Published: August 2010
Soft-tissue rheumatic disorders are painful conditions arising from periarticular musculoskeletal structures. This discussion focuses on regional soft tissue disorders that are commonly encountered in the primary care setting. When evaluating musculoskeletal complaints, an intra-articular process (arthritis) should first be excluded.
The rotator cuff is composed of four muscles: the subscapularis anteriorly (internal rotator), supraspinatus superiorly (elevator), and the infraspinatus and teres minor posteriorly (external rotators). Together they provide dynamic stability to the shoulder joint (Fig. 1).
Rotator cuff disorders range from impingement syndrome to tendon rupture. Impingement syndrome includes rotator cuff tears, tendinitis, and subacromial bursitis. The supraspinatus and infraspinatus tendons are particularly susceptible to impingement or tearing given their location beneath the coracoacromial arch. Because of their proximity, secondary involvement of the subdeltoid and subcoracoid bursae can also occur.
Although pain is the most common symptom of rotator cuff disorders, patients might also complain of weakness and loss of motion. The pain is usually localized to the lateral arm and shoulder and can awaken the patient during the night. Pain is worsened with overhead activities such as using a hair dryer and combing hair. Painful weakness, atrophy, and inability to abduct and elevate the arm are seen in more advanced conditions.1
The age of the patient can also provide clinical clues to the diagnosis. Underlying instability is more likely in a younger patient, and a mechanical or degenerative cause is more likely in an older patient (Table 1).
On physical examination, there is tenderness to palpation of the proximal humerus at the insertion site of the rotator cuff. Tenderness of the shoulder anteriorly suggests biceps tendinitis, whereas more lateral tenderness suggests supraspinatus tendinitis or subdeltoid bursitis. Passive ROM is greater than active ROM, with a painful arc between 60 and 120 degrees of abduction. The Neer and Hawkins impingement tests can be done to evaluate for rotator cuff disorders. With the Neer impingement test, the examiner forcibly flexes the patient’s arm forward with one hand while stabilizing the patient’s shoulder with the other hand. The Hawkins impingement test involves forward flexion of the shoulder to 90 degrees and internal rotation of the shoulder. Pain with these maneuvers suggests an impingement syndrome.2
When evaluating periarticular shoulder disorders, it is also important to test the strength of the rotator cuff muscles. The subscapularis is tested with resisted internal rotation, the supraspinatus is tested with resisted abduction in the plane of the scapula, and the infraspinatus and teres minor are tested with resisted external rotation. Weakness may be the result of pain inhibition or may be true weakness. The impingement test may be helpful in these cases. Approximately 5 to 10 mL of 1% lidocaine is injected into the subacromial bursa, and if the pain is relieved by at least 50%, then impingement is the more likely cause. Weakness that persists despite pain relief is probably true weakness.
|Diagnosis||Age||Type of Onset||Location of Pain||Night Pain||Active Range of Motion||Passive Range of Motion||Impingement Signs||Radiation of Pain||Parasthesias||Weakness||Instability||Radiographic Changes||Special Features|
|Rotator cuff tendinitis||Any||Acute or chronic||Deltoid region||+||↓↓ Guarding||Normal||+++||-||-||Only due to pain||Look for||In chronic cases||Painful arc of abduction|
|Rotator cuff tears (chronic)||>40 yr||Often chronic||Deltoid region||++||↓↓↓||Normal (can ↓ later)||++||-||-||++||-||-||Wasting of cuff muscles|
|Bicipital tendinitis||Any||Overuse||Anterior||-||↓ Guarding||Normal||+||Occasionally into biceps||-||Only due to pain||Look for||None||Special examination tests|
|Calcific tendinitis||30-60 yr||Acute||Point of shoulder||++||↓↓↓ Guarding||Normal except for pain||+++||-||-||Only due to pain||-||++||Tenderness ++|
|Capsulitis (frozen shoulder)||>40 yr||Insidious||Deep in shoulder||++||↓↓||↓↓||+||-||-||-||-||-||Global range of motion ↓|
|Acromioclavicular joint||Any||Acute or chronic||Over joint||Lying on side||↓ Full elevation||Normal||-||-||-||-||-||In chronic cases||Local tenderness|
|Osteoarthrosis of glenohumeral joint||>40 yr||Insidious||Deep in shoulder||++||↓↓||↓↓||-||-||-||May have mild||-||+++||Crepitus|
|Glenohumeral instability||Usually <25 yr||Episodic||Anterior or posterior||-||Only apprehension||Only apprehension||Possible||-||+ With acute episodes||+ With acute episodes||+++||Often||Stress tests|
|Cervical spondylosis||>40 yr||Insidious||Suprascapular||Often||Normal||Normal||-||++||+++||+||-||In cervical spine||Pain with neck movement|
|Thoracic outlet syndrome||Any||Usually with activity||Neck, shoulder, arm||-||Normal||Normal||-||++||++||++||-||-||Special examination tests|
From Hochberg MC, Silman Aj, Smolen JS et al (eds): Practical Rheumatology, 3rd edition. Philadelphia: Mosby, 2004.
