Sports Medicine & Outpatient Orthopedics – Comprehensive detail
in this article, we shall discuss shoulder pain. Musculoskeletal problems account for about 10–20% of outpatient primary care clinic visits. Orthopedic problems can be classified as traumatic (ie, injury-related) or atraumatic (ie, degenerative or overuse syndromes) as well as acute or chronic. The history and physical examination are sufficient in most cases to establish the working diagnosis; the mechanism of injury is usually the most helpful part of the history in determining the diagnosis.
Subacromial Impingement Syndrome
- Shoulder pain with overhead motion.
- Night pain with sleeping on the shoulder.
- Numbness and pain radiation below the elbow is usually due to cervical spine disease.
The shoulder is a ball and socket joint. The socket is very shallow, however, which enables this joint to have the most motion of any joint. The shoulder, therefore, relies heavily on the surrounding muscles and ligaments to provide stability. The subacromial impingement syndrome describes a collection of diagnoses that cause mechanical inflammation in the subacromial space. Causes of impingement syndrome can be related to muscle strength imbalances, poor scapula control, rotator cuff tears, subacromial bursitis, and bone spurs. With any shoulder problem, it is important to establish the patient’s hand dominance, occupation, and recreational activities because shoulder injuries may present differently depending on the demands placed on the shoulder joint. For example, baseball pitchers with impingement syndrome may complain of pain while throwing. Alternatively, older adults with even full-thickness rotator cuff tears may not complain of any pain because the demands on the joint are low.
Symptoms and Signs
Subacromial impingement syndrome classically presents with one or more of the following: pain with overhead activities, nocturnal pain with sleeping on the shoulder, or pain on internal rotation (eg, putting on a jacket or bra). On inspection, there may be appreciable atrophy in the supraspinatus or infraspinatus fossa. The patient with impingement syndrome can have mild scapula winging or “dyskinesis.” The patient often has a rolled-forward shoulder posture or head-forward posture. On palpation, the patient can have tenderness over the anterolateral shoulder at the edge of the greater tuberosity. The patient may lack full active range of motion (Table 41–1) but should have preserved a passive range of motion. Impingement symptoms can be elicited with the Neer and Hawkins impingement signs.
The following four radiographic views should be ordered to evaluate subacromial impingement syndrome: the anteroposterior (AP) scapula, the AP acromioclavicular joint, the lateral scapula (scapular Y), and the axillary lateral. The AP scapula view can rule out glenohumeral joint arthritis. The AP acromioclavicular view evaluates the acromioclavicular joint for inferior spurs. The scapula Y view evaluates the acromial shape, and the axillary lateral view visualizes the glenohumeral joint as well and for the presence of os acromiale. MRI of the shoulder may demonstrate full- or partial thickness tears or tendinosis. Ultrasound evaluation may demonstrate thickening of the rotator cuff tendons and tendinosis. Tears may also be visualized on ultrasound, although it is more difficult to identify partial tears from small full-thickness than on MRI.
There are two types of treatment
The first-line treatment for impingement syndrome is usually
a conservative approach with education, activity modification, and physical therapy exercises. Impingement syndrome can be caused by muscle weakness or tears.
Procedures include arthroscopic acromioplasty with coracoacromial ligament release, bursectomy, or debridement, or repair of rotator cuff tears.
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