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1888 SECTION 23: Musculoskeletal Disorders vertebral end plates, and disk space narrowing .23 See the section on osteomyelitis in Chapter 281 for further discussion. Diskitis In patients with diskitis, >90% present with a complaint of unremitting back or neck pain, which awakens them at night and is relieved by neither rest nor analgesics. 23 Fever is present in 60% to 70% of patients, whereas the percentage of patients with neurologic deficits is highly variable, from 10% to 50%. 23 Elevation in the erythrocyte sedi mentation rate occurs in >90% of patients, whereas elevated WBC count occurs in less than half of patients. Spinal Epidural Abscess The classic triad of symptoms suggesting spinal epidural abscess is severe back pain, fever, and neurologic defi cits, but the triad occurs in only 8% to 13% of patients.27 Spinal epidural abscess is commonly found in association with vertebral osteomyelitis and diskitis in 62% and 38% of cases, respectively. 27,64 Risk factors for epidural abscess include injection drug use, immunocompromise, alcohol abuse, recent spine procedure, distant site of infection, diabetes, indwelling catheter, recent spine fracture, chronic renal failure, and cancer. 19,27 Erythrocyte sedimentation rate is elevated (>20 mm/h) in >95% of patients,19,24,29,64 and the C-reactive protein is elevated in >90% of patients. 29 For all suspected spinal infections, contrast-enhanced MRI is the gold standard imaging study. For detailed discussion, see Chapter 174, “Central Nervous System and Spinal Infections. ” Treatment of Spinal Infections Evaluation of all spinal infections should occur initially with a spine surgeon. To better understand the approach that your surgeon may direct, we outline the general management of the various spinal infections. Epidural abscess requires antibiotics and emergent evaluation by a spine surgeon with surgical evacuation being a primary consideration. The treatment for diskitis is long-term antibiotics, with surgery reserved for those with spinal cord compression or biomechanical instability. The treatment for vertebral osteomyelitis is primarily medical, consisting of 6 weeks of IV antibiotics followed by a 4- to 8-week course of oral antibiotics. Empiric antibiotic therapy should be directed against methicillin-resistant Staphylococcus aureus. Parenteral piperacillin-tazobactam, 3.375 grams IV , and vancomycin, 1 gram IV , or similar agents with broad-spectrum coverage can be given until culture results are available. 20,21,29 REFERENCES The complete reference list is available online at www.TintinalliEM.com. Shoulder Pain David Della-Giustina David Hile ANATOMY The shoulder is designed for mobility in all directional planes, but stability is less than other joints. To meet the many demands placed on it, the shoulder uses three bones, four joints, and a specialized set of soft tissues consisting of muscles, tendons, ligaments, and bursae. Common causes of nontraumatic shoulder pain are subacromial impingement syndrome, rotator cuff tears, acromioclavicular joint disease, adhesive capsulitis, and referred pain.  BONES AND JOINTS The humerus, clavicle, and scapula are the bones of the shoulder com plex. The scapula consists of the body plus three bony extensions: the glenoid, the coracoid, and the acromion. The four joints of the shoulder are the glenohumeral, acromioclavicular, sternoclavicular, and scapu lothoracic.

d pain.  BONES AND JOINTS The humerus, clavicle, and scapula are the bones of the shoulder com plex. The scapula consists of the body plus three bony extensions: the glenoid, the coracoid, and the acromion. The four joints of the shoulder are the glenohumeral, acromioclavicular, sternoclavicular, and scapu lothoracic. The glenohumeral joint is a ball-and-socket joint and is the central axis of shoulder motion. The glenohumeral joint is the most CHAPTER mobile and least stable joint in the body. Stability is derived from three components. The first is the glenoid labrum, which is a fibrous ring of tissue encircling the glenoid cavity. The glenoid labrum increases the surface contact area of the humeral head within the relatively shallow glenoid fossa. The second component consists of three glenohumeral ligaments, which aid stability by reinforcing the joint capsule. Finally, four specialized muscles, known as the rotator cuff, encompass the gle nohumeral joint and provide stability during motion. The sternoclavicular and acromioclavicular joints together contribute to glenohumeral motion, but their primary function is to suspend and stabilize the shoulder girdle. Rotation at the acromioclavicular joint and elevation at the sternoclavicular joint allow complete arm elevation. The scapulothoracic joint represents the articulation of the scapula on the posterior wall of the thorax. Scapular motion is essential for over all shoulder motion: every degree of scapulothoracic motion allows 2 degrees of glenohumeral motion.  