Imaging of the shoulder is usually not necessary unless symptoms persist for more than 3 to 4 months despite conservative therapy. Other indications for imaging include features suggesting a need for surgery or if the diagnosis is in doubt. Findings on plain radiographs that can be associated with impingement include arthritic changes of the glenohumeral joint, subacromial space calcifications, acromial spurs, or decreased distance between the acromion and the humeral head. Arthrography was formerly the gold-standard imaging study for full-thickness rotator cuff tears, but it is now largely replaced by magnetic resonance imaging (MRI). The finding of a rotator cuff irregularity on imaging, however, does not necessarily imply causality of symptoms, because up to 26% of asymptomatic people have a rotator cuff tear on MRI.3
Rotator cuff tendinitis and subacromial bursitis are initially managed with a short period of rest (up to a week) and nonsteroidal anti-inflammatory drugs (NSAIDs). If this approach fails, a subacromial corticosteroid injection may be tried (Fig. 2 and Box 1). Once the pain is improved and normal shoulder movement has returned, a supervised therapy program should be instituted to strengthen the rotator cuff muscles and preserve range of motion. If symptoms persist despite an adequate trial of these measures, surgery may be indicated.
|Box 1 Equipment Required for Joint and Soft-Tissue Injections|
|Antiseptic solution (povidone-iodine)|
|4 × 4 gauze pads|
|23- to 27-gauge needles for local anesthetic|
|18-gauge needles for large to moderate sized joints (e.g., knees, shoulders, ankles)|
|23- to 25-gauge needles for small joints (e.g., wrists, metacarpophalangeal joints)|
|3-mL or 5-mL syringe for anesthetic-steroid injection|
|10-mL to 50-mL syringe for joint aspiration|
|Forceps for removing needles from syringe|
|Specimen tubes or plates for cultures and fluid studies|
From Hochberg MC, Silman Aj, Smolen JS et al (eds): Practical Rheumatology, 3rd edition. Philadelphia: Mosby, 2004.
Rotator cuff tears are treated in a manner similar to that for rotator cuff tendinitis. However, corticosteroid injection is not advised within 4 to 6 weeks of an acute injury. Indications for surgical intervention of complete tears are controversial. Earlier surgery for acute ruptures in young or active patients has been advocated.
Biceps tendinitis usually occurs in association with rotator cuff impingement rather than in isolation. Pain is localized over the anterior shoulder and can radiate to the biceps muscle. Palpation of the bicipital groove reproduces the pain. Yergason’s maneuver can be used to isolate and stress the bicipital tendon. The elbow is flexed to 90 degrees, and the forearm is pronated while keeping the arm against the body to prevent shoulder motion. The patient then supinates the forearm while the examiner resists this motion. Pain with this maneuver suggests bicipital tendinitis.4 Pain may also be reproduced with Speed’s test, which requires the patient, with the elbow in extension, to flex the shoulder against resistance.
Biceps tendinitis is managed conservatively with a short period of rest followed by physical therapy, NSAIDs, and local corticosteroid injections (Fig. 3). The examiner should evaluate for underlying rotator cuff disorders; failure to do so can result in recurrence of symptoms. For refractory cases, surgery may be considered.
Adhesive capsulitis, also known as frozen shoulder, is characterized by pain and global restriction of both active and passive glenohumeral joint motion. The joint capsule adheres to the anatomic neck and becomes thickened and contracted. It can be idiopathic (primary adhesive capsulitis) or related to other conditions such as diabetes mellitus, thyroid disease, hyperlipidemia, pulmonary disorders, and trauma (secondary adhesive capsulitis). Women in their sixth decade are most commonly affected.5
There are three phases in the natural history of this condition. The shoulder is initially painful, then it is painful and stiff, and eventually it becomes more stiff than painful. Patients complain of pain without any precipitating event; pain is brought on by movement of the shoulder. Night pain is common. On examination, the shoulder is tender and there is loss of active and passive range of motion in all planes. Radiographic films of the shoulder and laboratory testing are usually unrevealing. The diagnosis is predominantly made on clinical grounds.
Gradual spontaneous improvement of the pain occurs 1 to 3 years after onset, but there is often some residual limitation of shoulder motion. Because prolonged immobility of the glenohumeral joint allows adhesions to form, early mobilization is key. Physical therapy, NSAIDs, and local injections of glucocorticosteroids can be used for pain relief. Although less common, other methods to improve range of motion include manipulation under anesthesia, arthroscopic capsulotomy, and hydrodistention of the joint to lyse adhesions and stretch the capsule.
