1 What are the cardinal signs of joint inflammation?

The same as for inflammation in general: tumor, dolor, calor, rubor—all originally described by the Roman encyclopedist Celsus in the first century A.D. One hundred years later, the Greek Galen (personal physician to Marcus Aurelius) added functio laesa (i.e., the dysfunction of the organ involved). Virchow reiterated this concept in 1858. Note that these signs of inflammation can apply not only to the joint per se but also to the tendons, ligaments, bursa, or muscles controlling the joint.

2 What are tendons? What is tendinitis?

Tendons attach muscle to bone, thus transmitting muscular force across joints. They are often covered in tenosynovium, a sheath of connective tissue and synovium. Tendinitis is the general term for disorders of the tendon, including inflammation of the tenosynovium (tenosynovitis) and tears of either bone attachment (enthesis) or the tendon’s body.

3 How are disorders of tendons differentiated from joint problems?

By paying attention to the pain. Tendinous disorders cause pain only on (1) passive stretch of the tendon at its extreme range of motion and (2) active joint motion (i.e., requiring muscle contraction). Conversely, passive joint motion produces no pain.

4 What are ligaments? What are the findings of a ligament injury?

Ligaments attach bone to bone. Injuries present in different ways, based on their degree. Tenderness over the ligament, and pain upon ligament stretching, are the most common manifestations. Abnormal joint motion and gapping with stretching require instead a significant disruption of the ligament. Finally, ecchymoses over the site usually indicate severe injury.

5 What are bursae? How do you identify bursitis?

Bursae are fluid-filled synovial sacs that facilitate the movement of articulating structures. They can be found over bony prominences and between adjoining muscles with different directions of contraction. Their inflammation (bursitis) presents with tenderness and/or fluctuance in the periarticular area, but not in the joint per se.

6 Describe joint swelling (tumor)

Swelling is any increase from normal in the joint volume as a result of (1) bony enlargement (often due to osteophytes), (2) synovial proliferation (i.e., synovitis), or (3) intra-articular fluid. Palpation usually allows the examiner to separate these three conditions, insofar as bony enlargement is firm and synovial proliferation is also firm (although palpatory findings may range from indistinct joint margins to sponginess), whereas intra-articular fluid is instead fluctuant.

7 What is the significance of joint tenderness (dolor)?

It is another sign of joint pathology. Normal joints can be palpated with significant force without eliciting any pain. Hence, tenderness (ranging from mild discomfort to severe pain) is always abnormal. This also can limit joint motility, thus forming the basis of Galen’s “functio laesa.”

8 What is the significance of articular warmth and erythema (calor and rubor)?

They indicate pathology, too. Normal joints should be cooler than the surroundings and not red.

9 What is crepitus?

It is palpable crunching throughout the range of motion of either a joint or a tendon. This may originate from irregularities in the cartilage, bone-on-bone articulation, or tendon per se.

10 What is the significance of joint cracking or popping?

No significance, unless accompanied by pain. Sensation of passive joint cracking is common, probably due to tendon or ligament slippage over a bony prominence. This is different from the audible “pop” that can be induced by actively “cracking a joint,” which is instead due to sudden release of nitrogen gas from the synovial fluid under the negative pressure of joint distraction.

11 What are the main patterns of joint involvement?

Note that polyarticular involvement can be symmetric (with one side of the body mirroring the other [i.e., same joints, or rows of joints, on both extremities]) or asymmetric (involving different joints in different extremities).

12 How do you measure range of motion (ROM)?

With a goniometer—always comparing one side to the other.

13 What are the findings of joint hypermobility?

Note that joint hypermobility can be benign or associated with Ehlers-Danlos.

14 What is the anatomy of the shoulder?

It results from the confluence of three bones (humerus, clavicle, and scapula) and four joints (glenohumeral, acromioclavicular, sternoclavicular, and scapulothoracic). Everything is kept in place by various static and dynamic stabilizers: the “static” being labrum, capsule, and three ligaments (acromioclavicular, coracoclavicular, and coracoacromial); the “dynamic” being the scapular stabilizers (trapezius, rhomboid, and teres major) plus two muscles: rotator cuff and deltoid.

15 Describe the muscles and tendons of the shoulder

16 What are the shoulder’s movements? How do you test its ROM?

The shoulder can actively abduct, adduct, externally and internally rotate, flex, and extend. It has the largest ROM of any joint, since it provides mobility not only to the girdle but also to the hand. ROM is tested as follows:

If active ROM elicits pain, evaluate the same movements through passive ROM. To provide your patient with adequate support (and thus ensure maximal relaxation), gently rest one hand on his/her shoulder while using your other hand to move the humerus through the same ROM as previously discussed. Look for pain and crepitus. Pain and limitation on active, but not passive, ROM indicate muscular or tendinous problems. Crepitus suggests instead degenerative joint disease.

17 What areas of the shoulder girdle should be palpated?

As a mnemonic for structures to palpate, use Really Great and Beautiful ACtresses (Rotator cuff, Glenohumeral joint, Bicipital tendon, Acromioclavicular joint).

18 Can history identify the cause of a shoulder ailment?

Yes. For instance, recurrent subluxation in young individuals usually indicates multidirectional instability; constant shoulder pain and decreased ROM in diabetics classically reflect adhesive capsulitis; pain and weakness in workers whose jobs require recurrent overhead action suggest rotator cuff pathology; shoulder pain after a fall on an outstretched arm argues for acromioclavicular (AC) lesions.

19 What is the general approach to the shoulder exam?

Always expose both shoulders (and watch while the patient removes the shirt). Then carry out a systematic exam: inspect, palpate, assess ROM, measure strength, evaluate neurologically, and perform special shoulder tests. Also, examine the cervical spine and upper extremity.

