Shoulder Tendinitis

Work-related musculoskeletal injuries are one of the most common occupational health problems for which physicians are consulted. There is solid scientific evidence that these injuries may be occupational in origin.

3

GUIDE TO THE DIAGNOSIS OF WORK-RELATED MUSCULOSKELETAL DISORDERS

This guide was designed to help physicians interpret the results of a medical examination. By combining the standard clinical assessment procedure with guidelines concerning the identification of etiological factors, it helps physicians identify the cause of injury.

AUTHORS Louis Patry holds a degree in medicine from Laval University and a diploma in ergonomics from the Conservatoire National des Arts et Metiers de Paris (CNAM). He is a specialist in occupational medicine, an associate member of the Royal College of Physicians and Surgeons of Canada, a professor in McGill University’s Department of Epidemiology and Biostatistics and Occupational Health, and consulting physician to the Direction de la santé publique (Public Health Department), first in Québec City and currently at the MontréalCentre board.

Michel Rossignol holds degrees in biochemistry and medicine from the University of Sherbrooke, in epidemiology and community health from McGill University, and in occupational medicine from John Hopkins University. He is a professor in McGill University’s Department of Epidemiology and Biostatistics and Occupational Health, co-director of the Centre for Clinical Epidemiology of the Jewish General Hospital of Montréal, and physician-epidemiologist at the Montréal-Centre board of the Direction de la santé publique (Public Health Department).

Marie-Jeanne Costa holds a nursing degree from the Institut d’études paramédicales de Liège and a degree in ergonomics from the École Pratique des Hautes Études de Paris. She is an ergonomics consultant and has collaborated on several studies of CTDs. She is particularly interested in the development of participatory ergonomics, specifically in the problem-resolution and diagnostic processes.

Martine Baillargeon holds a degree in medicine from the Université de Montréal. She is a plastic surgeon and associate member of the Royal College of Physicians and Surgeons of Canada. After years of practising surgery she is now consulting physician, mainly in the field of musculoskeletal injuries affecting the upper limb, at the Montréal-Centre board of the Direction de la santé publique (Public Health Board).

Shoulder Tendinitis Louis PATRY, Occupational Medecine Physician, Ergonomist Michel ROSSIGNOL, Occupational Medecine Physician, Epidemiologist Marie-Jeanne COSTA, Nurse, Ergonomist Martine BAILLARGEON, Plastic Surgeon

GUIDE TO THE DIAGNOSIS OF WORK-RELATED MUSCULOSKELETAL DISORDERS

Shoulder Tendinitis Louis PATRY, Occupational Medecine Physician, Ergonomist Michel ROSSIGNOL, Occupational Medecine Physician, Epidemiologist Marie-Jeanne COSTA, Nurse, Ergonomist Martine BAILLARGEON, Plastic Surgeon

Canadian Cataloguing in Publication Data Main entry under title: Guide to the diagnosis of work-related musculoskeletal injuries Translation of: Guide pour le diagnostic des lésions musculo-squelettiques attribuables au travail répétitif. Includes bibliographical references. Contents: 1. Carpal tunnel syndrome – 2. De Quervain’s tenosynovitis – 3. Shoulder tendinitis. Co-published by: Institut de recherche en santé et en sécurité du travail du Québec. ISBN 2-921146-70-3 (v. 1) – ISBN 2-921146-71-1 (v. 2) – ISBN 2-921146-72-X (v. 3) 1. Musculoskeletal system – Wounds and injuries – Diagnosis. 2. Overuse injuries – Diagnosis. 3. Carpal tunnel syndrome – Diagnosis. 4. Tenosynovitis – Diagnosis. 5. Tendinitis – Diagnosis. 6. Occupational diseases – Diagnosis. I. Patry, Louis. II. IRSST (Quebec). III. Workplace Safety & Insurance Board. RC925.7.G8413 1998 616.7’075 C98-940950-3

Translation:

Les Services Organon, Steven Sacks

Graphic design:

Gérard Beaudry

Illustrations:

Marjolaine Rondeau, Medical Illustration Department of the Laval University Hospital Centre (CHUL) Max Stiebel, Instructional Communications Centre (ICC), McGill University

Rear-cover photographs: Gil Jacques Legal deposit – Bibliothèque nationale du Québec, 1998 Legal deposit – National Library of Canada, 1998 ISBN 2-921146-72-X Éditions MultiMondes (Original edition: ISBN 2-921146-63-0) © Éditions MultiMondes, 1998 Éditions MultiMondes 930, rue Pouliot Sainte-Foy (Québec) Canada G1V 3N9 Tel.: (418) 651-3885 Fax: (418) 651-6822

Institut de recherche en santé et en sécurité du travail 505, boul. de Maisonneuve Ouest Montréal (Québec) Canada H3A 3C2 Tel: (514) 288-1551 Fax: (514) 288-7636

Régie régionale de la santé et des services sociaux – Montréal-Centre Direction de la santé publique 1301, rue Sherbrooke Est Montréal (Québec) Canada H2L 1M3 Tel.: (514) 528-2400 Fax: (514) 528-2459

PREFACE

The diagnosis of cumulative trauma disorders (CTDs) presents many unique problems, especially for physicians. The absence of precise criteria upon which to establish a clinical diagnosis of CTD or decide whether a musculoskeletal injury is related to occupational factors was noted by several members of the advisory committee supporting an international expert group mandated by the IRSST to review the literature on CTDs*. To remedy this situation, in 1992 the IRSST asked a group of researchers to develop diagnostic guides for carpal tunnel syndrome, De Quervain’s tenosynovitis, and tendinitis of the shoulder. The project team was initially composed of Louis Patry, occupational physician and ergonomist, and Michel Rossignol, occupational physician and epidemiologist, but quickly grew and increased the scope of its expertise through the addition of Marie-Jeanne Costa, a nurse with ergonomics training, and Martine Baillargeon, a plastic surgeon. All four team members participated in the drafting of the guides. These guides were designed to help physicians arrive at a clinical diagnosis and identify the most probable etiological agents. It should be noted that these guides were not designed for administrative or legal purposes and that their reliability has not evaluated by the researchers. The publication of these guides designed specifically for physicians is one more advance in the IRSST’s efforts to shed light on the phenomenon of cumulative trauma disorders and provide specialists with appropriate tools with which to prevent these injuries and reduce related risk factors.

Jean Yves Savoie Director general Institut de recherche en santé et en sécurité du travail du Québec

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* Hagberg, M., Silverstein, B., Wells, R., Smith, M.J., Hendrick, H.W., Carayon, P., Pérusse, M. (1995), Work related musculoskeletal disorders (WMSDs): a reference book for prevention, scientific editors: Kuorinka, I., Forcier, L., publishers Taylor and Francis, London, 421 pages.

INTRODUCTION

This guide is the third in a series of practical summaries of current medical knowledge on musculoskeletal injuries with well-documented occupational etiology, namely: – carpal tunnel syndrome (CTS) – De Quervain’s tenosynovitis – tendinitis of the shoulder When occupational in origin, these injuries are often referred to as “CTDs”, a term applicable to “problems and diseases of the musculoskeletal system that include, among their causes, some factor related to work” (Kuorinka et al., 1995). Whatever term is used to designate them—occupational overuse syndrome (OOS), repetitive strain injuries (RSI) or cumulative trauma disorders (CTDs) in English, troubles musculo-squelettiques (TMS), lésions musculo-squelettiques (LMS), lésions musculo-tendineuses (LMS), lésions musculo-tendineuses liées aux tâches répétitives, or pathologies d’hyper-sollicitation in French—their defining characteristic is the presence of an injury caused by biomechanical strain due to tension, pressure, or friction which is excessively forceful, repetitive, or prolonged. This guide is designed for physicians who are called upon in the course of their practice to diagnose musculoskeletal injuries and establish the extent to which these injuries are caused by their patient’s work. Its goal is to help physicians arrive at clinical and etiological diagnoses. To this end, the guide first reviews the anatomical, physiopathological, and etiological knowledge upon which diagnosis depends. This is followed by guidelines for the evaluation of symptoms, the conduct of the clinical examination, and the control of potential risk factors related to the development of the injury. Musculoskeletal injuries may have many causes. For carpal tunnel syndrome (CTS), De Quervain’s tenosynovitis and tendinitis of the shoulder, these include not only occupational, sporting, recreational, and domestic activities, but also specific health problems and conditions. This guide was prepared in response to requests from physicians, increasingly preoccupied by CTDs, for information and support on this subject. Although the approach taken emphasizes the documentation of potential occupational risk factors—a subject little discussed in formal medical training—it does not neglect the evaluation of other potential causes of tendinitis of the shoulder. This guide is meant to be used in a clinical setting. To help physicians collect the information they need to diagnosis the injury and establish its causes, it therefore includes a series of questions, presented in readily identifiable text boxes, for them to ask their patients. These questions were derived from psycho-physical scales used by ergonomists to subjectively evaluate workload (Sinclair, 1992) and medical questionnaires developed for the diagnosis of CTS and the evaluation of functional capacity (Katz et al., 1994; Levine et al., 1993; Rossignol et al., 1995).

