277. Shoulder Pain

General

Most common causes of pain: rotator cuff tendinopathy, impingement, acromioclavicular joint disease, adhesive capsulitis, referred pain.

Usually pain related to progression of subacromial bursitis to tendinitis to partial/full thickness tears. Usually due to activity involving putting arm above shoulder.

Rotator Cuff Tendons: 4 muscles, all originate on scapula, go thru glenohumeral joint and insert onto proximal humerus.

Supraspinatus: back/top of scapula. Arm elevation/abduction. Isolate by doing ’empty beer can’ movement with arm abducted 90 degrees with 30 degrees of forward flexion and resist upward movement.

Infraspinatus: back/middle scapula. Arm external rotation. Isolate with teres minor with arm adducted at waist with elbow bent at 90 degrees and resist external rotation.

Teres Minor: lateral scapula. Similar function to infraspinatus with external rotation.

Subscapularis: Anterior scapula. Isolate with arm adducted, elbow flexed to 90 degrees and resist internal rotation.

Coracoacromial Arch: space that rotator cuff functions. Coracoid posteriorly, acromion anteriorly, humeral head inferiorly.

Subacromial bursa: main bursa for shoulder/rotator cuff.

Disorders

Impingement Syndrome: repetitive overuse of arm causes changes to bursa, rotator cuff, biceps tendon. Edema/hemorrhage of tendon (pain with activity, resolved with rest) leads to tendinitis/fibrosis (aching pain, night pain) leads to tears/tendon rupture/spurs (likely needing surgical decompression). Pain usually in anterior/lateral shoulder radiating into mid humerus. Pain at night. pain with resisted motions.

Neer maneuver: prevent scapular rotation and raise straight hand in forward flexion. Causes impingement at 70-120 degrees.

Hawkins impingement test: abducted 90 degrees, elbow at 90 degrees and internally rotate with resistance.

Tx: minimize all overhead activity. Immobilization not recommended. NSAIDs as always. Cryotherapy (ice) 3-4x/day. Exercises: pendulum swings in clockwise/counterclockwise to level of pain. Also walk fingers up wall. Steroid injections can be effective though can cause muscular atrophy/weakness.

Rotator Cuff Tears: acute injury rare (10%); majority related to chronic injury/use. Glenohumeral dislocation is common cause of tear. If dislocation with age> 40, 60% have tear. If still having weakness > 3 weeks after injury, likely tear involved. Partial thickness 2x more common than full tear Рconservative treatment where as full tear usually requires surgery. Supraspinatus most common tendon injured.

Rent test: patient has relaxed flexed elbow. Palpate rotator cuff (anterior to acromion thru deltoid). Soft tissue defect are palpated as arm is brought into full extension with internal/external rotation.

Drop arm test: patient unable to keep arm abducted 90 degrees when let go or falls with light push.

Xray: non helpful usually, narrowing of acromiohumeral space <7mm very specific for large tear.

Tx: slight for acute pain, prolonged immobilization should be avoided. NSAIDs, ROM, f/u with ortho/sports medicine.

Calcific Tendonitis: calcium deposits within the tendon. Females > males, age 40-60. Supraspinatus most likely involved. Calcium near proximal humerus. Catchy sensation on movement. Sometimes warm/tender shoulder. During resorptive phase, increase in pain can occur. Usually self-limited, lasting 1-2 weeks. Adhesive capsulitis most common complication. Worse at night, resorptive usually spontaneous. Tx: Same as above, keep arm abducted slightly either on back of chair or pillow in armpit at night. Can get ‘needle lavage’ to break up tension within tendon.

Adhesive capsulitis: ‘frozen shoulder’ syndrome. can be caused by post-menopause, DM, thyroid, pulmonary neoplasm, autoimmune. Usually women 40-60 yo, non dominant hand. Limited active and passive ROM.

Stage I: synvoial inflammation with limited shoulder movement (2-3 months). Stage II: freezing stage – decrease in shoulder motion with capsular thickening/scarring/chroinc pain (3-9 months). Stage III: frozen stage – less pain but more fibrosis (9-15 months). Stage IV: thawing stage – improvement with minimal pain (>15 months).