1. Inspect for scars, color, edema, deformities, muscle atrophy, asymmetry, and guarding.

2. Palpate for pain or point tenderness (the presence of either narrows the exam):

Bony and soft-tissue structures, such as coracoid process, acromioclavicular joint, greater tubercle

Subdeltoid and subacromial bursae

Supraspinatus muscle and its insertion (anteriorly, with arm externally rotated and flexed)

Infraspinatus muscle (with arm hyperextended)

Major muscle groups and biceps tendon

Sternum and sternoclavicular joint

3. Assess active and passive ROM, especially in regard to elicited pain and reduced movement.

4. Determine muscle strength. This is an essential part of the exam, and comparing side to side may help you locate the area of concern. Always carry it out with and without resistance. To isolate the various muscles, use the following maneuvers:

Supraspinatus: arm forward 90   degrees in the scapular plane and forearm pronated (thumbs down, “empty can” maneuver). Drooping of this position suggests full-thickness rotator cuff tears.

Subscapularis is tested by internal rotation. Arm is rotated internally with the dorsum against the buttock. Actively lift the hand from the buttocks against resistance.

External rotators, teres minor, and infraspinatus are primarily tested by external rotation (arm on the side and in 90   degrees of abduction).

Deltoids are primarily assessed by abduction.

Biceps is primarily tested by elbow flexion and supination.

20 What is the shoulder pad sign?

A sign of bilateral shoulder effusions. Very typical of amyloidosis.

21 What are the most common musculoskeletal causes of shoulder pain?

Hence the mnemonic, “Basically I Test Religiously For Damaged Objects.”

22 What are the origins of referred shoulder pain?

Various. Shoulder (or scapular) pain can originate from many internal organs, including the myocardium (angina and infarction), hepatobiliary system (cholecystitis), and diaphragm (subphrenic abscess). It also may originate from cervical spine and neurovascular entrapment. For example, burning and tingling in the deltoid area may result from irritation of nerve roots, especially C5 and C6. Hence, any patients with shoulder pain who also have C-spine symptoms should have a brief neck exam (with and without resistance) to exclude referred disease.

23 In addition to history, how else do you identify referred shoulder pain?

By its being typically nondescript, poorly localized, and not reproducible on shoulder exam.

24 What is shoulder synovitis? How do you diagnose it?

Shoulder synovitis is inflammation of the joint. Diagnosis is made by detecting “fullness” just below the clavicle, medial to the deltoid, and clearly visible when compared to the other side. On palpation, there is “bogginess” over the anterior surface of the joint, coinciding with the fullness.

25 What is acromioclavicular (AC) arthritis? How do you diagnose it?

It is arthritis of the AC joint, a structure that is minimally mobile but still prone to inflammation. This, in turn, may lead to rotator cuff irritation through the downward protrusion of bony spurs into the tendon. Pain of AC arthritis is initially vague, localized to the joint, and possibly radiated to the shoulder, anterior chest, and neck. With time, it may become associated with crepitus and swelling. Pain can be elicited by direct compression of the joint, or by stress maneuvers. These involve (1) cross-body adduction of the arm behind the back (which produces pain in the AC joint at the end of adduction); (2) movement of the arm across the chest (so that the hand touches the opposite shoulder); and (3) cross-arm maneuver (the arm is forward flexed and then adducted across the body). These tests are positive when they elicit pain in the AC joint.

26 What is AC separation?

A disruption of the AC joint, usually traumatic. When compared to the unaffected side, the area is swollen, deformed, and painful upon compression or stress maneuvers (such as moving the arm across the chest). In fact, the patient usually keeps the arm very still.

27 What is bicipital (or biceps) tendinitis?

Inflammation of the long head tendon. This can be sudden (from a direct injury) or gradual. The latter is usually the result of shoulder overuse and thus typical of “overhead” athletes: baseball pitchers, racquet players, swimmers, and rowers/kayakers. As the arm is passed into excessive abduction and external rotation, the long head tendon suffers repetitive injury and eventual wear-and-tear. Most commonly, though, the tendon becomes inflamed because of other shoulder problems, such as rotator cuff disease, impingement, instability, or labral tears.

28 What are the symptoms/findings of bicipital tendinitis?

Achy anterior shoulder pain, worsened by overhead activity, lifting of heavy objects, and elevated pushing/pulling. Rest is usually beneficial, whereas flexion of the elbow against resistance is detrimental. Pain is vague, though at times it may become localized to the anterior humerus. On exam, there is point tenderness over the bicipital groove, which is the area where the long tendon is anatomically exposed. This lies 3   inches below the anterior acromion and may be best localized by holding the arm in 10   degrees of external rotation. Pain also can be elicited by passive abduction of the arm in a painful arc maneuver (see question 41), which is typical of impingement syndrome, although at times it also may be positive in patients with isolated biceps tendinitis.

29 Which specific maneuvers can reproduce the pain of bicipital tendinitis?

Maneuvers that resist the normal function of the biceps—supination and flexion of the forearm:

30 What is the “Popeye” sign?

A sign of rupture of the long head of the biceps tendon. The patient reports a sudden, painful, and audible snap, associated with (1) retraction of the biceps belly toward the elbow and (2) bulging over the anterior upper arm—as in the cartoon character “Popeye.” In the elderly, this may occasionally result from trauma. Otherwise, it is usually due to long-standing tendinitis. Hence, it is preceded by a long history of shoulder pain, quickly resolving with a painful snap.

31 What is shoulder impingement?

A concept first introduced by Neer in 1972 to describe mechanical impingement of the rotator cuff tendon. This runs above the humeral head and glenoid, and below the acromial process, coracoacromial ligament, and acromioclavicular joint. Recurrent friction causes bursitis, tendinitis, and ultimately, tendon degeneration and tearing.

