Solving a Common Shoulder Problem

A 57-yr-old, right-handed woman with known diabetes mellitus, obesity, and a recent right below-knee amputation presented with a 3-mo history of right shoulder discomfort. Her specific symptoms included weakness with overhead activities and aching shoulder pain that worsened after her below-knee amputation, as she then relied on the shoulder joint for weightbearing with her rolling walker and for transfers. Physical examination of the right shoulder revealed diffuse anterior shoulder tenderness and crepitus on palpation, with limited range of motion at 45 degrees of abduction with the scapula stabilized. Mild weakness was noted during external rotation with applied resistance. The upper limb was otherwise neurologically intact. The decision was made to further investigate the shoulder joint, and hence, magnetic resonance imaging without contrast was chosen. Arthrography is specific for rotator cuff tears but has a low sensitivity because it does not pick up partial tears well and therefore has been largely replaced by magnetic resonance imaging.1 A review of the magnetic resonance image clearly revealed acromial impingement, with a resultant tear on the supraspinatus tendon (Fig. 1 and Fig. 2).FIGURE 1: Magnetic resonance image, coronal view, illustrating impingement of supraspinatus tendon anteriorly by the acromion (arrow 1, upper left) and absence of the tendon due to tear (arrow 2, lower right).FIGURE 2: Magnetic resonance image, sagittal view, showing acromial impingement (arrow 1, upper left) and erosion of the same tendon with fluid (arrow 2, lower left). Normal tendon is outlined by arrow 3 (lower right).The supraspinatus muscle is the largest component of the rotator cuff. Its primary function is abduction of the arm, particularly the first 20–30 degrees. Due to its size and position, it is the most likely to be impinged between the humeral head and lateral edge of the acromion. Three types of acromia are described: type I, flat with the least amount of degenerative changes; type II, curved with increasing wear changes prevalent; and type III, hooked with highest rate of tears and degenerative joint disease2 (the subject of this vignette has a type I acromion). The acromion can best be visualized with the outlet Y-view radiograph, which is typically included in the impingement series with the anteroposterior, external rotation, and West Point (modified axillary) views. Key history points in a patient with supraspinatus tendinopathy usually include worsening of pain with reaching overhead, along with more severe pain at night. Physical examination may review tenderness with direct pressure over the acromioclavicular joint and weakness with initial abduction. Treatment varies based on the severity and time from onset. Initial treatment consists of conservative measures, including initial relative rest, ice, compression, and elevation (RICE) and nonsteroidal antiinflammatory medications (NSAIDs) for 1–2 wks. After pain and inflammation have been managed, physical therapy can be initiated, first focusing on flexibility, followed by isometric and then isotonic exercises as tolerated. More specifically, wand and pendulum exercises are especially helpful, along with continued modalities such as ice, heat, and massage therapies.3 Difficult cases warrant an injection of an anesthetic agent such as lidocaine with or without steroid. If these approaches fail after a period of 3–6 mos, an orthopedic surgical consultation may be indicated.