SHOULDER MUSCLES The deltoid, which drapes the shoulder complex and forms its contour, acts as a powerful and independent elevator of the arm. Along with the pectoralis, the deltoid is the primary source of movement of the upper extremity. The rotator cuff consists of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis (Figures 280-1 and 280-2). All originate on the scapula, traverse the glenohumeral joint, and insert on the proximal humerus. The rotator cuff muscles also contribute to the power of the upper extremity, providing 30% to 50% of the power in abduction and 90% in external rotation. The supraspinatus muscle originates on the posterior and superior aspect of the scapula and passes beneath the acromion, inserting onto the great tuberosity of the humeral head. It initiates arm elevation and abducts the shoulder. It also balances the power of the deltoid, keeping the humerus centered in the glenoid during deltoid contraction. The infraspinatus originates on the posterior scapula just inferior to the scapular spine. It inserts on the posterior aspect of the greater tuberosity and acts primarily as an external rotator of the arm (Figure 280-1). The teres minor originates on the lateral border of the scapula just inferior to the infraspinatus and inserts on the posterior aspect of the humerus. It works with the infraspinatus to provide external rotation (Figure 280-1). The subscapularis is the only rotator cuff muscle that arises from the anterior aspect of the scapula. It attaches to the lesser tuberosity of the humeral head and provides internal rotation of the arm (Figure 280-2). The long head of the biceps tendon, although not part of the rotator cuff, assists in rotator cuff function. The long head of the biceps tendon Scapula Supraspinatus Acromion Infraspinatus Teres minor FIGURE 280-1. Posterior view of the shoulder illustrating rotator cuff muscles. Tintinalli_Sec23_p1881-1932.indd 1888 8/2/19 3:14 PM

of the biceps tendon, although not part of the rotator cuff, assists in rotator cuff function. The long head of the biceps tendon Scapula Supraspinatus Acromion Infraspinatus Teres minor FIGURE 280-1. Posterior view of the shoulder illustrating rotator cuff muscles. Tintinalli_Sec23_p1881-1932.indd 1888 8/2/19 3:14 PM CHAPTER 280: Shoulder Pain 1889 courses superiorly in the bicipital groove of the humerus between the greater and lesser tuberosities, passes between the subscapularis and supraspinatus tendons, and penetrates the glenohumeral joint to insert on the labrum ( Figure 280-2). During arm elevation, the tendon of the long head of the biceps depresses the humeral head, helping it remain centered in the glenoid.  BURSAE The bursae facilitate frictionless motion between the components of the shoulder. Although there are eight bursae in the shoulder complex, only the extra-articular subacromial bursa is clinically significant. Its roof adheres to the undersurface of the deltoid, and its floor to the underlying rotator cuff. The bursa is lubricated by synovial fluid and surrounded by a layer of peribursal fat.  CORACOACROMIAL ARCH The coracoacromial arch is formed by the coracoid posteriorly, by the acromion anteriorly, and by the coracoacromial ligament that forms the anterior roof of the arch ( Figure 280-3). The humeral head provides the floor of the arch. This arch defines the space within which the tendons of the rotator cuff, the tendon of the long head of the biceps, and the subacromial bursa must function.  SUBACROMIAL IMPINGEMENT SYNDROME PATHOPHYSIOLOGY Repetitive overhead use of the arm or movement of the shoulder above the horizontal causes encroachment on the subacromial space by the humeral head ( Figure 280-4). 1-3 Repetitive subacromial encroachment or “impingement” produces pathologic changes of the bursa, rotator cuff, and biceps tendon that result in a loss of the normal gliding mechanism between the rotator cuff and related soft tissues within the coracoacro mial arch. Subacromial impingement syndrome is the encompassing term including the conditions of subacromial bursitis, rotator cuff tendinitis, supraspinatus tendinitis, and painful arc syndrome. 1-4 Subacromial impingement syndrome represents a progressive threestage pattern of clinical findings due to repetitive impingement of the subacromial space rather than inflammation or injury of a specific structure. 3,4 In stage 1, reversible edema and hemorrhage about the rotator cuff occur. Although possible at any age, it is classically seen in young athletes <25 years old who have excessive overhead use of the shoulder. During this stage, patients complain of a dull ache over the anterolateral shoulder that is aggravated by activity and improved by rest. The clinical course at this point is typically reversible. Repeated mechanical trauma from the impingement can progress to stage 2, where tendinitis of the rotator cuff creates fibrosis and thickening of the tendons of the rotator cuff and bursa. This stage is typically seen in patients between the ages of 25 and 40, and the prolonged duration (weeks to months) or recurrence of symptoms is useful in making this diagnosis. During this stage, patients complain of a recurrent or chronic aching pain with daily activities, pain with vigorous activity, and night pain (caused by irritation triggered by a relaxed supporting muscle tone). Continued overuse can lead to stage 3 with rotator cuff tears, rupture of the long head of the biceps, and subacromial spurs. Patients at this stage have progressive symptoms and disability, and they often require surgical decompression of the subacromial space.