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Should however a physician remain unable to come to a definitive conclusion about the work-relatedness of an injury after consulting this guide, she or he should continue to seek information which will enable her or him to better evaluate the occupational musculoskeletal strain to which her or his patient is subjected. Finally, it should be noted that this guide does not address the issues of multiple injuries and the psycho-social aspects of musculoskeletal injuries, important as they may be for the global evaluation of the patient.

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TABLE OF CONTENTS

Chapter 1 – General Considerations Terminology................................................................................................................... 1 Epidemiology................................................................................................................. 1 Anatomical Review........................................................................................................ 1 Structure of the Shoulder Joint .............................................................................. 2 Structure of the Tendon ......................................................................................... 2 Biomechanical Considerations ............................................................................... 3 Innervation .............................................................................................................. 5 Physiopathology ............................................................................................................ 6 Chapter 2 – Etiology General Description of Risk Factors ............................................................................ 9 Specific Risk Factors for Shoulder Injuries ................................................................ 10 Occupational Sources of Musculoskeletal Strain ....................................................... 10 Strain Related to Sports-related, Recreational and Household Activities ................. 11 Strain in Musicians....................................................................................................... 11 Chapter 3 – Differential Diagnosis Injury to Structures Surrounding the Rotator Cuff..................................................... 13 Subacromial Bursitis ............................................................................................. 13 Adhesive Capsulitis (Retractile Capsulitis, Frozen Shoulder) ............................. 13 Shoulder Pathologies................................................................................................... 15 Cervicobrachial Disorders .................................................................................... 15 Compression of the Supraclavicular Nerve ......................................................... 15 Cervical Root Injuries ........................................................................................... 15 Thoracic Outlet Syndrome ................................................................................... 15 Shoulder Instability ............................................................................................... 16 General and Systemic Pathologies ............................................................................. 16 Chapter 4 – Clinical Considerations Symptoms..................................................................................................................... 17 Location of Symptoms (Where?).......................................................................... 17 Onset of Symptoms (When?) ............................................................................... 18 Characteristics of Onset (How?)........................................................................... 18

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Impact on Activities of Daily Living........................................................................... 18 Impact on Physical Activity ........................................................................................ 19 Chapter 5 – Recording of Information on Exposure Factors Occupational History .................................................................................................. 21 Previous Work....................................................................................................... 21 Current Work......................................................................................................... 21 Current Work and Organisational Factors ........................................................... 22 Sports-related, Recreational and Household Activities.............................................. 24 Chapter 6 – Physical Examination of the Shoulder General Evaluation ...................................................................................................... 25 Specific Evaluation ...................................................................................................... 27 Supraspinatus Tendinitis....................................................................................... 27 Infraspinatus Tendinitis ........................................................................................ 28 Subscapular Tendinitis and Teres Minor Tendinitis............................................ 28 Subacromial Impingement Syndrome.................................................................. 29 Rotator Cuff Tear .................................................................................................. 32 Tenosynovitis of the Long Head of the Biceps .................................................. 33 Chapter 7 – Summary of the Evaluation .................................................................... 35 Chapter 8 – Guidelines for Therapeutic and Preventive Interventions Therapeutic Guidelines ............................................................................................... 37 Prevention Guidelines................................................................................................. 37 Conclusion........................................................................................................................ 39 Bibliography .................................................................................................................... 41

List of Figures Figure 1.1

Structure of the Shoulder Joint ..................................................................... 2

Figure 1.2

Structure of Tendons ..................................................................................... 2

Figure 1.3a Muscles and Tendons of the Rotator Cuff (Anterior View)......................... 3 Figure 1.3b Muscles and Tendons of the Rotator Cuff (Posterior View) ....................... 3

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Figure 1.4

Course of the Tendon of the Long Head of the Biceps.............................. 3

Figure 1.5

Action of the Rotator Muscles ....................................................................... 4

Figure 1.6

Components of Rotary and Coaptation Forces During Shoulder Movements ..................................................................................................... 4

Figure 1.7

Dermatomes and Sensory Innervation ......................................................... 5

Figure 1.8

Critical Zone of the Tendons of the Supraspinatus and the Long Head of the Biceps Subjected to Premature Wear................................................. 6

Figure 2.1

Interrelation of Risk Factors .......................................................................... 9

Figure 3.1

Subacromial Bursitis..................................................................................... 13

Figure 3.2

Compression of the Supraclavicular Nerve ................................................ 15

Figure 3.3

Anatomy of the Cervicothoracoscapular Junction ..................................... 15

Figure 3.4

Structures Capable of Causing Shoulder Pain............................................ 16

Figure 4.1

Shoulder-Arm Diagrams .............................................................................. 17

Figure 6.1

Painful Points on the Shoulder ................................................................... 25

Figure 6.2

Painful Arcs .................................................................................................. 26

Figure 6.3

Resisted Abduction of the Arm ................................................................... 27

Figure 6.4

Jobe’s Manoeuvre......................................................................................... 27

Figure 6.5

Resisted External Rotation of the Forearm................................................. 28

Figure 6.6

Patte’s Manoeuvre........................................................................................ 28

Figure 6.7

Resisted Internal Rotation of the Forearm.................................................. 28

Figure 6.8

Mechanism of Impingement........................................................................ 29

Figure 6.9

Neer’s Sign.................................................................................................... 31

Figure 6.10 Hawkins’ Sign............................................................................................... 31 Figure 6.11 Drop-Arm Manoeuvre.................................................................................. 32 Figure 6.12 Resisted Elevation of the Arm..................................................................... 33 Figure 6.13 Resisted Flexion of the Elbow .................................................................... 33 Figure 8.1

Therapeutic Intervention Flow-Chart.......................................................... 38

Figure 8.2

Therapeutic Approach to Tears of the Rotator Cuff .................................. 38

List of Tables Table 6.1

Stages of Impingement Syndrome .............................................................. 30

Table 6.2

Imaging Techniques for Tears of the Rotator Cuff .................................... 32

Table 8.1

Preventive Approach ................................................................................... 37

List of Boxes Box 1.1

Innervation of the Rotator Cuff and Biceps Muscles................................... 5

Box 1.2

Contributory Factors for Tendinitis of the Rotator Cuff and Tenosynovitis of the Long Head of the Biceps............................................ 7

Box 2.1

Movements Most Commonly Associated with the Development of Shoulder Tendinitis ...................................................................................... 12

Box 3.1

Clinical Signs of Subacromial Bursitis......................................................... 14

Box 3.2

Clinical Summary of Adhesive Capsulitis ................................................... 14

Box 4.1

Questions about Activities of Daily Living ................................................. 18

Box 4.2

Presentation and Clinical Severity of Symptoms........................................ 19

Box 5.1

Questions about Previous Jobs ................................................................... 21

Box 5.2

General Questions Concerning Occupational Activities and Symptoms Associated with Them ............................................................... 22

