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Office Orthopedics for Primary Care: Diagnosis Copyright © 2006 Elsevier Inc. All rights reserved Author(s):

Office Orthopedics for Primary Care: Diagnosis

Copyright © 2006 Elsevier Inc. All rights reserved

Author(s): Bruce Carl Anderson, MD ISBN: 978-1-4160-2207-7

Table of Contents

Copyright,

Page ivCopyright ,

Page vDedication ,

Dedication,

Preface,

Pages vii-viiiPreface ,

Acknowledgments, ,

Page ix

Chapter 1 - , Neck ,Neck

Pages 1-18

Chapter 2 - Shoulder, ,

Pages 19-49

Chapter 3 - Upper Back Pages 50-65 Pages 50-65

Chapter 4 - Elbow, ,

Pages 66-81

Chapter 5 - Wrist, ,

Pages 82-100

Chapter 6 - ThumbPages 101-117

Pages 101-117

Chapter 7 - HandPages 118-136

Pages 118-136

Chapter 8 - ChestPages 137-148

Pages 137-148

Chapter 9 - Lumbosacral, ,

Spine

Pages 149-171

Chapter 10 , - Hip ,- Hip

Pages 172-194

Chapter 11 - , Knee ,Knee

Pages 195-221

Chapter 12 - AnklePages 222-249

Pages 222-249

Chapter 13 - FootPages 250-276

Pages 250-276

References, ,

Pages 277-293

Index, ,

Pages 295-301

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103–2899 OFFICE ORTHOPEDICS FOR PRIMARY CARE:

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103–2899

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS Copyright © 2006 by Elsevier Inc.

ISBN 987-1-4160-2207-7 ISBN 1-4160-2207-4

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 239 3804, fax: (+1) 215 239 3805, e-mail: healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevier homepages (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’.

Notice

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioners, relying on their own experience and knowledge of the patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editors assumes any liability for any injury and/or damage to persons or property arising out or related to any use of the material contained in this book.

Library of Congress Cataloging-in-Publication Data Anderson, Bruce Carl. Office orthopedics for primary care: diagnosis / Bruce Carl Anderson.—1st ed. p. ; cm. ISBN 1-4160-2207-4 1. Orthopedics—Diagnosis. 2. Primary care (Medicine) I. Title. [DNLM: 1. Musculoskeletal diseases--diagnosis. 2. Family Practice—methods. 3. Fractures—diagnosis. WE 141 A545oa 2006] RD732.A52 2006

616.7075—dc22

Acquisitions Editor: Rolla Couchman Developmental Editor: Dylan Parker Design Direction: Karen O’Keefe Owens

Printed in the United States of America

Last digit is the print number:987654321

2005049901

Karen O’Keefe Owens Printed in the United States of America Last digit is the print number:987654321

To the pioneering work of E C Kendall, biochemist and researcher at the Mayo Clinic of Rochester, Minnesota, and winner of the 1950 Nobel Prize in Biochemistry for the synthesis of cortisone from bile acids.

PREFACE

This is the first edition of Office Orthopedics for Primary Care: Diagnosis, the companion book to Office Orthopedics for Primary Care: Treatment. This two-volume set provides the clinician with the concise information to diagnose, treat, and determine the need for surgical referral on the most common conditions affecting the musculoskeletal system. Emphasis has been placed on those conditions that are most likely to present to the primary care physician, includ- ing the most common joint and soft tissue diagnoses as well as the noncatastrophic, uncomplicated fractures that fre- quently present to the primary care office. The book has been formatted in a unique manner, de- pending on the needs of the clinician and the time allotted for evaluation of the musculoskeletal complaints. For the clinician interested only in screening the patient, each sec- tion begins with the most effective maneuvers that allow a rapid and effective triage of the patient to radiographic or laboratory testing or general treatment guidelines. By con- trast, for the clinician interested in the complete manage- ment of the patient’s musculoskeletal complaints, the screening maneuvers of each section are followed by the de-

tailed examinations that allows for a definitive diagnosis and subsequent specific treatment guidelines. Traditionally local musculoskeletal diagnosis has relied upon combining the patient’s description of pain, the demonstration of loss of function, and the results of phys- ical examination with the changes either on plain radio- graphs or specialized imaging (MRI, CT, bone scanning) to distinguish involvement of the joint from involvement of the soft tissues or bone. In general, this is an effective approach when evaluating patients with degenerative arthritis or advanced tendon and ligament injuries where characteristic changes on plain radiographs or special imaging are unequivocal. However, the combination of history, examination, and imaging fails to accurately diag- nosis up to one-third of joint and soft tissue conditions (see the table below) because of the nonspecific nature of the complains, the overlap of physical signs, and the lack of diagnostic changes on radiographic testing. Previous publications have failed to address this inadequacy by failing to emphasize the importance of diagnostic local anesthetic block and synovial and bursal fluid aspiration

TABLE 1

SUMMARY: DIAGNOSTIC TESTING FOR 183 LOCAL MUSCULOSKELETAL CONDITIONS

JOINT

X-RAY

CT/MRI

BONE SCAN

EXAM

LOCAL ANESTHESIA

ASPIRATION

SURGERY

Neck

3

4

3

1

Shoulder

6

2

3

3

3

Upper Back

3

3

3

1

Elbow

3

1

2

3

6

Wrist

4

1

1

2

2

5

Thumb

2

2

3

Hand

3

1

8

1

1

Chest

1

1

1

4

2

Back

4

5

1

2

2

Hip

5

1

3

2

4

2

Knee

5

2

1

5

5

2

Ankle

7

2

8

2

1

TOTALS

47

21

10

40

37

25

3

26%

11%

5%

22%

20%

14%

2%

VIII

PREFACE

and analysis. For example, anserine bursitis frequently complicates medial compartment osteoarthritis of the knee. Both conditions are characterized by impaired gait, medial knee pain, and medial knee tenderness. Neither plain radiographs or special imaging effectively distin- guishes one from another. However, pain relief and improved ambulation after placing local anesthetic either intra-articularly or intrabursal is the only means of effec- tively distinguishing the role of each. Similarly, local anes- thetic block is often necessary to distinguish trochanteric bursitis from L4-5 radiculopathy, rotator cuff tendonitis from the referred pain of C4-5 radiculopathy, de Quervain’s tenosynovitis from carpometacarpal osteoarthritis, and so forth.

Table 1 also emphasizes the relative infrequent need to re- fer to the orthopedic surgical service for specific diagnostic testing. Only 2 percent of diagnoses require surgical inter- vention to complete the diagnostic workup; namely those conditions that require arthroscopy for confirmation (meniscal tear, ACL tear, and osteochondritis dissecans). Hopefully, this new edition will provide the practitioner with the means to manage the wide range of conditions that commonly affect the musculoskeletal system. With a more accurate means of diagnosis available to the clinician more effective and timely provided treatment will result in better patient outcomes.

Bruce Carl Anderson, MD

CHEST

IX

ACKNOWLEDGMENTS

This book represents the outgrowth of 27 years of postres- idency education and clinical experience with over 50,000 local procedures that would not have been possible without the support and encouragement from many sources. I wish to thank all the members of the departments of medicine, family practice, physiatry, neurosurgery, and surgical ortho- pedics at the Sunnyside Medical Center, especially Dr. Ian MacMillan of the department of medicine for his support and assistance in developing the medical orthopedic depart- ment and the surgeons of the department of orthopedics, Dr. Steven Ebner, Dr. Edward Stark, and Dr. Stephen Groman, for their stimulating feedback. I also wish to thank my ex- tremely capable physician assistant, Linda Onheiber, for her steady contributions to the medical orthopedic department, and all the medical residents of the graduating classes of 2003 and 2004 at Oregon Health Sciences University,

Eastmoreland Osteopathic Hospital, and Emmanual-Legacy and Providence teaching hospitals, for their constant encour- agement, contributions, and critical appraisal of the content of the book. I also wish to thank the medical directors of the various Portland, Oregon, teaching hospitals for their sup- port; namely, Dr. Nancy Loeb at Sisters of Providence St. Vincents hospital, Dr. Steven Jones at Emmanual-Legacy hospital, and Dr. Don Girard at the Oregon Health Sciences University. Lastly, I wish to thank Dr. David Gilbert, direc- tor emeritus of the Sisters of Providence Glisan hospital—my internal medicine residency director—for his stimulation to excellence, his encouragement to examine ever deeper into clinical problems, and his support and inspiration in my re- turn to clinical research.

Bruce Carl Anderson, MD

CHAPTER 1: NECK

CHAPTER 1: NECK DIFFERENTIAL DIAGNOSIS Diagnoses Confirmations Cervical strain (most common diagnosis) Stress

DIFFERENTIAL DIAGNOSIS

Diagnoses

Confirmations

Cervical strain (most common diagnosis) Stress Whiplash and related injuries Dorsokyphotic posture Fibromyalgia

Osteoarthritis of the neck Reactive cervical strain

Radiculopathy Vertebral body fracture Spinal cord injury or tumor

Socioeconomic or psychological issues Motor vehicle accident or head and neck trauma Typical in older adults or in patients with depression Confirmation by exam: multiple trigger points, normal lab X-ray: cervical series (lateral view) Underlying spinal column, nerves, or cord are threatened Neurologic testing Bone scan or magnetic resonance imaging (MRI) MRI

Cervical radiculopathy Foraminal encroachment

Herniated nucleus pulposus Epidural process

X-ray: cervical spine x-rays (oblique views); electromyography (EMG) MRI MRI

Thoracic outlet syndrome Cervical rib

Nerve conduction velocity (NCV) and EMG X-ray: cervical series (anteroposterior view)

Greater occipital neuralgia

Local anesthetic block

Temporomandibular joint syndrome

Referred pain Coronary arteries

Takayasu’s arteritis Thoracic aortic aneurysm Thyroid disease

Exam or local anesthetic block

Electrocardiogram, creatine phosphokinase, angiogram Erythrocyte sedimentation rate (ESR), angiogram Chest x-ray Thyroid-stimulating hormone, thyroxine, ESR, thyroid scan

2

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

INTRODUCTION Cervical strain and osteoarthritis are the two dominant conditions affecting the neck. Cervical strain caused by tension, stress, dorsokyphotic posture, or whiplash is a nearly universal condition early in life. In later life cervical strain is still common but rivaled by os- teoarthritis affecting the facet and paravertebral joints, also

a nearly universal condition. In the sixth and seventh

decades these two processes combine to cause the progres- sive stiffness and forward position of the head typical of older adults. The diagnosis of an uncomplicated cervical strain caused by tension, stress, poor posture, or mild whiplash is not dif-

ficult. Signs and symptoms are limited to the supporting muscles of the neck, the trapezius and paraspinal muscles. The muscles are tender, the range of motion is reduced by muscular spasm, and there is a conspicuous absence of bony

tenderness and radicular signs in the upper extremities. This

is in stark contrast to reactive cervical strain, which is the di-

rect result of an underlying threat to the spinal column. Bony disorders, spinal nerve compression, or the rare con- ditions affecting the spinal cord directly cause severe trapezial and paraspinal muscle spasm. The challenge to the primary care provider is to distinguish simple cervical strain from the severe muscular spasm that is a reaction to a seri- ous underlying neurologic process. Cervical arthritis is the second most common neck con- dition, increasing in prevalence and degree with advancing age. Symptoms can range from simple stiffness and loss of range of motion to radiculopathy from foraminal encroach- ment and spinal cord compression from spinal stenosis. Osteoarthritic wear occurs at the paravertebral facet joints and between the lateral margins of the vertebral bodies, the Luschka joints. Both cervical strain and cervical osteoarthritis are in- volved in the development of cervical radiculopathy, or compression of the spinal roots or nerves. Ninety percent of spinal nerve compression results from neuroforaminal nar- rowing by osteophyte overgrowth, foraminal encroachment disease. With this threat to the spinal nerve, reactive cervi- cal strain develops, compounding the nerve irritation. Only 10% of cervical radiculopathy is caused by a herniated nu- cleus pulposus (HNP), whereas 90% of radiculopathy in the lumbar spine is caused by HNP. Spinal stenosis is the most dramatic form of cervical radiculopathy. Upper extremity neurologic impairment can also result from brachial plexus nerve compression or inflammation. Loss of upper extremity sensation or motor function can be caused by thoracic outlet (cervical rib, hypertrophy of the scalenus anticus or pectoralis minor, or Pancoast’s tumor) or brachial plexopathy. Greater occipital neuritis is a unique problem arising from the neck. It is also related directly to cervical strain. The greater occipital nerve must traverse the upper cervical muscles to enter the subcutaneous tissue on its way to in- nervating the scalp. Persistent muscle spasm is the principal irritation of this nerve. Pain referred to the neck is uncommon. Intrinsic shoul- der conditions can incite reactive cervical strain. Diseases of the heart, major vessels of the chest, or thyroid (coronary artery disease, Takayasu’s arteritis, thoracic aortic aneurysm, thyroid disease) will cause pain in the jaw or, rarely, neck pain.