rritation triggered by a relaxed supporting muscle tone). Continued overuse can lead to stage 3 with rotator cuff tears, rupture of the long head of the biceps, and subacromial spurs. Patients at this stage have progressive symptoms and disability, and they often require surgical decompression of the subacromial space. CLINICAL FEATURES The primary symptom of subacromial impingement syndrome is pain, developing insidiously over a period of weeks to months. The pain is located over the anterior to lateral shoulder and frequently radiates to the lateral mid-humerus, but not below the elbow. 1,5 Patients usually complain of pain at night that is deep and aching and interferes with sleep. This pain occurs especially when the patient lies on that shoulder or sleeps with his or her arms overhead. The pain may be exacerbated Biceps tendon long head Subscapularis Acromion Coracoid Supraspinatus Scapula FIGURE 280-2. Anterior view of the shoulder illustrating the supraspinatus muscle and the long head of the biceps. Biceps tendon Superior glenohumeral ligament Middle glenohumeral ligament Inferior glenohumeral ligament Coracoacromial ligament Supraspinatus tendon Subacromial bursa Infraspinatus tendon Glenoid cavity Teres minor tendon Posterior Anterior FIGURE 280-3. Lateral view of the shoulder illustrating the coracoacromial arch with the rotator cuff and subacromial bursa. Subacromial bursa Supraspinatus FIGURE 280-4. Impingement of the subacromial bursa and rotator cuff. Tintinalli_Sec23_p1881-1932.indd 1889 8/2/19 3:14 PM

ity Teres minor tendon Posterior Anterior FIGURE 280-3. Lateral view of the shoulder illustrating the coracoacromial arch with the rotator cuff and subacromial bursa. Subacromial bursa Supraspinatus FIGURE 280-4. Impingement of the subacromial bursa and rotator cuff. Tintinalli_Sec23_p1881-1932.indd 1889 8/2/19 3:14 PM 1890 SECTION 23: Musculoskeletal Disorders by activities that require overhead arm use, such as brushing the hair or reaching into a cupboard. Patients also note weakness and stiffness of the shoulder that is usually secondary to pain. 1,5 Once the shoulder pain has resolved, any weakness should trigger a search for a rotator cuff tear or cervical radiculopathy. Disuse atrophy of the shoulder musculature occurs when impinge ment or tendinitis symptoms are chronic (stages 2 and 3). Palpation of the rotator cuff insertion at the lateral aspect of the proximal humerus usually produces tenderness. During range-of-motion maneuvers, fibrosis and scarring within the tendon can cause crepitus, but the patient should have a normal and full active and passive range of motion. with an active arc of abduction, especially between 60 and 100 degrees, is consistent with rotator cuff pathology. 1 A sensation of catching also may be present if scar tissue is trapped beneath the acromion. Rotator cuff strength testing usually reveals mild to moderate weakness secondary to pain. The pain is usually present when resistance is applied. The individual muscles of the rotator cuff should be isolated and tested individually, looking for pain or weakness; to isolate the supraspinatus, abduct the arm to 90 degrees and forward flex it 30 degrees with the thumb pointed down in the “empty can” position ( Figure 280-5). Either symptom against resistance (continued abduction) in this posi tion suggests inflammation or injury to the supraspinatus muscle, which is the most likely muscle to be involved in the subacromial impingement syndrome. To isolate the infraspinatus and the teres minor, externally rotate the shoulder with the patient’s arm against the body and the elbow bent to 90 degrees and the forearm in neutral position. Stabilize the elbow against the patient’s waist and instruct the patient to rotate the arm outward. To isolate the subscapularis, have the patient place the hand behind the back and attempt to push the examiner’s hand away by moving the dorsum of the hand away from the back (lift-off test). Specific maneuvers on physical examination test for signs of impingement by compressing the rotator cuff and bursa between the humeral head and coracoacromial arch. In the classic impingement maneuver of Neer, the examiner prevents scapular rotation with one hand while raising the patient’s straightened arm smoothly in full forward flexion to overhead. A positive sign is pain in the arc between 70 and 120 degrees. A second test, the Hawkins impingement test ( Figure 280-6), requires the examiner to position the patient’s arm (shoulder) in 90 degrees of abduction and 90 degrees of elbow flexion. Rotation of the arm inwardly across the front of the patient with internal rotation of the shoulder compresses the cuff and bursa between the humeral head and coracoacromial ligament. The Neer and Hawkins tests are 75% to 89% and 91% to 92% sensitive, respectively, but specificity is much lower at 30% to 40% and 25% to 44%, respectively. DIAGNOSIS The diagnosis is based on a history of chronic shoulder pain with a full range of motion, with possible weakness of the rotator cuff muscles and positive responses to provocative maneuvers. Radiography is used to identify other causes such as fracture or degenerative joint changes.

