Problems associated with the rotator cuff are the most frequent causes of shoulder problems. Impingement occurs chiefly in the supraspinatus as it courses underneath the acromion and coracoacromial ligament. Although this injury is most common in young athletes who engage in throwing or racquet sports, impingement may occur in anyone involved with overhead work or repetitive upper extremity motion. Evaluation of impingement syndromes is discussed in Reference 35, Chapter 52.
As a result of chronic impingement, the rotator cuff may tear. Cuff tears are more common in middle-aged or elderly individuals, often due to a hypovascular supply of the supraspinatus tendon as it inserts on the humerus.9 One hallmark of cuff tears is continuous pain, especially at night, which may radiate down the lateral humerus.
Examination of the patient with a rotator cuff injury reveals painful or limited active abduction (between 60 and 120 degrees), where the cuff comes in greatest contact with the overlying acromial arch.9 With a significant cuff tear, the patient is frequently unable to hold the arm in 90 degrees of abduction. Atrophy may develop in the supraspinatus or infraspinatus muscles of the scapula. If a cuff tear is suspected, orthopedic referral with arthroscopy or magnetic resonance imaging (MRI) is indicated to delineate potential surgical cases. With any cuff injury an extensive rehabilitation program of three to six months is needed to gain full motion and strength.
The subacromial bursa separates the deltoid muscle from the underlying rotator cuff. Irritation of adjacent structures, most commonly impingement of the rotator cuff, results in inflammatory bursitis. Often there is a history of overuse or trauma followed by pain and limited active motion. Aspiration of excessive bursal fluid followed by corticosteroid injection using a subacromial lateral or posterior approach can provide dramatic relief of this problem.3 Adequate volume of injection [5 to 10 cc lidocaine (Xylocaine) plus corticosteroid] should be used to optimize injection results.
Calcific tendonitis, usually within the supraspinatus insertion, may cause an acute inflammatory reaction of the overlying subacromial bursa. Roentgenograms demonstrate a calcific deposit superior and lateral to the humerus. The severe pain can be relieved by needle aspiration of the calcific mass along with a lidocaine and corticosteroid injection of the bursa. Occasionally surgical excision of the calcific deposition is required.10
The long head of the biceps tendon, which is palpable in the bicipital groove, may be irritated as it courses through the glenohumeral joint and below the supraspinatus tendon to its attachment at the superior sulcus of the glenoid. Isolated pain over the long head of the biceps tendon suggests this problem, although usually there is more diffuse tenderness involving the entire subacromial region. The short head of the biceps tendon attaches to the coracoid process and is rarely involved in inflammatory problems of the shoulder. In most cases rupture of the long head of the biceps tendon occurs as a result of advanced impingement in middle-aged or elderly patients. There is a sudden pop associated with a heavy isometric flexion of the arm such as lifting a heavy object with that arm. The patient experiences mild discomfort with ecchymosis in the upper arm and a palpable bulge of the biceps muscle mass. Because the short head remains intact, treatment is symptomatic as little functional loss occurs.11 Surgical repair is a rare consideration. Rupture of the distal insertion of the biceps tendon can also occur, with pain in the antecubital region. In contrast to proximal long head tear, this injury does warrant surgical repair.11
As a non-weight-bearing area, the true glenohumeral joint is subject to less mechanical stress than the lower extremity. When arthritic changes occur, there may have been a prior local injury. Inflammatory arthritis, with erosive changes of the glenohumeral joint and joint effusion, may occur, especially with severe rheumatoid arthritis.12 Treatment for any degenerative arthritis is primarily aimed at relief of pain and inflammation. Surgical intervention with joint replacement is possible, but functional results are not as satisfactory as with knee and hip joint replacement, and the major goal should be relief of pain.
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