SYMPTOMS Patients complain of neck pain, muscle spasm, stiffness or loss of range of motion, or upper ex- tremity sensorimotor symptoms reflective of radiculopathy. Most patients describe a combination of symptoms. Patients with moderate to severe cervical strain may experi- ence reversible sensory radiculopathy. Conversely, patients with radiculopathy often describe symptoms reflective of the accompanying reactive cervical strain. Neck pain is the most common presenting symptom. It is most often described at the base of the cervical spine or along the upper border of the trapezius muscle. Reactive cervical strain—irritation and spasm of the muscles of the neck or upper back—is the principal cause of this pain. Although cervical strain is most commonly caused by the ordinary emotional and physical stresses of everyday life, poor posture, or poor sleeping habits, it is also the body’s fi- nal common pathway for any process that threatens the in- tegrity of the spinal column, spinal nerves, or spinal cord; thus, cervical strain often accompanies whiplash, arthritis of the cervical spine, or radiculopathy. Patients also complain of neck stiffness. Varying degrees of neck stiffness often accompany cervical strain. Moderate to severe neck stiffness is typical of cervical degenerative arthritis; facet and paravertebral joint osteophyte formation and articular cartilage thinning correlate directly with the symptoms of stiffness and the measurable loss of neck flex- ibility, most notably in rotation and extension. Numbness, tingling, and pain down the arm are the common symptoms of cervical radiculopathy (“I think I have a ‘pinched nerve’”). Cervical radiculopathy is caused by spinal nerve compression due to cervical arthritis in 90% of cases. As the paravertebral and facet joints gradually wear, bony osteophytes gradually enlarge, compromising the exit neuroforamina (foraminal encroachment). If the overall sur- face area is reduced by 50%, the spinal nerve is at risk. It takes only a small degree of cervical strain to incite (pain and paresthesias) or impair (hypesthesias or motor weak- ness) the spinal nerve. Cervical radiculopathy is caused by a herniated disk in 10% of cases (younger, more acute, and greater degrees of motor involvement on average), and less than 0.1% is caused by spinal cord encasement by large os- teophytic bars (spinal stenosis). Some patients complain of a unilateral headache with numbness or tingling of the scalp. This unique headache pattern is the result of intense or chronic paraspinal muscle pain at the base of the neck. Greater occipital neuralgia re- sults from the irritation of this sensory nerve as it penetrates these paraspinal muscles at the base of the skull. Lastly, involvement of the vertebral bodies by fracture, tumor, or infection typically causes severe localized neck pain and dramatic cervical muscle spasm.

EXAMINATION The examination of the neck begins with the observation of the general movement of the head, neck, and eyes. The posture and general movements of the neck, whether rigid and guarded or loose and free, should be consistent during the interview phase as well as during the actual examination. Lack of consistency can be a clue to ma- lingering in the case of whiplash or cervical radiculopathy that is under litigation. Measurement of the range of motion of the neck, especially neck rotation and lateral bending, is

NECK

3

used to assess the general flexibility of the neck; loss of range of motion in these directions is the best indication of abnormal neck function. For example, when neck move- ment is impaired, endpoint stiffness is demonstrated, and mild to moderate pain is reproduced, cervical osteoarthritis is the likely diagnosis. Next, the supporting muscles of the neck—the trapezius and paraspinal muscles—are examined for local tenderness, spasm, and their effect on neck flexi- bility. Finally, the Spurling maneuver, the manual vertical traction maneuver, and a detailed upper extremity neuro-

BOX 1-1

SCREENING EXAMINATION OF THE NECK

1. Observe the movement of the head, neck, and eyes.

2. Perform and estimate neck rotation and lateral bending.

3. Palpate the paraspinal and upper trapezial muscles for tenderness and spasm.

4. Estimate the degree of reactive cervical muscle.

5. Determine the degree of cervical radiculopathy.

logic exam are performed to determine the presence of cer- vical radiculopathy. Patients with normal range of motion, normal upper ex- tremity neurologic function, and nontender neck muscles should undergo medical examination of the heart, upper chest, and thyroid to evaluate for possible referred pain to the head and neck area. By contrast, the approach to the patient who has sus- tained serious head or neck trauma differs dramatically from the typical outpatient evaluation. If the patient has sus- tained significant head or neck trauma, the integrity of the vertebral column is assessed by testing sensation and move- ment in all four extremities, palpating the spinous process for alignment and local tenderness, and testing range of motion of the neck. If the traumatized patient has focal ab- normalities, aggressive radiographic testing for occult verte- bral fracture or subluxation or paravertebral hemorrhage must be performed.

ONE-MINUTE SCREENING EXAM: MANEUVERS ASSESSING OVERALL NECK FUNCTION AND DIFFERENTIAL DIAGNOSIS

FIGURE 1–1. Posture and general movement of the head and neck. POSTURE AND GENERAL MOVEMENT

FIGURE 1–1. Posture and general movement of the head and neck.

POSTURE AND GENERAL MOVEMENT

SUMMARY:

The patient’s posture and general man-

ner of movement of the head, neck, and eyes can be an important clue to underlying neck disorders.

MANEUVER:

The consistency of the patient’s posture

and the general movement of the head, neck, and eyes are noted with and without examiner distraction.

INTERPRETATION:

Patients with depression and

older adults present with a dorsokyphotic posture (forward head position, partially flexed neck, slumped shoulders). Sluggish movement or general stiffness is characteristic of osteoarthritis, cervical strain, and fibromyalgia. Torticollis reflects acute muscular spasm, often from an HNP. Extreme guarding or apprehension is indicative of neck trauma or large disk herniation.

4

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 1–2. Measurement of passive rotation of the neck. PASSIVE ROTATION OF THE NECK SUMMARY:

FIGURE 1–2. Measurement of passive rotation of the neck.

PASSIVE ROTATION OF THE NECK

SUMMARY:

Range of motion testing in rotation is

the single most important clue to an underlying neck condition. The paravertebral and facet joints of the vertebral bodies, the odontoid process, and the supporting muscles allow the neck to rotate an average of 90 degrees to either side.

The patient is asked to relax. The ex-

aminer places one hand on the shoulder and one hand on the chin. The neck is passively rotated to the affected side, noting the degrees of rotation and endpoint stiffness.

Rotation less than 90 degrees is

abnormal. X-rays and neurologic testing of the up- per extremities are necessary to determine the un- derlying cause of the loss of flexibility (osteoarthri- tis, injury to the vertebral column, cervical

radiculopathy, and severe cervical strain).

MANEUVER:

INTERPRETATION:

FIGURE 1–3. Palpation of the upper trapezial muscle. PALPATION SUMMARY: The superior portion of the

FIGURE 1–3. Palpation of the upper trapezial muscle.

PALPATION

SUMMARY:

The superior portion of the trapezius

muscle is the most commonly irritated neck muscle. The upper portion of the trapezius muscle originates from the seven spinous processes and the distal as-

pect of the acromial process.

MANEUVER:

The superior trapezial muscle is pal-

pated for local tenderness and spasm approxi- mately halfway between the acromion and spinous processes of the neck.

INTERPRETATION:

Local muscular tenderness can re-

sult from trauma (a direct blow), but the majority of

cases are caused by reactive cervical muscular strain (cervical muscular strain, fibromyalgia, whiplash, stress, and poor posture).

NECK

5

FIGURE 1–4. Spurling maneuver to reproduce the lancinat- ing pain of cervical radiculopathy. SPURLING MANEUVER

FIGURE 1–4. Spurling maneuver to reproduce the lancinat- ing pain of cervical radiculopathy.

SPURLING MANEUVER

SUMMARY:

The Spurling maneuver attempts to re-

produce the patient’s symptoms by further compres- sion of the nerve as it passes by the vertebral disk or through the neuroforamina. Each spinal nerve must pass by the lateral portion of the cervical disk and through its corresponding bony canal, the neu- roforamina. Nerve compression is caused most of-

ten by bony osteophytes reducing the neuroforam- ina opening by 50% or by a herniated nucleus pulposus.

Several positions of the head are used

to provoke nerve irritation, starting with the head in neutral position. The examiner taps or presses down on the top of the head. If this is unsuccessful, the maneuver is repeated with the head rotated, hy-

perextended, or bent to the side.

MANEUVER:

INTERPRETATION:

This is the only maneuver that is

used to reproduce the patient’s radicular pain. It is

very specific but lacks sensitivity.

FIGURE 1–5. Focal tenderness of the greater occipital nerve. FOCAL TENDERNESS SUMMARY: The greater occipital

FIGURE 1–5. Focal tenderness of the greater occipital nerve.

FOCAL TENDERNESS

SUMMARY:

The greater occipital nerve is a pure

sensory nerve providing sensation to half the scalp. The greater occipital nerve passes through the up- per cervical muscles to enter the subcutaneous tis-

sue of the back of the head. Chronic cervical mus- cle strain causes compression and irritation of the nerve, leading to a unilateral headache with ac- companying paresthesias.

Local tenderness is present 1 inch be-

low the base of the skull and 1 inch lateral to the midline. Tapping over the nerve (Tinel sign) may in- duce paresthesias.

MANEUVER:

INTERPRETATION:

Greater occipital neuritis should

be considered when patients complain of a unilat- eral headache that is accompanied by sensory ab- normalities of the scalp.

6

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 1–6. Palpation of the TMJ comparing one side with the other. PALPATION OF THE

FIGURE 1–6. Palpation of the TMJ comparing one side with the other.

PALPATION OF THE TMJ

SUMMARY:

Local tenderness can be elicited either

in front of the tragus of the ear or in the external canal. In order to distinguish the pain arising from the TMJ from disorders of the ear, the patient is asked to open and close the jaw.

MANEUVER:

Local tenderness is palpated either just

anterior to the tragus or with the examiner’s finger placed in the outer aspect of the external canal. Firm pressure is applied, and the patient is asked to open and close the jaw.

The pain and local tenderness of

otitis externa and otitis media should not be aggra- vated by jaw movement. Sialadenitis of the parotid gland is characterized by diffuse tenderness and swelling in a triangular area anterior and inferiorly to the ear.

INTERPRETATION:

ONE-MINUTE SCREENING EXAM:

MANAGEMENT OPTIONS

TRIAGE TO X-RAY For patients with a history of trauma, those who are at risk of bony injury, those in whom radiculopathy is suspected, or those who have had chronic cervical strain:

• Order a cross-table lateral with the patient left in the neck collar if there has been a severe injury to the head or neck or the patient has sustained a concussion (fracture or dis- location). Complement this with an MRI if there has been severe neck trauma and the exam demonstrates either fo- cal neurologic deficits or focal bony tenderness (occult vertebral fracture).

• Order routine cervical spine series for patients with more than 25% loss of range of motion (osteoarthritis, severe cervical strain, early radiculopathy).

• Order routine cervical spine series for all patients with radiculopathy (90% of cervical radiculopathy is caused by narrowing of the exit foramina [foraminal encroachment disease]).

• Order a lateral view of the neck to assess the alignment of the cervical spine in patients with chronic cervical strain, fibromyalgia, and persistent whiplash symptoms.

TRIAGE TO THE LAB For the rare patient with fever, acute pain, exquisite tenderness, and signs of upper extrem- ity neurologic abnormalities (i.e., acute onset of radicu-

lopathy), order a complete blood cell count, blood cultures, and ESR (possible osteomyelitis or epidural abscess).

For patients with local-

ized vertebral body tenderness, a recent history of injury, and equivocal cervical spine x-rays (acute vertebral com- pression fractures).

CONSIDER A BONE SCAN

CONSIDER AN MRI For patients with acute cervical radiculopathy and rapidly developing neurodeficit (epidural abscess), for patients with cervical radiculopathy with nor- mal cervical series x-rays (disk herniation), and for patients with cervical radiculopathy and a known history of metasta- tic disease (epidural metastasis).

RECOMMEND EMPIRICAL TREATMENT For pa- tients with mild to moderate neck pain, neck stiffness but preserved rotation to 90 degrees (able to look down the shoulder), tightness and spasm of the paraspinal or trapezial muscles, but no radicular complaints (radicular pain, pares- thesias, or loss of upper extremity strength).

• Avoid stressful situations.

• Attend to improved posture.

• Apply ice to the muscle groups in spasm.

• Perform daily passive stretching exercises in rotation.

• Recommend a muscle relaxer over 7 consecutive nights.

• Use a soft Philadelphia collar during the daytime (optional).

NECK

7

DETAILED EXAMINATION: SPECIFIC NECK DIAGNOSES

Perform a detailed examination of the neck if the patient has persistent or chronic symptoms and one or more of the fol- lowing signs are present: moderate to severe neck pain and stiffness, focal spinous process tenderness, 40% to 50% loss of range of motion, intense paraspinal or trapezial muscle spasm (torticollis), or radiculopathy with motor involvement.

(torticollis), or radiculopathy with motor involvement. REACTIVE CERVICAL STRAIN The primary function of the

REACTIVE CERVICAL STRAIN

The primary function of

the paracervical and trapezial muscles is to support and provide movement for the head and neck. However, their secondary func- tion is to react to any threat to the integrity of the cervical column, spinal cord, or spinal nerves; reactive cervical strain is the neck’s

protective mechanism whenever the structures of the neck are in jeopardy.

FIGURE 1–7. Palpation of the upper trapezial muscle in reactive cervical strain. PALPATION SUMMARY: The

FIGURE 1–7. Palpation of the upper trapezial muscle in reactive cervical strain.

PALPATION

SUMMARY:

The superior portion of the trapezial

muscle is the most common neck muscle involved in acute and chronic cervical strain.

MANEUVER:

Palpate the superior trapezial muscle

along its entire superior border, with emphasis halfway between the acromion and spinous processes of the neck. Assess the degree of local

tenderness, focal muscle spasm (“knots”), and its overall tone (soft, moderate tension, hard).

ADDITIONAL SIGNS:

Palpate the paraspinal mus-

cles 1 to 2 inches from the midline for tenderness. Palpate the levator scapula and rhomboid muscles for tenderness. Palpate the subscapular bursa at the superomedial angle of the scapula for tenderness.

INTERPRETATION:

Cervical muscular strain resulting

from poor posture, stress, or unaccustomed use can be graded by the number of muscle groups affected. Fibromyalgia, whiplash, and reactive cervical strain secondary to an underlying process affecting the spinal column involve multiple muscle groups.

FIGURE 1–8. Local intramuscular anesthetic block of the trapezius to confirm of cervical strain. LOCAL

FIGURE 1–8. Local intramuscular anesthetic block of the trapezius to confirm of cervical strain.