d 25% to 44%, respectively. DIAGNOSIS The diagnosis is based on a history of chronic shoulder pain with a full range of motion, with possible weakness of the rotator cuff muscles and positive responses to provocative maneuvers. Radiography is used to identify other causes such as fracture or degenerative joint changes. Early nonspecific radiographic signs of rotator cuff syndromes include sclerosis and subchondral cyst formation of the greater tuberosity of the humerus or sclerosis or spur formation on the anterior edge of the acromion. 7 US can be used to rule out tendon rupture or assess for bursitis.5 TREATMENT The goals of treatment of subacromial impingement syndrome are to reduce pain and inflammation and to prevent progression of the process. Therapy starts with a conservative treatment program 5 that should include the following: • Relative rest and activity modification. Advise the patient to avoid the aggravating activity and minimize all overhead activities. Although brief periods of support with a sling may help, avoid complete immobilization and prescribe range-of-motion exercises (see later discussion) three to four times daily to minimize the chance of developing adhesive capsulitis. • Anti-inflammatories and analgesics. NSAIDs for 7 to 21 days are key, with short-term (3 days) opioid analgesics added if needed for severe pain. Acetaminophen may aid in lesser pain syndromes. • Cryotherapy. Apply ice to the affected shoulder for 10 to 15 minutes three to four times daily for analgesic effects and potential reduction of inflammation and edema. This is a cornerstone of treatment and should be used liberally. • Range-of-motion exercises. Two simple exercises can help the patient maintain glenohumeral motion. Pendulum swings are done with the patient slightly bent at the waist with the arm hanging freely in front of the body. The arms should be swung in gentle arcs of motion in both a clockwise and counterclockwise direction to the level of pain tolerance for 5 to 10 minutes three to four times daily. The size of the FIGURE 280-6. Hawkins impingement test. The examiner positions the patient’s shoulder at 90 degrees of abduction and 90 degrees of elbow flexion. The examiner then rotates the shoulder internally and brings the patient’s arm across the front of the patient. FIGURE 280-5. The “empty can” position, which isolates the supraspinatus tendon. Pain or weakness against resistance in this position suggests injury to the supraspinatus muscle. Tintinalli_Sec23_p1881-1932.indd 1890 8/2/19 3:14 PM

es the shoulder internally and brings the patient’s arm across the front of the patient. FIGURE 280-5. The “empty can” position, which isolates the supraspinatus tendon. Pain or weakness against resistance in this position suggests injury to the supraspinatus muscle. Tintinalli_Sec23_p1881-1932.indd 1890 8/2/19 3:14 PM CHAPTER 280: Shoulder Pain 1891 arcs should increase daily as symptoms allow. Also, the patient should stand sideways an arm’s length from a wall and walk the fingers up the wall to the level of pain tolerance, repeating the exercise three to four times daily. • Stretching and strengthening. Stretching and strengthening exercises are best carried out under the supervision of a physical therapist. • Corticosteroid injections. Although local corticosteroid injections into the subacromial space relieve pain, adverse effects include muscular atrophy, weakness, and further tissue degeneration. Injection directly into the tendon can lead to necrosis and rupture. Injection is not an emergency procedure and is best left to the primary care physician or orthopedist. • Follow-up. Ensure reassessment within 7 to 14 days with an ortho pedist and/or a rehabilitation expert for consideration of additional therapies.  ROTATOR CUFF TEARS PATHOPHYSIOLOGY Patients with rotator cuff tears present with shoulder pain after acute traumatic injury, chronic injury, or an acute extension of a chronic subacromial impingement syndrome (stage 3), the most common cause in patients over age 40. 8 In younger patients, rotator cuff tears are seen in laborers and athletes who participate in sports that require overhead activities like tennis, swimming, and baseball. 8 In general, healthy rotator cuff tendons are resistant to acute injury, with acute rotator cuff tears accounting for only a small minority of all rotator cuff tears. These acute tears usually occur as a result of trauma, such as forced or extreme hyperabduction or hyperextension from falling on an outstretched arm, lifting a heavy object, or catching a heavy object as it falls. Glenohumeral dislocation is a common cause of acute rotator cuff tear, with the frequency of rotator cuff tear after an ante rior dislocation ranging from 7% to 32%, with more occurring with advancing age. 8 In patients >40 years of age with a first-time disloca tion or in those with weakness >3 weeks after an acute dislocation, think of a rotator cuff tear. Rotator cuff tears are categorized by the acuteness of the injury and as full- or partial-thickness injuries; however, the differentiation is dif ficult to identify on the clinical evaluation. Partial-thickness tears are twice as common as full-thickness tears and most commonly occur on the inferior aspect of the tendon. The type and extent of the tear have significant implications for the ultimate treatment and prognosis. The supraspinatus, due to its location within the coracoacromial arch, is the most commonly affected tendon of the rotator cuff. CLINICAL FEATURES The clinical features of a chronic rotator cuff tear differ from those of an acute tear. Only about half of patients with chronic rotator cuff tears can recall specific trauma or an event associated with the onset of pain, often seemingly insignificant in description. Patients more commonly report a history of gradual and progressive pain; while initially described as worse at night, the pain eventually becomes persistent. The pain may be diffuse, but is commonly localized to the lateral aspect of the upper arm. Often, initial therapy with rest, anti-inflammatory agents, and glucocorticoid injections helps. If the rotator cuff weakens, the frequency, intensity, and duration of the symptoms increase and are less responsive to the usual treatments.

