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PAINMEDICINE:ACASE-BASEDLEARNINGSERIES THESHOULDERANDELBOW Copyright © 2022byElsevier,Inc.Allrightsreserved
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It’s Harder Than It Looks MAKING THE CASE FOR CASE-BASED LEARNING For sake of full disclosure, I was one of those guys. You know, the ones who wax poetic about how hard it is to teach our students how to do procedures. Let me tell you, teaching folks how to do epidurals on women in labor certainly takes its toll on the coronary arteries. It’ s true, I am amazing. . .I am great. . .I have nerves of steel. Yes, I could go on like this for hours. . .but you have heard it all before. But, it’ s again that time of year when our new students sit eagerly before us, full of hope and dreams. . .and that harsh reality comes slamming home. . .it is a lot harder to teach beginning medical students “doctoring” than it looks.
A few years ago, I was asked to teach first-year medical and physician assistant students how to take a history and perform a basic physical exam. In my mind I thought “this should be easy. . .no big deal” . I won ’t have to do much more than show up. After all, I was the guy who wrote that amazing book on physical diagnosis. After all, I had been teaching medical students, residents, and fellows how to do highly technical (and dangerous, I might add) interventional pain management procedures since right after the Civil War. Seriously, it was no big deal...I could do it in my sleep with one arm tied behind my back blah blah blah.
For those of you who have had the privilege of teaching “doctoring,” you already know what I am going to say next. It’s harder than it looks! Let me repeat this to disabuse any of you who, like me, didn’t get it the first time. It is harder than it looks! I only had to meet with my first-year medical and physician assistant students a couple of times to get it through my thick skull: It really is harder than it looks. In case you are wondering, the reason that our students look back at us with those blank, confused, bored, and ultimately dismissive looks is simple: They lack context. That’ s right, they lack the context to understand what we are talking about.
It’ s really that simple. . .or hard. . .depending on your point of view or stubbornness, as the case may be. To understand why context is king, you have to look only as far as something as basic as the Review of Systems. The Review of Systems is about as basic as it gets, yet why is it so perplexing to our students? Context. I guess it should come as no surprise to anyone that the student is completely lost when you talk about let’ s say the “constitutional” portion of the Review of Systems, without the context of what a specific constitutional finding, say a fever or chills, might mean to a patient who is suffering from the acute onset of headaches. If you tell the student that you need to ask about fever, chills, and the other “constitutional” stuff and you take it no further, you might as well be talking about the
InternationalSpaceStation.Justsaveyourbreath;itmakesabsolutelynosenseto yourstudents.Yes,theywanttoplease,sotheywillmemorizetheelementsofthe ReviewofSystems,butthatisaboutasfarasitgoes.Ontheotherhand,ifyoupresentthecaseofJannettePatton,a28-year-oldfirst-yearmedicalresidentwithafever andheadache,youcanseethelightsstarttocomeon.Bytheway,thisiswhat Jannettelookslike,andasyoucansee,Jannetteissickerthanadog.This,atitsmost basiclevel,iswhat Case-BasedLearning isallabout.
Iwouldliketotell youthat,smartguy thatIam,Iimmediatelysawthelight andbecameaconvert to Case-BasedLearning. Buttruthbetold,it wasCOVID-19that reallygotmethinkingabout Case-Based Learning.Beforethe COVID-19pandemic, Icouldjustdragthestudentsdowntothemed/surgwardsandwalkintoa patientroomandriff.Everyonewasawinner.Forthemostpart,thepatients lovedtoplayalongandthoughtitwascool.ThepatientandthebedsidewasallI neededtoprovidethecontextthatwasnecessarytoillustratewhatIwastrying toteach thewhyheadacheandfeverdon’tmixkindofstuff.HadCOVID-19 notrudelydisruptedmyabilitytoteachatthebedside,Isuspectthatyouwould notbereadingthis Preface,asIwouldnothavehadtowriteit.Withinaveryfew daysaftertheCOVID-19pandemichit,mydaysofbedsideteachingdisappeared,butmystudentsstillneededcontext.Thisgotmefocusedonhowto providethecontexttheyneeded.Theanswerwas,ofcourse, Case-BasedLearning. Whatstartedasadesiretoprovidecontext becauseitreallywas harderthanit looked ledmetobeginworkonthiseight-volume Case-BasedLearning textbookseries.Whatyouwillfindwithinthesevolumesareabunchoffun,real-life casesthathelpmakeeachpatientcomealiveforthestudent.Thesecasesprovide thecontextualteachingpointsthatmakeiteasyfortheteachertoexplainwhy, whenJannette’schiefcomplaintis, “MyheadiskillingmeandI’vegotafever,” itis abigdeal.
