Pain in the Upper Extremity

26 Pain in the Upper Extremity



Shoulder


After backache, upper extremity pain is the next most common type of musculoskeletal pain. It usually occurs in the joints (shoulder, elbow, and wrist), with the shoulder being the most common site. Subacromial impingement syndrome and rotator cuff tears are the most common disorders. Arm pain is frequently caused by occupational repetitive strain injury. Shoulder pain can be referred from the neck, chest, or diaphragmatic region; it is usually caused by a local process. On rare occasions, systemic disease affecting the viscera may cause pain referred to the shoulder (Fig. 26-1). The “shoulder joint” consists of three large bones (clavicle, scapula, humerus) and four joints (sternoclavicular, acromioclavicular, glenohumeral, thoracoscapular) (Figs. 26-2 to 26-4).


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Figure 26-1 Potential site for the referral of pain from the viscera.


(Reprinted from McGee DJ: Orthopedic Physical Assessment, 2nd ed. New York, Churchill Livingstone, 1992, p 125 [with permission].)


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Figure 26-2 Glenohumeral, acromioclavicular, and sternoclavicular joints. The thoracoscapular joint is between the anterior scapular surface and the chest wall.


(From Bland JH, Merrit JA, Boushey DR: The painful shoulder. Semin Arthritis Rheum 7:21-47, 1977.)


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Figure 26-3 Posterior view of the shoulder. A, Surface muscles (all groups). B, Rotator cuff; subscapularis not shown (medial rotator). Note that the rhomboids and levator scapulae displace the scapula medially toward the midline, whereas the scapulohumeral group rotates the humerus laterally.


(From Bland JH, Merrit JA, Boushey DR: The painful shoulder. Semin Arthritis Rheum 7:21-47, 1977.)


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Figure 26-4 Anterior view of the shoulder. A, Surface muscles. B, Deep layer of muscles.


(From Bland JH, Merrit JA, Boushey DR: The painful shoulder. Semin Arthritis Rheum 7:21-47, 1977.)


Terms used to describe painful disorders of the shoulder refer to variations of the same basic process and include supraspinatus tendinitis, rotator cuff tendinitis, subacromial bursitis, bicipital tendinitis, painful arc syndrome, impingement syndrome, calcific tendinitis, calcific bursitis, and calcific bicipital tendinitis.


Pain may originate in the bursa as well as in the shoulder joint. Many writers suggest that the only significant bursa in the shoulder is the subacromial bursa and that the subdeltoid, subcoracoid, and supraspinatus bursae are extensions of the subacromial bursa.


The initial process with shoulder pain is usually supraspinatus tendinitis with extension to other muscles of the rotator cuff. With severe or continuing damage, the inflammatory process spreads first to the subacromial bursa and then to the joint capsule and intra-articular and extra-articular structures. The greater the area of pain in the arm and shoulder and the greater the spontaneity of pain (i.e., onset without aggravating events), the greater the likelihood of an extensive lesion.


Pain in the shoulder (as well as in the elbow and wrist) can be caused by tendinitis, bursitis, trauma, arthritis, or referred pain. Cartilage and bone are not very sensitive to pain. The following are listed in order of decreasing pain sensitivity: tendons, bursae, ligaments, synovial tissue, capsular reinforcements, and muscles.



Nature of Patient


It is important to note the patient’s age, dominant hand, occupation, and sports activity.


Acute subacromial bursitis, which is painful enough to cause marked limitation of movement, is more common in younger patients. Calcific tendinitis is also more common in younger people and is seldom associated with tears; it is more often seen as a sequela to acute bursitis. A supraspinatus tear, which permits some movement, is more common in people 40 years and older. Dislocation of the shoulder is also more common in people older than 50 years. First-time dislocations after ages 40 to 50 have a much higher incidence of a rotator cuff tear, which is rare before age 40 years.



Nature of Symptoms


In general, most shoulder problems cause pain in the fifth cervical (C5) dermatome, particularly around the deltoid insertion. The exception is the acromioclavicular joint, which causes pain in the C4 dermatome, especially on the superior aspect of the shoulder or the joint itself. Intracapsular lesions of the glenohumeral joint, such as those resulting from arthritis or capsulitis, typically restrict active and passive ranges of motion. The more common extracapsular lesions, such as rotator cuff injuries and tendinitis, cause pain on active or resisted motion, whereas passive motion is usually maintained. When impingement causes inflammation of the superior part of the cuff, pain develops with resisted abduction and external rotation.


Shoulder pain, referred from the cervical spine, is not affected by shoulder movement but may be influenced by neck movement. The pain may also be felt in the neck and radiate down the arm to an area below the elbow.