LOCAL INTRAMUSCULAR ANESTHETIC BLOCK

SUMMARY:

A tentative diagnosis of an uncompli-

cated case of cervical strain is based on the palpa- tion of the supporting muscles of the neck. In order to distinguish simple cervical strain from subscapu- lar bursitis or radicular pain referred from the lower cervical roots, local intramuscular anesthetic block is performed.

NEEDLE:

1 1 2 inch, 22 gauge.

DEPTH:

1 to 1 1 2 inches.

VOLUME:

3 to 4 cc anesthetic, 1 mL D80, or both.

NOTE:

Lightly advance the needle until the firm, rub-

bery tension of the outer fascia of the trapezius muscle is encountered. Place 1 cc anesthetic at the interface of the subcutaneous fat and the fascia be- fore entering the body of the muscle. If corticos-

teroid is used, avoid the triamcinolone derivatives. Kenalog and Aristospan are much more likely to cause atrophy of the muscle or the overlying subcu- taneous tissue than methylprednisolone.

8

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

8 OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS Age takes its toll on the facet and the

Age takes its toll on the

facet and the paravertebral joints of the neck, leading to a variety of conditions, including the characteristic dorsokyphotic posture,

OSTEOARTHRITIS OF THE NECK

simple stiffness and pain from a gradual loss of rotation, osteoarthritis, and cervical radiculopathy caused by foraminal encroachment or spinal stenosis.

FIGURE 1–9. Passive rotation of the neck to estimate the de- gree of osteoarthritis of

FIGURE 1–9. Passive rotation of the neck to estimate the de- gree of osteoarthritis of the facet joints and the paravertebral joints of Luschka.

PASSIVE ROTATION OF THE NECK

SUMMARY:

The paravertebral and facet joints of the

vertebral bodies, the odontoid process, and the supporting muscles allow the neck to rotate an av- erage of 90 degrees. Progressive osteoarthritic wear of the paravertebral joints of Luschka and facet joints causes a gradual loss of rotation.

MANEUVER:

The patient is asked to relax. The ex-

aminer places one hand on the shoulder and one hand on the chin. The neck is passively rotated to the affected side, and the examiner notes the de- grees of rotation and endpoint stiffness.

The patient may describe grind-

ing or crunching with the back and forth rotation of the neck. With progressive impairment, lateral bend- ing and neck extension may be impaired. Signs of radiculopathy may be present with foraminal en- croachment. Manual vertical traction typically affords symptom relief. Vertebral artery flow may be im- paired with severe arthritic changes, causing the pa- tient to feel dizzy with passive extension of the neck.

ADDITIONAL SIGNS:

INTERPRETATION:

Rotation less than 90 degrees is

abnormal. X-rays and neurologic testing of the up- per extremities are necessary to determine the ex- act cause of the loss of flexibility. Osteoarthritis and severe cervical strain are the two most common causes of loss of rotation.

FIGURE 1–10. Lateral view of the neck to confirm the de- gree of osteoarthritis. LATERAL

FIGURE 1–10. Lateral view of the neck to confirm the de- gree of osteoarthritis.

LATERAL VIEW OF THE NECK

CASE:

This is the lateral neck x-ray of a 77-year-old

former pilot whose sole complaint was neck stiff- ness. He denied experiencing pain down the arm, numbness or tingling of the fingers, or loss of

strength in the upper extremities. Neck rotation measured 60 to 65 degrees (30% loss) with end- point stiffness. The Spurling maneuver was nega- tive, and the neurologic examination of the upper extremities was normal.

DIAGNOSIS:

Uncomplicated cervical osteoarthritis.

DISCUSSION:

The lateral view demonstrates an

exaggerated cervical lordosis, corresponding to the forward position of the head seen on exam. The disk spaces are uniformly narrowed and mildly irregular. The facet joints are narrowed, hy- pertrophic, and sclerotic. The posterior aspects of the vertebral bodies (the joints of Luschka) are hy- pertrophic and sclerotic. The bony osteophytes that form here are responsible for the foraminal encroachment of cervical radiculopathy.

NECK

9

NECK 9 CERVICAL RADICULOPATHY The diagnosis of cervical radiculopathy is most often suggested by the patient’s

CERVICAL RADICULOPATHY

The diagnosis of cervical

radiculopathy is most often suggested by the patient’s description of a lancinating pain that crosses at least two major joints and the description of abnormal sensations (paresthesias or hypesthe-

sias) involving selected digits. The neurologic examination is used to define the degree of nerve impairment. Radiographic studies (plain radiographs or MRI) are used to define the exact anatomic cause.

FIGURE 1–11. Spurling maneuver to reproduce the lancinat- ing pain of cervical radiculopathy. SPURLING MANEUVER

FIGURE 1–11. Spurling maneuver to reproduce the lancinat- ing pain of cervical radiculopathy.

SPURLING MANEUVER

SUMMARY:

The Spurling maneuver attempts to

reproduce the patient’s symptoms by further com- pressing the spinal nerve as it passes by the verte- bral disk or through the neuroforamina.

MANEUVER:

Several positions of the head are used

to provoke nerve irritation, starting with the head in neutral position. The examiner taps or presses down on the top of the head. If this is unsuccessful, the maneuver is repeated with the head rotated, hy-

perextended, or bent to the side.

ADDITIONAL SIGNS:

Manual cervical traction—the

opposite of the Spurling maneuver—may reduce the patient’s pain and sensory complaints. The nerve root may be tender when one firmly palpates between the transverse and spinous processes. Sensation, reflex asymmetry, muscle tone, en- durance, strength, or bulk may be impaired on neurologic examination of the upper extremities. Signs of reactive cervical strain are nearly always present.

INTERPRETATION:

This is the only maneuver that is

used to reproduce the patient’s radicular pain. It is very specific but rarely positive.

FIGURE 1–12. Manual cervical traction to assist in the diag- nosis of cervical radiculopathy and

FIGURE 1–12. Manual cervical traction to assist in the diag- nosis of cervical radiculopathy and to assess the patient’s tolerance to therapeutic home traction.

MANUAL CERVICAL TRACTION

SUMMARY:

If the Spurling maneuver is negative or

equivocal, the diagnosis of cervical radiculopathy is enhanced if manually applied vertical traction al- leviates the patient’s radicular pain. In addition, this

maneuver can be used to assess the patient’s toler- ance of therapeutic traction.

MANEUVER:

The head is grasped at the midjaw

and occiput. The patient is asked to relax the neck muscles. Gentle vertical traction is performed to as- sess the effect on the patient’s neck pain, stiffness, and radicular pain.

ADDITIONAL SIGNS:

INTERPRETATION:

See Figure 1–11.

The response to traction is most

important in determining the role of physical ther- apy based on traction. A positive response is non- specific. This maneuver will reduce the pain and stiffness of osteoarthritis and cervical strain and the radicular pain of cervical radiculopathy caused by foraminal encroachment.

10

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 1–13. Oblique views of the neck to confirm forami- nal encroachment (osteophytes reducing the

FIGURE 1–13. Oblique views of the neck to confirm forami- nal encroachment (osteophytes reducing the overall diameter of the neuroforamina).

OBLIQUE VIEWS OF THE NECK

CASE:

This radiograph is from a 54-year-old patient

who presented with a gradual onset of numbness and tingling of the middle fingers of the right hand. Symptoms waxed and waned over a period of sev- eral months. The triceps reflex and muscular strength were preserved.

DIAGNOSIS:

Cervical radiculopathy caused by

C6–C7 foraminal encroachment.

DISCUSSION:

The spinal nerve is approximately

one third the size of the foraminal opening. When bony osteophytes from the joints of Luschka (arrow) reduce the overall size of the foramina by 50%, nerve compression and irritation are possible. This potential nerve irritation is further aggravated by the accompanying reactive cervical strain (muscle spasm generated by the threat to the nerve) or sim- ple strain induced by posture or unaccustomed use. Most cases of reversible radiculopathy probably re- sult from the accompanying cervical strain.

FIGURE 1–14. MRI to evaluate the cervical spine for occult frac- ture, radiculopathy caused by

FIGURE 1–14. MRI to evaluate the cervical spine for occult frac- ture, radiculopathy caused by herniated disk, epidural abscess or tumor, or spinal cord disorder.

MRI

CASE:

This 43-year-old woman complained of an

acute onset of arm pain, numbness of the fingers, and stiffness of the neck. The pain radiated from the base of the neck, through the shoulder, down the arm, and into the hand. She experienced con- stant numbness and tingling of the first three digits. Her examination showed paraspinal tenderness be- tween the spinous and transverse processes of the lower neck, endpoint stiffness with guarding when the neck was rotated to the affected side, weakness of elbow flexion, and a diminished bicipital reflex.

DIAGNOSIS:

Cervical radiculopathy caused by a

C5–C6 disk herniation.

Cervical radiculopathy caused by disk

herniation should be suspected in the younger pa- tient with acute symptoms, patients with sensorimotor findings on neurologic examination, or patients with cervical radiculopathy who have a poor response to empirical treatment with cervical traction.

DISCUSSION:

GREATER OCCIPITAL NEURALGIA Irritation or inflam- mation of the greater occipital nerve is characterized by

GREATER OCCIPITAL NEURALGIA

Irritation or inflam-

mation of the greater occipital nerve is characterized by intense lo- cal tenderness at the base of the skull, a unilateral headache, and ipsilateral skin sensitivity or paresthesias over the scalp.

NECK

11

FIGURE 1–15. Palpation of the greater occipital nerve. PALPATION SUMMARY: Headaches are a very common

FIGURE 1–15. Palpation of the greater occipital nerve.

PALPATION

SUMMARY:

Headaches are a very common accom-

paniment of most conditions affecting the cervical spine, especially cervical strain, osteoarthritis, and radiculopathy. Greater occipital neuralgia presents with a unique headache pattern characterized by pain and paresthesias limited to one side of the head.

MANEUVER:

The greater occipital nerve is palpated

1 inch off the midline and approximately 1 2 to

1 inch below the base of the skull.

ADDITIONAL SIGNS:

Tapping over the nerve

(Tinel sign) may induce the scalp paresthesias. Sensory testing over the scalp may be impaired. Signs of cervical strain invariably are present with local muscular tenderness, particularly in the

paraspinal muscles.

INTERPRETATION:

The unilateral headache of

greater occipital neuritis must be distinguished from migraine and the headache that accompanies foraminal encroachment involvement of the upper three cervical roots.

FIGURE 1–16. Local anesthetic block to confirm greater oc- cipital neuralgia. LOCAL ANESTHETIC BLOCK SUMMARY:

FIGURE 1–16. Local anesthetic block to confirm greater oc- cipital neuralgia.

LOCAL ANESTHETIC BLOCK

SUMMARY:

Local anesthetic placed just above and

just below the level of the cervical fascia is used to confirm the direct involvement of the greater occipi- tal nerve and distinguish this unique headache from

migraine and the headache that accompanies up- per cervical root foraminal encroachment.

Enter 1 inch lateral to the midline and 1 inch caudal to the superior nuchal line of the skull (the base of the skull).

NEEDLE:

1 1 2 inch, 22 gauge.

DEPTH:

1 2 to 3 4 inch down to the fascia and then an

additional 1 4 inch into the muscle.

VOLUME:

NOTE:

3 to 4 cc anesthetic, 1 mL D80, or both.

Lightly advance the needle to feel the outer

fascia, then enter the body of the muscle. Avoid tri-

amcinolone because it increases the risk of muscle or subcutaneous atrophy.

12

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

12 OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS TEMPOROMANDIBULAR JOINT SYNDROME The tem- poromandibular joint (TMJ)

TEMPOROMANDIBULAR JOINT SYNDROME The tem-

poromandibular joint (TMJ) can be injured by trauma to the jaw or face, inflammed in the patient with hematoid arthritis, or irritated by the chronic effects of stress (high muscle tone, clenching

of teeth, or grinding of the jaw at night). Patients complain of jaw pain, ear pain, or difficulties with mastication. The diagnosis is always suggested when the patient describes pain located at or near the ear that is aggravated by opening and closing the jaw.

FIGURE 1–17. Palpation of the TMJ. PALPATION SUMMARY: The TMJ is located directly anterior to

FIGURE 1–17. Palpation of the TMJ.

PALPATION

SUMMARY:

The TMJ is located directly anterior to

the tragus of the ear and is palpated either at this point or from the entrance to the external ear canal.

MANEUVER:

The patient is asked to open and close

the jaw as the examiner palpates the area just ante- rior to the tragus and then palpates the joint from within the entrance of the external ear canal.

Tenderness and clicking are noted.

The maximum mouth opening

(measurement between the upper and lower teeth) may be restricted. The pterygoid muscles along the posterior aspect of the alveolar ridge may be ten- der and in spasm. Evidence of abnormal teeth wear (grinding) may be present. Anxiety or other signs of situational stress may be present.

Acute TMJ syndrome typically re-

sults from trauma or unusual degrees of chewing. Chronic TMJ syndrome is a manifestation of anxiety and situational stress.

ADDITIONAL SIGNS:

INTERPRETATION:

FIGURE 1–18. Local anesthetic block to distinguish TMJ in- volvement from primary involvement of the

FIGURE 1–18. Local anesthetic block to distinguish TMJ in- volvement from primary involvement of the ear or parotid gland.

LOCAL ANESTHETIC BLOCK

SUMMARY:

Ear or facial pain aggravated by chew-

ing or opening and closing the jaw does not pose a diagnostic challenge. Occasionally, in patients with subtle pain, concurrent ear disorders, or other

causes of lateral facial pain, anesthesia is needed to confirm involvement of the joint.

With the jaw fully opened, enter the joint 1 4 to 3 8 inch directly anterior to the tragus in the depression formed over the joint; angle perpendicular to the skin.

NEEDLE:

5 8 inch, 25 gauge.

DEPTH:

1 4 to 1 2 inch into the joint.

VOLUME:

1 2 to 1 cc anesthetic, 1 2 mL K40, or both.