Havefun!
StevenD.Waldman,MD,JD
Spring2021
Averyspecialthankstomyeditors,MichaelHouston,PhD,JeannineCarrado, andKarthikeyanMurthy,foralloftheirhardworkandperseveranceintheface ofdisaster.GreateditorssuchasMichael,Jeannine,andKarthikeyanmaketheir authorslookgreat,fortheynotonlyunderstandhowtobringtheThreeCsof greatwriting...Clarity 1 Consistency 1 Conciseness...totheauthor’swork,but unlikeme,theycanactuallypunctuateandspell!
StevenD.Waldman,MD,JD
P.S. ...Sorryforalltheellipses,guys!
14 JohanRyan A32-Year-OldMaleWithPainandElectric ShocklikeSensationRadiatingIntotheLateralForearm andRingandLittleFinger180
15 MitchMorales A38-Year-OldMaleWithSeverePosterior ElbowPain196
Index207
1 BillKidder A58-Year-OldMaleWithRight ShoulderPain LEARNINGOBJECTIVES • Learnthecommoncausesofshoulderpain.
• Developanunderstandingoftheuniqueanatomyoftheshoulderjoint.
• Developanunderstandingofthecausesofglenohumeraljointarthritis.
• Learntheclinicalpresentationofosteoarthritisoftheglenohumeraljoint.
• Learnhowtousephysicalexaminationtoidentifypathologyoftherotatorcuff.
• Developanunderstandingofthetreatmentoptionsforosteoarthritisofthe glenohumeraljoint.
• Learntheappropriatetestingoptionstohelpdiagnoseosteoarthritisofthe glenohumeraljoint.
• Learntoidentifyredflagswavinginpatientswhopresentwithshoulderpain.
• Developanunderstandingoftheroleininterventionalpainmanagementinthe treatmentofshoulderpain.
BillKidder BillKidderisa58-year-oldpainter withthechiefcomplaintof “ my rightshoulderiskillingme.” Bill wentontosaythathewouldn’t havebotheredcomingin,buthewas gettingwherehecouldn’tpaintceilingsanymore.IaskedBillifhehad anythinglikethishappenbefore. Heshookhisheadandresponded, “Justtheusualachesthataguymy agecomestoexpect.Youcan’twork alldayasapainterandnothave somepain.UsuallyIjusttakeacoupleofMotrinanduseaheatingpad. Thatwillusuallysetmerightafteradayorso.Whatworriesmethistimeisthat thisdamnrightshoulderishurtingallthetime,especiallywhenIreachuptocut inthetopofawallorpaintaceiling.I’mprettytough,butthishasmeworried becauseifIdon’twork,Idon’teat.Theotherthingis,thisdamnshoulderhasmy sleepalljackedup.EverytimeIrolloveronit,thedamnpainwakesmeup!Hell, somemorningsIcan’tevencombmyhair.”
IaskedBillaboutanyantecedenttraumaandhejustshookhishead. “Doc, thiskindofsnuckuponme.Atfirst,myshoulderhadthisdeepachethatwould getbetterwithsomeMotrinandrest.Overtime,theMotrinjustquitworking. ButDoc,likeIsaid,Igottawork.” IaskedBillwhatmadehispainworseandhe said, “AnytimeIusethisshoulder,ithurts.”
IaskedBilltopointwithonefingertoshowmewhereithurtsthemost.He grabbedhisrightshoulderandsaid, “Doc,Ican’treallypointtooneplace,itkind ofhurtsallover;andyouknowDoc,thecrazythingis,sometimesIfeellikethe shoulderispopping.” Iaskedifhehadanyfeverorchillsandheshookhishead no. “Whataboutsteroids?Didyouevertakeanycortisoneordrugslikethat,Bill?” Billagainshookhisheadno,thensaid, “Doc,youknowme.Iamhealthyasa horse.Ifitwasn’tforthisdamnshoulder,I’darm-wrestleyou!” Ilaughedandsaid I’dtakearaincheckonthearmwrestle,butafterIgothisshoulderbetter “ we wouldseewhowasthebetterman!” Billsmiledandsaid, “Doc,you’reon!”