Tx: avoid sling, physical therapy at stage II. Consider oral steroids. Injection help as well.

Bicipital Tendonitis: acute pain at anterior aspect of shoulder. Biceps tendon rupture is always proximal tendon. Palpate bicipital groove in anterior humeral head with arm externally rotated. Muscle isolated mainly with forearm supination.

Ferguson test: shoulder adducted, elbow at 90 degrees – resist supination.

Bicep tendon rupture: ‘popeye’ deformity caused by distal contraction of muscle belly. Tx: sling – usually surgery in younger adults.

Osteoarthritis: rare due to joint not weight bearing, though can occur.

Acute thrombosis of axillary artery: due to repetitive mechanical trauma or explosive stress from lifting objects.

Questions

References/Resources

Tintinalli, Chapter 277: Shoulder Pain

Rosen, Chapter 46: Shoulder

277. Shoulder Pain

276. Neck and Back Pain

Neck Pain

General

Look for RF in the HPI. Morning stiffness: arthritis, night pain: malignancy, fever/night sweats: infection.

Radiculopathy: sharp, burning, intense pain into trapezius, periscapular, down arm.

Myelopathy: weakness including clumsy hands, gait, sexual/bladder incontinece.

Spurling sign: pressure to top of head with extension/lateral rotation produces radiculopathy pain to ipsilateral side. Same with valsalva.

Aductor relief sign: placing hand on top of head for relief.

Lhermitter sign: neck flexion causes pain down whole spine into legs with cord compression.

Hoffman sign: flicking tip of middle finger causes pain into neck.

MRI recommended for neck pain with neuro signs/symptoms. IV contrast for r/o abscess.

Disorders

Atlantoaxial instability: C1 on C2 instability in rheumatic disease (RA, ankylosing arthritis, psoriatic spondylopathy) leading to spontaneous subluxation or with trivial trauma.

Whiplash: access-decel trauma; pain/stiffness with paracervical muscle tenderness. Pain delayed. Consider using NEXUS to r/o unstable neck injury.

Central cord syndrome: hyperflexion/hyperextension with underlying issue: cervical spondylosis, spinal stenosis, anklylosing spondylitis, disc herniation. Sometimes does not have radiographic evidence. Weakness greater in arms than legs. Spared sensory loss.

Cervical Disc Herniations: Most common levels are C7 (70%, C6-C7, left sided) and C6 (20%, C5-C6, right sided). Worse with hyperextension and lateral flexion to symptomatic side.

C2: neck/scalp pain.

C5: shoulder pain, abduction (deltoid) weakness.

C6: proximal forearm pain. Thumb/index finger sensation.

C7: posterior arm and middle finger pain; triceps weakness.

C8: ring/little finger pain, triceps weakness.

Tx: Pain without radiculopathy/myelopathy: NSAIDs, muscle relaxants, usual activity. Pain with radiculopathy: conservative if no myelopathy; Tintinalli considers soft/semirigid collar. Steroids or injection may be useful. Hospitalization for acute or progressive symptoms of myelopathy, progressive weakness, pain unresponsive to outpatient treatment. Pain with myelopathy: NSGY consult for guidance.

Cervical spondylosis: progressive degenerative condition of osteoarthritis. Osteophytes, disc narrowing or facet disease with symptoms make diagnosis. High prevalence in asymptomatic patients as well. Usually C5-C6, C6-C7.

Back Pain

General

Acute < 6 weeks (most resolve 80-90% of the time), subacute 6-12 weeks, chronic > 12 weeks.

Risk Factors: age < 18, age > 50 higher risk for infection/tumor. >50 more prone to fracture (definitely if > 70), spinal stenosis. Infection Risk Factors: recent bacterial infection, skin abscesses, UTIs, pneumonia, recent GU/GI procedure, immunocompromised state, IVDA, alcoholism, renal failure, DM.

Straight leg test: patient supine, lift leg to 70 degrees, positive causes radicular pain to below the knee. Pain in butt/hamstring is NOT positive. Pain worse with dorsiflexion, improved with plantar flexion. Positive 68-80% for L5, S1 disc herniation.