32 What is the cause of shoulder impingement?

Mechanical wear and tear. True tear of the cuff is actually a problem of older subjects, whereas rotator cuff disease and impingement tend to affect primarily laborers (whose job requires repetitive and protracted overhead activity) or young athletes (whose sport also involves repetitive overhead motions, such as throwing, swimming, volleyball, and tennis and other racquet-playing activities). Raising the arm over the shoulder forces the humerus against the edge of the acromion. Usually, there is enough room between the acromion and rotator cuff to allow the tendons to slide easily underneath the bone while the arm is being elevated. Recurrent arm-raising, however, eventually creates impingement (i.e., friction on the subacromial bursa and the distal part of the tendon). With time, this causes irritation and swelling of the bursa (bursitis), further narrowing the space between the acromion and rotator cuff. As a result, impingement on the tendon becomes more severe, which is risky since its blood supply is limited. Hence, the resulting tendinitis and, ultimately, the degenerative damage. Bony spurs of the AC joint (which sits directly above bursa and rotator cuff tendons) may further narrow the subacromial space, and so can abnormal acromial morphology (such as a hooked acromion).

33 How do you diagnose rotator cuff tendinitis?

By carefully examining the shoulder and by knowing the function of the four rotator cuff muscles (i.e., abduction, external rotation, and internal rotation).

Note that given the anatomic closeness of the long head tendon of the biceps (which passes down the bicipital groove in a fibrous sheath between the subscapularis and supraspinatus tendons), patients with rotator cuff disease also may have biceps tendinitis (see questions 27 and 28).

34 What is the “drop arm” test?

A good way to identify rotator cuff pathology. Ask patient to raise the extended arms to a complete overhead abduction. Those with rotator cuff tear will be unable to smoothly bring the arms down to the sides from their abducted position. In fact, they may even display a cogwheel effect.

35 What are the symptoms of shoulder impingement?

The initial one is pain—aching and gradual (acute and tearing suggest instead a rotator cuff tear), centered around the anterior-superior-lateral aspect of the shoulder, and occasionally referred to the deltoid region. Pain interferes with sleep (especially when the patient rolls onto the affected shoulder) and is exacerbated by lateral or anterior raising of the arm and by forward flexion and internal rotation of the humerus (as if trying to reach into a back pocket). Pain worsens with time, and the joint may become stiff, causing “catching” sensations upon lowering of the arm. Weakness and inability to raise the arm suggest instead a rotator cuff tear.

36 How do you examine for shoulder impingement?

(1) By palpating the subacromial space (which elicits pain in patients with bursitis/tendinitis), and (2) by assessing the shoulder girdle muscles, especially during external/internal rotation and abduction. Supraspinatus problems can be identified by the empty can test, also described by Jobe, and so named because the patient’s position is similar to that assumed when emptying a can. To carry this out, have the patients (1) abduct the shoulder to 90   degrees and forward flex it at 30   degrees and (2) fully rotate the upper extremity (so that the thumbs are pointing toward the floor). While they do so, instruct them to forward flex the shoulder while you are applying resistance from behind. Patients with supraspinatus tendinitis or partial injury to the tendon will experience pain. Those with a partial- or full-thickness tear will be instead unable to achieve any forward flexion.

37 Are there any special maneuvers that can be used for testing impingement?

The Neer (impingement) test and the Hawkins-Kennedy test. Both cause the supraspinatus tendons to rub against the acromion, thus eliciting pain in cases of impingement. Still, beware that it is usually very difficult to clinically identify the location of the problem, that is, to separate bursitis from tendinitis or even partial rotator cuff tears (which is why God created magnetic resonance imaging [MRI]). One possible exception is the diagnostic subacromial bursa injection: local anesthetic and steroids injected into the bursa will relieve bursitis but not tendinitis nor partial rotator cuff tear.

38 How do you perform the Neer (impingement) test?

The patient’s forearm is internally rotated, so that the thumb points downward. While standing behind the patient, place one hand on the patient’s scapula and with the other hand grasp the forearm and forward flex it, eventually positioning the patient’s hand over the head. Forced elevation and internal rotation of the arm cause the greater tuberosity of the humerus to compress the subacromial bursa. This, in turn, squeezes the supraspinatus tendon against the acromion, causing pain in cases of impingement. The test also can differentiate AC arthritis from subacromial bursitis (Fig. 21-1).

Figure 21-1 Impingement test.

(From Mellion MB: Office Sports Medicine, 2nd ed. Philadelphia, Hanley & Belfus, 1998.)

39 How do you perform the Hawkins-Kennedy test?

Hold up the patient’s arm to 90   degrees of forward flexion (i.e., to the shoulder level) and 90   degrees of elbow flexion. Then, forcefully internally rotate the arm to 90   degrees (i.e., thumb pointed down). This causes the greater tuberosity of the humerus to compress the subacromial bursa, and the supraspinatus tendon to impinge against the coracoacromial ligament—thus eliciting pain (“impingement sign”). Hawkins is more sensitive than Neer in detecting subtle degrees of impingement.

40 How else can one elicit pain in supraspinatus tendinitis?

Have the patient hold the elbow against the side and force it into external rotation against resistance.

41 What is the “painful arc” sign?

A painful arc of motion, a useful test for evaluating a painful shoulder. Arms are down at the patient’s side, and then abducted to 180   degrees above the head (rotating hands as necessary to complete the arc). The maneuver should be smooth and painless. Impingement disease (such as supraspinatus tendinitis or partial rotator cuff tear) will produce pain with elevation of the arm above the shoulder level (i.e., in an arc between 40 and 120   degrees). There will be no pain before 40   degrees and no pain after 120   degrees. Glenohumeral arthritis instead produces pain throughout the arc.