may be diffuse, but is commonly localized to the lateral aspect of the upper arm. Often, initial therapy with rest, anti-inflammatory agents, and glucocorticoid injections helps. If the rotator cuff weakens, the frequency, intensity, and duration of the symptoms increase and are less responsive to the usual treatments. Shoulder dysfunction progressively worsens and interferes with work, recreation, and normal daily activities. Arm elevation, external rotation, and lifting of even light objects worsen the symptoms. With acute injuries, such as those due to falling or catching a heavy object, the patient may report a “tearing” sensation in the shoulder fol lowed by severe pain and inability to raise the arm. An acute rotator cuff tear produces immediate profound pain and disability, with asym metry often present due to local swelling. Active motion is limited, with inability to abduct or externally rotate the arm against even minimal resistance. On examination, disuse atrophy is often present in patients with chronic rotator cuff tears. Palpation may produce discomfort at the lateral aspect of the upper arm or in the subacromial region. Most patients with rotator cuff tears have weakness and pain on abduction, elevation, and, most commonly, external rotation. The result of the drop arm test is positive if the patient is unable to hold or lower a fully extended arm at 90 degrees of shoulder abduction without dropping it. Crepitus and pain are usually present on range-of-motion testing. DIAGNOSIS It may be very difficult to distinguish a full-thickness tear from a partialthickness tear or a rotator cuff injury from impingement syndrome. The diagnosis is primarily clinical based on a finding of rotator cuff weakness on examination in a patient with a history of chronic shoulder pain or acute shoulder pain after significant trauma. In patients with an acute injury, it may be difficult to diagnose the tear due to excessive pain from the injury. In these cases, assume a preliminary diagnosis of acute rotator cuff tear and treat conservatively, with appropriate follow-up in 1 week. Routine shoulder radiographs occasionally give additional diagnos tic information. The most specific radiographic sign for large rotator cuff tears is a narrowing of the acromiohumeral space (<7 mm). 7 No radiographic findings are diagnostic of an acute rotator cuff tear, and the diagnosis should rely on clinical findings. MRI, US, and arthrog raphy are the most sensitive modalities for detecting rotator cuff tears, although all tend to underestimate the extent of the tear. TREATMENT The basic goals of emergency care for suspected rotator cuff injuries are the same as with impingement (see previous discussion), with analgesia, support, and prevention of further dysfunction and disability. An arm sling can provide support and comfort until the acute symptoms sub side. Avoid prolonged immobilization and prescribe range-of-motion exercises three to four times daily to minimize the development of adhesive capsulitis. Any evidence or suspicion of neurovascular compromise requires immediate orthopedic consultation. Refer all patients with an acute rotator cuff tear (with or without a history of chronic symptoms) and those with significant disability to an orthopedist for follow-up within 1 week. Complete rotator cuff tears usually require surgical repair, and functional results are better if repair is carried out early, before retraction, fibrosis, tendon degeneration, and muscular atrophy have occurred. Partial-thickness or chronic tears may respond to conservative measures.  CALCIFIC TENDINITIS PATHOPHYSIOLOGY Calcific tendinitis is a self-limiting disorder characterized by calcium crystal deposition within one or more tendons of the rotator cuff.

n, fibrosis, tendon degeneration, and muscular atrophy have occurred. Partial-thickness or chronic tears may respond to conservative measures.  CALCIFIC TENDINITIS PATHOPHYSIOLOGY Calcific tendinitis is a self-limiting disorder characterized by calcium crystal deposition within one or more tendons of the rotator cuff. In time, the calcium undergoes painful spontaneous resorption with subsequent healing of the tendon. The condition most commonly afflicts patients aged 30 to 50 years, and this process is rarely seen in patients >70 years of age. Females are more commonly affected than males, and calcification is often present bilaterally. Primary tendon degeneration as a result of chronic repetitive microtrauma, age, and tissue hypoxia is the proposed cause of this disorder, although a clear etiology remains elusive. Cal cific tendonitis most commonly affects the supraspinatus tendon, with calcium deposition usually occurring near its origin on the humerus. However, any of the rotator cuff tendons or the long head of the biceps may be affected. CLINICAL FEATURES Three stages represent the process of calcific tendonitis.9 Because calcification occurs over a period of time, patients are generally asymptomatic or have mild pain at rest or at night in the initial precalcific stage. Pain Tintinalli_Sec23_p1881-1932.indd 1891 8/2/19 3:14 PM

biceps may be affected. CLINICAL FEATURES Three stages represent the process of calcific tendonitis.9 Because calcification occurs over a period of time, patients are generally asymptomatic or have mild pain at rest or at night in the initial precalcific stage. Pain Tintinalli_Sec23_p1881-1932.indd 1891 8/2/19 3:14 PM 1892 SECTION 23: Musculoskeletal Disorders with abduction or a “catching” sensation may be present on movement. Calcium deposits accumulate during the calcific stage. During the third portion of the calcific stage, the resorptive phase, incapacitating pain can occur from vascular proliferation, formation of granulation tissue, and calcium crystal extravasation into the subacromial bursa. Symptoms typically last 1 to 2 weeks. After the initially painful resorptive phase, patients can have variable levels of pain and shoulder dysfunction that may last for several months (postcalcific period). Symptomatic patients experience sudden onset of shoulder pain, usually at rest. Movement of the shoulder further exacerbates the pain. The pain is often worse at night and interferes with sleep. Dur ing an acute attack with intense pain, the patient may hold the arm adducted and often is reluctant to move it. A point of maximum tenderness may be palpated over the proximal humerus near the ten dinous insertion of the rotator cuff. Both active and passive range of motion of the glenohumeral joint may be limited to varying degrees; document range of flexion, extension, abduction, and internal and external rotation. Crepitus may be present and muscle atrophy may develop. DIAGNOSIS Obtain shoulder radiographs for patients with suspected calcific tendi nitis to localize deposits and seek any signs of possible impingement. 