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xii

Box 5.3

Questions about Activities that Stress the Shoulder .................................. 23

Box 5.4

Questions about Work Organisation........................................................... 24

Box 5.5

Questions about Sports-related, Recreational, and Household Activities Involving the Shoulders............................................................... 24

Box 6.1

General Evaluation....................................................................................... 25

Box 6.2

Painful Arcs during Active Abduction of the Arm ..................................... 26

Box 7.1

Clinical Aspects ............................................................................................ 35

1

General Considerations

TERMINOLOGY Shoulder tendinitis is defined clinically as “pain in the shoulder associated with tenderness to palpation over the head of the humerus” (Hagberg and Wegman, 1987) and corresponds to inflammatory and degenerative injuries of the tendons of the rotator cuff and the long head of the biceps. The term “rotator cuff” is used to designate the tendons of the muscles which originate in the scapula, converge at the head of the humerus where they form a “cuff”, and insert on the greater or lesser tuberosity. The tendon of the long head of the biceps originates from the superior portion of the glenoid fossa near the supraspinatus tendon and is generally subject to the same strains as the rotator cuff tendons (Pujol et al., 1993). EPIDEMIOLOGY According to the Bureau of Labour Statistics of the United States, shoulder pain is the second most common complaint—after back pain—reported during clinical consultations; furthermore, the prevalence of occupational shoulder pain is increasing greatly (Sommerich et al., 1993). There have been few epidemiological studies of the relation between work and shoulder tendinitis, and exposure parameters in these studies have been poorly defined. Despite this, it appears that the incidence of shoulder tendinitis is related to the performance of activities involving prolonged elevation of the arms, repeated shoulder flexion, and repetitive and forceful movements of the arms (NIOSH, 1997; Hagberg et al., 1995). The risk of injury is particularly high when repetitive activities are

executed above shoulder height, because of the load on the shoulder tendons (Hagberg et al., 1995). Shoulder tendinitis has also been described among athletes—especially baseball pitchers, swimmers, and tennis players—and professional musicians (Dupuis, 1995). ANATOMICAL REVIEW The “shoulder” is in fact a collection of bony and ligamentous structures which depend on the interaction of multiple muscle groups to stabilise the humeral joint and perform movements. The muscles of the rotator cuff stabilise the head of the humerus in the glenoid fossa during movements of this joint and account for 50% of the shoulder’s strength during abduction and at least 80% of its strength during external rotation (Marks et al., 1994). The tendon of the long head of the biceps is involved in flexion of the forearm, coaptation of the head of the humerus, and abduction of the externally rotated arm.

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Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

Structure of the Shoulder Joint The shoulder joint is formed by: – three cartilaginous joints (the glenohumeral, acromioclavicular, and sternoclavicular) – two sliding surfaces (the subacromial and scapulothoracic) (Kapandji, 1983) – the compartment formed by the ligamentous junction of the acromion and the coracoid process (Figure 1.1) Figure 1.1

Structure of the Shoulder Joint Scapulothoracic sliding surface

Acromioclavicular joint Subacromial sliding surface

Most shoulder movements involve the simultaneous action of the glenohumeral and scapulothoracic joints, associated with subacromial sliding and movement of the sternoclavicular and acromioclavicular joints, respectively (Déziel, 1995; Murnaghan, 1988; Kapandji, 1983). Structure of the Tendon Tendons are composed of dense, regularly shaped, conjunctive tissue. Because of the parallel arrangement of their constituent collagen fibres, they are approximately 50% as strong as cortical bone. Some tendons are entirely covered by a fibrous synovial sheath that protects them against friction with surrounding bones and ligaments. The role of tendons is to transmit muscle force in order to stabilise joints, perform movements or maintain posture (Figure 1.2).

Sternoclavicular joint Glenohumeral joint Figure 1.2

Structure of Tendons Fibrous tendon sheath Synovial membrane (outer layer)

Bone

Synovial membrane (inner layer)

Periosteum

Fibrous tendon layer

Collagen fibres

2 Region of insertion tendinitis

Region of tenosynovitis

Tendon

Region of tendinitis and peritendinitis

Region of myotendinitis

Muscle

Biomechanical Considerations The rotator cuff and the long head of the biceps are central to the control of movements involving the glenohumeral joint. The muscles of the rotators centre the head of the humerus, allowing it to pivot in the glenoid fossa. The rotator cuff is formed by: – the ends of the tendons of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles, all of which have their insertion on the superior humerus, just below its head (Figures 1.3a and 1.3b).

The tendon of the long head of the biceps comes into close proximity with the rotator cuff: – Originating on the subglenoid tuberosity, it runs under the capsule of the glenohumeral joint, follows the curve of the head of the humerus, turns 90°, slides through the bicipital groove where it acquires a sheath, and finally inserts into the biceps muscle (Figure 1.4).

Figure 1.4

Course of the Tendon of the Long Head of the Biceps

Figure 1.3a

Muscles and Tendons of the Rotator Cuff (Anterior View) Biceps (long head)

Tendon of the long head of the biceps

Supraspinatus

Subscapularis

Figure 1.3b

Muscles and Tendons of the Rotator Cuff (Posterior View) Infraspinatus

During abduction and elevation, this group of tendons depresses the head of the humerus, sliding the greater tuberosity under the coracoacromial arch (Lacoste, 1993). This opposes the action of the deltoid muscle and raises the head of the humerus against the acromial bursa. The role of the acromial bursa is to dampen various forces and facilitate the sliding of the head of the humerus under the deltoid muscle and coracoacromial arch (DupuisLeclaire, 1986).

3 Teres minor

SHOULDER TENDINITIS

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

Figure 1.5

Action of the muscles of the rotator cuff and the biceps (Kendall Peterson and Kendall McCreary, 1988) (Figure 1.5) Supraspinatus Subscapularis Infraspinatus Teres minor Long head of the biceps

Action of the Rotator Muscles 1

– – – – –

abduction of the arm (1) internal rotation of the arm (2) external rotation of the arm (3) external rotation of the arm (4) flexion and abduction of the arm with the humerus rotated (5) – also involved with elbow flexion

The rotator cuff and the tendon of the long head of the biceps are particularly important in coaptation and rotation of the head of the humerus. “Coaptation” is the term used to describe the muscle action which brings joint surfaces closer together and maintains them in that position. Rotary force, in contrast, is responsible for moving the arm

2 1 3

5 4

(Williams et al., 1986). The components of the rotary and coaptation forces of the deltoid muscle are illustrated in Figure 1.6.

Figure 1.6

Components of Rotary and Coaptation Forces during Shoulder Movements

D

Fr

Fc

G

4 D = force developed by the deltoid muscle; Fr = rotary force; Fc = coaptation force; G = weight of the arm

Innervation The motor function of the rotator cuff and long head of the biceps is controlled by the nerves originating in the C4-C7 roots (Box 1.1), while sensory

innervation is primarily provided by the sensory branches arising from the C4-D1 roots (Kendall Peterson and Kendall McCreary, 1988) (Figure 1.7).

Box 1.1

Innervation of the Rotator Cuff and Biceps Muscles Supraspinatus

Suprascapular nerve; C5, C6

Infraspinatus

Suprascapular nerve; C5, C6

Teres minor

Axillary nerve; C5, C6

Subscapularis

Superior and inferior subscapular nerves; C5, C6

Long head of the biceps

Musculocutaneous nerve; C5, C6

Source: Kendall Peterson and Kendall McCreary, 1988, Tubiana and Thomine, 1990

Figure 1.7

Dermatomes and Sensory Innervation

DERMATOMES C7

C7 C6

C4

C5 C3 D2 C4 D2

C8 D1

C6

C5

C8 D1

SENSORY INNERVATION 1

1

2 4 3

2 4 3

1. 2. 3. 4.