NOTE:

Identify and mark the course of the temporal

artery and then lightly advance the needle into joint. If arterial blood enters the syringe, exit the skin, hold pressure for 5 minutes, and reenter either slightly anterior or posterior to the artery.

NECK

13

NECK 13 THORACIC OUTLET SYNDROME The diagnosis of thoracic outlet syndrome should be considered in patients

THORACIC OUTLET SYNDROME

The diagnosis of thoracic

outlet syndrome should be considered in patients presenting with paresthesias in the upper extremity that are not arising from a pathologic process in the neck (normal neck examination and radi- ographs) or from a peripheral compression neuropathy. Cervical

ribs, hypertrophy of the scalenus anticus or pectoralis minor mus- cles, Pancoast’s tumor of the chest, or brachial plexopathy cause paresthesias and variable degrees of muscular impairment of the upper extremity. In most cases the lower trunk of the brachial plexus is most vulnerable (ulnar or C8 radicular patterns).

FIGURE 1–19. Adson maneuver to screen for thoracic outlet syndrome. ADSON MANEUVER SUMMARY: After leaving

FIGURE 1–19. Adson maneuver to screen for thoracic outlet syndrome.

ADSON MANEUVER

SUMMARY:

After leaving the cervical spine, the

roots form the brachial plexus, which traverses the base of the neck, through the muscles of the ante- rior cervical triangles, under the clavicle, and through the axilla. Compression or traction of the plexus anywhere along this path can lead to neuro- logic impairment of the upper extremity.

MANEUVER:

The head and neck are positioned in

extension and ipsilateral rotation. The patient is asked to shrug the shoulder and take a deep breath. The examiner palpates the radial pulse and notes any decrease when performing the maneuver. In addition, the patient is asked whether this posi- tion reproduces the pain down the arm.

ADDITIONAL SIGNS:

A full neurologic examination

of the upper extremity is necessary. Symptoms can also be brought out by an exaggerated military posture (shoulders held back).

INTERPRETATION:

A decrease in the radial pulse

and a reproduction of the C8 radiculopathy sug- gests thoracic outlet syndrome that must be con-

firmed by NCV EMG.

FIGURE 1–20. EMG of the upper extremity to confirm tho- racic outlet syndrome. EMG OF

FIGURE 1–20. EMG of the upper extremity to confirm tho- racic outlet syndrome.

EMG OF THE UPPER EXTREMITY

SUMMARY:

Patients presenting with ulnar or C8

root distribution paresthesias, motor loss, or both but an absence of signs suggesting a neck or pe- ripheral compression neuropathy should undergo EMG to evaluate for thoracic outlet.

14

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

1–1

DETAILED EXAMINATION SUMMARY

EXAMINATION MANEUVERS

DIAGNOSIS

CONFIRMATION PROCEDURES

Trapezial or paracervical muscle local tenderness and spasm

1. Cervical strain

Pain with passive neck rotation, local anesthetic placed in the affected muscle (optional)

Painful or limited rotation and lateral bending

Trapezial or paracervical muscle stiffness

2. Osteoarthritis

Cervical series x-ray (the lateral view can be used for screening)

Fixed loss of rotation and lateral bending with stiff endpoints

Loss of conjugate movement of the eyes and head

Dorsokyphotic posture

Head and neck locked in the lateral bent position

Torticollis

Cervical series x-ray (the posteroanterior view can be used for screening)

Local tenderness and spasm in the trapezium muscle

Spurling sign

Cervical radiculopathy

Cervical series, MRI, or EMG

Improvement with manual traction

Paraspinal or spinous process tenderness

Abnormal UE neurologic exam; abnormal threshold of reflexes; weakness of grip, biceps, or triceps

Tenderness at the base of the skull 1 inch from the midline

Greater occipital neuralgia

Local anesthetic placed over the outer fascia of the paraspinal muscle

Paraspinal or trapezial muscle tenderness and spasm

Abnormal sensory testing over the scalp

TMJ local tenderness

TMJ syndrome

Local anesthetic placed in the synovial cavity

Restricted opening of the mouth

Clicking or crepitation

Pterygoid muscle spasm

Signs of anxiety or stress

Signs of abnormal teeth wear

Rigidity of the trapezial or paraspinal muscles

Suspect vertebral fracture or dislocation

Cross-table lateral x-ray, cervical series x-ray, or MRI

Apprehension with any attempts at passive movement

Spinous process tenderness

Positive Adson maneuver

Thoracic outlet syndrome

Confirmation with EMG

Symptoms reproduced by exaggerated military posture

Abnormalities on neurologic testing of the upper extremity

NECK

15

FOR THE TRAUMA PATIENT

SUMMARY

The guidelines for the emergency room evaluation of the head and neck trauma patient must be strictly adhered to. A step-by-step method to ensure the integrity of the spinal column, spinal nerves, and spinal cord must be followed until the provider is assured that the patient’s neurological status is not in jeopardy.

BOX 1-2

EVALUATION OF HEAD AND NECK TRAUMA PATIENTS

Examination of the trauma patient focuses on the integrity of the vertebral column.

7. Obtain an MRI of the cervical spine if focal tenderness is present at any spinous process.

1. Evaluate the patient’s mental status.

8. Assess range of motion of the neck and palpate the paraspinal muscles.

2. Assess the patient’s airway and cardiovascular stability.

3. Check sensation of the four extremities.

9. If the patient has extreme muscle guarding, remains apprehensive with any movement of the neck, and has focal tenderness, obtain a neurosurgical consultation to observe for possible occult fracture of the cervical spine, despite “normal” radiographic studies.

4. Check motor strength in the hands and feet.

5. Obtain a cross-table lateral x-ray of the cervical and fur- ther radiographic studies if there is any sign of fracture or potential dislocation.

6. If cervical alignment is preserved and there is no obvi- ous fracture, palpate the spinous process for tenderness and alignment (normal cervical lordosis).

FIGURE 1–21. Sensory testing to assess the integrity of the cervical spine. SENSORY TESTING SUMMARY:

FIGURE 1–21. Sensory testing to assess the integrity of the cervical spine.

SENSORY TESTING

SUMMARY:

Sensory testing is used to determine the

integrity of the sensory nerve pathways from spinal cord via the spinal nerves to the peripheral skele- ton. A normal sensory exam indicates an intact ner- vous system.

Light touch or pain sensation is tested

in all four extremities (at the fingertips and the tips of the toes).

MANEUVER:

INTERPRETATION:

Loss of sensation in all four ex-

tremities indicates midneck spinal cord injury. Loss of sensation in the legs indicates lower neck spinal cord injury.

16

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 1–22. Motor testing to assess the integrity of the cervi- cal spine. MOTOR TESTING

FIGURE 1–22. Motor testing to assess the integrity of the cervi- cal spine.

MOTOR TESTING

OBJECTIVE:

To determine the integrity of the motor

nerve pathways from the spinal cord via the spinal nerves to the peripheral motor nerves.

MANEUVER:

Grip strength and the strength of dorsi-

flexion and plantarflexion are tested on the right and left sides of the body.

ANATOMY:

Normal strength testing in all four

extremities indicates an intact nervous system.

Loss of strength in all four extrem-

ities indicates midneck spinal cord injury. Loss of strength in the legs indicates lower neck spinal cord injury.

INTERPRETATION:

FIGURE 1–23. Palpation of the spinous processes of the verte- bral bodies. PALPATION OBJECTIVE: Palpation

FIGURE 1–23. Palpation of the spinous processes of the verte- bral bodies.

PALPATION

OBJECTIVE:

Palpation of each of the seven spinous

processes is used to determine the degree of ten- derness of the vertebral bodies and assess their alignment. The seven spinous processes form a smooth lordotic curve (similar to the lower back). The seventh spinous process at the base is the most prominent.

MANEUVER:

Each spinous process must be pal-

pated, lightly at first, to assess alignment, followed by a greater degree of pressure to assess local tenderness.

INTERPRETATION:

Any degree of focal spinous

process tenderness is significant. Involvement of the underlying bone is assumed until proven other- wise. The differential diagnosis includes vertebral column injury, bony tumor, spondylolisthesis, and osteomyelitis.

NECK

17

FIGURE 1–24. Cross-table lateral x-ray to assess the align- ment of the cervical spine. CROSS-TABLE

FIGURE 1–24. Cross-table lateral x-ray to assess the align- ment of the cervical spine.

CROSS-TABLE LATERAL X-RAY

CASE:

This 19-year-old hockey player was hard

checked into the rink wall. He suffered a mild con- cussion and severe neck pain. He was transferred to the emergency room in a hard collar. His mental status, cardiovascular exam, airway, and screening neurologic exam were normal. This cross-table lat- eral x-ray was obtained while the patient was still in the hard cervical collar.

DIAGNOSIS:

Severe reactive cervical strain with

straightening of the cervical lordotic curve. No evidence of fracture or dislocation.

DISCUSSION:

Further examination of the patient af-

ter the collar was removed showed intense muscle spasm, focal tenderness at C4, and great appre- hension with any attempt to rotate the neck. Initial MRI to define an occult fracture was negative. Follow-up MRI at 10 days showed a healing frac- ture of the lamina of C4. The suspicion for fracture remained high because of the focal vertebral spin- ous process tenderness and the severe reactive cervical muscle spasm.

FIGURE 1–25. Palpation of the paraspinal muscles in reactive cervical strain. PALPATION SUMMARY: The paraspinal

FIGURE 1–25. Palpation of the paraspinal muscles in reactive cervical strain.

PALPATION

SUMMARY:

The paraspinal muscles and the superior

portion of the trapezial muscle react with severe spasm when the spinal column has been traumatized.

MANEUVER:

Palpate the paraspinal muscles and

the superior trapezial muscle along the entire length of the cervical spine. Compare the muscle tender-

ness and degree of muscle spasm on either side of the spine.

INTERPRETATION:

The most severe reactive

cervical muscular strain occurs when the neck has been traumatized. Muscle spasms are extreme with fracture, fracture with dislocation, occult fracture, and malignancy-associated fracture.

18

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

CLINICAL PEARLS
CLINICAL PEARLS

CLINICAL PEARLS

CLINICAL PEARLS
CLINICAL PEARLS

• Loss of rotation can be considered the universal sign of the conditions that are intrinsic to the neck. Rotation is impaired in the early stages of nearly all conditions that affect the neck; for this reason, it is the best maneuver to use to screen for neck conditions (i.e., more sensitive than changes in flexion, lateral bending, and extension).

• Acute muscular spasm associated with acute cervical strain causes a loss of full rotation.

used to screen for loss of alignment (e.g., cervical strain, whiplash), the degree of osteoarthritis (at the facet and paravertebral joints), disk space narrowing (osteoarthritis or radiculopathy), or bony disorders (compression fracture).

• All patients who present with symptoms and signs of radiculopathy should undergo a cervical series of radiographs. Foraminal encroachment is the underly-

• Loss of rotation is the hallmark of osteoarthritis of the neck and correlates directly with its severity.

• Trapezius muscle irritation and spasm is a common presenting sign of conditions that are intrinsic to the neck, second only to the changes in the normal range of motion of the neck. Of the three divisions of the trapezius muscle (superior, middle, and lower), selec- tive tenderness, spasm, and irritability of the superior portion correlate highly with an intrinsic neck process. By contrast, involvement of all three divisions with tenderness, spasm, and irritability is seen with fi- bromyalgia, scoliosis, and poor posture.

• Cervical radiculopathy is classified according to the de- gree of nerve impairment as sensory, sensorimotor, or sensorimotor with spinal cord compression; 80% to 85% of patients have sensory impairment only. The prognosis in these cases is uniformly good; treatment consists of rest, stress reduction, attention to posture, a muscle relaxer taken at night, and gentle stretching ex- ercises in rotation over a period of 4 to 6 weeks.

• The prognosis of patients with radiculopathy involving both sensory and motor nerves is less predictable. Patients with motor involvement are more likely to have larger disk herniations, are at higher risk for nerve damage, and are more likely to need neurosurgical in- tervention. For these reasons, subtle motor involve- ment should be sought through examination for vari- ability in the thresholds of the neuroreflexes, muscular fatigue when individual muscles are repeated tested for strength, and the loss of bulk in the arms and forearms.

ing cause of cervical radiculopathy in 90% of cases. If the oblique views of the neck do not disclose at least

50% narrowing of the foramina at the appropriate spinal level, MRI should be performed to evaluate for herniated disk.

• Every patient who has sustained severe trauma to the head or neck must be cleared neurologically before proceeding to special radiographic studies. The first priority is to perform a screening neurologic exam. Next, a cross-table lateral x-ray is obtained to assess the alignment of the vertebral bodies (with the patient in the transport collar). Next, the collar is removed, the spinous processes are palpated, and the neck muscles are assessed for irritability. Once the patient is cleared neurologically, special studies are obtained to further determine alignment and evaluate for fracture, disloca- tion, or epidural bleeding.

• Caution: Injury to the vertebral column must be as- sumed if the patient manifests anxiety when one at- tempts to remove the transport collar, guarding when one attempts to move the neck in any direction, or rigidity of the paraspinal muscles. For instance, the body interprets even a small, nondisplaced vertebral body or laminar fracture as a potential threat to the spinal cord and nerves. This threat generates severe re- active muscle spasm.

• For major trauma with signs of neurologic compro- mise, consult the neurosurgeon.

• For major trauma without signs of neurologic compro- mise, proceed cautiously to radiographic studies to ex- clude occult neck fracture and epidural bleeding.

• Although the routine cervical series of x-rays consists of five views, including the odontoid, lateral, pos- teroanterior, and two oblique views, the lateral view provides the most useful clinical information. It can be

• Rotating the neck is nearly impossible in patients who have sustained significant neck trauma. Vertebral body subluxation or fracture leads to neck rigidity from in- tense muscle spasm.