10 During the initial formative phase, calcium deposits are usually dense and well defined if visualized. In patients who are experiencing intense pain in the resorptive phase, calcium deposits may appear hazy with poorly defined borders. The presence of visible calcifications is not necessarily specific for this disorder. US is unlikely to be helpful during the resorptive phase because the poorly defined calcifications produce little or no acoustic shadowing. TREATMENT Treatment is similar to that for impingement syndrome, and nonoperative management is successful in 90% of cases. 10 During an acute attack, NSAIDs, analgesics, and ice help to calm the intense pain. The shoulder may be rested using a sling for brief periods, but avoid prolonged immobilization. Instruct patients to rest the shoulder in abduction on the back of a chair as often as is tolerable. At night, instruct patients to sleep with a pillow beneath the axilla in order to prevent restriction of motion. Local application of heat may be recommended once acute symptoms have diminished. Emphasize and encourage gentle and progressive range-of-motion exercises. Consider physical therapy for patients with more chronic cases who have significantly limited range of motion of the shoulder. Multiple treatment modalities including subacromial corticosteroid injection, oral steroids, platelet-rich plasma therapy, transcu taneous electrical nerve stimulation, and therapeutic US are used, but no strong supporting evidence exists for their use. 10 Emerging evi dence exists for US-guided needle lavage; a comparison of US-guided needle lavage with corticosteroid injection to corticosteroid injection alone showed modestly favorable clinical and radiographic results for the US group at 1 year. 11 This modality also results in an estimated 55% reduction in pain at 1 year. 12 This procedure is not available at many centers. DISPOSITION AND FOLLOW-UP Calcific tendinitis is a self-limited process in the vast majority of cases.

howed modestly favorable clinical and radiographic results for the US group at 1 year. 11 This modality also results in an estimated 55% reduction in pain at 1 year. 12 This procedure is not available at many centers. DISPOSITION AND FOLLOW-UP Calcific tendinitis is a self-limited process in the vast majority of cases. For patients with new presentation of this disease, arrange follow-up with a primary care doctor within a week. For the 10% of patients in whom nonoperative methods are unsuccessful, arthroscopic or open surgery may be indicated. 10 Refer patients who have progression of symptoms, constant pain interfering with daily activities, or absence of improvement after conservative therapy. 13 Adhesive capsulitis is the most common complication of calcific tendinitis and results in more chronic symptoms.  ADHESIVE CAPSULITIS PATHOPHYSIOLOGY Adhesive capsulitis, commonly referred to as frozen shoulder syndrome, begins as painful inflammation of the glenohumeral joint, followed by eventual fibrosis of the joint capsule and restriction of shoulder motion, especially external rotation. Primary or idiopathic adhesive capsulitis is associated with a wide variety of unrelated conditions, including diabetes; thyroid disease; postmenopausal; pulmonary neoplasm; and autoimmune disorders. Secondary adhesive capsulitis produces similar findings, but results from a known cause, such as prolonged immobilization after trauma, surgery, stroke, or a primary inflammatory condition of the shoulder such as impingement syndrome or bicipital tendinitis. The condition is typically unilateral and resolves with conservative therapy in most patients within 1 to 2 years, although some are left with residual pain or stiffness. Four stages of this disorder exist, although patients do not necessar ily follow these stages in a linear fashion. Stage 1, within the first 2 to 3 months, presents with acute synovial inflammation with limitation of shoulder movement due to pain. Decreased shoulder motion, from capsular thickening and scarring, and chronic pain characterize stage 2 (freezing stage) around months 3 to 9. Stage 3 (frozen stage), months 9 to 15, is characterized by less pain but a more fibrotic thick capsule and increased limitation in range of motion. Progressive improvement in the range of motion of the shoulder, usually after 15 months, dis tinguishes stage 4 (thawing stage), along with significant improvement in pain. DIAGNOSIS Limited active and passive range of motion are the hallmarks of adhesive capsulitis. Pain is typically diffuse and aching, poorly localized, accom panied by stiffness, and often extends down the upper arm. The pain is frequently worse at night and at rest, especially in earlier stages. Disuse may lead to muscle atrophy. Impingement testing is difficult due to the restriction of motion. Occasionally, posterior glenohumeral dislocation leads to additional restricted motion of the shoulder; exam and imaging can help detect this condition. US may demonstrate increased vascular flow, thickening of rotator cuff structures, and bulging of the supra spinatus tendon. MRI or magnetic resonance angiography (through follow-up) findings approach 70% sensitivity and 95% specificity for the condition. TREATMENT Treatment is geared toward reducing pain and restoring motion and function. Avoid shoulder immobilization; if a sling is used in patients in early stage 1 who have severe pain, limit it to daytime to prevent increased loss of motion due to further capsular restriction. Although physical therapy is difficult in the early, more painful stages of disease, it is crucial, along with NSAIDs, analgesics, and ice.