Suprascapular nerve C3,C4 Axillary nerve C5, C6 Radial nerve C5, C6 Intercostobrachial and medial brachial cutaneous nerves, D1, D2 5. Medial antebrachial cutaneous nerve C8, D1

5

Anterior View Reference: Netter F.H. (1995), Atlas of human anatomy,

Posterior View 7th

edition, Ciba-Geigy Corporation, New Jersey, 314 pages.

SHOULDER TENDINITIS

5

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

PHYSIOPATHOLOGY The most commonly advanced physiopathological mechanism underlying rotator cuff tendinitis and tenosynovitis of the long head of the biceps involves mechanical phenomena related to the motor function of the shoulder and anatomical instability of the joint. Codman, in 1934, was the first to describe damage to the rotator cuff in individuals who maintained awkward postures with the arms flexed or abducted in the course of their daily or occupational activities. In 1983, Neer described “impingement syndrome”, a degenerative pathology associated with friction of the supraspinatus tendon with the anterior margin of the acromion, primarily during elevation of the internally rotated arm (Leffert, 1992). This mechanical effect is exacerbated by muscular exertion, e.g. the maintenance of certain postures, which reduces local blood circulation. Jarvhölm et al. (1990) demonstrated that flexion of the arm exceeding 60° or abduction exceeding 30° disrupts circulation to the supraspinatus. Other arteriographical studies have revealed that lateral compression of the tendinous and peritendinous vascular bed can result in a virtually avascular state (Caillet, 1985). In the shoulder, this phenomenon is most commonly observed in the tendons of the supraspinatus and of the long head of the biceps (Figure 1.8). Interruption of normal healing processes appears to be a factor in the development of inflammation following tendon damage. If muscle strain is repeated or prolonged, scar tissue will be produced around the damaged tendon, predisposing it to further damage. The stages in the development of this pathology are (Lacoste, 1993): 1. 2. 3. 4.

Fibrin deposition Continuous oedema with inflammation Development of granulomatous tissue Tissue calcification and ossification

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The tissue formed as a result of this interruption

Figure 1.8

Critical Zone of the Tendons of the Supraspinatus and the Long Head of the Biceps Subjected to Premature Wear Critical zone of the supraspinatus tendon

Coracoacromial ligament

Critical zone of the tendon of the long head of the biceps

of healing has different properties and not only leads to a functional imbalance between the deltoid and supraspinatus muscles but also affects periarticular structures. The other tendons of the rotator cuff (infraspinatus, subscapularis, teres minor) are rarely affected on their own; damage to these structures usually occurs in cases of tendinitis of the supraspinatus or tenosynovitis of the long head of the biceps with functional decompensation (Box 1.2). GENERAL DESCRIPTION OF RISK FACTORS

Box 1.2

Contributory Factors for Tendinitis of the Rotator Cuff and Tenosynovitis of the Long Head of the Biceps •

Anatomical – Presence of a critical avascular zone (Codman zone) approximately 1 cm from the insertion of the tendons, especially the supraspinatus

•

Mechanical – Compression-related stress when the head of the humerus is elevated against the coracoacromial arch – Inflammation as a result of repeated or prolonged stress – Traction associated with throwing motions with the arm abducted or elevated

•

Vascular – Disruption of the circulation caused by arm flexion exceeding 30° – Compression of the tendinous and peritendinous vascular bed

Source: Hagberg et al., 1995; Dupuis-Leclaire, 1986

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SHOULDER TENDINITIS

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Etiology

Establishing the cause of disorders affecting the shoulder tendons, in common with other CTDs, depends on the evaluation of: – individual factors such as age, sex, aging, physical fitness, and medical history – biomechanical factors such as force, repetition, and posture – organisational factors such as the cadence and rhythm of work activities

disorders can be seen as the result of imbalances between load and functional capacity (Figure 2.1) (Cnockaert and Claudon, 1994). The primary biomechanical components are repetition, force, posture, and duration of exposure. Functional capacity, on the other hand, is a function of individual characteristics, health status, and individual perceptions of work tasks and organization. Although sometimes difficult to define and

From a clinical point of view, musculoskeletal

Figure 2.1

Interrelation of Risk Factors Work Context Duration

Repetition

Force

Risk of injury =

Posture

Load Functional capacity 9

Individual characteristics (age, sex, physical fitness) Adapted from Cnockaert and Claudon, 1994

Health status (medical history)

Psycho-social factors (perception of work tasks and organisation)

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

quantify, repetition has been clearly shown to be a risk factor for musculoskeletal injury (NIOSH, 1997; Hagberg et al., 1995; Bjelle et al., 1981). In purely scientific terms, repetitious work involves cyclical movement of the same tissue. Repetitiveness is usually defined in terms of components of work activities, e.g. production rate or work cycles per unit time, although it may also be defined in terms of an individual’s response to work activities. Practically, it may be measured through analysis of the speed of movements or of electromyographic activity (Malchaire and Indesteege, 1997). Force is easier to define, but difficult to measure. Typically, it is measured in terms of electromyographic activity or loads to be lifted or maintained (Malchaire and Indesteege, 1997). The maintenance of awkward postures is a recognized risk factor for musculoskeletal injuries of the neck and cervicoscapular region, and tendon injuries of the shoulder, wrist, and hand (NIOSH, 1997; Hagberg et al., 1995). The most commonly observed high-risk situations are prolonged maintenance of static postures, and postures associated with rapidly executed or continuous movements are the most commonly observed high-risk situations. The risk is particularly high when highly repetitive and forceful work is performed in awkward positions. SPECIFIC RISK FACTORS FOR SHOULDER INJURIES

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Although age-related degenerative phenomena may cause rotator cuff tendinitis and tenosynovitis of the long head of the biceps, these conditions may also result from the mechanical effects of repeated or prolonged musculoskeletal stress. Hyperplastic modifications caused by repeated friction and microtrauma may reduce the capacity of tendons to function adequately during attempted shoulder coaptation and mobilisation. Even if slight, such dysfunction tends to amplify degenerative tissue effects at the tuberosities of the head of the humerus and under the acromion.

Musculoskeletal loading—be it occupational, sports-related, recreational, or related to household activities—is a recognized risk factor for shoulder injuries. Injury to the shoulder tendons among musicians who play string and percussion instruments is a particularly interesting example of such loading. OCCUPATIONAL SOURCES OF MUSCULOSKELETAL STRAIN Musculoskeletal loads which exceed a worker’s capacity to adapt and work without pain cause softtissue damage and modification of the peripheral circulation. These changes are the underlying cause of load-related occupational injuries of the periarticular structures of the shoulder. The accurate determination of risk factors for such injuries relies upon the discrimination between static and dynamic muscular work, e.g. prolonged maintenance of a posture, and repetitive movements, respectively. Static muscular work immobilises the shoulder, allowing the hand to perform dynamic work. Elevation of the arm, on the other hand, puts particular mechanical stress on the tendons of the supraspinatus and the long head of the biceps (Hagberg et al., 1995; Lacoste, 1995). Prolonged maintenance of awkward postures, elevation or abduction of the arm, and repetitive handling of heavy loads all increase the risk of shoulder tendinitis (Dimberg et al, 1989; Kroemer, 1989), although the specific tendons involved will vary as a function of the type of movement in question. For example, anterior flexion of the arm primarily affects the tendon of the long head of the biceps, while abduction of the shoulder primarily affects the supraspinatus (Chipman et al., 1991). STRAIN RELATED TO SPORTS-RELATED,

RECREATIONAL AND HOUSEHOLD ACTIVITIES Shoulder tendinitis may be secondary to trauma or develop insidiously following fine movements performed repetitively or at the limit of the joint’s range of movement (Lacoste, 1994). Patients suffering from sports-related injuries are usually younger and may exhibit subclinical glenohumeral instability. Movements which exert traction on the joints are among those associated with the highest risk of developing painful shoulder syndromes (Hagberg et al., 1995; Lacoste, 1994). These include:

Playing musical instruments is a particularly effective way of stressing the joints of the upper limb. Shoulder tendinitis has been observed among musicians who play string instruments; the stress in this case is believed to be caused by the bowing action, which combines repetitive movement with static arm elevation (Dupuis, 1994). Among percussionists, the effort required to stabilise the instruments generates stress on the rotator cuff. Box 2.1 illustrates postures and movements typically associated with the development of shoulder tendinitis.

