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).






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 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.









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

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