Exercise Your Shoulder Pain-free
Throwing athletes are prone to shoulder injuries due to the extreme positioning of the shoulder in the various phases of the throw, the adaptive changes that develop over time to allow an advantageous arc of motion, and the chronic, repetitive nature of an activity that places such a high demand on the shoulder joint. The injuries are often particular to a specific phase of the throw and are well demonstrated with MRI. In this article, the authors review the phases of the throw, MRI techniques, and the MR appearances of the injuries associated with particular phases.
M.L., a 56-year-old business executive and former college football player, was referred to an orthopedic surgeon for recurrent shoulder pain. M.L. was unable to abduct his right arm without pain even after 6 months of physical therapy and NSAIDs. In addition, he had taken supplements of glucosamine, chondroitin, and S-adenosylmethionine for several months in an effort to protect the flexibility of his
Coracoid or subcoracoid impingement is another cause of shoulder pain that may occur during the deceleration phase. The pain is anteromedial, is accentuated by cross-arm adduction, internal rotation, and forward flexion (the ''coracoid impingement test''), and is due to impingement of the subscapularis between the lesser tuberosity and coracoid 45,46 . Patients who have this type of impingement have a narrow distance between the lesser tuberosity of the humeral head and the lateral aspect of the coracoid. The narrowing may be congenital due to a long or lateral coracoid, posttraumatic resulting from fracture deformity of either the coracoid or humeral head (especially the lesser tuberosity), or iatrogenic resulting from glenoid osteotomy or coracoplasty The coracohumeral distance may be evaluated radiographically on an axillary view or an anteroposterior view that is perpendicular to the scapular plane 47 . Using axial CT images, Gerber and colleagues 48 evaluated 47 normal shoulders...
Back pain and radiculitis may be secondary to leukemic meningeal involvement or be the initial manifestation of Hodgkin's disease. Shoulder pain with normal findings on shoulder examination may be referred pain caused by infradiaphragmatic, intraabdominal neoplasms. Alternatively, intrathoracic neoplasms (e.g., Pancoast tumor) may extend into the brachial plexus and cause pain in a shoulder with a normal range of motion but evidence of muscle atrophy and loss of deep tendon reflexes.
This issue deals primarily with the more complex imaging modalities of MRI and ultrasound. First, excellent review articles provide a basic approach to the evaluation of an MR examination of the shoulder, elbow, and wrist. These articles provide a framework for the interpretation of these complex exams, reviewing the pertinent imaging anatomy as well as specific injury patterns that can be seen on MRI. Next, the role of MRI is discussed as it pertains to specific clinical problems that involve the shoulder, including an article on the MR evaluation of shoulder pain in the high-performance thrower and a review of the complexities of imaging the postoperative shoulder. Next, a review of the numerous nerve entrapment syndromes of the upper extremity specific to the athlete is provided, and the role of MRI in establishing these sometimes-elusive diagnoses is discussed. Stress fractures of the upper extremity are uncommon and often overlooked clinically. The various stress fractures of the...
The most common shoulder problems are impingement syndrome with rotator cuff tears, calcific tendinitis, adhesive capsulitis, acromioclavicular joint pain, thoracic outlet syndrome, and shoulder instability. 3. A muscle-strengthening program of exercise must be established because shoulder pain often leads to weakness, particularly of the rotator cuff. In carrying out these exercises, the patient should avoid the pain-producing positions. 1. In the acute process, the patient notes the sudden occurrence of severe shoulder pain and will present holding the arm carefully at the side to avoid all shoulder movement. a. There is a long history, often of multiple attacks of shoulder pain. Complaints will often mimic those of the impingement-type syndromes. E. Subluxation of the shoulder is an important cause of pain in the younger population. Often, the patient will state that the shoulder comes out, although some patients will complain only of shoulder pain,...
Examine the primary site of the discomfort and extend the evaluation to the shoulder, ribs, and pelvis to determine if there is a referred source. Shoulder pain may be referred from a subdiaphragmatic source knee and hip pain may be referred from a lumbar spine lesion. The source of pain can be created by muscle or tendon insertions from the shoulders, ribs, or pelvis to the back and cause limitation in motion.
Patient's positioning We nearly always keep both arms at the side of the patient, because this is usually possible and may secure the patient on the bed more firmly. This also lessens the possibility of shoulder injury compared with having the arm extended during the operation. If the first assistant stands on the left side of the patients, the monitors should be positioned on both sides of the patient.
Ration can be free or walled off and carries a high mortality rate of up to 40 29 . Free perforation occurs in approximately 2 of patients with UC and is usually associated with toxic colitis or toxic mega-colon. If perforation occurs due the course of the disease, it is clear, but for a substantial proportion of patients, it is unfortunately an indication that is too late for urgent surgical treatment. The best prevention of this complication is proper, early surgical treatment in patients with fulminant colitis or toxic megacolon before perforation occurs. It should be emphasised that sometimes signs of perforation can be masked in patients receiving high-dose steroids. The patient with this complication is typically severely ill with increased abdominal or shoulder pain associated with tachycardia and fever 30 . Only early recognition of this complication can save the patient's life, necessitating multidisciplinary treatment and frequent monitoring (close cooperation between...