CHAPTER 2: SHOULDER

CHAPTER 2: SHOULDER DIFFERENTIAL DIAGNOSIS Diagnoses Confirmations Rotator cuff syndromes (most common) Impingement

DIFFERENTIAL DIAGNOSIS

Diagnoses

Confirmations

Rotator cuff syndromes (most common) Impingement syndrome Rotator cuff tendonitis Rotator cuff tendon thinning

Rotator cuff tendon tear Frozen shoulder

Examination, passive painful arc Lidocaine injection test X-ray: shoulder series showing a narrow subacromial space Magnetic resonance imaging (MRI) arthrography Examination showing a loss of range of motion, normal x-ray

Acromioclavicular (AC) joint Osteoarthritis AC separation Osteolysis of the clavicle

X-ray: shoulder series X-ray: weighted views of the shoulder X-ray: shoulder series

Subscapular bursitis

Local anesthetic block

Sternoclavicular joint Strain or inflammatory arthritis Septic arthritis (intravenous drug abuse)

Local anesthetic block Aspiration and culture

Glenohumeral joint Osteoarthritis Inflammatory arthritis Septic arthritis

X-ray: shoulder series (axillary view) Synovial fluid analysis Synovial fluid culture

Multidirectional instability of the shoulder Dislocation Subluxation Glenoid labral tear

X-ray: shoulder series Abnormal sulcus sign Double contrast arthrography

Referred pain Cervical spine Lung Diaphragm Upper abdomen

.

Neck rotation, x-ray, MRI Chest x-ray Chest x-ray, computed tomography scan Chemistries, ultrasound

20

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

INTRODUCTION The unique anatomy of the shoulder allows the greatest range of motion of all of the joints of the body, but at a tremendous price: The vital rotator cuff ten- dons that are responsible for the support and movement of the shoulder joint are susceptible to the compression forces between the undersurface of the acromion and the top of the humeral head. Specifically, the supraspinatus and infra- spinatus tendons are the only tendons in the body that must perform their vital functions while being subjected to the compressive forces between these two bony surfaces. Every time the arm is raised to shoulder level or above, these ten- dons are compressed and are subject to friction in this sub- acromial space, a force called subacromial impingement. The largest lubricating sac in the body, the subacromial bursa, attempts to counter these forces but often fails to keep up with the demands; subacromial bursitis results. If the subacromial bursa does not effectively counter the fric- tion and compression caused by overhead reaching, inflam- mation is carried over to the tendons, and rotator cuff ten- donitis results. Inflammation of the supraspinatus and infraspinatus tendons is the most common condition af- fecting the shoulder, a problem that affects nearly everyone at least once in their lifetime. Left unrecognized and untreated, subacromial impinge- ment can persist and progress over months and years. The repeated mechanical irritation of impingement and the re- lentless deleterious effects of inflammation lead to recur- rent and chronic subacromial bursitis and rotator cuff tendonitis. This in turn can lead to degenerative thinning of the tendon and ultimately to rotator cuff tendon tear with accompanying muscle atrophy. When approaching the patient presenting with upper arm pain and shoulder dysfunction, the provider must view the conditions that affect the subacromial area and rotator cuff tendons, in particular, as a continuum of pathological states: from the earliest stage of mechanical impingement through active subacromial bursitis and uncomplicated rotator cuff ten- donitis to the degenerative rotator cuff tendon thinning and the final result of rotator cuff tendon tear. The chal- lenge to the provider is to determine where on this con- tinuum the patient falls. Frozen shoulder, the reversible loss of glenohumeral range of motion, is another complication of impingement and rotator cuff tendonitis. At least 10% of patients with active rotator cuff tendonitis develop frozen shoulder or adhesive capsulitis. Although rotator cuff tendonitis is its most common cause, frozen shoulder can also result from stroke, shoulder surgery, or bony fracture. The second most common condition affecting the shoul- der involves the acromioclavicular (AC) joint. The clavicle juts out from the bony thorax and abuts the acromial process of the scapula. The joint is susceptible to wear-and- tear and injury with repetitive overhead reaching, to-and-fro movement across the chest, and compression from lateral shoulder pressure. Degenerative osteoarthritis of the AC joint is nearly universal, although not every patient devel- ops symptoms. AC separation is another common condi- tion that occurs after direct blows to the shoulder or falls on an outstretched arm. Glenohumeral osteoarthritis is surprisingly uncommon given the wide range of motion the shoulder is capable of. Unlike degenerative osteoarthritis of the AC joint, osteo-

arthritis is rare outside the setting of previous bony fracture, dislocation, or complete rotator cuff tendon tear. Hyper- mobility or multidirectional instability of the glenohumeral joint is also associated with late-onset osteoarthritic change, probably through the complication of glenoid labral tear. The other major bursa affecting the shoulder is the sub- scapular bursa. Subscapular bursitis, also called costotho- racic syndrome, is caused by the exaggerated movement of the scapula across the bony rib cage when normal gleno- humeral movement is impaired (frozen shoulder and glenohumeral joint arthritis). This exaggerated degree of shoulder shrugging increases friction between the second and third ribs and the undersurface of the superior medial angle of the scapula. The shoulder is susceptible to trauma, including fractures of the clavicle in early life and humeral head and neck frac- tures in older adults with advanced osteoporosis. Finally, pain is commonly referred to and through the shoulder from conditions arising in the neck and condi- tions affecting the heart, lungs, pleura, great vessels, or up- per abdomen.

SYMPTOMS Conditions intrinsic to the shoulder cause the following symptoms: shoulder pain provoked by spe- cific shoulder movements, loss of mobility (impaired reach- ing, lifting, pushing, and pulling, pain or stiffness), bony or soft tissue deformity (AC separation and arthritis, disloca- tion), muscular weakness, or a combination of these symp- toms. However, the strongest clue to a specific anatomic diagnosis often is based on the patient’s description and lo- cation of their pain. Shoulder pain aggravated by reaching and localized to the lateral deltoid area is the most common pain pattern. This is the classic pain pattern of impingement syndrome and the various stages of rotator cuff tendonitis: simple strain, uncomplicated tendonitis, chronic calcific ten- donitis, and tendonitis complicated by tendon tear. When this pain pattern is accompanied by joint stiffness and a measurable loss of movement in external rotation or ab- duction, frozen shoulder is the most likely diagnosis. When this pain pattern is complicated by weakness and a measurable loss of strength in external rotation or abduc- tion (a loss that cannot be attributed to pain and poor ef- fort), rotator cuff tendonitis complicated by tendon tear is most likely. Shoulder pain localized to the anterior shoulder area is less common and is most characteristic of the conditions af- fecting the AC joint, glenohumeral joint, or the anterior tendons (long head of the biceps, subscapularis, and rarely the pectoralis major tendon). When this pain is well local- ized and specifically identified by the patient (often point- ing to the distal end of the clavicle), AC separation or os- teoarthritis of the AC joint is the most likely diagnosis. When this pain is aggravated by movement of the shoulder in several different directions, involvement of the gleno- humeral joint should be suspected. When this pain is ag- gravated by selective movement in one direction, tendonitis of one of the anterior tendons should be suspected (lifting, the long head of the biceps; reaching, rotator cuff ten- donitis, especially when the subscapularis predominates; pushing, pectoralis major).

SHOULDER

21

Posterior shoulder pain is the least common pain pattern at the shoulder. Rotator cuff tendonitis can refer pain over the broad area of the scapula, the anatomic location of the rotator cuff muscles. However, when the pain localizes to the superior medial angle of the scapula, subscapular bursi- tis is the more likely diagnosis. Poorly localized posterior shoulder pain is referred from the neck, is caused by com- pression neuropathy, or arises from the underlying bony structures. Poorly localized and vaguely described poste- rior shoulder pain may also reflect exaggerated symptoms in patients who are malingering or are involved in worker’s compensation claims or insurance litigation.

BOX 2-1

DIFFERENTIAL DIAGNOSIS OF SHOULDER PAIN BASED ON ANATOMIC AREA

Lateral deltoid pain

Impingement syndrome Subacromial bursitis Rotator cuff tendonitis Rotator cuff tendon tear Deltoid tendonitis Acromioclavicular osteoarthritis Acromioclavicular separation Osteolysis of the clavicle Frozen shoulder Glenohumeral osteoarthritis Glenohumeral inflammatory arthritis Glenohumeral septic arthritis Multidirectional instability Sternoclavicular strain Subscapularis tendonitis Subscapular bursitis Cervical strain Cervical radiculopathy Medical causes of shoulder pain

Anterior shoulder pain

Posterior shoulder pain Referred pain

EXAMINATION The examination of the shoulder al- ways begins with assessment of the overall function of the glenohumeral joint followed by a focused evaluation of the most common conditions affecting the surrounding ten- dons and joints. Functional testing determines the involve- ment of the glenohumeral joint, readily assesses the severity of the condition, and includes the following maneuvers:

range of motion testing in abduction and external rotation (passively performed), estimation of the strength of the in- fraspinatus muscle (the muscle that is most susceptible to at- rophy with disuse), and an assessment of the overall tight-

ness of the subacromial space. Next, the painful arc maneu- ver (passively abducting the glenohumeral joint while si- multaneously preventing shoulder shrugging) is combined with the degree of subacromial tenderness to assess the de- gree of subacromial impingement. If impingement is con- firmed, isometric testing of each individual tendon is per- formed to determine the number of inflamed tendons; for example, subacromial tenderness combined with isometri- cally resisted external rotation identifies the involvement of the infraspinatus tendon. Pain reproduced by isometrically resisted abduction identifies the involvement of the supraspinatus tendon. Pain reproduced by resisted flexion of the elbow identifies the involvement of the long head of the biceps. To complete the shoulder exam, focal tenderness of the AC joint, sternoclavicular (SC) joint, and subscapu- lar bursa is determined by direct palpation.

BOX 2-2

ESSENTIAL EXAMINATION OF THE SHOULDER

1. Evaluate the general function of the shoulder and glenohumeral joint: Observe the general movement of the shoulder, estimate the tone and strength of the supporting muscles, especially the infraspinatus, and determine the overall tightness of the subacro- mial space.

2. Perform the painful arc maneuver to determine the degree of subacromial impingement.

3. Palpate the subacromial space, the bicipital groove, and the anterior glenohumeral joint line.

4. Perform isometric testing of the major supporting tendons rotator cuff and biceps.

5. Palpate the AC joint, the SC joint, and the sub- scapular bursa for tenderness.

6. Perform range of motion of the neck or a general medical exam if a referred source of shoulder pain is suspected.

ONE-MINUTE SCREENING EXAM: MANEUVERS ASSESSING OVERALL SHOULDER FUNCTION AND DIFFERENTIAL DIAGNOSIS

The next 10 maneuvers represent the minimal examination of the patient presenting with shoulder symptoms. Function testing, range of motion measurement, and screening ma- neuvers for tendonitis, the accessory joints, and bursitis pro- vide enough information to triage to x-ray, order appropri- ate labs, suggest general treatment recommendations, or proceed to more detailed examination and treatment.

22

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 2–1. The touchdown sign is used to assess active glenohumeral joint abduction. THE TOUCHDOWN

FIGURE 2–1. The touchdown sign is used to assess active glenohumeral joint abduction.

THE TOUCHDOWN SIGN

SUMMARY:

Full abduction requires a normal gleno-

humeral joint, intact rotator cuff tendons, a freely moving AC joint, and well-developed deltoid and rotator cuff muscles. This is the optimal screening maneuver for intact abduction.

MANEUVER:

The patient is asked to raise both arms

directly overhead. The smoothness of the move- ment, the degree of discomfort, and the ability to complete the maneuver are compared side to side. Similarly, the ability to smoothly control lowering the arm is compared side to side (the latter maneu- ver is analogous to the drop-arm sign).

INTERPRETATION:

Severe pain limits abduction with

acute rotator cuff tendonitis, rotator cuff tendonitis with partial tear, the uncommon inflammatory or sep- tic arthritis of the glenohumeral joint, and advanced

glenohumeral arthritis. Patients with dislocation or fracture will not attempt the maneuver. Patients with mild glenohumeral osteoarthritis or frozen shoulder have restricted movement with modest pain. Patients with complete rotator cuff tendon tears have impaired movement caused by profound weakness. A diagno- sis of polymyalgia rheumatica should be considered in older adults who complain of bilateral stiff shoul- ders (with or without concurrent hip involvement).

FIGURE 2–2. The Apley scratch sign is used to screen rota- tion of the glenohumeral

FIGURE 2–2. The Apley scratch sign is used to screen rota- tion of the glenohumeral joint.

THE APLEY SCRATCH SIGN

SUMMARY:

Full rotation requires a normal gleno-

humeral joint, intact rotator cuff tendons, and rea- sonably well-developed rotator cuff muscles. The Apley scratch maneuver is the most practical means of screening shoulder movement. In addition, it pro- vides the most objective measurement of rotation.

MANEUVER:

The patient is asked to scratch the

lower back and place the thumb as high up on the back in the midline as comfortable. The distance between the thumbs is measured, and the level reached by the thumb is recorded.

INTERPRETATION:

Rotation is limited with frozen

shoulder, arthritis of the glenohumeral joint (os- teoarthritis or inflammatory arthritis), and the acute inflammation of rotator cuff tendonitis. The loss of rotation correlates well with the severity of these conditions. Rotation of the shoulder is impossible or the patient refuses to perform the maneuver with dislocation and humeral head fracture.

SHOULDER

23

FIGURE 2–3. Isometric testing of the external rotation using resistance bands. ISOMETRIC TESTING SUMMARY: The

FIGURE 2–3. Isometric testing of the external rotation using resistance bands.

ISOMETRIC TESTING

SUMMARY:

The infraspinatus and teres minor

muscles are responsible for external rotation of the shoulder. This is the first muscle to atrophy with any chronic condition affecting the shoulder. It is also the second most common rotator tendon to rupture. In general, testing the strength of external rotation provides the best screening of the shoul-

der’s overall conditioning.