Onphysicalexamination,Billwasafebrile.Hisrespirationswere18and hispulsewas74andregular.Hisbloodpressure(BP)wasslightlyelevated at142/84.Imadeanotetorecheckitagainbeforeheleftbecausewhoknew whenorifhewouldcomeback.Hishead,eyes,ears,nose,throat(HEENT)exam wasnormal,aswashiscardiopulmonaryexamination.Histhyroidwasnormal. Hisabdominalexaminationrevealednoabnormalmassororganomegaly.There
Fig.1.1 Visualinspectionoftheshoulder.(FromWaldmanSD. PhysicalDiagnosisofPain:AnAtlasof SignsandSymptoms.3rded.StLouis,MO:Elsevier;2016[Fig.18.1].)
Fig.1.2 Palpationoftheshoulder.(FromWaldmanSD. PhysicalDiagnosisofPain:AnAtlasofSigns andSymptoms.3rded.StLouis,MO:Elsevier;2016[Fig.19.1].)
wasnocostovertebralangle(CVA)tenderness.Therewasnoperipheraledema. Hislowbackexaminationwasunremarkable.Ididarectalexam,whichrevealed nomassandanormalprostate.Visualinspectionoftherightshoulderrevealedno cutaneouslesionsorobviousmass(Fig.1.1).Theshoulderwascooltotouch. Palpationoftherightshoulderrevealedmilddiffusetenderness,withnoobvious effusionorpointtenderness(Fig.1.2).Therewasmildcrepitus,butIdidnot
Fig.1.3 Internalrotationoftheshoulder.(FromWaldmanS. PhysicalDiagnosisofPain:AnAtlasof SignsandSymptoms.3rded.StLouis,MO:Elsevier;2016[Fig.21.1].)
appreciateanypopping.Rangeofmotionwasdecreased,withpainexacerbated withelevationandinternalrotationoftheshoulder(Fig.1.3).Thedroptestwas negativebilaterally(Fig.1.4).Theleftshoulderexaminationwasnormal,aswas examinationofhisothermajorjoints,otherthansomemildosteoarthritisinthe righthand.Acarefulneurologicexaminationoftheupperextremitiesrevealed thattherewasnoevidenceofperipheralorentrapmentneuropathy,andthedeep tendonreflexeswerenormal.
KeyClinicalPoints
’ Nohistoryofacutetrauma
’ Nohistoryofprevioussignificantshoulderpain
’ Nofeverorchills
’ Gradualonsetofshoulderpain,withexacerbationofpainwithshoulderuse
’ Poppingsensationintherightshoulder
’ Sleepdisturbance
’ Difficultyelevatingtheaffectedupperextremitytocombhairorpaintceilings
THEPHYSICALEXAMINATION ’ Thepatientisafebrile
’ Normalvisualinspectionofshoulder
Fig.1.4 (A,B)Thedroparmtestforcompleterotatorcufftear.(FromWaldmanS. PhysicalDiagnosis ofPain:AnAtlasofSignsandSymptoms.3rded.StLouis,MO:Elsevier;2016[Figs.52.1and52.2].)
’ Palpationofrightshoulderrevealsdiffusetenderness
’ Nopointtenderness
’ Noincreasedtemperatureofrightshoulder
’ Crepitustopalpation(see Fig.1.2)
’ Thedroptestwasnegative(see Fig.1.4)
OTHERFINDINGSOFNOTE ’ SlightlyelevatedBP
’ NormalHEENTexamination
’ Normalcardiovascularexamination
Fig.1.5 Anteroposterior(AP)radiographofapatientwithsevereglenohumeraljointosteoarthritis. Notethesuperiormigrationofthehumeralheadwithcompletelossofthesubacromialspaceand bonyeburnationoftheacromion.(FromWaldmanS,CampbellRSD. ImagingofPain.Philadelphia, PA:Saunders;2011[Fig.86.2].)