– throwing objects (balls, javelin, discus) – sports such as handball, volleyball, tennis, and swimming (butterfly stroke and crawl) STRAIN IN MUSICIANS

11

SHOULDER TENDINITIS

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

Box 2.1

Movements Most Commonly Associated with the Development of Shoulder Tendinitis

Avoid

Shoulder rotation

Avoid

Abduction and flexion of the shoulder

OK

Extension

Shoulder flexion

Throwing objects

Working with the arms elevated

CTD Risk Cofactors – Exposure to cold – Use of vibrating tools – Wearing work gloves 12 Source: Kroemer, 1989; Dimberg et al., 1989; Hagberg, 1995; NIOSH, 1997

3

Differential Diagnosis

Many pathologies involving the structures surrounding the rotator cuff and many regional, general, or systemic conditions can cause shoulder pain.

Figure 3.1

Subacromial Bursitis

INJURY TO STRUCTURES SURROUNDING THE ROTATOR CUFF Subacromial Bursitis There are two forms of subacromial bursitis. The acute form reflects subacromial swelling which presents as intense pain which worsens at night (Leduc, 1986). When the calcified deposit works its way out of the tendon and ruptures into the subacromial bursa, it produces severe irritation and pain in the shoulder (Caillet, 1985) (Figure 3.1). Local palpation is painful and patients may exhibit reduced joint mobility. Activities involving repeated shoulder abduction may favour the development of this condition, especially if they are accompanied by lateral rotation of the shoulder (Sommerich et al., 1993). The chronic form presents with a more subtle clinical profile which is often difficult to distinguish from tendinitis of the supraspinatus, and reflects an inflammatory thickening of the bursa, accompanied by adhesions. Pain is usually localised at the distal insertion of the deltoid (Leduc, 1986). Box 3.1 lists the main signs and symptoms of subacromial bursitis. Adhesive Capsulitis (Retractile Capsulitis, Frozen Shoulder) This condition is an inflammatory condition reflecting fibrous thickening, and retraction, of the cap-

Calcified deposit

Rupture into the subacromial bursa

sule of the glenohumeral joint. Typically, shoulder mobility is reduced (Dupuis-Leclaire, 1986). The primary form is particularly prevalent among individuals older than 50 years suffering from limited shoulder mobility of variable etiology. The condition is generally progressive and may take as long as 30 months to develop; spontaneous but sometimes incomplete recovery may occur (Dupuis-

13

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

Box 3.1

Clinical Signs of Subacromial Bursitis Acute bursitis – intense pain, worsening at night – pain on local palpation – possible reduction of active mobilisation of the shoulder – inability to lie on the affected side; typically, patients adopt antalgic positions Chronic bursitis – pain near the distal insertion of the deltoid – local cellulitis – difficulty lying on the affected side Source: Béliveau, 1993; Leduc, 1986

Leclaire, 1986). There is usually no apparent underlying cause. The secondary form, even if often associated with inflammation of the joint or rotator cuff, may result from a variety of health problems

that lead the patient to adopt antalgic positions. The initial clinical profile of adhesive capsulitis may resemble that of shoulder tendinitis. Box 3.2 summarises the clinical signs and some possible causes of adhesive capsulitis.

Box 3.2

Clinical Summary of Adhesive Capsulitis Signs upon examination – painful spasm over the trapezius – disrupted glenohumeral movement – reduced active and passive mobilisation of the shoulder Possible causes Primary form Progressive onset with no apparent cause. May initially appear in association with anxiety or stress. 14

Secondary form Shoulder capsulitis may be related to: shoulder trauma, nervous system disorders, coronary heart disease failure and other cardiac conditions, diabetes mellitus, hyperthyroidism, burns, inflammation, infection, and psychological factors. Source: Dupuis- Leclaire, 1986

SHOULDER PATHOLOGIES These pathologies include problems of both muscular and neurological origin. Cervicobrachial Disorders Cervical injuries may cause shoulder pain, usually felt in the upper portion of the shoulder and over the upper and middle trapezius. The pain is generally associated with the performance of repetitive movements with the hands (assembly of electronic parts, data entry) while the trunk, head or arms are maintained in static postures for prolonged periods (Sommerich et al., 1993). Compression of the Supraclavicular Nerve This condition may be mistaken for bursitis. The supraclavicular nerve originates in the brachial plexus and innervates the supraspinatus and infraspinatus muscles. Its compression causes pain in the lateral and posterior shoulder. Common causes of compression include falls and carrying loads slung across the shoulder or directly on the shoulder joint (Sommerich et al., 1993) (Figure 3.2).

Upon examination, patients exhibit weakness in abduction and external rotation; atrophy of the infraspinataous fossa may also be present. Cervical Root Injuries Cervical root syndromes are characterised by damage to one or more cervical nerve roots, most commonly C6 and C7 (Berger and Kleinert, 1991). Pain may appear suddenly or develop progressively. The acute form usually is seen following trauma, while the chronic form results from a protuberant or degenerative discopathy. Thoracic Outlet Syndrome Clinical examination is the key to diagnosing thoracic outlet syndrome, whose primary cause is the compression of nerves or blood vessels at the base of the neck in the cervicothoracoscapular junction (Figure 3.3) (Vender et al., 1998; Leffert, 1992; Leclaire, 1986). The neurological form is related to the compression of the lateral branches of the C8 and D1 roots of the brachial plexus; its main signs are paresthesia, numbness, and pain in the ulnar nerve’s field. The vascular form is primarily associated

Figure 3.3

Figure 3.2

Anatomy of the Cervicothoracoscapular Junction

Compression of the Supraclavicular Nerve

Scalenus medius

Scalenus anterior

Brachial plexus Scalenus posterior Axillary artery Axillary vein Median nerve

15

Ulnar nerve Carrying loads directly on or slung across the shoulder

Pectoralis minor SHOULDER TENDINITIS

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

with compression of the subclavicular artery and is characterised by coldness, sore muscles, and diminished strength during continuous exertion (Vender et al., 1998; Leffert, 1992). These symptoms may be accompanied by swelling and cyanosis of the forearm and hand.

16

1994). It is important to note that patients suffering from glenohumeral instability also often suffer from damage to the rotator cuff, which may secondarily contribute to the instability of the shoulder. GENERAL AND SYSTEMIC PATHOLOGIES

There is controversy in the scientific literature regarding the diagnostic tests for this condition and the anatomical structures involved in its pathogenesis (Leffert, 1992; Berger et al., 1991; Dawson et al., 1990). According to Leffert (1992), pathogenesis is not solely a function of anatomy (cervical ribs, fibrous bands, birth defects) but is also associated with dynamic constraints related to growth, trauma, and posture. The commonly cited hazardous postures are repeated or prolonged flexion of the shoulder at angles exceeding 60° and those that involve arm movements above the shoulders or force the shoulders backwards or downwards (e.g. lifting and carrying loads) (Vender, 1998; Sommerich et al., 1993).

Diffuse shoulder pain may result from general or systemic pathologies (Béliveau, 1993). The existence of such pathologies should be considered when the range of motion is unaffected, movement is painfree, and radiological examination is normal.

Shoulder Instability Instability of the glenohumeral joint reflects the inability to maintain the head of the humerus centred within the glenoid fossa (Jackins and Matsen, 1994). It is important to distinguish the trauma-related form of this condition from instability due to other factors. Non-trauma-related instability is usually associated with loose ligaments and often affects both shoulders. The most common causes of the trauma-related form, on the other hand, are acute trauma, dislocation of the glenohumeral joint, or microtrauma related to repeated movements above the shoulder (e.g. throwing objects, swimming) (Sagerman et al., 1998; Iannotti, 1994).

