Bilateral shoulder pain may be a feature of a systemic disorder such as polymyalgia rheumatica or RA. On the other hand, osteoarthritis of the glenohumeral joint is very uncommon except in cases where there was antecedent shoulder joint or rotator cuff injury or prior metabolic damage to the cartilage, as seen in chondrocalcinosis.

    Patients may describe a history of insidious onset of pain. Those who have an abrupt onset of pain during activity may be describing a partial tear of an affected tendon (e.g., rotator cuff tear). In those cases patients will often present with marked inability to raise the arm. Why does tendinitis occur so commonly in the shoulder region? This is because during shoulder abduction, the rotator cuff and long biceps tendons are subjected to impingement at the greater tuberosity of the humerus and the coracoacromial arch. With excessive or frequent repetitive overhead activities, there is tissue injury resulting in tears of the rotator cuff as well as tendinitis within the cuff mechanism. A viable rotator cuff is required for abduction and external rotation of the shoulder as well as stabilizing the glenohumeral joint and preventing the superior migration of the humeral head. Thus, an injured or damaged rotator cuff may be unable to prevent some degree of superior migration of the humeral head, resulting in further damage to the rotator cuff and to the long biceps tendon (which sits on the humeral head), which are now being squeezed by the changing architecture of the joint. With time and recurrent injury, there may be osteophyte formation over the inferior surface of the acromioclavicular joint, and this will intensify the degree of impingement of the rotator cuff and the biceps tendon. Thus, the spectrum of these chronic impingement syndromes can range from episodes of mild tendinitis of the rotator cuff to the development of tears of the rotator cuff or the long head of the biceps tendon. Because the subacromial bursa is adjacent to the rotator cuff, many of these cases are also associated with a subacromial bursitis.

    In some patients there may be the onset of an explosive, exquisitely painful shoulder pain with marked difficulty with any range of motion. Patients are extremely uncomfortable and are very reluctant to comply with a physical examination of the shoulder. Radiographs of the affected shoulder demonstrate calcification within the rotator cuff tendon or subacromial bursa. These calcific deposits often disappear following resolution of the episode.

Physical Examination

The physical examination of the shoulder should begin with inspection for evidence of muscle wasting or bony hypertrophy over the acromioclavicular joint. These findings suggest a long-standing problem. Shoulder fullness (suggesting effusion) is unusual and not easily visualized, because a shoulder joint effusion would be deep within the tissues and must be diagnosed through imaging such as magnetic resonance imaging (MRI) or shoulder ultrasound. Shoulder range of motion and function is assessed by having the patient place his or her arm by his or her side and slowly raise it laterally to assess the range of shoulder abduction. The first 30–40° of abduction is controlled by the deltoid muscle. Beyond 40°, abduction is performed using the rotator cuff mechanism. In patients with rotator cuff–related tendinitis or impingement syndromes, there will be a definite loss of motion and a description of pain with abduction beyond 40°. The patient continues this motion against the resistance of the examiner’s hand, which is placed on the patient’s elbow while applying downward pressure. The patient’s ability to continue abduction against resistance is noted: if he or she complains of pain, the diagnosis of a rotator cuff–related injury (either tendinitis or tear or both) is made. A rotator cuff tear can be distinguished from tendinitis if the patient is unable to actively abduct the arm beyond 40° but can passively move the arm through this arc of motion without pain.

    Patients who have a subacromial bursitis may note local tenderness on palpation of the subacromial bursa that sits at the top of the humerus just below the glenoid arch. Patients with a bicipital tendinitis often describe pain that is felt more anteriorly over the top part of the humerus corresponding to the biceps tendon insertion area. However, it should be noted that many patients may have features of each of these conditions because the affected areas lie in close proximity to one another.

ELBOW PAIN

The most common causes of elbow pain include medial and lateral epicondylitis. Although initially described as tennis elbow, lateral epicondylitis is more commonly seen with other activities such as excessive computer mouse use or repeated gripping of work tools such as screwdrivers and hammers. These activities all require repeated, frequent use of the hand flexor tendons. Although it was initially considered to be a form of tendinitis with suspected inflammation at the tendon bone insertion interface, it is now considered by some to be due to a cumulative trauma overuse disorder with repetitive mechanical overloading of the common extensor tendon, particularly involving the portion derived from the extensor carpi radialis brevis tendon. In some histopathologic specimens of excised epicondylar tissue, there is evidence for fibroblastic hyperplasia and disorganized collagen bundles.