Both medial and lateral epicondylitis are due to repetitive microtrauma from work or sports activities that involve repetitive twisting or gripping movements. Examples include tennis, golf, carpentry, gardening, and dentistry.
Medial epicondylitis, also known as golfer’s elbow, is the result of repetitive flexion and pronation of the wrist. Tenderness over the medial epicondyle can be elicited with palpation over the medial epicondyle. Pain is reproduced with resisted wrist flexion and pronation. On the other hand, lateral epicondylitis, often referred to as tennis elbow, is seen with repetitive extension and supination of the wrist. It causes pain over the lateral epicondyle with palpation and is reproduced with resisted wrist extension and supination.6
The initial treatment for epicondylitis is splinting of the elbow at 90 degrees of flexion for 3 to 5 days. If symptoms persist, other conservative measures such as nonsteroidal anti-inflammatory drugs (NSAIDs), ice, or local glucocorticosteroid injections may be tried (Fig. 4). For chronic cases of epicondylitis, a compression band may be used for symptomatic relief. Pain that is refractory to these measures should raise suspicion for medial or ulnar nerve entrapment, which might require surgical intervention.
The bursa is a synovial tissue–lined sac that provides a gliding surface to reduce friction between tendons and muscles over bony structures. Inflammation of this structure resulting from overuse, infection, trauma, or systemic inflammatory disease is known as bursitis.
Patients with olecranon bursitis complain of swelling over the posterior elbow and tenderness with pressure, but they have normal elbow range of motion. Pain may be minimal. When localized erythema is present, infection or gout should be excluded by aspiration. Drainage and protective measures against trauma are usually sufficient. A compression bandage might provide enough pressure to prevent reaccumulation of fluid in the bursa. In some instances, the bursa can be excised if there is persistent infection or recurrent bursitis.7
de Quervain’s tenosynovitis is inflammation and stenosis of the tendon sheath enveloping the abductor pollicis longus and the extensor pollicis brevis as they course through the sheath at the level of the radial styloid process. It can be seen in pregnancy and in new mothers, the latter possibly related to lifting or holding their babies with an outstretched thumb. It might result from repetitive motions that involve pinching with the thumb and twisting the wrist.
There is pain and occasionally swelling over the radial styloid. Pain is associated with movement of the thumb and wrist. The Finklestein maneuver can elicit pain in patients with de Quervain’s tenosynovitis. The thumb is folded across the palm and the other fingers form a fist around the thumb. The wrist is passively deviated toward the ulnar side. It should be noted, however, that this maneuver can also cause pain in persons with osteoarthritis of the first carpometacarpal joint. Thus, the presence of first carpometacarpal joint osteoarthritis should also be evaluated if the Finklestein test is positive.
This condition is treated initially with wrist splinting and NSAIDs. If symptoms persist, a local corticosteroid injection can be given. In rare cases, surgical decompression with or without tenosynovectomy is necessary.8
The anserine bursa lies beneath the pes anserinus, which comprises the conjoined tendons of the sartorius, gracilis, and semitendinosus muscles. This bursa is situated between these tendons and the tibial collateral ligament.
Anserine bursitis is most common in obese, middle-aged to elderly women with knee osteoarthritis. Other predisposing factors include genu valgum, hamstring contractures, and an out-toeing gait. Patients complain of medial knee pain that can sometimes radiate to the posterior medial thigh. It is accentuated with stair climbing. On examination, pain and tenderness are localized to approximately 3 to 5 inches below the medial knee joint line. Treatment consists of NSAIDs, stretching exercises of the adductor and quadriceps muscles, and corticosteroid injection into the bursa.9
Trochanteric bursitis is the most common cause of pain around the hip joint. It can be associated with hip osteoarthritis, leg-length discrepancy, and scoliosis. It is more commonly seen in women.
Trochanteric bursitis is manifested as a deep, aching pain on the lateral aspect of the hip and thigh. It is brought on by activities that involve hip flexion such as walking, squatting, and climbing stairs. Pain improves with rest and is exacerbated by applying pressure to the affected side. The pain may be so severe that it causes a limping gait.
It is clinically diagnosed by noting point tenderness over the greater trochanteric region. Tenderness may also be seen along the lateral aspect of the thigh. Additionally, pain can be elicited by hip flexion, external rotation, and resisted abduction.
Trochanteric bursitis is treated with a local injection of corticosteroid into the bursa (Fig. 5). Weight loss, rest, stretching and strengthening exercises of the gluteus medius muscle, and NSAIDs can also be helpful.