Involvement of Supraspinatus Tendon


Shoulder pain is most often located in the lower part of the deltoid region; this is the referral area for pain originating in the supraspinatus tendon. When a dull ache in the region of the deltoid insertion is exacerbated with abduction to 60 degrees or more (painful arc), internal rotation, reaching overhead, or putting on a coat, the physician should suspect supraspinatus tendinitis. Characteristically, patients report that the pain is worse at night or when they lie on the affected shoulder.



Involvement of Teres Minor, Infraspinatus, and Subscapularis Muscles


If the shoulder is diffusely tender and moving the humerus posteriorly causes pain, teres minor or infraspinatus muscle involvement should be suspected. If there is pain with resisted medial rotation, the subscapularis muscle may be involved. In patients with teres minor, infraspinatus, and subscapularis involvement with diffuse shoulder tenderness, pain does not usually radiate into the arm or neck and is usually absent or minimal when the arm is dependent.



Tears and Ruptures of Rotator Cuff


If the patient has a sudden onset of shoulder pain in the deltoid area that intensifies within 6 to 12 hours after the initial trauma, a rotator cuff tear should be suspected. The patient may have extreme tenderness over the greater tuberosity as well as pain and restricted motion in one plane of movement at the glenohumeral joint. Patients with these findings and recurrent, severe pain that awakens them at night may have a rotator cuff tear, even if the arthrographic findings are normal. In cases of complete rotator cuff rupture, the patient has severe pain and is totally unable to abduct the arm.



Calcific Tendinitis


After a rotator cuff tear, calcification and calcific tendinitis of the rotator cuff may develop. Calcification has been reported in the rotator cuff in 8% of the asymptomatic population older than 30 years. Nevertheless, studies have shown that 35% of all patients with calcific tendinitis have had symptoms at some time. If 8% of the population has calcific tendinitis and 35% of these people experience symptoms, about 3% of patients older than 30 years eventually present with pain referable to calcific tendinitis. Some studies have related the extent of the symptoms to the size of the calcific area. In the patient in whom the diameter of the calcific mass reaches 1 to 1.5 cm (about 1⁄2 inch), symptoms invariably develop. Such a patient has an abrupt onset of severe, aching pain and finds all shoulder movement painful.



Bicipital and Tricipital Tendinitis


When the patient has generalized tenderness anteriorly in the region of the long head of the biceps (the region of the anterior subacromial bursa), particularly if the pain seems to be worse at night, bicipital tendinitis should be suspected. This pain resembles that of adhesive capsulitis, except that the patient with bicipital tendinitis has relative freedom of abduction and forward flexion. Resisted forearm supination causing anterior shoulder pain is a hallmark of bicipital tendinitis. If there is pain in the triceps region with resisted extension of the elbow, tricipital tendinitis is probable.



Bursitis


When the patient has point tenderness over the subacromial bursa (often associated with swelling and warmth), subacromial bursitis is probable. Pain in the acromioclavicular joint suggests that this joint is the source of pain. Patients with subacromial bursitis experience particular pain while performing activities such as lifting objects and combing hair. Virtually all cases of subacromial bursitis are preceded by tendinitis or tenosynovitis in the rotator cuff, biceps, or biceps tendon sheath. When acute onset of excruciating pain occurs in the subdeltoid region of such severity that shoulder movement is totally limited, calcific bursitis is probable. Friction of an inflamed bursal surface may be detected with passive motion if the patient is unable to abduct or rotate the upper arm. This acute inflammatory process is probably secondary to calcific deposits in the coracoacromial arch, which ultimately ruptures into the bursal sac, leading to acute bursitis.



Frozen Shoulder


A frozen shoulder should be suspected when the patient has gradual onset of pain with limitation of motion at both the glenohumeral and scapulothoracic joints and has limitation of abduction, external rotation, and forward flexion. Although a frozen shoulder is most often caused by inflammation of the capsule or rotator cuff, it has many other possible causes. The hallmark of frozen shoulder is a spontaneous onset of pain that worsens gradually and insidiously. The pain may radiate into the neck and arm, but pain below the elbow is unusual.



Subluxation or Dislocation


When pain in the shoulder follows severe trauma (as opposed to the minor trauma of everyday activity and routine athletic endeavors), it may be caused by subluxation or dislocation of the shoulder joint. The patient may state that the shoulder “doesn’t feel right,” that “something popped,” or that “something feels out of place.” If this problem occurs in a child, particularly with other evidence of external trauma, child abuse should be considered.

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Mar 21, 2018 | Posted by in BIOCHEMISTRY | Comments Off on Pain in the Upper Extremity

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