42 What are rotator cuff injuries?

They are a spectrum of diseases (ranging from acute reversible tendinitis to massive tears of the supraspinatus, infraspinatus, and subscapularis) that are common causes of shoulder pain. Although seen in all ages, they usually present after the fourth decade, with peak at 55–85.

43 What are the causes of rotator cuff tear?

Most are the end-result of chronic tendineal degeneration, usually from repetitive friction against the overlying coracoacromial arch. This may be due to recurrent overhand motions (as in baseball pitching), but also to more lowly and routine daily activities, such as cleaning windows, washing and waxing cars, or painting. Once the tendons are weakened, excessive force will tear them. This may occur when trying to catch a heavy falling object, trying to lift a big load with the arm extended, or simply falling directly onto the shoulder.

44 What are the symptoms of rotator cuff tear?

The most common is pain, anterolateral and superior, usually referred to the deltoid insertion, and worsened by holding the arm in an overhead or forward flexed position. The next most common is weakness and decreased range of motion. In cases of complete tear, there also is inability to raise the arm. Finally, there may be articular clicking, catching, or crepitus.

45 What are the findings of a complete rotator cuff tear?

The patient cannot actively abduct the arm from 0   degrees. If the arm is passively abducted above 90   degrees, there will be inability to hold it up and further abduct to 180   degrees. If the arm is passively lowered below 90   degrees, it will fall to the side (drop arm test). Finally, with the elbow against the side, there will be inability to externally rotate the arm.

46 What is glenohumeral (shoulder) dislocation?

A problem as old as mankind (Egyptian tomb murals from 3000 B.C. depict reduction techniques, while Hippocrates fully described them) because the shoulder, being the most mobile joint in the body, is also the one more likely to dislocate. Anterior dislocations are the most frequent (95%), followed by posterior (4%) and inferior (0.5%).

47 What are the causes of dislocation?

The most common is a traumatic force that overcomes the stability of the joint. Anterior shoulder dislocations usually result from abduction, extension, and external rotation (typical, for example, of the preparation for a volleyball spike). Falls on an outstretched hand also are common, especially in older subjects, and so are seizures. Whatever the cause, the resulting blow overcomes the resistance provided by the glenohumeral capsule, the labrum, and the rotator cuff muscles, forcing the humeral head out of the glenohumeral joint and rupturing or detaching the anterior capsule. The labrum itself also may tear.

48 What is the presentation of dislocation?

The typical is posttraumatic shoulder pain and decreased range of motion. In an anterior dislocation, the arm is held in slight abduction and external rotation, the shoulder is “squared off” with loss of deltoid contour, and the humeral head is anteriorly palpable (just beneath the clavicle, in the subcoracoid region). There also will be inability to touch the opposite shoulder, plus resistance to abduction and internal rotation. Given the risk of impingement of the neurovascular bundle, one should always check (and compare) radial pulses and also evaluate the axillary nerve. This can be done by testing pinprick sensation in the “regimental badge” area of the deltoid and through palpable contraction of the same muscle during attempted abduction.

49 How do you test for glenohumeral instability?

It depends on the type of instability: anterior versus inferior.

50 How do you test for anterior shoulder instability?

Through the apprehension and Jobe’s relocation tests. Start with “apprehension” (Fig. 21-2). To perform it, ask patients to lie supine, with the affected shoulder just off the examining table. Grasp the elbow with one hand, and gently bring the arm to 90-degree abduction and 90-degree external rotation. Then push with your other hand on the posterior aspect of the humeral head, from back to front. Anterior shoulder instability will give a feeling that the arm is about to pop out of the joint. At the same time, patients will experience pain, apprehension, and guarding. In the original series of Rowe and Zarins, all 60 cases of anterior shoulder instability had a positive apprehension test. If the patient experiences pain and/or apprehension, move on to the second part of the maneuver: the Jobe’s relocation test. This is performed in the same position, but this time by pushing on the anterior aspect of the humeral head, from front to back, as if relocating a glenohumeral joint that had been partially dislocated by the apprehension test. Patients with primary impingement will have no change in pain, whereas those with anterior instability (subluxation) and secondary impingement will have relief of pain and/or apprehension. When relying primarily on relief of apprehension, the relocation test has sensitivity for anterior instability of 68%; specificity, 100%; positive predictive value, 100%; negative predictive value, 78%; and accuracy, 85%.

Figure 21-2 Apprehension test.

(From Mellion MB: Office Sports Medicine, 2nd ed. Philadelphia, Hanley & Belfus, 1998.)

51 How do you test for inferior shoulder instability?

Through the sulcus sign. Allow the arms to rest on the patient’s side, then pull them down. Compare shoulders. Any asymmetric anterior dimpling suggests inferior shoulder instability.

52 How do you diagnose multidirectional instability?

By the presence of both inferior instability (positive sulcus sign) and anterior instability (positive apprehension and Jobe’s relocation tests).

53 How do you test for glenoid labral tears?

Through the O’Brien and anterior slide tests.

54 How do you perform the O’Brien test?

The patient stands, with arm flexed to 90   degrees and elbow in full extension. Then (s)he adducts the arm to 10–15   degrees medial to the sagittal plane of the body, and internally rotates it, so that the thumb points down. The examiner stands behind the patient applying a downward force to the arm. With the arm in the same position, patient is then asked to supinate the palm (thumb pointing up), and the maneuver is repeated (i.e., the examiner again applies a downward force to the arm). The test is positive if it elicits pain with the thumb pointed down and relieves it with the thumb pointing up.

55 How do you perform the anterior slide test?

The patient is standing or sitting, with hands on hips, and thumbs pointing posteriorly. The examiner stands behind the patient and places one hand on the elbow and the other on the posterior aspect of the top of the shoulder, with the index finger extending over the anterior aspect of the acromion at the glenohumeral joint. Then the examiner applies a force to the elbow and upper arm that is directed forward and slightly superiorly. The patient is asked to push back against this force. The test is positive if it elicits pain and/or pops and clicks in the shoulder. It has sensitivity of 78.4% and specificity of 91.5%. Hence, it is useful but not sufficient.