SYMPTOMS

Evaluation of patients exhibiting glenohumeral instability requires detailed investigation of the symptomatology, in order to identify the movements responsible for the initial injury or related to recurrences, and identify the direction of the instability. This etiological evaluation is essential for the characterisation of the type of instability and the development of an appropriate therapeutic approach (Marks et al., 1997; Iannotti, 1994; Jackins et al.,

Examples of general pathologies capable of causing shoulder pain include cardiovascular conditions, apical pulmonary tumours, and diaphragmatic irritations with damage to the abdominal viscera (Figure 3.4). Systemic conditions capable of causing diffuse pain include rheumatoid arthritis and the shoulder-hand syndrome (reflex sympathetic algiodystrophy).

Figure 3.4

Structures Capable of Causing Shoulder Pain

Cervical spine

Lungs

Heart

Diaphragm Elbow

Gallbladder

4

Clinical Considerations

The symptoms of shoulder tendinitis may develop progressively as a resulting of repetitive movements, significant exertion, or prolonged maintenance of awkward postures, or may appear suddenly following an accident or violent movements. The most common symptom is pain on the external or anterior face of the shoulder (Bélisle and Croteau, 1988), with possible radiation as far as the elbow (Chipman et al., 1991). As symptoms progress, the pain may become constant and prevent patients from sleeping on the affected shoulder. The following questions should be asked of all patients exhibiting symptoms affecting the shoulder: – – – –

as intense pain on the superior-external face of the shoulder, with possible radiation to the external face of the shoulder and to the arm. Active movement, particularly abduction, increases the pain. Tenosynovitis of the long head of the biceps presents as pain on the anterior face of the shoulder with possible radiation to the arm. Resisted flexion elicits pain (Dupuis-Leclaire, 1986; Choquette, 1988; Hazeltine, 1990).

Figure 4.1

Shoulder-Arm Diagrams

Where do you feel the pain? When did the pain begin? What did the pain feel like when it started? What does it the pain feel like now?

In addition, the impact of the symptoms on daily living should be assessed. Location of Symptoms (Where?) The use of a shoulder-arm diagram is a useful means of helping patients localise their symptoms (Figure 4.1). Damage to any of the tendons of the rotator cuff however yields similar results, and objective examination is therefore the only way to identify the specific tendons involved in these cases. Tendinitis of the rotator cuff generally presents

17

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

Onset of Symptoms (When?) It is essential to determine the time that has elapsed between the onset of symptoms and the examination. Shoulder tendinitis is a painful condition which is usually unrelated to trauma. As every physical activity generates a physiological response to external stress, it is necessary to establish whether exposure actually preceded the onset of symptoms. Patients should also be explicitly asked the reason for the current visit. Characteristics of Onset (How?) Patients should be asked to describe the circumstances surrounding the onset of symptoms. Tendinitis of the rotator cuff may appear abruptly, insidiously, or progressively. Certain movements of daily living such as dressing or brushing one’s hair

may trigger symptoms, and traction and exertion may aggravate them. Symptoms of tenosynovitis of the long head of the biceps may appear during resisted elbow flexion, especially with the forearm supinated. They may also appear during movements combining abduction, extension and rotation (e.g. putting on a coat) or combining flexion and rotation of the forearm (e.g. using a screwdriver) (Lacoste, 1993). Impact on Activities of Daily Living In addition to pain, patients may exhibit a deterioration of their ability to perform movements requiring rotation, flexion, or abduction of the shoulder. Box 4.1 lists a series of questions that help determine the impact of symptoms on the activities of daily life.

Box 4.1

Questions about Activities of Daily Living Which is your dominant hand?

Right ❐ Never

Do you have difficulty – picking up objects located over your shoulders? – using your arms over your shoulders (e.g. changing a lightbulb in the ceiling)? – driving a car? – putting on a shirt or coat? – throwing something? – brushing your hair or putting on makeup? – peeling vegetables? – holding a cup of coffee? 18

– knitting or turning a key in a lock? – buttoning a shirt?

Sometimes

Left ❐ Often

Always

Impact on Physical Activity There is a relation between the severity of musculoskeletal damage and the ability to perform physical, occupational, sports-related, recreational or household activities. Box 4.2 lists a scale with which to grade the severity of damage.

Box 4.2

Presentation and Clinical Severity of Symptoms Severity

Symptoms

0. None

No pain during physical activity

1. Slight

Symptoms only after intense and repetitive activity

2. Moderate

Symptoms only after light or occasionally activity

3. Severe

Symptoms present regardless of activity

19

SHOULDER TENDINITIS

Recording of Information on Exposure Factors

5

To establish the etiological link between shoulder tendinitis and physical activity, it is essential to document the patient’s movements and postures. Symptoms generally appear in the shoulder which is subjected to the most stress. This approach proposed here allows physicians to collect as much as information as possible on the occupational activities that are the most likely to play an important role in the development of symptoms, and to collect summary information on sports-related, recreational and household activities. OCCUPATIONAL HISTORY Previous Work The goal of collecting information on previous work is to determine the extent to which previous jobs exposed the patient to arm stress (Box 5.1).

Current Work Patients should be asked to describe their current job in sufficient detail for physicians to clearly understand the nature of their work and the conditions under which it is performed. As it is generally difficult for physicians to visit workplaces, this guide provides a series of questions designed to help them: – generally characterise the patient’s work (Box 5.2) – identify occupational musculoskeletal strains which favour the development of shoulder tendinitis (Boxes 5.3) – estimate the work rhythm and degree of autonomy associated with the work (Box 5.4) There are a multitude of work-related activities that cause musculoskeletal strain. Common activities which may present a risk for the development

Box 5.1

Questions about Previous Jobs Work performed

Starting date and duration in months or years

Hours per day

Risk factors or cofactors*

21 * See Box 2.1

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

of shoulder tendinitis are listed in Box 5.3. If a patient’s activities correspond little or not at all to those on this list, it may be useful to ask her or him to describe the activities or movements she or he finds difficult, and evaluate their biomechanical characteristics (duration, frequency, force).

Current Work and Organisational Factors Certain factors related to the rhythm, organisation, and perception of a patient’s work may favour the development of musculoskeletal disorders.

Box 5.2

General Questions Concerning Occupational Activities and Symptoms Associated with Them – Is your current job full- or part-time? – Which arm do you use the most to perform your work? – Was an accident or an abrupt, sudden, or unusual movement responsible for your pain? – Did your pain appear progressively? If so, how long did it take to appear and what form did it take? – What activities and movements aggravate your symptoms?

22

Box 5.3

Questions about Activities that Stress the Shoulder Activity

Hours per day

Frequency of movements low medium high

low

Force exerted medium high

– Working with the hands above the shoulder – Handling objects or tools above the shoulder or away from the body – Lifting objects with the arms flexed or abducted – Pulling or throwing objects – Performing movements with the arms extended to the side – Maintaining fixed postures with the arms flexed or abducted – Picking up or putting down objects behind the back (extension) – Applying pressure with the hand Other (describe)

Comments

Cofactors which increase musculoskeletal load

Never

Occasionnally

Regularly

– Wearing work gloves – Exposure to cold – Use of vibrating or percussion tools

23

SHOULDER TENDINITIS

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

Box 5.4

Questions about Work Organisation During your work –

Never

Occasionnally

Regularly

Do you feed a machine tool at a constant rhythm?

– Do you feel time or production pressures? – Do you have to pay constant attention? – Do you find your work monotonous? – Can you vary your work rhythm? – Do you work at several different workstations? Comments

SPORTS-RELATED, RECREATIONAL AND HOUSEHOLD ACTIVITIES As sports-related, recreational, and household activities may contribute to the development of shoulder tendinitis, it is important to establish the intensity with which these activities are practised

(Box 5.5). Swimming, baseball, and tennis appear to be particularly high-risk activities for this type of injury.