    The pain is often insidious and sometimes bilateral, although usually involving the dominant arm. The pain is generally localized to the lateral epicondyle but over time may extend both distally toward the wrist and proximally upward toward the shoulder. It is exacerbated by any squeezing activities of the hands such as holding a pen, gripping, or lifting objects. This can be confirmed by having the patient try to squeeze an object such as a cup; this will often elicit the pain. Palpation over the lateral epicondylar area usually provokes intense pain and discomfort. However, the elbow range of motions such as flexion and extension as well as pronation and supination are maintained. One way to distinguish epicondylitis from a true elbow joint arthritis is to assess pronation and supination range of motion. In patients with elbow joint synovitis, there is a reduction in these motions, whereas there is no effect on these motions with either type of epicondylitis.

    Medial epicondylitis is less commonly seen than the lateral form. Although it is known as “golfer’s elbow,” this condition is more commonly seen in patients who are at risk for lateral epicondylitis as well. Typically, there is an antecedent history of cumulative repetitive strain of the common flexor muscle of the forearm provoking pain and tenderness at the medial epicondylar region. The pain may radiate proximally and distally as well. The diagnosis is confirmed by noting pain over the medial epicondyle with either palpation or by the simultaneous forced full extension of the elbow and the wrist.

OLECRANON BURSITIS

The olecranon bursa sits below the tip of the elbow and can become swollen and sometimes painful from a number of conditions. These include trauma, inflammation (e.g., RA or gout), or sepsis. Because gouty bursitis and sepsis can both be associated with similar findings, such as increased warmth, swelling, and redness along with pain, it is generally necessary to aspirate the bursa for synovial fluid analysis including cell count, Gram stain, and culture of the joint fluid. Septic olecranon bursitis is usually the result of direct inoculation of bacteria via a skin abrasion and can occur in otherwise healthy individuals engaged in physical work that results in frequent trauma to the elbows. The most common pathogen is Staphylococcus aureus. Traumatic bursitis can occur with recurrent or incidental trauma to the elbow. Patients often present because of swelling that may be only minimally painful. The diagnosis is confirmed by joint aspiration demonstrating hemorrhagic joint fluid with few white blood cells and no bacteria or crystals being present.

WRIST AND HAND DISORDERS

Carpal Tunnel Syndrome

Perhaps the most common soft tissue disorder involving the wrist and hand is the carpal tunnel syndrome. This is caused by entrapment of the median nerve within the carpal tunnel. It is characterized by painful paresthesias and sensory loss in a median nerve distribution (generally this involves the thumb, second digit, and half of the third digit). In more advanced cases there may be loss of motor power in the median distribution in the hands as well as atrophy of the thenar muscles. There is generally a history of nocturnal pain in the median nerve distribution. Percussion of the median nerve at the flexor retinaculum just radial to the palmaris longus tendon at the distal wrist crease (Tinel sign) will produce paresthesias in the median nerve distribution. Phalen sign is the development of paresthesias following sustained palmar flexion of the wrist for 20–30 seconds. The severity of the entrapment and the need for surgical decompression can be assessed by electromyography (EMG).

    Flexor tendon entrapment syndromes of the digits can occur in patients without a history of an inflammatory arthritis or diabetes. Most cases are idiopathic, although patients with diabetes and RA may be at increased risk for this condition. Patients present with triggering symptoms involving a digit, especially following periods of inactivity such as arising in the morning. They often must use their other hand to help “unlock” the affected digit. A nodular thickening of the tendon is often present at the site of maximum tenderness that is generally in a part of the flexor tendon just proximal to the metacarpophalangeal (MCP) joint of the affected digit. The histopathology of the lesion consists of hypertrophy and fibrocartilaginous metaplasia of the ligamentous layer of the tendon sheath that results in stenosis of the tendon sheath canal and mechanical entrapment of the tendon.

De Quervain Tenosynovitis

De Quervain tenosynovitis a disorder affecting the common tendon sheath of the abductor pollicis longus and extensor pollicis brevis tendons. It is characterized by pain over the radial aspect of the wrist that is aggravated by movements of the thumb during pinching, grasping, and lifting activities. It is actually a tendon entrapment syndrome, resulting in thickening of the extensor retinaculum that covers the first compartment of the wrist and leads to a tendon entrapment. Palpation of the affected tendon sheath recreates pain and exquisite tenderness. In the Finkelstein test, the patient makes a fist with the fingers wrapped around the thumb and then is instructed to flex the thumb in the ulnar direction. This reproduces the pain and confirms the diagnosis.