L4: pain down lateral leg, numbness in thigh/around knee, weakness with ankle dorsiflexion, leg extension at knee.

L5: pain down lateral/posterior leg, medial shin numbness, big toe webbing numbness, toe dorsiflexion, have patient walk on toes.

S1: back of leg radiculopathy, plantar flexion, lateral foot numbness.

ESR elevated 90% of the time even in immunocompromised state with infection.

Xray: consider only lateral X-ray when looking for trauma or if you are going to just do xray. Full lumbar series has same gonadal radiation as PA/lateral CXR done daily for a year.

Disorders

Nonspecific back pain: Only 15% of back pain will have specific diagnosis. Tx: activity, no bedrest, analgesia. Medications: tylenol/NSAIDs.Lowest dose NSAID to avoid GI issues. Rosen doesn’t recommend muscle relaxants. Cochrane study showed only slight benefit over placebo with side effects likely worse than any effect. Chronic back pain: make sure you didn’t overlook any previous workup/process. Annulus fibrosis tear causes nerve irritation with pain radiating down legs, but only to knee.

Disc herniations: 95% of disc herniations with have sciatica symptoms. 95% of herniated discs occur at L4-L5, L5-S1 due to most flexion of back occurring at lumbosacral joint. NSAIDs less effective than compared to treatment for nonspecific back pain. Oral steroids have little benefit for sciatica (varied opinion. Another mentioned only slight benefit with 1x dose of IV 10mg decadron). MRI needed only for severe symptoms or progressive neurological deficits. Surgery only if still present after 4-6 weeks of failed improvement. 70% after surgery get some relief though at 4-10 year mark, same results as no surgery.

Spinal stenosis: narrowing at any point (canal, nerve root canal, intervertebral foramina). Worse with walking (pseudoclaudication), relieved with rest and forward flexion/reclining.

Spondylolisthesis: slippage of vertebral body on another. Secondary to degenerative changes.

Ankylosing spondylitis: autoimmune arthritis of spine/pelvis, related to B27 inflammatory disorders as well as trauma/infection. Males < 40 usually. Back pain that improves with activity. Imaging shows sacroilitis and squaring of vertebral body (“bamboo spine”). Tx: NSAIDs and rheumatology referral.

Epidural compression syndromes: spinal cord compression, cauda equina, conus medullaris (end of spinal cord). Causes: blood, tumor, infection, massive midline disc herniation (MCC cauda equina). Transverse myelitis is non compressive cause that looks similar. Back pain + perianal sensory loss, fecal/urinary incontinence. Sciatica to unilateral or bilateral legs. Most common finding with cauda equina is urinary retention. Saddle anesthesia (S3-S5) is common sensory finding. If concerned for malignancy, give 10mg decadron prior to imagining and need to likely get entire spine MRI.

Tranverse myelitis: inflammatory disorder involving complete transverse section of spinal cord. Bilateral symptoms worsening over days/weeks. Secondary to viral infection, post-vaccine, lupus, cancer, multiple sclerosis. Can have normal imaging for this diagnosis as well (if having epidural compression symptoms). LP might help showing lymphocytosis and elevated protein. Tx: steroids and plasma exchange per neurology.

Vertebral osteomyelitis: pain > 3 months. 50% have fever, bony tenderness. ESR elevated. Blood cultures in only 40%. Tx: IV abx for 6 weeks though consider surgery consult first before abx for need for biopsy. Potts disease is osteomyelitis from TB.

Diskitis: 90% have unremitting back pain. Fever in 60-70%, ESR elevated. Tx: long term antibiotics.

Spinal Epidural abscess: back pain, fever, neuro deficits. RF: IVDA, immunocompromised, alcohol abuse, spine procedure, renal failure, caner. ESR elevated. Tx: emergent evaluation. usually from bacteremia. 50% staph, others include strep, enteric anaerobes.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 276: Neck and Back Pain

Rosen, Chapter 47: Musculoskeletal Back Pain

Crashingpatient.com, Back Pain and Non-Traumatic Spinal Cord Disorders

276. Neck and Back Pain