Pain syndromes of the shoulder

1. Painful arc syndrome (rotator cuff tendinitis, subacromial bursitis)

-pain over the anterior or lateral shoulder, most severe during abduction.
-restriction of joint motion.
General considerations
Inflammation within the glenohumeral joint is the most frequent cause of shoulder
pain and limitation of motion. The patient is typically middle-aged. Repeated minor
trauma from occupational or sports activity is the cause, and the most common site of
inflammation at onset is the rotator cuff, particularly the supraspinatus tendon. The
location of the supraspinatus tendon between the greater tuberosity of the humeral
head and the overhanging acromion process renders it particularly vulnerable to
mechanical compression. Rotator cuff inflamation will often spill over into the
subacromial bursa, and subdeltoid soreness frequently radiates along the lateral
humerus to the deltoid insertion.
Clinical Findings
Active abduction becomes especially painful when the shoulder moves between 60
and 120 degrees because the inflamed rotator cuff and overlying bursa are compressed
beneath the acromion. Because of this characteristic feature, the condition is known as
painful arc syndrome. The range of active abduction may be extended if the patient is
instructed to rotate the arms so that the palms face upward. This rotates the greater
tuberosity posteriorly, so that the attached rotator cuff tendons pass behind the
acromion, rsulting in diminished pain with continued abduction.
Treatment
Treatment of rotator cuff tendinitis and subacrimial bursitis is with analgesics such as
aspirin or nonsteroidal anti-inflammatory agents (naproxen, ibuprofen), and local
application of cold packs. Physical therapy may beuseful in preserving full range of
motion. Slings and shoulder immobilization should not be used for more than a few
days, since capsular adhesions and prolonged stiffness may result. Gentle passive
range-of-motion exercises by a therapist or family member should be started as soon
as tolerated, followed by active pendulum exercises consistig of circular swinging
motions of the dangling arm while leaning forward. Active exercise is gradually
increased while passive range of motion is extended with exercises such as pulleyenhanced abduction using a bath towel over a shower curtain rod.
If pain does not respond to oral anti-inflammatory agents, prolonged relief
may be obtained by injecting 40mg of methylprednisolone acetate (of equivalent) and
1-2 mL of lidocaine into the subacromial bursa. The patient should be warned that

injection may produce a brief exacerbation of pain before relief is noted and should be
provided with analgesic medications. When full function has been recovered,
reduction of stressful activities should be advised.
2. Calcific tendinitis
General considerations
Calcium deposition in the degenerative rotator cuff may lead to a variant form of
tendinitis in the shoulder region. Asymptomatic bilateral calcium deposits in the
shoulder tissues are common finding in persons over age 40. The pathogenesis is
unclear. The deposits may enlarge or rupture into the subacromial bursa.
Clinical findings
a. Symptoms and signs
The presentation of acute calcific tendinitis or bursitis is dramatic, with
excruciating pain and severe restrection of shoulder motion. The patient may
refuse even the gentlest examination for fear of motion-induced muscle spasm.
b. Imaging studies
X-rays reveal either focal calcium deposits within the rotator cuff or a large cap
of calcium overlying the humeral head, which represents dissemination of calcium
into the subacromial bursa.
Treatment
Treatment of acure calcific tendinitis includes immediate injection of a
corticosteroid and lidocaine solution into the tendon near the calcium deposit or
into the bursa if calcium has entered that structure. Multiple needle punctures into
the calcium deposit may break up the deposit and provide dramatic relief.
Mobilization of the shoulder should procced as described in the preceding section.
3. Biceps tendinitis
Essentials of daignosis
-localized tenderness over the bicipital groove
-pain during supination of the forearm against resistance.
General considerations
A common inflammatory lesion producing shoulder pain involves the biceps tendong
in the bicipital groove. Biceps tendon inflammation usually affects individuals whose
occupation involves repetitive biceps flexion against resistance or whose recreational
activities include forceful throwing of a ball. Pain is prominent over the anterior
aspect of the arm and is aggravated by shoulder motion. Symptomms are worse at
night and improve with rest. Deltoid muscle spasm may be present and may limit both
active and passive motion.
Clinical findings
Biceps tendinitis can be distinguished from rotator cuff tendinitis by localization of
tenderness to the bicipital groove. Forearm supination against resistance with the
elbow flexed at the patients side elicits extreme tenderness in the region of the

bicipital groove when the tendon is palpated near the shoulder. Instability of the
tendon in the groove is occasionally manifested by a snapping sensation as the arm is
abducted and externally rotated. Subluxation of the tendons can be provoked for
diagnostic verification by Yergasons maneuver, in which the patient actively flexes
the elbow against resistance while the physician rotates the humerus externally. An
unstable tendon will pop out of the groove.
Treatment
Treatment of bicipital tendinitis includes cessation of offending activities and shortthem immobilization of the shoulder in a sling ; a trial of aspirin or nonsteroidal antiinflammatory agents ; and, occasionally, local injection of corticosteroids. Repeated
corrticosteroid injections may result in tendon attrition or rupture and should be
avoided. Surgery is occasionally required to stabilize a subluxating tendon.
When discomfort has subsided, progressive mobilization is begun with
exercises similar to those described in the section in rotator cuff tendinitis.
4. Adhesive capsulitis (frozen shoulder)
Essentials of diagnosis
-diffuse shoulder tenderness
-restriction of shoulder joint motion
General considerations
A common cause of shoulder pain in middle-aged and elderly patients is adhesive
capsulitis, or so-called frozen shoulder. This disorder may complicate other
inflamatory shoulder ailments, particularly in individuals immobilized for prolonged
periods. It may also occur without any identifiable inciting trauma and has been
associated with cardiovascular disease, rheumatoid arthritis, and degenerative cervical
spine disease. Though the exact pathogenesis is unknown, the end result is a
chronically inflamed, contracted fibrotic capsule densely adherent to the humeral
head, the acromion, and the underlying biceps and rotator cuff tendons. Normal
bursae are obliterated by scarring.
Clinical findings
A. Symptoms and signs
The onset of symptoms is usually gradual and heralded by complaints of diffuse
tenderness with disproportionately severe restriction of active and passive motion.
Motion is not improved by lidocaine or corticosteroid injection.
B. Imaging studies
Arthrography reveals a contracted joint capsule and no bursal filling. X-rays may
reveal severe osteoporosis of the humeral head.
Trearment
The success of various treatment is difficult to assess, as the natural history of
adhesive capsulitis is spontaneus resolution. Subsidence of pain and return of

nearly full motion can be anticipated, though the process may persist for 6 months
to several years. Efforts to speed return of function have included intensive
physical therapy, oral corticosteroids and anti inflammatory agents, and a
procedure called infiltration brisement, which consists of pressure injection of the
joint with 50 mL of saline and corticosteroid solution in order to break the
adhesions binding the capsule to the surrounding structures.
Clearly, the best treatment of this condition is prevention. Prolonged disuse or
immobilization of a painful shoulder must be avoided. Early mobilization is
stressed, with initiation of gentle range of motion exercises and persistent
encouragement and guidance by the physician and the physical therapist.