’ Normalpulmonaryexamination
’ Normalabdominalexamination
’ Noperipheraledema
’ Normalupperextremityneurologicexamination,motorandsensory examination
’ Examinationofotherjointsnormal
WhatTestsWouldYouLiketoOrder? Thefollowingtestwasordered:
’ Plainradiographsoftherightshoulder
TESTRESULTS Theplainradiographsoftherightshoulderrevealedsevereosteoarthritisofthe glenohumeraljointwithlossofthesubacromialspaceandbonyeburnationof theacromium(Fig.1.5).
ClinicalCorrelation—PuttingItAllTogether
Whatisthediagnosis?
’ Osteoarthritisoftherightglenohumeraljoint
TheScienceBehindtheDiagnosis ANATOMYOFTHEJOINTSOFTHESHOULDER Theshoulderisauniquejointforavarietyofreasons.Unlikethekneeandthe hipwiththeirinherentprimarystabilitythatresultsfromtheirsolidbonyarchitecture,theshoulderisarelativelyunstablejointheldtogetherbyacomplex combinationofligaments,tendons,muscles,anduniquesofttissues mostnotably,thelabrumandrotatorcuff.Whattheshoulderlacksinstability,itmore thanmakesupforinitsextensiverangeofmotion.Althoughnotatrueweightbearingjointlikethehiporknee,theshoulderjointissubjectedtoextreme mechanicalforcesduetoitsextensiverangeofmotion.Commonactivitiessuch asliftingobjectsoverheadorthrowingservetomagnifythesemechanicalload factorsandmakethejointsusceptibletorepetitivemotioninjuries.
Tomakethemostoftheinformationgleanedfromthephysicalexamination oftheshoulder,onemustfullyunderstanditsfunctionalanatomy.Tofully understandthefunctionalanatomyoftheshoulder,onemustrecognizethatthe shoulderjointcannotbethoughtofasasinglejointlikethekneebutratheras
Acromioclavicularjoint
Glenohumeral joint
Humerus
Scapula
AcromionCoracoidprocess
Fig. 1.6 The shoulder joint. (From Waldman S. Pain Review 1st ed. Philadelphia, PA: Saunders; 2009 [Fig. 37.1].)
fourseparatejointsworkinginconcerttofunctionasone(Fig.1.6).Thesefour jointsareasfollows:
’ Sternoclavicularjoint
’ Acromioclavicularjoint
’ Glenohumeraljoint
’ Scapulothoracicjoint
Whiletheglenohumeraljointisresponsibleforthemainfunctionalmobility oftheshoulderjoint,eachoftheotherjointsworkssynergisticallywithitscounterpartstoallowfortheextensiveandextremelyvariedrangeofmotionofthe shoulderjoint.Thisuniquerangeofmotionoftheshoulderjointisfurther enhancedbytheunusualphysicalcharacteristicsofthehumeralheadandthe glenoidfossa.Whilethearticularsurfacesofmostjointsarewellmatchedin termsoftheircomplementaryshapewithoneanother(e.g.,theacetabulumand thefemoralhead),thelarge,roundedhumeralheadisamazinglymismatchedto themuchsmallerandshallower,ovoid-shapedglenoidfossa.Whilethismismatchallowsfortheuniquerangeofmotionoftheshoulderjoint,italsocontributestotherelativeinstabilityofthejointandisinlargepartresponsibleforthe shoulderjoint’spropensityforinjury.Tothisend,theshoulderjointisthemost commonlydislocatedlargejointinthebody.
CLINICALPRESENTATIONOFARTHRITISOFTHE GLENOHUMERALJOINT Theshoulderjointissusceptibletothedevelopmentofarthritisfromvarious conditionsthatcausedamagetothejointcartilage(Table1.1).Osteoarthritisis themostcommoncauseofshoulderpainandfunctionaldisability.Itmayoccur afterseeminglyminortraumaormaybetheresultofrepeatedmicrotrauma. Painaroundtheshoulderandupperarmthatisworsewithactivityispresentin mostpatientssufferingfromosteoarthritisoftheshoulder.Difficultysleepingis alsocommon,asisprogressivelossofmotion.
Mostpatientspresentingwithshoulderpainsecondarytoosteoarthritis,rotatorcuffarthropathy,orposttraumaticarthritiscomplainofpainthatislocalized aroundtheshoulderandupperarm.Activitymakesthepainworse,whereas restandheatprovidesomerelief.Thepainisconstantandischaracterizedas aching;itmayinterferewithsleep.Somepatientscomplainofagratingorpoppingsensationwithuseofthejoint,andcrepitusmaybepresentonphysical examination.