MANEUVER:

Using a Theraband, bungee cord, or

10-10 resistance bands (depicted here), the patient

is asked to pull the bands apart while keeping the elbows at the sides (pure rotation). The symmetry of motion, strength, and ability to hold the bands steady are compared side to side.

INTERPRETATION:

Unilateral weakness of external

rotation is seen with rotator cuff tendon tear, C5 radiculopathy, and the uncommon suprascapular nerve palsy (hod carrier’s disease). Bilateral weak- ness of external rotation is seen with poor muscular development, bilateral rotator cuff tears, bilateral glenohumeral arthritis, or any chronic disease.

FIGURE 2–4. The weighted touchdown sign to assess over- all shoulder strength. THE WEIGHTED TOUCHDOWN

FIGURE 2–4. The weighted touchdown sign to assess over- all shoulder strength.

THE WEIGHTED TOUCHDOWN SIGN

SUMMARY:

Full abduction requires a normal gleno-

humeral joint, intact rotator cuff tendons, a func- tional AC joint, and well-developed deltoid and rotator cuff muscles. The ability to lift progressively heavier weights provides an objective measurement of general, overall shoulder strength.

MANEUVER:

The patient is asked to raise 1-, 2-,

and 5-lb weights overhead. The smoothness of the movement, the degree of discomfort, and the ability to complete the maneuver are compared side to side.

INTERPRETATION:

Inability to lift the unweighted

arm is seen with a complete rotator cuff tear, severe muscular atrophy, severe C5 radiculopathy, or the rare suprascapular nerve palsy. Ability to lift 1- or 2-lb weights is compatible with a partial rotator cuff tear, poorly developed muscles, or a partial C5 radiculopathy. The ability to lift 5 lb or more is consistent with intact rotator cuff tendon.

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OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 2–5. The sulcus sign evaluates the looseness or tight- ness of the shoulder and

FIGURE 2–5. The sulcus sign evaluates the looseness or tight- ness of the shoulder and can be used to determine the appropri- ateness of the pendulum stretch exercise.

THE SULCUS SIGN

SUMMARY:

The deltoid muscle arises from the

acromion and attaches to the midhumerus. The supraspinatus tendon attaches to the greater tuber- cle. Downward movement of the humeral head is restricted by the tone and bulk of the deltoid, the tone and thickness of the supraspinatus tendon, and the redundancy of the glenohumeral capsule. This maneuver is used to assess the looseness of the shoulder joint, the subacromial space (subluxation), and the patient’s potential tolerance of the pendu- lum stretch exercise.

MANEUVER:

The patient is asked to relax the shoul-

der. One hand is placed atop the acromion, and one hand is placed in the antecubital fossa. Down- ward pressure is applied to the arm to open the

subacromial space. The examiner assesses the looseness of the shoulder and the discomfort of the maneuver.

INTERPRETATION:

A tight shoulder—no movement

with downward pressure—is seen with extreme guarding and tension due to pain, frozen shoulder, fibromyalgia, or an overly developed deltoid. Downward movement of 1 4 inch is considered aver- age looseness. Downward movement of more than 1 2 inch indicates hypermobility (subluxation).

FIGURE 2–6. Subacromial impingement is assessed by the pas- sive painful arc maneuver. PASSIVE PAINFUL

FIGURE 2–6. Subacromial impingement is assessed by the pas- sive painful arc maneuver.

PASSIVE PAINFUL ARC MANEUVER

SUMMARY:

Several maneuvers are used to define

the degree of subacromial impingement, including the Neer and Hawkins maneuvers. The passively performed painful arc maneuver (depicted here) is the easiest maneuver to perform and provides the most reproducible assessment of impingement. The combination of this maneuver with focal tenderness defines the degree of subacromial impingement.

MANEUVER:

One hand is placed atop the

acromion, and one hand grasps the proximal fore- arm. The patient is asked to relax the shoulder. While applying simultaneously downward pressure on the acromion to prevent the protective effect of shrugging, the arm is carefully raised, and the an- gle at which pain is reproduced is noted.

INTERPRETATION:

Mild impingement is defined

by pain reproduced at 90 degrees of abduction. Moderate impingement occurs at an angle of 60 to 70 degrees, and severe impingement is defined by pain at 45 degrees.

SHOULDER

25

FIGURE 2–7. Palpation of the subacromial space. PALPATION OF THE SUBACROMIAL SPACE SUMMARY: The subacromial

FIGURE 2–7. Palpation of the subacromial space.

PALPATION OF THE SUBACROMIAL SPACE

SUMMARY:

The subacromial space is occupied by

the subacromial bursa, the rotator cuff tendons, and 1 to 2 mm of articular cartilage. The deltoid muscle is layered over the acromion, the subacromial space, and the greater tubercle of the upper humerus. Subacromial tenderness, just under the lateral edge of the acromion, combined with the

passive painful arc maneuver defines the impinge- ment syndrome.

MANEUVER:

The anterior, lateral, and posterior

edges of the acromion are marked with a pen. The subacromial space is palpated just under the lateral edge of the acromion.

INTERPRETATION:

Focal tenderness is typical of im-

pingement syndrome, active rotator cuff tendonitis, rotator cuff tendonitis with tear, and bony lesions of

the humerus. Diffuse tenderness is characteristic of acute subacromial bursitis and patients with active shoulder tendonitis with a low pain threshold.

FIGURE 2–8. Palpation of the AC joint. PALPATION OF THE AC JOINT OBJECTIVE: The AC

FIGURE 2–8. Palpation of the AC joint.

PALPATION OF THE AC JOINT

OBJECTIVE:

The AC joint is formed by the acromial

process of the scapula and the distal end of the clavicle. The joint is held together by the acromio- clavicular, coracoacromial, and coracoclavicular ligaments. The joint is susceptible to osteoarthritis and traumatic separation.

MANEUVER:

The anterior, lateral, and posterior

edges of the acromion are marked with a pen. The AC joint is 1 3 4 inches from the lateral edge of the acromion.

INTERPRETATION:

Osteoarthritis of the AC joint

is characterized by bony enlargement. An os- teoarthritic flare is characterized by bony enlarge-

ment combined with local tenderness. Local tender- ness with normal-positioned and normal-sized bones is characteristic of a first-degree AC separa- tion. Local tenderness and bony deformity after trauma to the shoulder are seen with second- and third-degree AC separations.

26

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 2–9. Palpation of the subscapular bursa. PALPATION OF THE SUBSCAPULAR BURSA SUMMARY: The levator

FIGURE 2–9. Palpation of the subscapular bursa.

PALPATION OF THE SUBSCAPULAR BURSA

SUMMARY:

The levator scapula attaches to the su-

perior medial angle of the scapula. The rhomboid muscles attach to the medial border of the scapula. The middle portion of the trapezius muscle forms the outer muscular layer that covers the muscles and the scapula. The subscapular muscle is located underneath the scapula, acting as a natural protec-

tive pad between the ribs and scapula.

MANEUVER:

The ipsilateral arm is fully abducted.

The patient is asked to place the hand on the con-

tralateral shoulder. The superior medial angle of the scapula and the center of the ribs are marked with

a pen. Bursal tenderness is palpated directly over the rib closest to the angle of the scapula.

INTERPRETATION:

A half dollar–sized area of ten-

derness at the superior medial angle is most com- monly caused by subscapular bursitis as opposed

to the generalized muscular tenderness of the strain

of the upper back muscles. Primary involvement of the rib or the scapula must be considered in the case of the patient with a known primary cancer (e.g., breast, lung, prostate).

F I G U R E 2 – 1 0 . P a l p

FIGURE 210. Palpation of the SC joint.

PALPATION OF THE SC JOINT

SUMMARY:

The SC joint is formed by the upper

portion of the sternum and the proximal clavicle. When the joint swells, the proximal clavicle pro- jects anteriorly. The anterior position of the clavicle

causes a pseudoenlargement of the clavicle.

MANEUVER:

The sternal notch, proximal clavicle,

and center of sternum are palpated and marked with a pen. The SC joint is palpated at the junction of the sternum and the proximal clavicle, approxi-

mately 3 4 to 1 inch from the midline.

INTERPRETATION:

SC joint involvement is uncom-

mon. SC joint strain is characterized solely by local tenderness. SC joint local tenderness and pseudo- enlargement of the clavicle are seen with SC joint arthritis, most commonly Reiter’s disease. A red, hot, swollen joint is a unique complication of intra- venous drug abuse, acute septic arthritis.

SHOULDER

27

ONE-MINUTE SCREENING EXAM:

MANAGEMENT OPTIONS

TRIAGE TO X-RAY The patient has a history of trauma, is at risk of bony injury, has recurrent episodes of rotator cuff tendonitis, has significant loss of range of motion in ro- tation or abduction, or has an enlarged AC or SC joint by history or exam:

• Order three views of the shoulder for patients with a history of fall to an outstretched arm, a severe blow to the shoul- der, or a hyperextension injury (humeral or clavicular frac- ture, AC separation, or glenohumeral joint dislocation).

• Order three views of the shoulder for patient with recur- rent or chronic rotator cuff tendonitis (narrowing of the subacromial space also known as high-riding humeral head seen with thinning of the rotator cuff tendons).

• Order weighted views of the shoulder (traumatic AC separation).

• Order three views of the shoulder and an axillary view (glenohumeral joint osteoarthritis or as a part of the workup for frozen shoulder).

• Order apical lordotic views of the upper chest (SC joint swelling and subluxation).

TRIAGE TO THE LAB For patients suspected of having gout, acute arthritis, or septic arthritis (rare):

• Order a complete blood cell count, uric acid, and eryth- rocyte sedimentation rate for patients with acute pain, ex- quisite anterior joint line tenderness, signs of active in- flammation, and dramatic loss of range of motion in all directions (gout or acute arthritis) and include blood cul- tures if the acute inflammatory changes are accompanied by significant fever or concurrent signs of infection else- where in the body.

CONSIDER A BONE SCAN For patients with vague pain about the shoulder with a history of previous solid tu-

mor and for patients with osteoporosis, a history of fall, and

a high suspicion for occult fracture.

CONSIDER MRI

gestive of rotator cuff tear or glenoid labral tear from previ- ous subluxation or dislocation.

For patients with an examination sug-

RECOMMEND EMPIRICAL TREATMENT For pa- tients with mild to moderate shoulder pain and stiffness, unrestricted movement of the joint, and normal strength in rotation and abduction.

• Restrict reaching, lifting, pushing, and pulling.

• Apply ice up to four times a day or take a full-strength nonsteroidal anti-inflammatory drug for 10 to 14 days.

• Perform the pendulum stretch exercise once or twice daily.

• Perform isometric toning exercise of external rotation.

DETAILED EXAMINATION: SPECIFIC SHOULDER DIAGNOSES

Perform a detailed examination of the shoulder if the pa- tient has persistent or chronic symptoms, has sustained an injury, demonstrates moderate loss of range of motion, or has lost strength in rotation or abduction.

28

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

28 OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS IMPINGEMENT SYNDROME Shoulder pain and impaired reaching at or

IMPINGEMENT SYNDROME

Shoulder pain and impaired

reaching at or above shoulder level that is caused by the direct bony contact of the undersurface of the acromion and the greater tubercle of the humeral head is called impingement syndrome.

It is the mechanical abnormality of the shoulder that is the princi- ple cause of inflammation of the subacromial bursa—common shoulder bursitis—and rotator cuff tendonitis.

FIGURE 2–11. Subacromial impingement assessed by the pas- sive painful arc maneuver . PASSIVE PAINFUL

FIGURE 2–11. Subacromial impingement assessed by the pas- sive painful arc maneuver.

PASSIVE PAINFUL ARC MANEUVER

SUMMARY:

Several maneuvers are used to define

the degree of subacromial impingement, including the Neer and Hawkins maneuvers and the pas- sively performed painful arc maneuver (depicted here). The painful arc maneuver is the easiest to perform and is applicable to most patients with clinically significant impingement. The combination of this maneuver with focal tenderness defines the

degree of subacromial impingement.

MANEUVER:

One hand is placed atop the

acromion, and one hand grasps the proximal fore- arm. The patient is asked to relax the shoulder. While downward pressure is applied on the acromion to prevent the protective effect of shrug- ging, the arm is carefully raised, and the angle at

which pain is reproduced is noted.

INTERPRETATION:

Mild impingement is defined

by pain reproduced at 90 degrees of abduction. Moderate impingement occurs at an angle of 60 to 70 degrees, and severe impingement is defined by pain at 45 degrees.

FIGURE 2–12. The lidocaine injection test is used to confirm impingement. LIDOCAINE INJECTION TEST SUMMARY:

FIGURE 2–12. The lidocaine injection test is used to confirm impingement.

LIDOCAINE INJECTION TEST

SUMMARY:

The lidocaine injection test is used to

confirm impingement as the primary cause of shoul- der pain and to define the various presentations of shoulder tendonitis (rotator cuff tendonitis, rotator cuff tendonitis with tear, and rotator cuff tendonitis

complicated by frozen shoulder) and glenohumeral joint arthritis.

POSITIONING:

Sitting, relaxed shoulder, with or

without downward traction applied to the elbow.

SURFACE ANATOMY:

POINT OF ENTRY:

Lateral edge of the acromion.

1 to 1 1 2 inches below the mid-

point of the acromion.

ANGLE OF ENTRY:

Paralleling the acromion.

NEEDLE:

1 2 inch, 22 gauge.

DEPTH:

1 to 1 1 2 inches.

ANESTHESIA:

Ethyl chloride, skin: 1 mL, deltoid;

1 to 2 mL, subacromial bursa.