56 What is adhesive capsulitis?

A painful shoulder condition often referred to as frozen shoulder. This may follow an injury, or more commonly a wrist fracture that caused the arm to remain immobilized for several weeks, possibly triggering an autoimmune process, and eventually leading to severe loss of motion.

57 What is the mechanism of adhesive capsulitis?

Inflammation, which “glues” the capsule and surrounding structures into a frozen shoulder.

58 What are the symptoms of adhesive capsulitis?

The most common is shoulder pain, causing a reduced range of motion, both on active and passive movements. Pain and tightness may occur at night and often interfere with activities of daily living, like getting dressed, combing hair, or reaching across a table.

59 How is the diagnosis made?

By history and physical exam. A crucial finding that helps differentiate a frozen shoulder from a rotator cuff tear is the limitation of ROM both on active and passive movements. Conversely, a rotator cuff tear limits active, but not passive movements.

60 What are the elbow’s movements? Range of motion?

The elbow flexes to 150   degrees (allowing us to touch the shoulder with the thumb). It also extends to 0   degrees. Finally, it provides motion to the forearm, making it pronate and supinate to 80   degrees.

61 Is the elbow varus or valgus?

Valgus. With the elbow fully extended, the normal angle is indeed in valgus (cubitus valgus). Fractures, however (especially in children), may cause a varus (gunstock) deformity.

62 What do valgus and varus mean?

This is a very confusing terminology. In orthopedics, valgus indicates an outward angulation of the “distal segment” of a bone or joint, so that it is “twisted away” (i.e., away from the body, or midline of the limb). Conversely, varus indicates its inward angulation (so that it is now twisted toward the body, or midline of the limb). Note that both terms always refer to the direction in which the distal segment of the joint (or bone) is pointing. In fact, when referred to as a bone, the bone itself is considered to be the distal segment of the joint. Hence, a varus or valgus deformity of the forearm refers to the arm/forearm joint (the elbow) and not to the wrist. Having said that, a normal elbow is in valgus, because with the joint fully extended (and the palms facing upward) the distal segment of the forearm will point away from the body (or midline of the limb). If you think this is confusing, wait until you see how it applies to the knee exam (see question 213).

63 How do you detect swelling of the elbow?

It depends. Mild swelling can be appreciated as a filling in of the groove between the olecranon and lateral epicondyle. Conversely, moderate to severe swelling causes loss of bony margins on palpation.

64 What is the most common finding of an abnormal elbow?

A flexion contracture. This is the first abnormality to develop and one that often becomes permanent. A common sequela of fracture, elbow flexion contracture also may occur in subjects who have to keep their elbow flexed for long periods, like long-distance truck drivers.

65 What is “tennis elbow” (lateral epicondylitis)?

The most common elbow injury: 10   times more frequent than medial epicondylitis (i.e., “golfer’s elbow”), and occurring in 50% of tennis players. The mechanism is overuse wear-and-tear of the proximal attachment of the extensor/supinator muscles of the forearm, typically affecting a 30- to 50-year-old recreational athlete. It usually responds to rest and conservative measures.

66 Other than tennis, does anything else cause tennis elbow?

Any activity that requires repetitive contraction of the wrist extensors. This includes hammering nails, picking up heavy buckets, or pruning shrubs. The repeated hyperextension required by these movements eventually results in enthesitis of the wrist extensors (i.e., inflammation of the enthesis, that is, the site of tendinous attachment to the bone—actually a more degenerative than inflammatory process. Hence an enthesopathy). With time, this leads to tendineal microtears, subsequent fibrosis, and, ultimately, tissue failure.

67 What is the presentation of tennis elbow?

The classic one is lateral elbow pain, aching, gradual, at times nocturnal, but typically worsened by hyperextension of the wrist. Pain may eventually spread down the forearm, possibly reaching the back of the middle and ring fingers. Forearm muscles also may feel tight and sore. Activities of daily living (like picking up a cup of coffee or a gallon of milk) often precipitate it. Diagnosis is made by demonstrating point tenderness over the lateral epicondyle, elicited by grasping and worsened by forced hyperextension of the wrist or by supination against resistance. Flexion or pronation is instead normal (see Golfer’s Elbow). Range of motion is normal too, although there may be a weakened grip on the affected side. A helpful maneuver is the chair raise test, where the patient stands behind a chair and attempts to raise it by placing the hands on top of the chair back, and then lifting. This typically elicits pain over the lateral elbow.

68 What is “golfer’s elbow” (medial epicondylitis)?

An overuse injury to the proximal attachment of the flexor/pronator muscles of the forearm, commonly seen in the dominant elbow of a golfer. Its mechanism is similar to that of lateral epicondylitis, but less common since wrist flexors are stronger and less likely overstressed (see Fig. 21-3).

Figure 21-3 Testing for lateral epicondylitis (left) and medial epicondylitis (right).

(From Mellion MB: Office Sports Medicine, 2nd ed. Philadelphia, Hanley & Belfus, 1998.)

69 What is the cause of golfer’s elbow?

Overuse tendinopathy (i.e., the same cause of its more lateral counterpart, “tennis elbow”). This results not only from recurrent swinging of a golf club, but also from any racquet sport that requires repeated flexion at the wrist and pronation. Hence, medial epicondylitis can affect tennis players who hit their forehand with heavy topspin (or serve poorly), bowlers, archers, weight lifters, various throwers, lumberjacks (who chop wood with axes or run chain saws), and any individual who frequently uses screwdrivers or hammers. Repetitive stress at the musculotendinous junction (and at its insertion over the medial epicondyle) eventually leads to acute tendinitis or chronic tendinosis, tendineal microtears, fibrosis, and tissue failure. One half of golfer’s elbows also develop ulnar compressive neuropathy, in or around the medial epicondylar groove.

