Shoulder Impingement

The rotator cuff is composed of four muscles: the supraspinatus, infraspina-tus, subscapularis, and terres minor. The supraspinatus is the primary rotator cuff area involved in impingement and tears. Impingement is the primary cause of rotator cuff tendinopathy, calcification, and degenerative tears. Acromioclavicular osteoarthritis resulting in osteophyte formation often results in impingement. Repetitive overhead work, reaching, and throwing activities can begin the process of impingement beginning in the third decade. By the fifth decade, ischemia can lead to fibrosis and tendonitis and a weakened supraspinatus that is more susceptible to tears with lesser trauma (44).

Pain at night and with overhead activities is typical of shoulder impingement injuries. Clinical signs include painful arc, positive empty-can sign, liftoff sign, and Hawkins and Neer impingement signs. Radiographs may show acromioclavicular (AC) narrowing and inferior osteophyte formation. Magnetic resonance imaging (MRI) is indicated if a rotator cuff tear is suspected and may reveal impingement upon the supraspinatus tendon, supraspinatus tendinopathy, or partial or complete tear. Subacromial corticosteroid and lidocaine injection may give temporary or permanent relief. If impingement or tear is present, arthroscopy with subacromial decompression and repair is

Table 24.2. Common upper extremity musculoskeletal disorders (MSDs).

Disorder

Clinical features

Tests/radiographic findings

Treatment

Impingement syndrome

1.

Positive impingement signs

1.

Positive lidocaine injection test

1.

NSAIDs

2.

Nighttime pain

2.

AC arthropathy

2.

PT

3.

MRI-supraspinatus tendinopathy

3.

Subacromial injection

4.

Subacromial decompression

Biceps tendonitis

1.

Often anterior manifestation

1.

Often unremarkable

1.

NSAIDs

of impingement

2.

Positive Speed's/Yrgasen's

2.

Possible calcification of

2.

PT

signs

bicipital tendon

3.

Steroid injections may cause tend

on rupture

Acromioclavicular (AC)

1.

Tender AC

1.

AC osteophyte

1.

NSAIDs

arthritis

2.

Positive crossover

2.

Narrowing of AC joint

2.

Judicious steroid injection

3.

Resection distal clavicle in severe cases

Carpal tunnel syndrome

1.

Nighttime symptoms

1.

Positive EMG for median

1.

Nocturnal splint

2.

Tinel's/Phalen's signs

entrapment

2.

Steroid injection

3.

Thenar atrophy is severe

2.

MRI not indicated

3.

Carpal tunnel release

Lateral epicondylitis

1.

Lateral elbow pain

1.

Occasional calcification

1.

PT/iontophoresis

2.

Pain opening doors/

2.

X-rays usually not indicated

2.

NSAIDs/forearm strap

holding objects

3.

Steroid injection tendon sheath

4.

Rare lateral epicondylar release

DeQuervain's tenosynovitis

1.

Pain pinching

Not indicated

1.

NSAIDs

2.

Positive Finkelstein's test

2.

Thumb spica splint

3.

Steroid injection

4.

Release of first dorsal compartment

EMG, electromyogram; NSAID, nonsteroidal antiinflammatory drug; PT, physical therapy. Source: Data from Rose et al. (40), Harris and Glass (41), Zuckerman et al. (42), and Guidotti (43).

EMG, electromyogram; NSAID, nonsteroidal antiinflammatory drug; PT, physical therapy. Source: Data from Rose et al. (40), Harris and Glass (41), Zuckerman et al. (42), and Guidotti (43).

Table 24.3. Management strategies.

1. Work modification

Proper working posture to keep the affected area at a neutral position

Improve lighting

Decrease work hours

Decrease repetitive motion tasks

Decrease certain hazards such as working over head or squeezing on a tool

2. Workplace hazard modification Proper equipment, chairs, etc. Proper tools

Modify computer programs to decrease key strokes Mechanization

3. Resting the injured part

4. Splinting Night splints

Day splints to allow the person to work

5. Antiinflammatory medications Nonsteroidal antiinflammatory drugs (NSAIDs) Cox-2 inhibitors (far more expensive than NSAIDs)

6. Injections Joint

Tendon sheaths

7. Physical therapy Range of motion Iontophoresis

Teach active exercise and conditioning programs

8. Surgery (in severe and resistant cases)

Source: Data from Rose et al. (40), Harris and Glass (41), Zuckerman et al. (42), and Guidotti

diagnostic and usually the definitive treatment. Differential diagnosis includes AC arthritis, bicipital tendonitis, rotator cuff tear, labral tear, and glenohumeral arthritis (44,45).

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Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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