Inadditiontopain,patientssufferingfromarthritisoftheshoulderjointoften experienceagradualreductioninfunctionalabilitybecauseofdecreasingshoulderrangeofmotion.Thischangemakessimpleeverydaytaskssuchascombing one ’shair,fasteningabrassiere,orreachingoverheadquitedifficult.Withcontinueddisuse,musclewastingmayoccur,andafrozenshouldermaydevelop.
TABLE1.1 ’ CausesofShoulderPain LocalizedBonyor
JointSpacePathology
Periarticular PathologySystemicDisease
SympatheticallyMediated PainReferredFromOtherBodyAreas
FractureBursitisRheumatoidarthritisCausalgiaBrachialplexopathy
PrimarybonetumorTendinitisCollagenvasculardiseaseReflexsympatheticdystrophyCervicalradiculopathy
Primarysynovialtissue tumor RotatorcufftearReitersyndromeShoulder-handsyndromeCervicalspondylosis
JointinstabilityImpingement syndromes GoutDresslersyndromeFibromyalgia
LocalizedarthritisAdhesivecapsulitisOthercrystalarthropathiesPostmyocardialinfarction adhesivecapsulitisofthe shoulder
OsteophyteformationJointinstabilityCharcotneuropathic arthritis
Myofascialpainsyndromessuchas scapulocostalsyndrome
Parsonage-Turnersyndrome (idiopathicbrachialneuritis)
JointspaceinfectionMusclestrainThoracicoutletsyndrome
HemarthrosisPeriarticularinfection notinvolvingjoint space
Entrapmentneuropathies
VillonodularsynovitisMusclesprainIntrathoracictumors
Intraarticularforeignbody Pneumothorax
Subdiaphragmaticpathology suchassubcapsularhematoma ofthespleenwithKerrsign
FromWaldmanS. PhysicalDiagnosisofPain:AnAtlasofSignsandSymptoms.3rded.StLouis,MO:Elsevier;2016[Table24.1].
TESTING Plainradiographsareindic atedinallpatientswhopresentwithshoulderpain (see Fig.1.5 ).Basedonthepatient ’ sclinicalpresentation,additionaltesting maybeindicated,includingacompletebloodcount,erythrocytesedimentationrate,andantinuclearantibodyt esting.Computerizedtomographymay helpidentifybonyabnormalities.Magn eticresonanceandultrasoundimagingoftheshoulderareindicatedifarotat orcufftearorothersofttissuepathologyissuspected( Figs.1.7 and 1.8 ).Radionuclidebonescanningisindicatedif metastaticdiseaseorprimarytumorinvolvingtheshoulderisapossibility ( Fig.1.9 ).
DIFFERENTIALDIAGNOSIS Osteoarthritisofthejointisthemostcommonformofarthritisthatresultsin shoulderpain;however,rheumatoidarthritis,posttraumaticarthritis,androtatorcuffarthropathyarealsocommoncausesofshoulderpain(Table1.2; Fig.1.10).Lesscommoncausesofarthritis-inducedshoulderpaininclude collagenvasculardiseases,infection,villonodularsynovitis,andLymedisease. Acuteinfectiousarthritisisusuallyaccompaniedbysignificantsystemic symptoms,includingfeverandmalaise,andshouldbeeasilyrecognized;itis diagnosedwithcultureandtreatedwithantibioticsratherthaninjectiontherapy. Collagenvasculardiseasesgenerallymanifestasapolyarthropathyratherthan amonoarthropathylimitedtotheshoulderjoint;however,shoulderpain secondarytocollagenvasculardiseaserespondsexceedinglywelltotheintraarticularinjectiontechniquedescribedhere.
Fig.1.7 Longitudinalultrasoundimageoftheshoulderdemonstratingalargetearofthesupraspinatus muscle.(Imagecredit:StevenWaldman,MD.)