The pain and loss of function after laparoscopic colorectal surgery is significantly less, and of shorter duration compared with the laparotomy approach. Minimally invasive surgery reduces the systemic inflammatory response and has been noted to reduce postoperative ileus (PI).19 Furthermore, earlier discharge from the hospital is possible with proper pain control, prevention of nausea, and resolution of PI. Postoperative pain occurs in the upper abdomen, lower abdomen, back, or shoulders. The greatest incidence of pain is in the upper abdomen. Shoulder pain may occur in 35 -63 of patients. Pain at any location is greatest after the operation, decreases to a low level within 24 hours, but may peak later a second or third time. The duration of pain may be transient or persist for 3 days.20 Continued and heightened pain delays resolution of ileus, nausea and vomiting, and thus recovery. The level of pain is obviously greater with hand-assisted laparoscopic procedures. Nonsteroidal...
Be worthwhile in younger patients who have refractory shoulder pain, because studies have demonstrated that arthroscopic debridement of even shallow (25 thickness) articular surface tears can result in a significant decrease in pain 9 . In certain athletic populations with a high prevalence of cuff and labral tears it may be reasonable to proceed directly to MR arthrography without first obtaining a conventional MRI.
Subcortical cysts and posterior capsular stripping in a 16-year-old male who had right shoulder pain when throwing for 3 months. (A) Subcortical cysts (arrow) in the greater tuberosity at the insertion of the supraspinatus tendon are seen as high signal intensity on a fat-suppressed T2-weighted image. (B) Axial gradient echo T2-weighted image shows a nondisplaced tear of the posterior labrum and capsular stripping (arrow). Fig. 3. Posterosuperior labral tear and impaction of the greater tuberosity in a 17-year-old female pitcher who had right shoulder pain and impingement for 5 years. (A) Axial proton-density image through the superior humeral head, which should normally be round, shows flattening of the posterosuperior aspect (arrows). (B) Axial proton-density weighted image demonstrates curvilinear high signal intensity extending from the articular surface into the posterior aspect of the labral (arrow), indicating a nondetached tear. Fig. 3. Posterosuperior labral tear and...
Plain radiographs in two orthogonal planes should be obtained to rule out post-traumatic deformity, neoplasm, cervical ribs, or other possible bony causes of the nerve condition. A carpal tunnel view can sometimes show a hook of the hamate fracture, but often computed tomography is needed to visualize this injury. Magnetic resonance imaging (MRI) has a specific role in the workup of this condition. For instance, MRI can be extremely helpful in assessing the extent of a soft tissue mass like a ganglion causing ulnar tunnel syndrome. An apical tumor of the lung can also compress or invade the inferior brachial plexus, causing ulnar nerve symptoms. A chest x-ray to rule out a Pancoast tumor should be obtained whenever the patient gives a history of smoking, ulnar nerve symptoms, and shoulder pain.
The quadrilateral space syndrome is defined as compression of the axillary nerve within the quadrilateral space. Fractures of the proximal humerus and scapula can produce direct nerve injury 19 . Entrapment of the nerve can be produced by extreme abduction of the arm during athletic endeavors, or even during sleep. Mass effect secondary to tumors, hypertrophy of teres minor muscle in paraplegic patients, or by a fibrous band within the quadrilateral space 19 are other causes of entrapment of the nerve. Symptoms related to this syndrome include shoulder pain and paresthesia. Advanced cases may result in atrophy of the deltoid and teres minor muscles.
In the elderly, biliary disease should be considered foremost in the differential diagnosis of the physician when eliciting the history of upper abdominal pain. The pain may be steady and persistent in the right subcostal, epigastric region or both. Often the pain may develop after ingestion of a meal. Radiation of this pain may be to the back or to the tip of the right scapula. Also, irritation of the diaphragm may cause right shoulder pain. Nausea and vomiting are common in about 65 of patients. Fever, which is found in 80 of all acute cholecystitis patients, may be absent in the elderly, especially if they are taking nonsteroidal anti-inflammatory drugs. The physical examination should elicit tenderness in the right upper quadrant, epigastrium, or both. A common physical finding is inspiratory arrest during deep palpation of the right upper quadrant, which is called Murphy's sign. Rigidity, rebound tenderness, and or a palpable mass may be found as well. In 10 of patients with...
Cervical spondylosis of C5-6 often results in a referred type of pain to the shoulder. If the radiculopathy includes weakness of shoulder abduction and external rotation, it may closely mimic a torn rotator cuff. Cervical types of shoulder pain are usually increased by neck motion, particularly extension with rotation to the involved side. C. Intrinsic shoulder pain is generally worse at night and is increased by lying on the shoulder. Shoulder motion will generally aggravate the pain, particularly full elevation in the forward flexed position or abduction to 90 degrees. Tears of the rotator cuff may also cause pain radiating into the forearm and, rarely, the hand. Specific problems of the shoulder region tend to occur at certain age intervals.
Thoracic cage injuries often have visible external bruising, indicating damage to the ribs, lung parenchyma, small or great vessels. A fracture of the upper ribs indicates severe trauma and is often associated with spinal, brachial plexus or shoulder injuries. Fractures of the lower ribs can indicate injury to abdominal viscera. Fractures of the sternum are painful and can be associated with a flail segment and cardiac or pulmonary contusion.
Evaluation of shoulder pain in RA requires differentiating soft-tissue pain from that of articular origin. Bursitis, bicipital tendinitis, and rotator cuff tears can be discerned with a careful history, examination, diagnostic xylocaine injections, and MRI when indicated (see Chapter.13). Rotator cuff tears are difficult to repair in this group because of degenerated tissue. The presence of severe articular destruction and refractory pain and disability is an indication for total joint replacement. Shoulder prostheses are in a state of evolution, as problems of restoring rotator cuff power in the face of degenerated tissue and loosening of the glenoid component have required design adjustment.
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