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29

SHOULDER 29 ROTATOR CUFF TENDONITIS Rotator cuff tendonitis, in- flammation of the important supporting tendons of

ROTATOR CUFF TENDONITIS

Rotator cuff tendonitis, in-

flammation of the important supporting tendons of glenohumeral joint, results from repeated subacromial impingement and a fail- ure of the subacromial bursa to provide adequate lubrication

and protection. Of the four rotator cuff tendons, the supraspinatus tendon is the most susceptible to injury and inflammation because of its vulnerable position just under the acromion process.

FIGURE 2–13. Isometric testing of the supraspinatus tendon in midarc. ISOMETRIC TESTING SUMMARY: Of the

FIGURE 2–13. Isometric testing of the supraspinatus tendon in midarc.

ISOMETRIC TESTING

SUMMARY:

Of the three abductors of the shoulder—

the deltoid, supraspinatus, and trapezius—the supraspinatus is responsible for abduction in the mi- darc. Active shoulder tendonitis is defined by repro- ducing the patient’s pain with active isometric test- ing of the actions of the various tendons. Active resisting abduction in the midarc defines the degree of inflammation of the supraspinatus tendon.

MANEUVER:

The patient’s arm is abducted to 45

degrees. The patient is asked to actively abduct the arm against the resistance of the examiner’s hand placed at the elbow. The effort, strength, and dis- comfort are noted.

ADDITIONAL SIGNS:

The diagnosis of rotator cuff

tendonitis is suggested when the signs of impinge- ment (local tenderness and the painful arc maneu- ver) are accompanied by pain reproduced by iso- metric testing of the rotator cuff tendons. Strength of midarc abduction should be normal unless the ten- don has been split or torn.

INTERPRETATION:

Isometric induced pain and nor-

mal strength suggests rotator cuff tendonitis. Pain and weakness of midarc abduction suggests rotator cuff tendonitis with tear. Weakness without pain suggests chronic rotator cuff tear, muscular atrophy, C5 radiculopathy, or suprascapular nerve palsy.

FIGURE 2–14. Isometric testing of the infraspinatus tendon in neutral position. ISOMETRIC TESTING SUMMARY: The

FIGURE 2–14. Isometric testing of the infraspinatus tendon in neutral position.

ISOMETRIC TESTING

SUMMARY:

The infraspinatus is the primary external

rotator of the shoulder (the teres minor plays a mi- nor role). This maneuver is performed with the shoulder kept in neutral position. If the patient’s pain is reproduced only by resistance to external rotation, one can assume that the infraspinatus ten- don is solely responsible for the active tendonitis.

MANEUVER:

The elbow is flexed to 90 degrees and

held next to the body with one hand. The patient is asked to actively rotate the arm against the resis- tance of the examiner’s hand placed at the wrist. The effort, strength, and discomfort are noted.

The diagnosis of rotator cuff

tendonitis is suggested when the signs of impinge- ment (local tenderness and the painful arc maneu- ver) are accompanied by pain reproduced by iso- metric testing of the rotator cuff tendons.

ASSOCIATED SIGNS:

INTERPRETATION:

Identical to isometric testing of

the supraspinatus tendon (see Figure 2–13).

30

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 2–15. X-rays of the shoulder to determine the normal subacromial width . NORMAL SUBACROMIAL

FIGURE 2–15. X-rays of the shoulder to determine the normal subacromial width.

NORMAL SUBACROMIAL WIDTH

SUMMARY:

The subacromial space—the anatomic

areas between the superior humeral head and the undersurface of the acromion—contains the sub- acromial bursa, the rotator cuff tendons, and 2 mm of articular cartilage. Chronic inflammation of the subacromial bursa leads to bursa wall fibrosis and eventual loss of its normal lubricating function. If the

bursa cannot protect the rotator cuff tendons from the friction and compressive forces of subacromial impingement, the rotator cuff tendons will be vulner- able to mucinoid degenerative thinning.

CASE:

This radiograph demonstrates the normal

relationships of the acromion and the humeral head. The normal subacromial space (depicted here) measures 10 to 11 mm. Narrowing of the space correlates directly with thinning of the rotator cuff tendons. Radiologists often refer to a narrowed subacromial space as a “high-riding humeral head” sign.

FIGURE 2–16. X-rays of the shoulder demonstrating the abnor- mal subacromial width . ABNORMAL SUBACROMIAL

FIGURE 2–16. X-rays of the shoulder demonstrating the abnor- mal subacromial width.

ABNORMAL SUBACROMIAL WIDTH

CASE:

This patient had a history of recurrent rotator

cuff tendonitis over many years. He worked in con- struction all his life, performing heavy physical work, including physical work at or above his shoulder level. He was forced to retire because of refractory right shoulder pain. This radiograph demonstrates a near obliteration of the subacromial space, measuring 1 mm or less (loss of the subacro- mial bursa and complete thinning of the rotator cuff tendons). The greater tubercle of the humeral head shows severe sclerosis caused by the chronic com- pressive forces of impingement over the years. Patients with loss of the normal subacromial space are at the highest risk for rotator cuff tendon tear. (Radiologists often fail to comment on the sclerotic changes occuring at the greater tubercle, the radio- graphic signs of impingement.)

SHOULDER

31

FIGURE 2–17. The lidocaine injection test confirming rotator cuff tendonitis. LIDOCAINE INJECTION TEST SUMMARY:

FIGURE 2–17. The lidocaine injection test confirming rotator cuff tendonitis.

LIDOCAINE INJECTION TEST

SUMMARY:

Patients presenting with severe shoulder

pain and severe guarding on examination need lo- cal anesthetic block in order to more accurately as- sess the function of the shoulder. The lidocaine in- jection test is used to confirm rotator cuff tendonitis, exclude rotator cuff tear (normal strength), exclude glenohumeral joint involvement, and determine the

degree of frozen shoulder (persistent loss of range of motion).

POSITIONING:

Sitting, relaxed shoulder, downward

traction applied to the elbow.

SURFACE ANATOMY:

POINT OF ENTRY:

Lateral edge of the acromion.

1 to 1 1 2 inches below the mid-

point of the acromion.

ANGLE OF ENTRY:

Paralleling the acromion.

NEEDLE:

1 1 2 inch, 22 gauge.

DEPTH:

1 to 1 1 2 inches.

ANESTHESIA:

Ethyl chloride, skin: 1 mL, deltoid;

1 to 2 mL, subacromial bursa.

skin: 1 mL, deltoid; 1 to 2 mL, subacromial bursa. FROZEN SHOULDER Frozen shoulder or adhesive

FROZEN SHOULDER

Frozen shoulder or adhesive capsulitis,

a loss of the normal range of motion of the glenohumeral joint, is

a direct result of injury or inflammation of the shoulder. The

most common causes are rotator cuff tendonitis, fracture of

the humerus, dislocation of the glenohumeral joint, and shoulder surgery. In 95% of cases the contracture of the glenohumeral capsule is reversible.

FIGURE 2–18. The Apley scratch sign to estimate the sever- ity of frozen shoulder. APLEY

FIGURE 2–18. The Apley scratch sign to estimate the sever- ity of frozen shoulder.

APLEY SCRATCH SIGN

SUMMARY:

Full rotation requires a normal gleno-

humeral joint, intact rotator cuff tendons, and rea- sonably well-developed rotator cuff muscles. The Apley scratch sign is the most practical and objec- tive measurement of rotation.

MANEUVER:

The patient is asked to scratch the

lower back and place the thumb as high up on the back in the midline as comfortable. The distance between the thumbs is measured, and the level reached by the thumb is recorded.

ADDITIONAL SIGNS:

The touchdown sign demon-

strating an abnormal abduction range of motion is typically abnormal as well. The passive range of motion of external rotation and abduction are dra- matically lower than that of any other direction. Signs of active rotator cuff tendonitis often accom- pany the exam because it is the most common cause of frozen shoulder.

INTERPRETATION:

Rotation is limited with frozen

shoulder, arthritis of the glenohumeral joint (osteo- arthritis or inflammatory arthritis), and the acute inflammation of rotator cuff tendonitis. The loss of rotation correlates well with the severity of these

conditions.

32

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 2–19. Arthrography of the glenohumeral joint demonstrating loss of the normal synovial cavity distensibility.

FIGURE 2–19. Arthrography of the glenohumeral joint demonstrating loss of the normal synovial cavity distensibility.

ARTHROGRAPHY OF THE GLENOHUMERAL JOINT

SUMMARY:

The diagnosis of frozen shoulder is

based on the clinical criteria of preferential loss of external rotation and abduction relative to other di- rections of motion, no underlying primary involve- ment of the glenohumeral joint, and no concomitant neurologic disease that would restrict range of mo- tion. Plain radiographs are necessary to exclude an underlying glenohumeral osteoarthritis that can mimic the physical findings of frozen shoulder. Arthrography (depicted here to emphasize the loss of distensibility of the glenohumeral joint) is not nec- essary to confirm the diagnosis.

This middle-aged woman with insulin-dependent

diabetes developed a painful shoulder 6 months ago. She was treated with restriction in reaching and heavy lifting, ice, ibuprofen, and physical ther- apy exercises. Her pain gradually improved, but she gradually developed stiffness and lost full range of motion. Her Apley scratch signs were 10 inches apart. Her passive measurements of external rotation and abduction were 15 degrees and 50 degrees, respectively. The arthrogram depicted here demonstrates a poorly filled synovial cavity that ac- cepted only 6 to 7 mL of radiopaque dye.

CASE:

SHOULDER

33

SHOULDER 33 ROTATOR CUFF TENDON TEAR In the majority of cases rupture of the rotator cuff

ROTATOR CUFF TENDON TEAR

In the majority of cases

rupture of the rotator cuff tendons occurs as a complication of pre- existing rotator cuff tendonitis. Other risk factors include chronic mucinoid degenerative tendon thinning, injury (fall to an out-

stretched arm or direct blow), age greater than 62 years, a history of recurrent tendonitis, a narrowed subacromial space on x-ray, muscular weakness, systemic steroids, concomitant rheumatic disease, and intratendinous injection.

FIGURE 2–20. Rotator cuff tendon weakness and inability to lift the arm. ROTATOR CUFF TENDON

FIGURE 2–20. Rotator cuff tendon weakness and inability to lift the arm.

ROTATOR CUFF TENDON WEAKNESS

SUMMARY:

Approximately 15% of cases of rotator

cuff tendonitis are complicated by tear. The hallmark feature of rotator cuff tear is loss of strength in the direction of the affected tendon (external rotation, infraspinatus; midarc abduction, supraspinatus). The diagnostic challenge is to identify the patient at risk and to evaluate the extent of the tear by estimating

the degree of weakness and the impact of the tear on overall shoulder function. In many cases, a lido- caine injection test (see Figure 2–17) is necessary to reduce pain to allow completion of the examination.

MANEUVER:

To assess the impact of a possible rota-

tor cuff tendon tear on overall function, the patient is asked to actively raise the arm overhead. Patients with large complete tears (depicted here) are unable

to raise the arm without contralateral arm assist. In order to grade the size of tears and their impact on the shoulder, the patient can be asked to raise pro- gressively heavier weights (see Figure 2–4).

ASSOCIATED SIGNS:

Weakness of external rotation

(see Figure 2–3), weakness of midarc abduction (see Figure 2–13), bruising of the anterior shoulder

or upper arm, previous ruptured biceps tendons (in- creased risk), and swelling of the glenohumeral joint (depicted here).

FIGURE 2–21. The high-riding humeral head sign, strongest evidence of mucinoid degenerative thinning of the

FIGURE 2–21. The high-riding humeral head sign, strongest evidence of mucinoid degenerative thinning of the rotator cuff tendons.

HIGH-RIDING HUMERAL HEAD

CASE:

This 74-year-old woman has a 25-year his-

tory of “shoulder bursitis.” She is unable to raise her arm overhead, cannot comb her hair, and cannot reach up to remove dishes from her higher shelves. She uses her left arm to assist with abduc- tion. Her external rotation strength is nonexistent, and her abduction strength is poor.

DIAGNOSIS:

Complete rotator tendon tear.

DISCUSSION:

The high-riding humeral head sign

focuses on the cephalad migration of the humeral head. From a clinical perspective, a more helpful description would be “narrowed subacromial space,” thus shifting the emphasis to the narrowed thickness of the soft tissues located between the humeral head and the undersurface of the acromion. The normal width is 10 to 11 mm (1 mm humeral articular cartilage, 7 mm rotator cuff ten- don, 1 mm subacromial bursa).

34

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 2–22. Arthrography to confirm a rotator cuff tendon tear. Hypaque 60 injected into the

FIGURE 2–22. Arthrography to confirm a rotator cuff tendon tear. Hypaque 60 injected into the glenohumeral joint leaks through a tear in the rotator cuff and into the subacromial bursa.

ARTHROGRAPHY

CASE:

This 71-year-old woman presented with recur-

rent rotator cuff tendonitis. She presented with local subacromial tenderness, a painful arc at 70 de- grees, and pain and mild weakness when resisting midarc abduction and external rotation. Her strength improved modestly with the lidocaine injec- tion test. Arthrography demonstrated a complex

tear (the lower arrow). Dye entered the subacromial bursa (upper arrow) from the glenohumeral joint (the bursa and the synovial cavity to not communi- cate in the normal shoulder).

DIAGNOSIS:

Full-thickness rotator tendon tear. The

subacromial space measures 10 mm (normal 10 to 11 mm), indicating a normal thickness rotator cuff tendon.

DISCUSSION:

The patient fully recovered with a

combination of restricted reaching and lifting, the pendulum stretch exercise, a subacromial injection of Depo-Medrol, and recovery toning exercises. The prognosis for full recovery depends on the thickness of the tendons (normal thickness indicates no mucinoid degenerative thinning).

FIGURE 2–23. Shoulder MRI showing supraspinatus tendon tear with muscle retraction. SHOULDER MRI CASE: This

FIGURE 2–23. Shoulder MRI showing supraspinatus tendon tear with muscle retraction.