r immobilization; if a sling is used in patients in early stage 1 who have severe pain, limit it to daytime to prevent increased loss of motion due to further capsular restriction. Although physical therapy is difficult in the early, more painful stages of disease, it is crucial, along with NSAIDs, analgesics, and ice. Intra-articular steroid injection is a potential option during follow-up to improve pain and function in the short term; the long-term efficacy is unclear. Refer patients to an orthopedist if ongoing symptoms persist despite adequate therapy (usually after >6 months) or when the diagnosis is unsure. Closed manipulation under general anesthesia, arthroscopic capsular release, and open capsular release are surgical options.  DISORDERS OF THE BICEPS TENDON PATHOPHYSIOLOGY Disorders of the proximal aspect of the long head of the biceps tendon include tendinopathy, subluxation or dislocation, and partial or com plete tears; these occur from inflammation, instability, or trauma. 15 The long head of the biceps tendon originates from the superior labrum and the supraglenoid tubercle on the scapula. As it exits the glenohumeral Tintinalli_Sec23_p1881-1932.indd 1892 8/2/19 3:14 PM

hy, subluxation or dislocation, and partial or com plete tears; these occur from inflammation, instability, or trauma. 15 The long head of the biceps tendon originates from the superior labrum and the supraglenoid tubercle on the scapula. As it exits the glenohumeral Tintinalli_Sec23_p1881-1932.indd 1892 8/2/19 3:14 PM CHAPTER 280: Shoulder Pain 1893 joint, it courses through the bicipital groove and travels anterior and superior to the humeral head. 15 Approximately 50% of the long head of the biceps tendon originates from the superior labrum. Due to this anatomic association, tears of the superior labrum, known as SLAP (superior labrum anterior to posterior) lesions, are frequently found in conjunction with long head of the biceps tendon pathology. Injuries of one or the other structure may be difficult to distinguish, both clinically and operatively. Biceps tendon pathology is also commonly associated with adjacent pathologies including rotator cuff dysfunction, adhesive capsulitis, glenohumeral joint arthritis, and supraspinatus tendinosis. (See Chapter 271, “Shoulder and Humerus Injuries, ” for the approach to traumatic ruptures of the distal bicipital tendon.) CLINICAL FEATURES Bicipital tendinopathy may be due to inflammation (tendinitis) or col lagen tears in or around the tendon (tendinosis) and may be acute or chronic. Tendinitis and tendinosis are difficult to distinguish clinically. Bicipital tendinopathy triggers intense pain localized to the anterior aspect of the shoulder. Repetitive overhead arm motion may result in an acute SLAP lesion, particularly in athletes, or chronic inflam mation. Pain at rest, night pain, and pain on rotation are common. Subluxation of the biceps tendon from the bicipital groove is painful and occurs medially or laterally, while complete dislocation is seen only medially and is associated with a subscapularis tear. Posterolateral instability is associated with a supraspinatus tear. Concurrent injury to the biceps reflection pulley is necessary for tendon dislocation in either direction. Partial or complete rupture is almost always proximal and is due to micro-tears and other age-related degenerative changes in this area of the tendon. In younger patients, mild trauma may cause complete rup ture of the biceps tendon, which is heralded by an audible snap or pop followed by severe pain and deformity. DIAGNOSIS Palpation of the tendon within the bicipital groove reproduces the intense pain. However, even the apparently simple maneuver of palpat ing the long head of the biceps tendon is notoriously inaccurate; its identification may be assisted by US. Forearm supination, one of the main actions of the long head of the biceps, also reproduces pain, especially when resistance is applied. In assessing for instability, resisted forearm supination may cause palpable subluxation or a painful popping sensa tion as the tendon undergoes subluxation; these findings are classic but not common. Because biceps tendon pathology is frequently associated with pathology of adjacent structures, clinical testing is often inconclusive and inaccurate. 15 Many provocative tests to confirm the presence of pathology of the long head of the biceps or superior labrum have been described in the literature. Speed’s test identifies tear or tendinitis of the long head of the biceps; flex the shoulder to 90 degrees with the patient’s arm (elbow) fully extended and supinated. Provide downward resistance against shoulder flexion. Pain localized to the bicipital groove indicates a positive test. The Speed’s test appears to have a sensitivity of 60% to 87% and a specificity of 80% for tear of the long head of the biceps, with a positive likelihood ratio of 2.77.