70 What is the presentation of golfer’s elbow?

Very similar to that of cubital tunnel syndrome. Athletes usually complain of aching pain over the medial epicondyle, triggered by the acceleration phase of throwing. Nonathletes report discomfort even while shaking someone’s hand. With more advanced disease, there also may be grip weakness. Diagnosis is made by demonstrating point tenderness over the medial epicondyle, worsened by forced flexion of the wrist against resistance. There also may be pain with resisted forearm pronation, and in more protracted cases, with resisted elbow flexion. Yet, ROM of the elbow and wrist is usually normal. Tinel’s sign should be tested over the ulnar nerve, just to rule out ulnar neuropathy. In fact, ulnar symptoms can occur in 25–50% of patients, with occasional/constant numbness and/or tingling radiating down into fourth and fifth fingers.

71 How frequent is ulnar nerve entrapment at the elbow?

Very frequent. In fact, most ulnar nerve entrapments do indeed occur at the elbow (i.e., in the cubital tunnel, which is located on the medial side of it—hence, the term, cubital tunnel syndrome). This is the second most common compressive neuropathy after carpal tunnel syndrome, affecting men 3–8   times more often than women.

72 What are the causes of cubital tunnel syndrome?

Various. Swelling of the elbow joint, bony spurs, constricting fascial bands, or trauma to the ulnar notch have all been implicated. Work also may be a factor, especially when causing repetitive elbow flexion and extension (such as pulling levers, reaching out, or lifting) or protracted direct pressure on the joint (like leaning on the elbow while sitting at a desk, or during a long drive). The ulnar nerve also can be damaged from a direct blow to the cubital tunnel. Still, a clear-cut relationship with occupational activities is not well defined.

73 What is the presentation of cubital tunnel syndrome?

Similar to that of medial epicondylitis (golfer’s elbow), ranging from a vague discomfort at the elbow to frank hypersensitivity, intermittent at first and more constant as time goes by. Exam reveals pain and tenderness in the cubital tunnel, which may radiate proximally or distally. There also may be sensory changes in the distribution of the nerve, involving the ulnar side of the forearm and extending into the fourth and fifth fingers. Paresthesias also are common, especially after protracted resting upon, or flexion of, the elbow (as when sleeping or talking on the phone). Tinel’s sign can occur over the medial epicondylar groove, but only in 25% of asymptomatic patients. In later stages, there may be weakness of grip and pinch, plus loss of fine dexterity. Intrinsic muscle atrophy and clawing of the fifth finger (Wartenberg sign) are less common.

74 How do you diagnose cubital tunnel syndrome?

Through the elbow flexion test. This is carried out by asking the patient to flex the elbow past 90   degrees, supinate the forearm, and extend the wrist. The maneuver is positive if it reproduces discomfort or paresthesia within 60   seconds. Addition of shoulder abduction may further enhance its yield. Differential diagnosis of cubital tunnel syndrome includes other causes of paresthesias and weakness along the C8–T1 distribution, such as cervical disk disease/arthritis, thoracic outlet syndrome, or ulnar nerve impingement at the Guyon canal.

75 What is olecranon bursitis?

A common inflammation of the bursa overlying the olecranon. This is located over the posterior tip of the elbow, between the skin and proximal aspect of the ulna.

76 How does it present?

Suddenly if due to infection or acute trauma, gradually if due to chronic irritation. The hallmark is posterior elbow swelling, quite demarcated, and presenting as a goose egg over the olecranon. Swelling is fluctuant, often recurrent, and usually painless. Yet, it may be associated with point tenderness over the olecranon, worsened by full flexion or pressure, as when the patient leans on the elbow or rubs it against the table while writing. The area may be warm and red, especially with infection (fever). ROM is usually normal, even though pain at the posterior elbow may limit some functional activities (like writing) and prevent the end-range of elbow flexion.

77 What are the causes of olecranon bursitis?

Many. Given its superficial location, the most common is acute trauma (like falling onto a hard floor) or repetitive microtrauma (recurrent rubbing of the olecranon against a desktop during writing). Less common reasons include infection (via skin abrasion or hematogenous seeding—septic bursitis), inflammation as part of a systemic inflammatory process (rheumatoid arthritis [RA]), and crystal deposition (gout, pseudogout). The last two may present with focal inflammation at other sites.

78 Which finding differentiates infection from other causes of olecranon bursitis?

The definitive one, of course, is a positive gram stain or culture of the fluid aspirated from the bursa. Still, if erythema extends past the margins of the bursa, infection is the most likely cause.

79 How do you tell rheumatoid nodules from gouty tophi?

By palpation: rheumatoid nodules are rubbery (whereas tophi are firm) and either subcutaneous, subperiosteal, or intrabursal (whereas tophi are instead subcutaneous or intrabursal, but never subperiosteal). Still, biopsy or aspiration for monosodium urate crystals remains the test of choice. Note that both rheumatoid nodules and gouty tophi are quite common at the extensor surface of the elbow, as well as in other sites of chronic and repetitive pressure. Yet, only tophi may occasionally drain to the surface, so that urate can be recovered from an ulcer overlying the nodule.

80 What is the carpal tunnel?

A wrist channel, whose floor is formed by the carpal bones and the ceiling by the transverse carpal ligament. Through this tunnel flows the median nerve, bringing sensory fibers to the palmar surface of the first three fingers and to one half of the fourth finger. It also provides a motor branch to the thenar muscles, responsible for thumb opposition. Through the tunnel also pass the flexor tendons, providing the hand and fingers with movements that are crucial for grasping. In the tunnel, the median nerve rests on top of the tendons, just below the transverse carpal ligament.

