion Abduction O b s e r v e d painful arc O p p o s e d a b d u c t i o n at 90 °

Palpation AC j o i n t / s t e r n o c l a v i c u l a r j o i n t / c l a v i c l e A c r o m i o n / s u b d e l t o i d bursal area Bicipital t e n d o n / a n t e r i o r GH joint line (capsule)

Non-shoulder abnormalities Neck/axilla/arm/hand Neurologic examination "Suggested format for recording findings in patient's chart.