Dupuytren Contracture

Dupuytren contracture is caused by a nodular thickening and contracture of the palmar fascia leading to marked flexion deformities of the fingers. Most often the ring finger is affected, but it can also involve any of the others. It can involve one or both hands. It may start in the ring finger flexor tendons and then continue to involve all the others. With the tendon scarring that develops, there is a gradual development of a flexion deformity of the fingers at the level of the MCP joints and an inability to fully extend the digits. The histopathology demonstrates fibrous nodules proliferating fibrosis and myofibrosis in the palmar fascia.

PELVIS AND HIP

There are three major bursae around the pelvis and hip region. These include the ischiogluteal, iliopsoas, and trochanteric bursae, with the latter being the most commonly affected. The trochanteric bursae are composed of three bursae, with the largest and most important one clinically separating the fibers of the gluteus maximus muscle from the greater trochanter. The other two bursae lie between the greater trochanter and the gluteus medius and greater trochanter, respectively. Trochanteric bursitis presents with a deep aching pain over the lateral aspect of the upper thigh made worse by walking but also noted to be painful at night when the patient is lying on the affected side. The diagnosis is confirmed by obtaining a history of pain both at rest and with activity but in the presence of a normal range of motion of the affected hip joint. Additionally, there is pain with palpation over the trochanteric bursae. The pain may radiate distally but rarely beyond the knee. Risk factors include overuse activities such as excessive walking or running and improper foot wear. The differential diagnosis of trochanteric bursitis includes lumbar radiculopathy involving the L1 and L2 nerve roots and the uncommon meralgia paresthetica, a syndrome characterized by entrapment of the lateral cutaneous nerve of the thigh resulting in discomfort in the same region. Unlike bursitis, these patients tend to have more dysesthesia symptoms than pain.

    Ischiogluteal bursitis presents with pain felt over the ischial tuberosity. Previously known as “weavers bottom,” it is caused by repeated leg flexion and extension in the sitting position or prolonged sitting on hard surfaces. Diagnosis is confirmed by eliciting tenderness on palpation over the ischial tuberosity with the patient lying supine and the hip and knee flexed.

    The iliopsoas bursa lies over the anterior surface of the hip joint. In most cases of iliopsoas bursitis there appears to be communication between the hip joint and the bursa, and this may allow for a transfer of excess synovial fluid from one region to the other. The predisposing factors for excess synovial fluid include osteoarthritis, RA, and septic arthritis. The typical presentation consists of the onset of painful swelling in the inguinal area. When there is adjacent femoral vein or nerve compression, the resulting pain and or swelling may involve the entire leg.

SOFT TISSUE DISORDERS AROUND THE KNEE

There are three major bursae around the knee that can become inflamed or, rarely, infected resulting in pain. These include the prepatellar, infrapatellar, and anserine bursae.

    The prepatellar bursa lies anterior to the patella and can become infected in patients who frequently kneel. Presumably there is skin breakdown resulting in bacterial infection, most commonly Staphylococcus aureus. There is superficial swelling over the dorsum of the patella with surrounding redness and erythema. Rarely there may be systemic complaints such as fever and chills. The infrapatellar bursa lies between the upper portion of the tibial tuberosity and the prepatellar ligament. It is separated from the knee joint synovium by a fat pad. Similar to prepatellar bursitis, excessive kneeling may predispose to skin breakdown in the region and infection. In other patients there may be a noninfectious inflammatory swelling of the bursa.

    The anserine bursa lies under and adjacent to the pes anserinus, which is the insertion of the thigh adductor complex consisting of the sartorius, gracilis, and semitendinosus muscles. This region is about 5 cm below the medial aspect of the knee joint space. Pain in this area is often referred to as anserine bursitis. Predisposing factors include underlying osteoarthritis of the medial knee compartment and excessive physical stress to the knee. Patients will often describe nocturnal pain awakening them, and this can help to distinguish this condition from osteoarthritis, which is rarely painful at night except if there is end-stage osteoarthritis in the knee that would require total knee replacement. Women more commonly develop anserine bursitis, perhaps in part because they have a broader pelvic area leading to greater tension caused by greater angulation of the knee adductors. Obesity is another risk factor. There is a “no-name bursa” that is found over the medial joint margin of the knee. Some clinicians believe that this bursa, when inflamed, can lead to intense medial knee pain. However, medial knee pain can also be due to osteoarthritis, trauma, and ligamentous injury.

    The iliotibial band, which connects the ilium with the lateral tibia, can become painful from repetitive flexion and extension with running. This results in the iliotibial band syndrome. On examination there is tenderness over the lateral femoral condyle approximately 2 cm above the joint line, with pain on weightbearing when the knee is flexed at about 40°. Correction of the problem with foot orthotics can be helpful.

