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Patients usually present with nonspecific pain localized to the shoulder, often noticed more at night when lying on the affected side Locking sensations occur with motion of the shoulder, particularly through abduction Because of the shared innervation, symptoms are frequently referred down the proximal lateral arm With rotator cuff tears, the patient may be unable to abduct or flex the shoulder, depending on the site of the tear The rotator cuff may be palpated just lateral to the head of the acromion Maximum tenderness is usually noted over the supraspinatus insertion The acromioclavicular joint may also be tender if there is accompanying degenerative arthritis in that joint There may be prominent crepitus Pain with range of motion is most pronounced between 60 and 120 degrees of abduction, the site of greatest impingement of the rotator cuff tissues between the humerus and coracoacromial arch For patients with partial rotator cuff tendon ruptures, the findings are identical to those of chronic tendinitis and bursitis Patients with partial ruptures often demonstrate mild abduction weakness With complete ruptures, weakness of abduction (and, to a lesser extent, flexion) is substantial, even though full range of motion may be maintained by the shoulder s accessory rotator muscles Patients with complete tears usually have positive drop arm signs: inability to sustain passive abduction of the arm to 90 degrees
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2 Lateral & Medial Epicondylitis
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These disorders are better known by their sports associations: tennis elbow and golf elbow, respectively Lateral epicondylitis is the more common of the two The conditions are caused by overuse, and the pain results from minor tears in the tendons of the forearm s extensor and flexor muscles
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The patient presents with pain at the site of tendon insertion Tasks that require grasping and squeezing, such as shaking hands or opening jars, cause pain The diagnoses are easily confirmed on physical examination by elicitation of point tenderness over the involved site The characteristic pain may also be reproduced by extension or flexion of the wrist against pressure Clenching the fist and extending the wrist against the pressure of the examiner s palm is a useful maneuver for localizing lateral epicondylitis Medial epicondylitis may be demonstrated by performing the same maneuver in flexion
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NSAIDs and rest are effective in mild cases Symptoms that persist after 2 weeks of conservative therapy usually respond either to infiltration of triamcinolone, 10 20 mg mixed with 1 2 mL of 1% lidocaine, around the involved epicondyle or to physiotherapy Results are quicker with corticosteroid injections but longer-lasting with physiotherapy Only experienced clinicians should inject the medial epicondyle because of the risk of injury to the ulnar nerve After the pain and tenderness have subsided, patients may begin a physical therapy program involving daily stretching of the flexor and extensor tendons
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Trudel D et al Rehabilitation for patients with lateral epicondylitis: a systematic review J Hand Ther 2004 Apr Jun; 17(2):243 66 [PMID: 15162109]
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For most rotator cuff disorders, the central tenets of therapy are rest and abstention from inciting activities Temporary use of a sling is helpful in enforcing rest NSAIDs and moist heat afford some relief For patients with symptoms persisting after 2 weeks of conservative management, injections of a corticosteroid preparation (eg, 1 mL of triamcinolone, 40 mg/mL) mixed with 2 3 mL of lidocaine hydrochloride (1 2%) may be useful Tears or partial tears of the rotator cuff tendons that are believed to be chronic do not preclude a corticosteroid injection Most patients obtain significant relief with one injection, but the procedure along with continued rest may be repeated after 2 3 weeks Physical therapy is valuable for refractory cases if the patient does not maintain the shoulder s normal range of motion, stiffness and impaired function from a frozen shoulder may ensue Aside from patients with complete rotator cuff tears, only those who do not improve after months of conservative therapy are candidates for operation Persistent symptoms may be a sign of complete tear, which may be diagnosed by MRI Patients with symptoms that continue in the absence of a complete tear, however, sometimes
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