Box 5.5

Questions about Sports-related, Recreational, and Household Activities Involving the Shoulders Activity

24

* See Box 2.1

Hours per week

Risk factors or cofactors*

Physical Examination of the Shoulder

The shoulder is a complex joint and it sometimes proves difficult to precisely identify the origin of symptoms. The goal of this section is to provide physicians with a structured approach to guide the diagnosis of shoulder tendinitis. Following a presentation of the general elements of shoulder evaluation, tests and manoeuvres that allow precise identification of the site of the injury will be described.

of points which are sensitive to palpation helps orient clinical diagnosis (Figure 6.1).

GENERAL EVALUATION

Painful Points on the Shoulder

2 ↓

Observation of the affected shoulder and comparison with the unaffected one allows physicians to identify the postures adopted by the patient, evaluate functional limitations, and determine the limits of the affected shoulder. Box 6.1 summarises the main elements of the visual examination. Palpation is performed to confirm the impressions formed during observation, manually evaluate the state of the tissues and determine whether deformation or painful points are present. The presence

8

Anterior view 1. 2. 3. 4. 5. 6. 7. 8.

7

↑

↑ 4

observation palpation and identification of painful points evaluation of joint mobility detection of painful arcs

6

↑

↑ 1

5

↑

↑

3

The general evaluation includes: – – – –

Figure 6.1

↑

6

Posterior view

Sternoclavicular arthritis or arthrosis Acromioclavicular arthritis Supraspinatus tendinitis and subacromial bursitis Tenosynovitis of the long head of the biceps Cellulitis of the trapezius Tendinitis of the tip of the scapula Tenderness over the supraspinatus Tenderness over the infraspinatus

Source: Leduc, 1986

Box 6.1

General Evaluation Appearance of the limbs Observation pula

– antalgic posture of the shoulders or cervical region – appearance of the head of the humerus and of the sca– deformation of various joints

25

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

Passive and active evaluation of joint mobility helps establish the extent of any functional limitations. Passive evaluation, performed by the examiner, helps establish the mobility of the head of the humerus in the glenoid fossa. Active evaluation, on the other hand, is performed by the patient her- or himself and establishes the ability of the muscle-ligament system to raise the arm or maintain it at an a specified angle (Figure 6.2). More specifically, it allows the physician to determine:

Figure 6.2

Painful Arcs

– the symmetry and active amplitude of movements – the glenohumeral rhythm during abduction, through observation of the elevation and lowering of the arm – the existence of painful arcs (Box 6.2) (Chipman et al., 1991; Bélisle and Croteau, 1988; DupuisLeclaire, 1986).

Active abduction of the arm may trigger a painful arc.

Box 6.2

Painful Arcs during Active Abduction of the Arm Between 60° and 120°

– Painful friction of the bursa-tendon complex as it passes under the coracoacromial arch

Between 120° and 180°

– Problems involving the acromioclavicular joint

Source: Dupuis-Leclaire, 1986; Bélisle and Croteau, 1988; Marshall, 1993

26

SPECIFIC EVALUATION The specific evaluation of shoulder function involves the use of resisted movements to reproduce pain reported by the patient. The reaction to these movements helps identify the structures which are damaged and are responsible for observed symptoms. This section presents the diagnostic manoeuvres that help assess the following conditions: tendinitis of of the various tendons of the rotator cuff, subacromial impingement syndrome, tears of the rotator cuff, and tenosynovitis of the long head of the biceps.

Supraspinatus Tendinitis Damage to this tendon causes pain over the bicipital groove, where the tendon attaches to the greater head of the humerus. Pain radiates to the “V” of the deltoid muscle, but the range of motion is unaffected (Bélisle and Croteau, 1988).

Figure 6.3

Resisted Abduction of the Arm

Figure 6.4

Jobe’s Manoeuvre

Diagnostic Manoeuvres Resisted abduction (Figure 6.3) is accomplished by placing the patient’s arm at an angle of 30° and asking her or him to push against the examiner’s hand. Pain during this manoeuvre usually indicates damage to the tendon of the supraspinatus. Jobe’s manoeuvre (Figure 6.4) is performed by abducting the patient’s hand, thumbs down, to an angle of 90° and angling it 30° forward. The patient is then asked to resist pressure on the arm. Pain in the absence of weakness usually indicates tendinitis of the supraspinatus. Inability to resist the examiner’s downward force usually indicates a tendon tear.

27

SHOULDER TENDINITIS

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

Infraspinatus Tendinitis This insertion tendinitis is primarily linked to external rotation (Béliveau, 1993). It may also develop into a tear and favour the development of supraspinatus tendinitis.

Subscapular Tendinitis and Teres Minor Tendinitis These conditions appear with advanced functional decompensation of the shoulder, and rarely occur independently. They are however difficult to demonstrate.

Diagnostic Manoeuvres Symptoms are usually elicited by resisted external rotation of the forearm with the elbow pressed against the body and flexed at an angle of 90° (Figure 6.5).

Diagnostic Manoeuvres Symptoms are elicited on resisted internal rotation of the forearm with the elbow pressed against the side of the body and flexed to an angle of 90° (Figure 6.7)

Patte’s manoeuvre (Figure 6.6) consists of resisting the patient’s active external rotation of the arm abducted to 90° and in a position similar to that of a baseball pitcher’s. Pain on resisted movement constitutes a positive test result.

Figure 6.5

Figure 6.7

Resisted External Rotation of the Forearm

Resisted Internal Rotation of the Forearm

Figure 6.6

Patte’s Manoeuvre

28

Subacromial Impingement Syndrome This syndrome reflects a disruption in the subacromial region and may be caused by damage (tendinitis, bursitis) to tissue in the coracoacromial arch or reduction of the space through which the tendons of the supraspinatus and long head of the biceps pass. This space, termed the supraspinatus outlet, is bounded by the anterior portion of the acromion, the coracoacromial ligament, and the acromioclavicular joint (Markes et al., 1994) (Figure 6.8).

There are several distinct stages to this syndrome, described by Neer (1983), reflecting different degrees of dysfunction or incapacity of the glenohumeral joint (Table 6.1). The existence of subacromial impingement syndrome or impingement syndrome may be detected through demonstration of Neer’s sign (Figure 6.9) or Hawkins’ sign (Figure 6.10).

Figure 6.8

Mechanism of Impingement Coracoacromial ligament

Relative avascular zone

Supraspinatus tendon

Compression zone

ABDUCTION

A

Normal subacromial space

ADDUCTION

B

Reduced subacromial space

29

SHOULDER TENDINITIS

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

Table 6.1

Stages of Impingement Syndrome Stage

Symptoms

Examination results

Physiopathology

First, or acute, stage*

Diffuse pain in the anteriorlateral portion of the shoulder. Pain generally follows prolonged work with the arm elevated anteriorly and internally rotated.

Normal passive and active movements. Painful arc present.

Corresponds to an inflammatory phase: inflamed tendon, edematous bursa, bursal microhaemorrhages.

Second stage (chronic state)*

Pain upon elevating the arm, ceasing with the arm at rest.

Signs of bursitis and tendinitis, in addition to the above.

Bursal fibrosis, with either tendinitis of the supraspinatus or tenosynovitis of the long head of the biceps.

Third stage

Constant pain. Nocturnal pain prevents patients from sleeping on the affected shoulder.

Passive movements are usually complete.

Corresponds to a degenerative phase, with more significant tendon damage.

Weakness in anterior elevaActive movements are tion or in abduction indicates reduced and painful. the beginning of a tear. More significant difficulty indicates a massive tear. * According to the author, the order of appearance of the first and second stages may be reversed. Source: Neer, 1983

30

Possible degenerative rupture of supraspinatus or the long head of the biceps. Infraspinatus may also be affected.

Figure 6.9

Figure 6.10

Neer’s Sign

Hawkins’ Sign

90°

90°

Diagnostic Manoeuvre

Diagnostic Manoeuvre

To perform Neer’s test (Figure 6.0), the examiner stands behind the patient and stabilises the scapula by placing a hand on the shoulder. With the other hand, the examiner takes the patient’s arm in order to perform assisted active flexion. Pain in the range of 60°-120° constitutes a positive test result. This test reproduces the rubbing of the tendons of the rotator cuff against the anterior border of the acromion and the inferior face of the coracoacromial ligament (Pujold, 1993).