SHOULDER MRI

CASE:

This right-handed, 55-year-old construction

worker fell 5 to 6 feet onto concrete, striking his right side and right shoulder. He felt immediate pain so severe he could not raise his arm up with- out the help of his left arm. Testing of midarc ab- duction and external rotation strength was impossi- ble due to pain. Plain x-rays did not disclose a fracture or dislocation.

DIAGNOSIS:

Acute rotator cuff tendon rupture with

muscle retraction.

Given the type of injury, the profound

changes on examination, and the risk of an acute tendon rupture, MRI was the test of choice in this la- borer with profound loss of shoulder function on the dominant side. The patient underwent acute surgi- cal intervention to repair the torn tendon. Criteria for surgical treatment of rotator cuff tears include dramatic loss of function, weakness of external rota- tion or abduction that approaches 50% and that is not exaggerated by concurrent rotator cuff ten- donitis pain, acute traumatic tears (a more favor- able outcome than the chronic mucinoid degenera-

tive tears of older adults), dominant side, and no medical contraindications.

DISCUSSION:

SHOULDER

35

SHOULDER 35 BICEPITAL TENDONITIS Acute inflammation of the long head of the biceps causes anterior shoulder

BICEPITAL TENDONITIS

Acute inflammation of the long

head of the biceps causes anterior shoulder pain, bicipital groove tenderness, and pain aggravated by resisting flexion at the elbow. Chronic inflammation of the biceps tendon can lead to bicipital tendon rupture.

FIGURE 2–24. Palpation of the bicipital groove for bicipital tendonitis. PALPATION SUMMARY: Local tenderness is

FIGURE 2–24. Palpation of the bicipital groove for bicipital tendonitis.

PALPATION

SUMMARY:

Local tenderness is located directly over

the bicipital groove and is palpable approximately 1 inch down from the anterolateral tip of the acromion. Tenderness is invariably present but not absolutely necessary for the diagnosis.

MANEUVER:

The bicipital groove is identified by

placing a finger on the anterolateral humeral head between the greater and lesser tubercles. Passive ro- tation of the arm aids in the identification as the greater and lesser tubercles are felt moving under the fingertip.

Pain aggravated by flexion of

the elbow, isometrically performed; a positive pas- sive painful arc maneuver if impingement is present (see Figure 2–6); a bulge in the antecubital fossa, signifying long head tendon rupture; and preserved strength of elbow flexion despite tendon rupture. The strength of the unaffected short head of the bi- ceps and the brachioradialis muscles combine to make up 80% of the strength of elbow flexion.

ADDITIONAL SIGNS:

INTERPRETATION:

Each patient is examined for

swelling and inflammation of the long head of the biceps in the bicipital groove, for signs of tendon rupture, and for associated subacromial impinge- ment. Bicipital tendonitis is less common than rota- tor cuff tendonitis.

36

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 2–25. Bicipital tendonitis confirmed by local anes- thetic placed at the bicipital groove. BICIPITAL

FIGURE 2–25. Bicipital tendonitis confirmed by local anes- thetic placed at the bicipital groove.

BICIPITAL TENDONITIS

SUMMARY:

The ribbon-like long head of the biceps

lies in the bicipital groove and is susceptible to in- flammation and tendon rupture. It is the third most common form of tendonitis at the shoulder. It ranks behind tendonitis of the supraspinatus and infra- spinatus tendons.

POSITIONING:

the leg.

Sitting, relaxed shoulder, hand on

SURFACE ANATOMY:

Anterior humeral head, lesser

and greater tubercles, anterolateral corner of the acromion.

POINT OF ENTRY:

Between the lesser and greater

tubercles of the humerus, 1 inch below the antero- lateral corner of the acromion.

ANGLE OF ENTRY:

Perpendicular to the skin.

NEEDLE:

1 1 2 inch, 22 gauge.

DEPTH:

1 to 1 1 2 inches.

ANESTHESIA:

Ethyl chloride, skin: 1 mL, deltoid;

1 mL, bicipital groove.

FIGURE 2–26. Bicipital tendon rupture confirmed by clinical examination. BICIPITAL TENDON RUPTURE CASE: This

FIGURE 2–26. Bicipital tendon rupture confirmed by clinical examination.

BICIPITAL TENDON RUPTURE

CASE:

This 64-year-old man on coumarin had a

“spontaneous” rupture of the right long head of the biceps. He denies injury, a fall to an outstretched arm, or unusual lifting. Note the extensive bruising from his coumarin. His international normalized ratio was 3.7 at the time of presentation.

DIAGNOSIS:

Acute rupture of the long head of the

biceps on the right side and an old bicipital rupture on the left.

DISCUSSION:

Complete bicipital tendon ruptures

cause the typical “Popeye” deformity in the antecu- bital fossa and often are associated with extensive ecchymosis. Although dramatic in appearance, these are rarely repaired. The short head of the biceps and the brachioradialis are responsible for 80% to 85% of the strength of elbow flexion.

SHOULDER

37

SHOULDER 37 AC JOINT OSTEOARTHRITIS AND SEPARATION The diagnosis of AC arthritis or separation is readily

AC JOINT OSTEOARTHRITIS AND SEPARATION

The

diagnosis of AC arthritis or separation is readily made based on its characteristic focal tenderness; in fact, patients readily identify the AC joint by pointing directly to it when describing their ante- rior shoulder pain. Osteoarthritis is a nearly universal occurrence with advancing age. Injury to its supporting ligaments is called

shoulder separation.

FIGURE 2–27. Palpation of the AC joint. PALPATION OF THE AC JOINT SUMMARY: The diagnosis

FIGURE 2–27. Palpation of the AC joint.

PALPATION OF THE AC JOINT

SUMMARY:

The diagnosis of AC osteoarthritis

or shoulder separation—injury to the supporting ligaments—is based on the demonstration of focal tenderness over the anterosuperior portion of the joint. Arthritis is further characterized by the degree of bony enlargement. AC separation is defined as

first, second, or third degree based on the radio- graphic measurement of bony separation.

MANEUVER:

The anterior, lateral, and posterior

edges of the acromion are marked with a pen. The AC joint is located along the anterior portion of the acromion, approximately 1 3 4 inches from its

lateral edge.

ADDITIONAL SIGNS:

Bony enlargement defines the

degree of osteoarthritis. Downward pressure on the arm to displace the joint defines the degree of AC separation. Pain can be reproduced by passively adducting the arm across the chest, forcing the ends of the articulating bones together. If the condi- tion is severe, pain can be reproduced by actively resisting the biceps; the action of the biceps gener- ates traction across the joint.

INTERPRETATION:

Local tenderness combined with

bony enlargement defines the degree of osteoarthri- tis. Local tenderness occurring after injury but with the normal alignment of the acromion and clavicle defines first-degree AC separation. Local tenderness

occurring after injury with widening of the joint when downward traction is placed on the joint de- fines a second-degree AC separation. Third-degree separations are obvious to inspection; the clavicle is abnormally positioned above the plane of the acromion.

38

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 2–28. AC joint osteoarthritis is confirmed by plain x-rays. AC JOINT OSTEOARTHRITIS CASE: This

FIGURE 2–28. AC joint osteoarthritis is confirmed by plain x-rays.

AC JOINT OSTEOARTHRITIS

CASE:

This middle-aged plywood mill worker com-

plained of anterior shoulder pain and pointed to the AC joint as the most sensitive area of his shoul- der. He has pain with reaching overhead and when he rolls onto his right side during the night.

DIAGNOSIS:

AC joint osteoarthritis with inferiorly

directed osteophytes.

DISCUSSION:

Osteoarthritis of the AC joint is a uni-

versal condition, developing in nearly all patients older than 50 years. However, only 5% ever de- velop symptoms. The diagnosis is suggested by an- terior shoulder pain, focal tenderness directly over the joint, and bony enlargement. The diagnosis is confirmed by x-ray or by anesthetic placed just over the joint. Large inferiorly directed osteophytes can cause rotator cuff tendonitis; the supraspinatus ten- don is positioned directly under the AC joint.

FIGURE 2–29. Local anesthetic block of the AC joint to confirm osteoarthritis and first-degree separation.

FIGURE 2–29. Local anesthetic block of the AC joint to confirm osteoarthritis and first-degree separation.

LOCAL ANESTHETIC BLOCK OF THE AC JOINT

SUMMARY:

Occasionally patients present with a

combination of symptoms suggesting simultaneous involvement of the AC joint and rotator cuff ten- donitis, two common shoulder conditions. Local anesthetic block is used to determine the role of the AC joint in the patient’s clinical presentation. The needle enters just over the end of the clavicle (1 1 2

inches medially to the lateral edge of the acromion).

NEEDLE:

5 8 inch, 25 gauge.

DEPTH:

3 8 to 5 8 inches, down to the periosteum of

the clavicle.

VOLUME:

NOTE:

1 mL anesthetic and 1 2 mL K40.

The needle does not enter the joint directly.

The injection is placed just under the synovial mem- brane attached to the distal clavicle.

SHOULDER

39

FIGURE 2–30. Third-degree AC separation confirmed by plain x-rays. THIRD-DEGREE AC SEPARATION CASE: This 35-year-old

FIGURE 2–30. Third-degree AC separation confirmed by plain x-rays.

THIRD-DEGREE AC SEPARATION

CASE:

This 35-year-old mountain biker fell forward

over the handlebars after striking a rock. His shoulder struck the ground. The direct blow to the anterior shoul- der caused immediate shoulder pain and deformity.

DIAGNOSIS:

Third-degree AC separation.

DISCUSSION:

The acromioclavicular, coracoclavicu-

lar, and coracoacromial ligaments are attached tightly to the periosteum and hold the acromion, clavicle, and coracoid together. Falls to an out- stretched arm, a dramatic blow to the anterior shoul- der (tackling in football), or a fall landing directly on the anterior portion of the shoulder can cause the ligaments to be sprained, partially torn, or com- pletely disrupted (first-degree sprain and second- and third-degree AC separations, respectively).

and second- and third-degree AC separations, respectively). GLENOHUMERAL OSTEOARTHRITIS Osteoarthritis of the

GLENOHUMERAL OSTEOARTHRITIS

Osteoarthritis of the

glenohumeral joint is an uncommon problem. Most cases are pre- ceded by a history of shoulder injury, either recent or remote. The

diagnosis often is overlooked because of its similarity to frozen

shoulder on examination. The diagnosis is made by the character- istic changes seen on routine x-rays, including asymmetrical nar- rowing of the cartilage, increased bony sclerosis, and the unique osteophyte formation that projects inferiorly off the humeral head.

FIGURE 2–31. Anterior shoulder swelling characteristic of a swollen glenohumeral joint. ANTERIOR SHOULDER SWELLING

FIGURE 2–31. Anterior shoulder swelling characteristic of a swollen glenohumeral joint.

ANTERIOR SHOULDER SWELLING

SUMMARY:

Active arthritis of the glenohumeral joint

is not common.

MANEUVER:

The coracoid process, the AC joint,

and the humeral head are palpated and marked. Glenohumeral joint swelling and its accompanying joint line tenderness are located in the infraclavicu- lar fossa just lateral to the coracoid process.

Swelling ranges from subtle filling in of the fossa to anterior enlargement, often seen best by inspecting the shoulder from above, looking down.

ADDITIONAL SIGNS:

The range of motion in all di-

rections can be limited, depending on the acute- ness of the process. Joint line tenderness located just under the coracoid process can be elicited by palpation in a superior and slightly lateral direc- tion. Crepitation is evident with active movement of the shoulder either passively or against resistance (osteoarthritis). Signs of inflammation are notably absent because of the depth of the joint.

INTERPRETATION:

Osteoarthritis and rheumatoid

arthritis are the most common causes of glenohumeral joint swelling. The severity correlates directly with the loss of range of motion, particularly in external rota- tion and abduction. Septic arthritis is rare. Patients with acute bacterial infections cradle their arm and do not allow any movement in any direction.

40

OFFICE ORTHOPEDICS FOR PRIMARY CARE: DIAGNOSIS

FIGURE 2–32. Glenohumeral joint osteoarthritis con- firmed by plain x-ray of the shoulder. GLENOHUMERAL JOINT

FIGURE 2–32. Glenohumeral joint osteoarthritis con- firmed by plain x-ray of the shoulder.

GLENOHUMERAL JOINT OSTEOARTHRITIS

CASE:

A 67-year-old rancher’s wife presents with

anterolateral shoulder pain and stiffness over several years. She denies any history of fracture, dislocation, or severe injury. However, she states, “People say I’ve always done a man’s work. It doesn’t surprise me that it is arthritic, since arthritis runs in my family.”

DIAGNOSIS:

DISCUSSION:

Glenohumeral osteoarthritis.

Arthritis of the glenohumeral joint is

characterized by a loss of articular cartilage be- tween the humeral head and the glenoid, osteo- phyte formation extending from the inferior portion of the humeral head, and humeral head sclerosis. Note that the combination of the loss of articular cartilage and osteophyte formation transforms the normally round humeral head into the characteristic clublike deformity.

FIGURE 2–33. Glenohumeral joint osteoarthritis con- firmed by aspiration of the shoulder. GLENOHUMERAL JOINT

FIGURE 2–33. Glenohumeral joint osteoarthritis con- firmed by aspiration of the shoulder.

GLENOHUMERAL JOINT OSTEOARTHRITIS

SUMMARY:

Intra-articular injection enters 1 2 inch

below the coracoid process and is directed out- ward toward the medial portion of the humeral head. Err toward the superior aspect of the joint to avoid the neurovascular bundle of the axilla.

NEEDLE:

1 1 2 inch to 3 1 2 inch spinal needle,

22 gauge.

DEPTH:

1 1 2 to 2 1 2 inches, down to periosteum

of the humeral head or glenoid.

VOLUME:

NOTE:

3 to 4 mL anesthetic and 1 mL K40.