81 What is carpal tunnel syndrome (CTS)?

An important cause of painful impairment of the hand. It is due to compression of the median nerve at the wrist, resulting in a constellation of typical signs and symptoms. It affects women three times more commonly than men, usually during the third to fifth decades.

82 What is the cause of CTS?

Any condition that narrows the carpal tunnel. A major one is trauma, especially repetitive microtrauma (such as the one of typing, or operating a jackhammer). Other causes simply swell the tissues delimiting the tunnel, through either inflammation or fluid retention. Among these are rheumatoid arthritis, pregnancy, hypothyroidism, and diabetes (the latter also may cause a direct neuropathy of the median nerve). Smoking, obesity, and caffeine often play a predisposing role.

83 What are the symptoms of CTS?

The earliest is paresthesia in the median nerve distribution: thumb, forefinger, middle finger, and one half of the ring finger, but typically not the small finger. The “asleep” sensation is then followed by pain, which may occur during gripping activities, such as sweeping, hammering, or driving. Eventually, pain occurs at rest, and even awakens the patient at night. Hand-shaking (flick sign) can often provide relief. With time, pain and numbness may spread up the arm, into the shoulder, and even to the side of the neck. Eventually, the patient develops weakness (and ultimately atrophy) of the thenar muscles, making thumb opposition increasingly difficult. This interferes with grasping, including driving, holding a phone, or picking up a newspaper.

84 What is the physical exam of CTS?

Once the appropriate history is obtained, two maneuvers are typically carried out: Tinel’s sign and Phalen’s sign (first described by the American orthopedist George S. Phalen, 1911–1998) (see Fig. 21-4).

Figure 21-4 Tinel’s sign (left) and Phalen’s sign (right).

(From the American Society for Surgery of the Hand: The Hand: Examination and Diagnosis, 3rd ed. New York, Churchill Livingstone, 1990.)

85 How do you elicit Tinel’s sign?

By asking the patient to hyperextend the wrist while you tap over the median nerve (i.e., over the carpal tunnel) with either a forefinger or the reflex hammer. The test is positive when it reproduces the symptoms (i.e., a tingling sensation along the distribution of the median nerve).

86 How do you elicit Phalen’s sign?

By having the patient juxtapose the dorsal surfaces of the hands while holding the wrists in hyperflexion for 60   seconds (or less in case symptoms were to occur sooner). This will increase the intratunnel pressure, thus reproducing the tingling. Note that in Phalen’s original definition of CTS, diagnosis was established by one or more of three bedside findings: (1) sensory changes of the hand restricted to the median nerve distribution, (2) a positive Tinel’s, and (3) a positive Phalen’s. Yet, many traditional findings, including Phalen’s, Tinel’s, and the flick sign have low sensitivity and limited or no value. Hence, electrodiagnosis has become so crucial that some third-party payers would now not even compensate claims without it. Nerve conduction studies have good sensitivity and superb specificity (49–84% and 95–99%, respectively).

87 How do you elicit the flick sign?

By asking patients what they do with their hands and wrists when symptoms occur. The response is positive when the patient demonstrates a flicking motion of hands and wrists—as if shaking down a thermometer. Although initially promising, the flick test also has shown limited utility.

88 How valuable is physical exam in confirming the diagnosis?

Not too valuable. Since the classic signs only occur in one half of the cases, other maneuvers have been suggested, such as: (1) assessing sensory loss in the distribution of the median nerve; (2) looking for atrophy of the thenar eminence (which, however, occurs only in long-standing and neglected cases, plus also may result from cervical radiculopathies and polyneuropathies); and (3) testing the strength of the abductor pollicis brevis muscle. Findings most helpful in predicting the electrodiagnosis of CTS (which is the gold standard) are: (1) classic or probable Katz hand diagram results (i.e., tingling that primarily involves the thumb and index and long fingers as opposed to the little finger); (2) hypalgesia in the median nerve territory; and (3) thumb abduction weakness.

89 Who was Tinel?

Jules Tinel (1879–1952) was another product of the superb French medicine of the turn of the century. The son of a medical family, Tinel studied with Troisier, Dejerine, Landouzy, and Netter. Convinced by Dejerine to go into neurology, he eventually became chair at the Salpêtrière in Paris. After serving in World War I, he focused on psychosomatic medicine. During WWII, he took a very active role in the French resistance, for which he was imprisoned and even lost his son, Jacques, killed by the Nazis in the death camp of Dora in Neuhausen. After the war, he worked in the Boucicaut Hospital, until his death of heart failure in 1952.

90 What is the piano key sign?

A sign of rheumatoid arthritis of the wrist, typically due to a synovitis that is stretching ulnar-carpal ligaments and causing dorsal dislocation of the distal prominence of the ulnar head (caput ulnae syndrome). Because of its dorsal subluxation, the ulnar styloid can be pressed volarly on examination, giving the feel of a piano key being pressed down—hence, the name. To elicit it, first stabilize the distal radius with one hand, then grasp the head of the ulna between the thumb and index finger of your other hand. Evaluate freedom of motion, and look for pain or crepitus. Pressing the ulnar head will elicit the piano key sign.