Fig.1.8 (A)Anteroposterior(AP)radiographofapatientwithearlyosteoarthritis(OA)oftheglenohumeraljoint.Thereisasymmetricjointspacenarrowingandminorinferiorosteophyteformation. Theacromioclavicular(AC)jointisnormal,andthesubacromialspaceispreserved.(B)Thecoronal T1-weighted(T1W)magneticresonance(MR)arthrogramimagedemonstrateschondralthinning (whitearrows),theinferiorosteophyte (blackarrow),andlow signalintensity(SI)loosebodieswithin thespinoglenoidnotch (brokenarrow).(C)ThechondralthinningisalsoseenonanaxialT1Wwithfat suppression(FST1W)MRimage (whitearrows).(D)OnamoreinferioraxialFST1WMRimage,the osteophytes (blackarrow) arevisualizedinassociationwithbonyeburnationoftheposteriorglenoid (thickwhitearrow).(FromWaldmanSD,CampbellRSD. ImagingofPain.Philadelphia,PA:Saunders; 2011[Fig.86.1].)
TREATMENT Initialtreatmentofthepainandfunctionaldisabilityassociatedwithosteoarthritisoftheshoulderincludesacombinationofnonsteroidalantiinflammatory drugs(NSAIDs)orcyclooxygenase-2(COX-2)inhibitorsandphysicaltherapy. Localapplicationofheatandcoldmayalsobebeneficial,asmaybethetopical applicationofcapsaicin.Forpatientswhodonotrespondtothesetreatment
Fig. 1.9 A 67-year-old male with clear-cell chondrosarcoma of the humerus. (A) Plain radiograph of proximal right humerus demonstrates diffuse sclerosis. Also evident are articular margins, irregularities reconstituted by tumor matrix, ill-defined glenoid, and increase in matrix density in the subcoracoid bursal space. (B) Axial computed tomography (CT) of proximal humerus at tip of coracoids demonstrates intraarticular bodies and tumor matrix in the medullary canal with disorganized cortical margination and reactive sclerosis. (C, D) Comparable axial T1 and T2 with fat saturation at inferior glenoid. Note complete fat marrow replacement and extension of tumor into anteromedial joint recess and expansion of lesser tuberosity. (E) Coronal inversion recovery demonstrates diffuse marrow involvement and tumor involving the articular segment and extending into the metadiaphyseal junction with permeation of the cortices and medial subcoracoid extension into the joint. (F) Postgadolinium imaging shows heterogeneous enhancing tumor, replacement of marrow cavity cortices, and periosteal surface with extension along undersurface of the supraspinatus tendon of the rotator cuff and diaphyseal satellite lesions. (From Elojeimy S, Ahrens WA, Howard B, et al. Clear-cell chondrosarcoma of the humerus. Radiol Case Rep 2013;8(2):848 [Fig. 1].) reserved.
TABLE1.2 ’ DifferentialDiagnosisofShoulderPain (Continued) Age Diagnosis
Rotatorcuff tendinitis
Rotatorcuff tears(chronic)
Acuteor Any chronic Deltoidregion 1 kk Normal Guarding
Olderthan 40years Often chronic Deltoidregion 11 kk Normal(may later k)
Bicipital tendinitis Anterior Overuse Any k Normal Guarding
Calcific tendinitis
Capsulitis (“frozen shoulder”)
30 60 yearsold Pointof Acute shoulder 11 kk Normalexcept Guarding forpain
Olderthan 40years Deepin Insidious shoulder 11 kk kk
Acromioclavicular joint Acuteor Any chronic Lying Overjoint on side k FullelevationNormal
Osteoarthrosis ofglenohumeraljoint
Glenohumeral instability
Cervical spondylosis
Olderthan 40years usually Deepin Insidious shoulder 11 kk kk
Anterioror Episodic 25years posterior Only apprehension Only apprehension
Olderthan 40years Normal Normal SuprascapularOften Insidious
Thoracicoutlet syndrome Usuallywith Any activity Neck, shoulder, arm Normal Normal
Sympathetically mediated pain With Any contact Neck, shoulder, arm,diffuse Often k Guarding k Guarding
FromWaldmanS. PhysicalDiagnosisofPain:AnAtlasofSignsandSymptoms.3rded.StLouis, MO:Elsevier;2016[Table24.2].
modalities,intraarticularinjectionoflocalanestheticandsteroidisareasonable nextstep.