) fully extended and supinated. Provide downward resistance against shoulder flexion. Pain localized to the bicipital groove indicates a positive test. The Speed’s test appears to have a sensitivity of 60% to 87% and a specificity of 80% for tear of the long head of the biceps, with a positive likelihood ratio of 2.77. 16 The uppercut test results in the most favorable positive likelihood ratio (3.38) for diagnosis of biceps tendi nopathy, with a sensitivity of 73% and specificity of 78%. The upper cut test combined with US results in 97% sensitivity and up to 100% specificity. 17 The uppercut test is performed with the shoulder held in a neutral position, elbow flexed to 90 degrees, and the forearm supinated, as the patient forms a fist. The patient is instructed to simulate a boxing “uppercut” punch resisted by the examiner who places a hand over the patient’s fist. Pain or a painful pop over the anterior portion of the involved shoulder indicates a positive test. SLAP lesions (superior labral tear from anterior to posterior) are complex, and physical examination alone is usually insufficient to diagnose a SLAP lesion. The test most likely to indicate a SLAP lesion is the active compression test. To perform the test, have the standing patient flex his or her shoulder to 90 degrees, and then adduct 10 to 15 degrees medially and internally rotate so the thumb points to the floor, with elbow extended. The examiner applies a uniform downward force to the arm. This is repeated in full supination. A positive response is indicated by eliciting pain on the first maneuver, which is significantly diminished or absent on the second maneuver; the test is 60% to 100% sensitive and 85% to 98% specific. The classic finding of biceps tendon rupture is described as a “Popeye” deformity caused by distal contraction of the muscle belly. Supination is weak on muscle testing, but elbow flexion remains strong because of the presence of other intact elbow flexors (short head of the biceps and brachialis muscles). Plain radiographs are generally unhelpful in diagnosing biceps ten don or SLAP lesions. MRI is also poor in diagnosing biceps tendon and SLAP lesions; magnetic resonance arthrography is preferable. In the hands of skilled operators, US reliably detects biceps tendon disloca tion and complete tears. US currently appears to have sensitivity similar to MRI (50%) in detecting partial biceps tendon tears. Arthroscopy is considered the gold standard, although studies have demonstrated poor inter-rater reliability of arthroscopic diagnosis. TREATMENT Manage tendinitis and subluxation with brief use of a sling as needed for support and comfort, aided by analgesics, anti-inflammatory agents, application of ice several times daily, and elevation to reduce swelling. Prescribe early mobilization with stretching exercises and follow-up within 7 to 14 days with a primary care provider. Although not commonly administered by emergency physicians, intra-articular injections of local anesthetic and steroid can improve symptoms. Intra-articular injections can relieve bicipital symptoms but may be ineffective if adhesions or synovitis prevent dispersal into the bicipital groove. Direct injection into the bicipital groove with US guidance may be an option for specialists if previous intra-articular injections have not worked. 18 Bicipital tendinitis usually resolves with conservative therapy. Reserve orthopedic consultation for those with tendinopathy associ ated with instability, partial rupture, or high-grade SLAP lesion, or those failing to respond to a conservative treatment regimen. Surgical options include debridement, tenotomy, or tenodesis. 18 Bicipital tendon rupture often requires surgical repair; refer to an orthopedic surgeon for evaluation within 24 to 48 hours.

ed with instability, partial rupture, or high-grade SLAP lesion, or those failing to respond to a conservative treatment regimen. Surgical options include debridement, tenotomy, or tenodesis. 18 Bicipital tendon rupture often requires surgical repair; refer to an orthopedic surgeon for evaluation within 24 to 48 hours. Patients with suspected SLAP lesions or other mechanical proximal biceps injuries generally require arthroscopic or other surgical intervention when symptomatic.  OSTEOARTHRITIS Because the glenohumeral joint is non–weight bearing, primary osteoarthritis is rare. When it does occur, presentation is like that of degenerative disease in other joints: the patient experiences gradual and progressive onset of pain that is worse with motion and better with rest. This usually occurs concurrently with degenerative disease of the acromioclavicular joint. Secondary osteoarthritis is more com mon and is usually associated with a previous fracture, recurrent dis locations, or an underlying rheumatologic, metabolic, or endocrine disorder. ED care of both primary and secondary arthritis relies on analgesics, anti-inflammatory agents, and gentle exercises to preserve range of motion.  OTHER CAUSES OF SHOULDER PAIN Although disorders of the rotator cuff and other intrinsic structures of the shoulder are the most common cause of shoulder pain, extrinsic conditions outside the shoulder complex can refer pain to the shoulder. The differential diagnosis includes disorders of the cervical spine, bra chial plexus injuries, axillary artery thrombosis, suprascapular nerve injury, thoracic outlet syndrome, Pancoast’s tumor, and miscellaneous thoracoabdominal disorders. Tintinalli_Sec23_p1881-1932.indd 1893 8/2/19 3:14 PM