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rotator cuff tendonitis; impingement syndrome; painful arc syndrome; subacromial pain syndrome

The major cause of shoulder pain. Etiology: - repetitive impingement on the tendon(s) forming the rotator cuff a) the supraspinatus tendon is most often affected 1] impingement between the humeral head & the coracoacromial arch [2,3] 2] impingement syndrome b) the tendon of the infraspinatus or the long head of the biceps are less commonly involved Epidemiology: 1) individuals over 40 are especially susceptible 2) asoociated with baseball, tennis & swimming 3) occupations requiring repeated elevation of the arms Pathology: 1) edema & hemorrhage of the rotator cuff 2) fibrotic thickening & rotator cuff degeneration 3) tendon tears & bone spurs 4) subacromial bursitis 5) degeneration of the supraspinatus if torn Clinical manifestations: 1) symptoms generally appear after overuse or injury 2) dull aching in shoulder that may interfere with sleep - often worse when lying on affected side [3] 3) severe pain when arm is actively abducted overhead; lateral deltoid pain aggravated by reaching [3] 4) movement in range of 60-120 degrees is especially painful - passive abduction of the arm may be painful [3] 5) tenderness over the lateral aspect of the humeral head just below the acromion 6) pain, weakness of abduction & external rotation of the shoulder with supraspinatus tendon tear 7) pain may radiate down arm into forearm [2] 8) may be wasting of deltoid & supraspinatus muscles 9) active range of motion impaired > passive range of motion* 10) pain aggravated by overhead reaching 11) positive impingement signs [9] a) pain with passive internal rotation & forward flexion of the shoulder b) pain with internal rotation & forward-flexing of the shoulder & while passively flexing the elbow & shoulder to 90 degrees 12) normal strength of rotator cuff muscles [9] 13) Neer test & Hawkins test often positive [9] 14) supraspinatus test (drop arm test) * contrast to adhesive capsulitis where both active & passive range of motion are impaired Radiology: generally not needed [3] 1) indications a) suspected full thickness rotator cuff tear b) diagnostic uncertainty 2) X-ray of shoulder may show narrowing of space between the humeral head & undersurface of acromion - a space < 8 mm suggests rotator cuff tear 3) arthrogram 4) ultrasound Complications: - the supraspinatus tendon may be torn by falling on an outstreched arm or lifting a heavy object Differential diagnosis: 1) radiculopathy of cervical spine 2) acromio-clavicular (AC) arthritis - pain at AC joint intensified with abduction beyond 100 degrees 3) rotator cuff test is suggested by positive supraspinatus test Management: 1) identify & eliminate provocative activities 2) a brief period of rest may be helpful 3) acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) 4) physical therapy a) restoration of range of motion b) range of motion daily to prevent adhesive capsulitis [3] c) wall walking [4] d) specific exercises & strengthening maneuvers involving the rotator cuff & scapula-stabilizing muscles, using external loads is superior to range of motion exercises [5] e) insufficient evidence for clinical effectiveness of physical therapy [13] 5) glucocorticoid injection into subacromial bursa - anterior & lateral approach better than posterior approach [6] - benefit at 8 weeks but not at 1 year [14] 6) one year outcomes for glucocorticoid injection similar to physical therapy [7] 7) immoblization with a sling may increase risk for adhesive capsulitis [3] 8) surgery for supraspinatus tendon tear 9) Subacromial decompression surgery should not be offered to patients with atraumatic rotator cuff tendonitis [12]

Related

rotator cuff impingement test/sign rotator cuff tear rotator cuff; musculotendinous cuff shoulder pain

General

tendonitis (tendon injury) repetitive strain disorder; repetitive motion disorder; cumulative trauma disorder; overuse syndrome rotator cuff disease

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1708-1709
  2. Clyman B, in: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  3. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2018, 2021.
  4. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  5. Holmgren T et al. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: Randomised controlled study. BMJ 2012 Feb 20; 344:e787 PMID: 22349588
  6. Marder RA et al. Injection of the subacromial bursa in patients with rotator cuff syndrome: A prospective, randomized study comparing the effectiveness of different routes. J Bone Joint Surg Am 2012 Aug 15; 94:1442 PMID: 22992814 http://jbjs.org/article.aspx?articleid=1306117
  7. Rhon DI et al One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome: A Pragmatic Randomized Trial. Ann Intern Med. 2014;161(3):161-169 PMID: 25089860 http://annals.org/article.aspx?articleid=1892614 - Coombes BK and Vicenzino B Pragmatic Study of Corticosteroid Injections and Manual Physical Therapy for the Shoulder Impingement Syndrome. Ann Intern Med. 2014;161(3):224-225 PMID: 25089865 http://annals.org/article.aspx?articleid=1892622
  8. Hermans J, Luime JJ, Meuffels DE, et al. Does this patient with shoulder pain have rotator cuff disease? The Rational Clinical Examination systematic review. JAMA. 2013;310:837-847 PMID: 23982370
  9. NEJM Knowledge+ Question of the Week. Aug 1, 2017 https://knowledgeplus.nejm.org/question-of-week/3076/
  10. Michener LA, Walsworth MK, Doukas WC, Murphy KP. Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Arch Phys Med Rehabil 2009 Nov 6; 90:1898. PMID: 19887215
  11. Michener LA, Walsworth MK, Burnet EN. Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. J Hand Ther 2004 May 27; 17:152 PMID: 15162102
  12. Vandvik PO, Lahdeoja T, Ardern C et al Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. BMJ 2019;364:l294 PMID: 30728120 https://www.bmj.com/content/364/bmj.l294
  13. Page MJ, Green S, McBain B et al Manual therapy and exercise for rotator cuff disease. Cochrane Database of Systematic Reviews. June 10, 2016 PMID: 27283590 Review https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012224/full
  14. Hopewell S et al. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): A multicentre, pragmatic, 2 2 factorial, randomised controlled trial. Lancet 2021 Jul 31; 398:416. PMID: 34265255 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00846-1/fulltext