Intraarticularinjectionoftheshoulderisperformedbyplacingthepatient inthesupinepositionandpreparingtheskinoverlyingtheshoulder,subacromialregion,andjointspacewithantisepticsolution.Usingstrictaseptictechnique,thepractitionerattachesasterilesyringecontaining2mLof0.25% preservative-freebupivacaineand40m gmethylprednisolonetoa1.5-inch, 25-gaugeneedle.Themidpointoftheacromionisidentified,andatapoint approximately1inchbelowthemidpoint,theshoulderjointspaceisidentified
Impingement Signs Radiation Instability ParesthesiaWeakness ofPain
Radiographic Changes Special Features
111
Onlydueto pain LookforInchronic cases Painfularcof abduction 2211221 11 Wastingof cuffmuscles 1 Occasionally intobiceps Onlydueto pain LookforSpecial None examination tests 11122
Onlydueto pain 2211 Tenderness11 12222222222 Globalrangeof motion k
Inchronic cases Local tenderness
Mayhave mild 1 withacute episodes 22111 Crepitus
Possible 1 With acute episodes 111 Stresstests Often 1 1122 111 Incervical spine Painwithneck movement 11 1122 11 Special examination tests
Illdefined Possible Withdisuse 221 Bonescan, articular changes, anddemineralization Vasomotorand sudomotor changes
( Fig.1.11 ).Theneedleiscarefullyadvancedthroughtheskinandsubcutaneoustissues,throughthejointcapsule,andintothejoint.Ifboneisencountered, theneedleiswithdrawnintothesubcutaneoustissuesandisredirectedsuperiorlyandslightlymoremedially.After thejointspaceisentered,thecontents ofthesyringearegentlyinjected.Littleresistancetoinjectionisfelt;ifresistanceisencountered,theneedleisprobablyinaligamentortendonand shouldbeadvancedslightlyintothejointspaceuntiltheinjectioncanproceed withoutsignificantresistance.Theneedleisthenremoved,andasterilepressuredressingandicepackareappliedtotheinjectionsite.Recentclinical
Fig.1.10 Ultrasoundimagedemonstratingrotatorcufftendinopathy.(Imagecredit:StevenWaldman, MD)
Fig.1.11 Intraarticularinjectionoftheglenohumeraljoint.(FromWaldmanSD. AtlasofPain ManagementInjectionTechniques.4thed.StLouis,MO:Elsevier;2017[Fig.26.2].)
Glenoid fossa
Worn arthritic cartilage
Fig.1.12 Ultrasoundguidedintraarticularinjectionoftheglenohumeraljoint.(Imagecredit:Steven Waldman,MD)
experiencehassuggestedthattheinjecti onofplatelet-richplasmaintotheglenohumeraljointmayprovideimprovementofthepainandfunctionaldisabilityassociatedwithosteoarthritisofthe shoulder.Ultrasoundneedleguidance mayaidintheintraarticularplacementoftheneedleinpatientsinwhomanatomiclandmarksaredifficulttoidentify( Fig.1.12 ).
Physicalmodalities,includinglocalheatandgentlerangeofmotionexercises, shouldbeintroducedseveraldaysafterthepatientundergoesinjectionfor shoulderpain.Vigorousexercisesshouldbeavoidedbecausetheywillexacerbatethepatient’ssymptoms.
HIGH-YIELDTAKEAWAYS • Thepatientisafebrile,makinganacuteinfectiousetiology(e.g.,septicarthritis) unlikely.
• Thepatient’ssymptomatologyisnottheresultofacutetraumabutmorelikely theresultofrepetitivemicrotraumathathasdamagedthejointovertime.
• Thepatient’spainisdiffuseratherthanhighlylocalizedaswouldbethecase withapathologicprocesslikesubdeltoidbursitis.
• Thepatient’ssymptomsareunilateralandonlyinvolveonejoint,whichismore suggestiveofalocalprocessthanasystemicpolyarthropathy.
• Sleepdisturbanceiscommonandmustbeaddressedconcurrentlywiththe patient’spainsymptomatology.
• Plainradiographswillprovidehigh-yieldinformationregardingthebony contentsofthejoint,butultrasoundimagingandmagneticresonanceimaging willbemoreusefulinidentifyingsofttissuepathology.
SuggestedReadings AllenH,ChanBY,DavisKW,etal.Overuseinjuriesoftheshoulder. RadiolClinNAm. 2019;57(5):897 909.
CibulasA,LeyvaA,CibulasG,etal.Acuteshoulderinjury. RadiolClinNAm.2019;57 (5):883 896.