    Patellofemoral pain syndrome, formerly known as chondromalacia patella, refers to poorly localized anterior knee pain often made worse when the patient initiates activities such as getting up from a seated position. There is pain felt over the entire knee and it is often made worse by forced flexion or extension of the affected knee. It is thought to result from anatomical abnormalities resulting in abnormal angulation of the patellar surface misaligning with the rest of the knee. Other theories include repetitive microtrauma to the patellar surface. This condition is more commonly seen in women but can occur in patients of either sex and at all ages. Radiographs of the knee are often unremarkable. Intensive physical therapy to enhance the strength of the medial aspect of the quadriceps mechanism is often helpful in alleviating symptoms.

FOOT PAIN

The most common soft tissue disorders around the ankle and feet include Achilles tendinitis, retrocalcaneal bursitis, and plantar fasciitis. They share a common causation in that these conditions are typically seen in patients who have a pes planus deformity resulting in altered foot biomechanics and excessive stress over other parts of the bone and soft tissue. The Achilles tendon can become inflamed and in rare cases can tear. Risk factors for tear also include recent use of quinolone antibiotics. Achilles tendinitis can also be the presenting manifestation of a spondyloarthropathy. Retrocalcaneal bursitis may be confused with Achilles tendinitis because the bursa lies between the tendon and a fat pad adjacent to the talus. Causes of bursitis include repetitive trauma, poor footwear, RA, and spondyloarthropathy. Plantar fasciitis is a common condition thought to be due to repetitive microtrauma at the attachment site of the plantar fascia to the calcaneus, resulting in injury and inflammation. There is localized pain over the heel with weight-bearing activities that is worst with the initiation of walking activities. Although the vast majority of patients with this condition do not have an underlying arthropathy, in younger individuals this might be the initial presentation of a spondyloarthropathy. A careful history and musculoskeletal examination can help identify these patients.

    The tarsal tunnel syndrome refers to the compression of the posterior tibial nerve as it courses through the canal adjacent to the tarsal bone. It is similar to carpal tunnel syndrome, with patients presenting with sensory dysesthesias involving the plantar aspect of the foot. Nocturnal symptoms are worse and often awaken the patient. Percussion of the flexor retinaculum reproduces the symptoms. There may be reduced vibratory sensation and decreased two-point discrimination over the plantar aspect of the foot and toes. Diagnosis can be confirmed by nerve conduction studies documenting a delay in the nerve conduction of the posterior tibial nerve across the ankle.

    Morton’s neuroma is a condition that presents with paresthesias or dysesthesias in the interdigital web spaces, particularly between the third and fourth interspaces. The pain is increased by weight bearing or by tight-fitting footwear. There is tenderness and a clicking sensation noted on simultaneous palpation of the webspace while squeezing the patient’s metatarsal bones with the other hand (Mulder sign). The diagnosis can be confirmed by injection of a local anesthetic into the interspace, which should immediately, though temporarily, relieve symptoms.

FIBROMYALGIA

Fibromyalgia is a disorder characterized by widespread areas of achiness and pain with an otherwise unremarkable musculoskeletal examination (box 27.1). Laboratory tests are normal. To fulfill the clinical criteria for fibromyalgia patients generally must demonstrate tenderness over 11 of the 19 trigger points found in patients with fibromyalgia. Many of these trigger points actually correspond to the sensitive periarticular areas (medial and lateral epicondyles, medial knee pain, chest wall, base of cervical and lumbar spines) that are discussed earlier in this chapter. The etiology of fibromyalgia remains unclear, and there is great debate as to whether the underlying causation relates to a pain perception disorder in the spinal cord or the higher structures of the central nervous system. There is a female preponderance, and the age of onset peaks between 30 and 50. Other chronic pain disorders such as migraine headaches, irritable bowel syndrome, temporomandibular joint pain syndrome, and bladder dysfunctions secondary to interstitial cystitis may all be seen more frequently in patients with fibromyalgia. The hallmark features include characterizations of widespread body pain and achiness along with some component of fatigue and malaise. The physical examination should confirm the absence of objective evidence for musculoskeletal inflammation, such as no evidence for synovitis or myositis. Laboratory testing including complete blood count (CBC); hepatic, renal, and thyroid function; C-reactive protein (CRP); erythrocyte sedimentation rate (ESR); and autoantibody production are all typically within normal limits.

Box 27.1 GENERALIZED SOFT TISSUE PAIN SYNDROMES

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