To perform Hawkins’ test (Figure 6.10), the examiner flexes the arm and elbow of the patient to 90°, brings the arm horizontally in front of the chest, and then lowers the forearm, forcing the shoulder into internal rotation. Pain indicates reduced tendon mobility under the coracoacromial ligament (Pujold, 1983).

31

SHOULDER TENDINITIS

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

Figure 6.11

Rotator Cuff Tear The rotator cuff is very sensitive to tears, such tears being found on autopsy in 40% of subjects older than 50 years (Leduc, 1986). These may result from microtrauma associated with repeated or prolonged stress of the muscle and tendons of the shoulders, as well from degenerative changes associated with aging (Iannoti, 1994). The clinical profile of partial tears is often asymptomatic and essentially mirrors that of shoulder tendinitis. Total rupture of the rotator cuff, corresponding to a tear of the tendon through its entire thickness, is rather rare. It most commonly affects the tendon of the supraspinatus, followed by the tendons of the infraspinatus and subscapularis. Falls are a frequent cause. If the rupture is recent, abduction is impossible and patients will exhibit a characteristically raised shoulder when attempting abduction (Leduc, 1986). Three types of manoeuvres may help diagnose partial or complete tears of the rotator cuff: Jobe’s test (Figure 6.4) for the supraspinatus tendon, resisted active external rotation of the forearm (Figure 6.5) for tears involving the infraspinatus, and the falling arm manoeuvre (Figure 6.11) for complete tears of the rotator cuff. Clinical evaluation may be complemented by medical imaging techniques such as radiography, arthrography, sonography, and magnetic resonance (Table 6.2).

Drop-Arm Manoeuvre

Diagnostic Manoeuvre The examiner completely abducts the arm of the patient, who attempts to lower it slowly and progressively. In cases of complete rupture of the supraspinatus tendon, progressive lowering of the arm fails abruptly at approximately 90° of abduction, due to pain.

Table 6.2

Imaging Techniques for Tears of the Rotator Cuff

Tear of the rotator cuff

32

Radiography

Arthography

Magnetic Resonance Imaging

Normal in the early stages. Reduced subacromial space in later stages.

Reference technique. Presence of contrast medium between the glenohumeral and subacromial joints indicates a complete tear of the rotator cuff. Validity – Sensitivity: 71-100% – Specificity: 71-100%

This diagnostic test is becoming the technique of choice. Validity Partial tear: – Sensitivity: 67-89% – Specificity: 84-89% Total tear: – Sensitivity: 80-97% – Specificity: 93-94%

Source: Irwin et al., 1998; Cuomo et al., 1997; Murnaghan, 1988; Marks et al., 1994; Ladd, 1994

Echography Allows identification of damage to the rotator cuff primarily involving the supraspinatus tendon. Validity Unknown

Tenosynovitis of the Long Head of the Biceps Damage to the long portion of this tendon generally presents as well-localised pain over the anterior shoulder, with possible radiation as far as the elbow (Chipman et al., 1991). The physiopathological process reflects:

Figure 6.12

Resisted Elevation of the Arm

– the long course of the tendon, with a 90° turn and a encasement of the tendon in the intertuberal groove – mechanical stress (traction, friction), maximal over the curve of the lesser tuberosity (Lacoste, 1993; Dupuis-Leclaire, 1986) Palm-up, or Speed’s test

Diagnostic Manoeuvres Tenosynovitis of the long head of the biceps may be demonstrated by resisted elevation of the arm with the forearm supinated (Figure 6.12). This manoeuvre, also known as Speed’s test or the palm-up test, reproduces the mechanism which causes pain. This test is also positive in cases of partial rupture of the tendon of the long head of the biceps. Such rupture may occur following the appearance of tendinitis, and may cause swelling at the entry to the bicipital groove during resisted flexion of the elbow (Figure 6.13).

Figure 6.13

Resisted Flexion of the Elbow

33

SHOULDER TENDINITIS

7

Summary of the Evaluation

Box 7.1

Clinical Aspects EXTENT OF PROBLEMS

None

Slight

Moderate Severe

Symptoms reported – Frequency and intensity of symptoms (p. 17 and 18) – Disruption of activities of daily living (p. 18) Physical examination – Abnormalities observed (p. 25) – Abnormalities palpated (p. 25 and 26) – Abnormalities noted during shoulder movements (p. 26) – Abnormalities noted during specific manoeuvres (p. 27 to 33) Details: Differential diagnosis

Yes

No

– Damage to the structures surrounding the rotator cuff (p. 13 and 14)

❏

❏

– Damage in the cervicoscapular region (p. 15 and 16)

❏

❏

– General or systemic damage (p. 16)

❏

❏

Musculoskeletal stress

None

Slight

Moderate Severe

– During previous work (p. 21) – During current work (p. 21 to 24) – In sports-related, recreational, or household activities (p. 24) Diagnosis and opinion on the relation to work

35

Guidelines for Therapeutic and Preventive Interventions

8

This section presents some fundamental therapeutic and preventive principles, rather than describing specific interventions in detail. These principles should prove useful in developing an approach to the management of shoulder tendinitis. It is important to note that therapeutic success depends on a knowledge of etiological factors and requires full understanding of the anatomy and biomechanics of the scapular region. THERAPEUTIC GUIDELINES The goal of the therapeutic approach is to reduce pain, reestablish joint mobility, improve function, strength the shoulder muscles, and prevent aggravation and recurrence (Marks et al., 1994). The algorithms presented in Figures 8.1 and 8.2 describe the therapeutic regime for patients suffering from shoulder tendinitis or rupture of the rotator cuff.

PREVENTION GUIDELINES In cases of shoulder tendinitis in which it is possible to identify probable causes of stress it may prove useful to suggest preventive measures. Table 8.1 lists preventive measures that take into account the specific diagnosis and extent of musculoskeletal strain. This preventive approach incorporates corrective measures which address activities which strongly influence the development of shoulder tendinitis. The implementation of these measures is essential to prevent aggravation and recurrence of injury, and accentuation of the symptoms with return to or continuation of work.

Table 8.1

Preventive Approach Musculoskeletal strain Diagnosis

Evidence of shoulder tendinitis

+

No evidence of shoulder tendinitis

–

Significant

Not significant

+

–

– Modification of activities – Reduction of musculoskeletal strain – Corrective ergonomic interventions

– Treatment of causal factors – Modification of activities

– Reduction of musculoskeletal strain – Corrective ergonomic interventions

– Information on risk factors

37

Guide To The Diagnosis Of Work-Related Musculoskeletal Disorders

Figure 8.1

Therapeutic Intervention Flow-Chart Shoulder tendinitis ▲

Acute ▲

Identification of risk factors + Control of pain – rest – ice – NSAID

▲ Chronic ▲

▲

▲ ▲

▲

Improvement ▲

No improvement ▲ Improvement

Consider infiltration*

▲

▲

– Progressive mobilisation – Muscle strengthening – Functional reeducation ▲

▲

Interventions to modify risk factors

No improvement ▲ After 6 months, consider surgery

*Repeated infiltrations may lead to tendon atrophy.

Figure 8.2

Therapeutic Approach to Tears of the Rotator Cuff Incomplete

Complete

▲

Tears of the rotator cuff

▲

Physiotherapy

Persistant pain lasting more than 3 months or significant functional impairment ▲

38

Arthrography or magnetic resonance imaging ▲

Acute, patient older than 60 years

Surgery

▲

▲

CONCLUSION

This guide was designed to help physicians, who in recent years have been faced with an increase in the number of consultations for musculoskeletal problems of possible occupational etiology. The core elements of current knowledge on the subject have been reviewed and an approach that facilitates the documentation of the injury’s clinical aspects and its dependence on occupational musculoskeletal strain presented. Furthermore, a therapeutic approach that integrates preventive elements designed to reduce the impact of risk factors has been outlined.

39

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SHOULDER TENDINITIS