NetterFH.Shoulder(glenohumeraljoint).In: AtlasofHumanAnatomy.4thed. Philadelphia,PA:Saunders;2006.
ReschkeD,DagrosaR,MattesonDT.Anunusualcauseofshoulderpainandweakness. AmJEmergMed.2018;36(12):2339.e5 2339.e6.
WaldmanSD.Clinicalcorrelates:functionalanatomyoftheshoulder.In: Physical DiagnosisofPain:AnAtlasofSignsandSymptoms.3rded.Philadelphia,PA: Saunders;2016.
WaldmanSD.Rotatorcufftear.In: AtlasofCommonPainSyndromes.4thed. Philadelphia,PA:Elsevier;2019:129 133.
TerrellWilliams A28-Year-OldMaleWithLeft ShoulderPain LEARNINGOBJECTIVES • Learnthecommoncausesofshoulderpain.
• Developanunderstandingoftheuniqueanatomyoftheshoulderjoint.
• Developanunderstandingofthecausesofacromioclavicularjointpain.
• Developanunderstandingofthevarioustypesofacromioclavicularjointinjury.
• Learntheclinicalpresentationofosteoarthritisoftheacromioclavicularjoint.
• Learnhowtoexaminetheshoulder.
• Learnhowtousephysicalexaminationtoidentifypathologyofthe acromioclavicularjoint.
• Developanunderstandingofthetreatmentoptionsforacromioclavicularjoint pain.
TerrellWilliams TerrellWilliamsisa28-year-old bicyclemessengerwiththechief complaintof “myleftshoulderis killingme.” Terrellstatedthatabout aweekago,akidthrewarockat himwhilehewasdeliveringsome papersforalawyeronhisroute. “Therockflewoutofnowhereandit startledme.ThenextthingIknewI wasfalling.Iputoutmylefthandto tryandbreakmyfall,butIlandedreallyhardanyway.” Iaskedifhewaswearingahelmetandhegavemethe “areyoukiddingme” lookasheansweredthat healwayswearsahelmet. “Good,” Isaid,thenasked, “Sodidyouhityour head?” Hesaid, “No,butIreallybangedupthepalmofmylefthandandhadto digoutsomegravelandsplinters.”
IaskedTerrellifhehadanythinglikethishappenbefore.Heshookhishead andresponded, “Never.Isawthekidoutofthecornerofmyeye,butthingsjust happenedtoofast.”“WhatImeant,Terrell,washaveyoueverpassedoutorlost concentrationandfallenoffyourbike?”“No,thathasneverhappened.Iam verycarefulwithallthedistracteddrivingandall.YouknowwhatImean? Whatworriesmeisthatmyleftshoulderisn’tworkingrightanditismakingit hardtoride.Itfeelslikesomethinghascomelooseinsidethejoint.Iamevenhavingahardtimegettingmycoffeecupoffthecupboardshelf.”
IaskedTerrellaboutanyantecedentshouldertraumaandhejustshookhis headno. “Doc,Iwasnevermuchforsports,butIlovemybike.Itriedsome AdvilandTylenolandtheydon’tdomuch.” IaskedTerrellwhatmadehispain worseandhesaid, “AnytimeIusemyleftshoulder,ithurts.” Terrellwentonto saythatwhenhereachedup,hefeltakindofgratingsensation,especiallyinthe morningwhenhefirstgotup.Iaskedhowhewassleepingandheshookhis headandsaid, “Doc,I’llbetthisshoulderwakesmeuponehundredtimesa night.Iusuallysleeponmyleftside,butsinceIfell,Ican’tdothat,soItryto sleeponmyrightside.EverytimeIrollovertomyleftside,myshoulderwakes meup. ”
IaskedTerrelltopointwithonefingertoshowmewhereithurtsthemost.He pointedtotheanterioraspectoftheshoulderandsaid, “Doc,it’srighthere wheresomethingiswrong.Itfeelslikesomethingislooseinthereandthewhole shoulderfeelskindofsquishyorswollenup.” Iaskedifhehadanyfeverorchills andheshookhisheadno.
Onphysicalexamination,Terrellwasafebrile.Hisrespirationswere16and hispulsewas68andregular.Hisbloodpressure(BP)was112/70.Hishead,
