Shoulder pain is the second most common musculoske-
letal complaint after back pain with a reported point prevalence of between 7 and 21 percent of adults.140,141,
142 Once present, shoulder pain may persist indefinitely, such that at least half of all patients presenting to a general practitioner with pain continue to have symptoms at one year.143 Shoulder pain may be due to either intrinsic disorders or to referred pain syndromes although a standard history and examination should enable a diagnosis to be made in the majority of cases.144 A longstanding comprehensive diagnostic system recognizing various independent entities such as frozen shoulder and tendonitis remains in widespread use today145 and this approach is mirrored in more recent diagnostic criteria developed using a Delphi consensus approach146 (see Table 38.4).
The site and distribution of pain usually provides important diagnostic information. Lateral or anterolateral shoulder pain is often associated with impingement syndromes involving the rotator cuff or with frozen shoulder. Posterior shoulder pain can arise from tendo-nitis of the external rotators but is more generally a reflection of referred cervical pain. Similarly, poorly localized pain, or pain that is referred below the elbow into the forearm of hand, should prompt a search for more central pathology.
Cluster analysis of examination findings has revealed three patterns based on range of movement.147 The first includes patients with pain plus severely restricted passive range of glenohumeral movement who are most commonly suffering from frozen shoulder. Other patterns include mildly reduced passive range of movement and patients with pain but no restricted movement. The vast majority of patients exhibiting these features will have a rotator cuff disorder which is the largest single diagnostic category accounting for shoulder pain. In common with other tendinopathies, rotator cuff tendonitis is often characterized by pain on resisted movement with an
Table 38.4 Diagnostic criteria for upper limb disorders.
Rotator cuff tendinitis
Bicipital tendinitis Shoulder capsulitis
Tenosynovitis of the wrist
History of pain in the deltoid region and pain on resisted active movement (abduction, supraspinatus;
external rotation, infraspinatus; internal rotation, subscapularis) History of anterior shoulder pain and pain on resisted active flexion or supination of forearm History of pain in the deltoid area and equal restriction of active and passive glenohumeral movement with capsular pattern (external rotation > abduction > internal rotation) Epicondylar pain and epicondylar tenderness and pain on resisted extension of the wrist Epicondylar pain and epicondylar tenderness and pain on resisted flexion of the wrist Pain over the radial styloid and tender swelling of the first extensor of the wrist compartment and either pain reproduced by resisted thumb extension or a positive Finkelstein's test Pain on movement localized to the tendon sheaths of the wrist and reproduction of pain by resisted active movement
Pain or paresthesiae or sensory loss in the median nerve distribution and one of: positive Tinel's test; positive Phalen's test; nocturnal exacerbation of symptoms; motor loss with wasting of abductor pollicus brevis; abnormal nerve conduction time Pain in the forearm in the absence of a specific diagnosis or forearm pain pathology (sometimes includes loss of function, weakness, cramp, muscle tenderness, allodynia, or slowing of fine movements)
Adapted from Annals of the Rheumatic Diseases, 1998, 57, 1-2, with permission of BMJ Publishing Group Ltd.
additional sign being that of a painful arc on active abduction of the affected side. The differential diagnosis includes true acromioclavicular joint disease arising from either OA or trauma, however, in these disorders gleno-humeral movements are normal, there is no resisted pain, and symptoms are generally confined to the joint with the patient often pointing to the affected area (the "point sign'').
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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.