91 What is a common cause of pain on the radial side of the wrist?

De Quervain’s tendinitis. This is a hand-and-wrist disorder caused by entrapment tenosynovitis of the two thumb muscles’ tendons (abductor pollicis longus and extensor pollicis brevis) as they travel through a retinaculum tunnel near the end of the radius. Thickening of the tendons from either acute or repetitive trauma restrains their gliding through the tendon sheath, thus causing the problem. This sort of friction tendinitis is very frequent in day care workers and new mothers, as a result of awkward hand positions while caring for infants (such as repetitive lifting of babies as they grow heavier). Patients present with aching pain on the thumb side of the wrist and at the base of the thumb, usually noticed when forming a fist, grasping, gripping, or turning the wrist. There also may be swelling over the thumb side of the wrist, point tenderness, and at times crepitation and “triggering” (i.e., catching or snapping when moving the thumb—hence, the term “snapping thumb syndrome”). Because of pain and swelling, there also may be difficulties in moving the wrist and thumb, including opposition. Thus the inability to “pinch.” Finally, extrinsic compression of radial branches by the swollen tendon sheath may cause paresthesias on the back of the thumb and index finger. Pain can be elicited by the Finkelstein test.

92 How do you diagnose de Quervain’s tendinitis?

Through the Finkelstein test, first described by the American surgeon Harry Finkelstein (1865–1939). This is performed by placing the thumb into the palm, closing the fingers around it, and moving the hand in ulnar deviation. Stretching of the involved tendon(s) will reproduce the pain.

93 Who was de Quervain?

Fritz de Quervain (1868–1940) was a Huguenot Swiss, who studied in Bern, trained with Kocher and Langhans, and later on became chair of surgery, dean, and rector at the University of Bern. He retired on the eve of WWII and eventually died of acute pancreatitis in 1940. A prolific writer with a keen interest in thyroid diseases, de Quervain was responsible for introducing iodized table salt in the treatment of goiter, a common problem in mountainous Switzerland. He also was a strong proponent of a general approach to the patient rather than an artificial division into specialties. Finally, he was one of the first clinicians to understand that many cases of postoperative pneumonia were in reality pulmonary infarcts. He reported his tendinitis in 1895, as case series of five patients with tender and thickened first dorsal compartments at the wrist.

 94 What is the “intersection” syndrome?

A painful wrist condition that can affect individuals who do repeated wrist actions. Patients present with pain on top of their forearm, about 3   inches proximally to the wrist. This also is the site where the two thumb muscles cross over (i.e., intersect) the two wrist tendons of the extensor carpi radialis longus and extensor carpi radialis brevis, both responsible for extending the wrist. Friction tenosynovitis of the wrist tendons eventually interferes with their smooth gliding in the tendon sheath, causing swelling and redness at the intersection point and a pain that can spread either up along the edge of the forearm or down into the thumb. Crepitus may be present.

 95 How do you differentiate de Quervain’s tendinitis from an intersection syndrome?

Both involve inflammation of the wrist tendons, but the pain has different location: in intersection syndrome, it is over the wrist, at the intersection point , whereas in de Quervain’s tenosynovitis is instead over the hand (i.e., in the de Quervain’s tunnel [along the edge of the wrist and near the end of the radius]). The Finkelstein’s test is positive in de Quervain, but negative in intersection.

 96 What causes the intersection syndrome?

Overuse of the wrist extensor tendons. This causes the tendons to rub against the thumb muscles, as if they were a violin bow, until, like overused strings, they eventually develop friction tendinitis. Predisposing activities are those that make the wrist curl down (and in) toward the thumb. Hence, intersection syndrome is very common in downhill skiers (who have to plant their ski poles deep in powder snow) and also in practitioners of racket sports, weight lifting, canoeing, and rowing. More lowly activities, such as raking leaves against a hard ground or shoveling snow, also can produce stress on the wrist extensor tendons, and thus the syndrome.

 97 What is a wrist ganglion? How is identified?

Ganglions are benign and often asymptomatic fluid-filled cysts, closely associated with an underlying joint or tendon sheath, and usually connected to it by a stalk. They are the most common soft tissue tumors of the hands and wrists and are not occupationally related. They affect women three times more often than men, usually during the second and fifth decades. They tend to be solitary, rarely exceeding 2  cm in diameter. Although generally asymptomatic, they may present with pain, paresthesias, weakness, and limitation of motion. They can involve almost any joint of the hands and wrists, although their most common forms are: (1) the dorsal wrist ganglions (60–70%), (2) the volar wrist ganglions (20%), and (3) the distal interphalangeal ganglions of the flexor tendon sheath (10–12%). The cysts are smooth walled, translucent, and white. They have a fluctuant swelling that moves with the involved tendon and a mucinous content that is rich in hyaluronic acid, albumin, globulin, and glucosamine.

 98 What is the cause?

Unknown, although repetitive injuries (like playing tennis or golf) may have a predisposing effect. According to one theory, wrist ganglions are formed whenever wear-and-tear of a joint or tendon sheath allows fluid to escape into a cyst. This also would explain why ganglions have a stalk. Over time, the cyst grows large, since fluid can only enter it but not exit it (one-way valve).

 99 What are the typical wrist findings of rheumatoid arthritis?

An early finding is swelling of the extensor carpi ulnaris tendon. Later findings include protrusion and instability of the distal ulna, due to laxity of the radial ulnar ligaments. Finally, in more advanced disease the carpal rows sublux toward the dorsal side, causing a bayonet deformity.

100 What is Guyon’s canal syndrome?

It is a compression neuropathy that affects the ulnar nerve as it travels through a wrist tunnel called the Guyon’s canal. Note that the ulnar nerve can be compressed either at the wrist (in the Guyon’s canal) or at the elbow (in the epicondylar groove). Given its more superficial position at the elbow, the most common site of injury is indeed repetitive elbow pressure, such as leaning on it while working or driving. Compression in Guyon’s canal requires instead repetitive pressure on the palm, often because of excessive wrist and hand twisting. Heavy gripping can do it, too, as in the case of cyclists or weight lifters, but also jackhammer operators and patients on crutches. Finally, fracture of the hamate bone can cause Guyon’s canal syndrome in golfers who club the ground instead of the golf ball, or baseball players during batting.