Limited abduction t Norr
Repeated shoulder motion, as in throwing or swimming, can cause edema and hemorrhage followed by inflammation, most commonly involving the supraspinatus tendon. Acute, recurrent, or chronic pain may result, often aggravated by activity. Patients may report sharp catches of pain, grating, and weakness when lifting the arm overhead. When the supraspinatus tendon is involved, tenderness is maximal just below the tip of the acromion. Patients are typically athletically active.
When the arm is raised in forward flexion, the rotator cuff may impinge against the undersurface of the acromion and the coracoacromial ligament. Injury from a fall or repeated impingement may weaken the rotator cuff, causing a partial or complete tear, usually after age 40. Weakness, atrophy of the supraspinatus and infraspinatus muscles, pain, and tenderness may ensue. In a complete tear of the supraspinatus tendon (illustrated), active abduction and forward flexion at the glenohumeral joint is severely impaired, producing a characteristic shrugging of the shoulder.
Calcific tendinitis refers to a degenerative process in the tendon that is associated with the deposition of calcium salts. Like rotator cuff tendinitis, it usually involves the supraspinatus tendon. Acute, disabling attacks of shoulder pain may occur, usually in patients over 30 years of age and more often in women. The arm is held close to the side, and all motions are severely limited by pain. Tenderness is maximal below the tip of the acromion. The subacromial bursa, which overlies the supraspinatus tendon, may become involved in the inflammation. Chronic, less severe pain may also occur.
Inflammation of the long head of the biceps tendon and its sheath causes anterior shoulder pain that may resemble rotator cuff tendinitis and may coexist with it. Often this is a sign of shoulder instability. This tendon, like the cuff, may suffer impingement injury. Tenderness is maximal in the bicipital groove. By externally rotating and abducting the arm, you can more easily separate this area from the subacromial tenderness of supraspinatus tendinitis. With the patient's arm at the side, elbow flexed to 90°, ask the patient to supinate the forearm against your resistance. Increased pain in the bicipital groove confirms this condition.
Acromioclavicular arthritis is not a common cause of shoulder pain. When present, it usually is the result of direct injury to the shoulder girdle with resulting degenerative changes. Tenderness is localized over the acromioclavicular joint. Although motion in the glenohumeral joint is not painful in acromioclavicular arthritis, as it is in many other painful conditions of the shoulder, movements of the scapula, such as shoulder shrugging, are.
Adhesive capsulitis refers to a mysterious fibrosis of the glenohumeral joint capsule, manifested by diffuse, dull, aching pain in the shoulder and progressive restriction of active and passive range of motion, but usually no localized tenderness. The condition is usually unilateral and occurs in persons aged 50 to 70. There is often an antecedent painful disorder of the shoulder or possibly another condition (such as myocardial infarction) that has decreased shoulder movements. The course is chronic, lasting months to years, but the disorder often resolves spontaneously, at least partially.
TABLE 15-5 ■ Swollen or Tender Elbows
Swelling and inflammation of the olecranon bursa may result from trauma or may be associated with rheumatoid or gouty arthritis. The swelling is superficial to the olecranon process.
Subcutaneous nodules may develop at pressure points along the extensor surface of the ulna in patients with rheumatoid arthritis or acute rheumatic fever. They are firm and nontender, and are not attached to the overlying skin. They may or may not be attached to the underlying periosteum. Although they may develop in the area of the olecranon bursa, they often occur more distally.
Synovial inflammation or fluid is felt best in the grooves between the olecranon process and the epicondyles on either side. Palpate for a boggy, soft, or fluctuant swelling and for tenderness.
Lateral epicondylitis (tennis elbow) follows repetitive extension of the wrist or pronation-supination of the forearm. Pain and tenderness develop at the lateral epicondyle and possibly in the extensor muscles close to it. When the patient tries to extend the wrist against resistance, pain increases. Medial epicondylitis (pitcher's, golfer's, or Little League elbow) follows repetitive wrist flexion, as in throwing. Tenderness is maximal at the medial epicondyle. Wrist flexion against resistance increases the pain.
TABLE 15-6 ■ Swellings and Deformities of the Hands
Nodules on the dorsolateral aspects of the distal interphalangeal joints (.Heberden's nodes) are due to the bony overgrowth of osteoarthritis. Usually hard and painless, they affect the middle-aged or elderly and often, although not always, are associated with arthritic changes in other joints. Flexion and deviation deformities may develop. Similar nodules on the proximal interphalangeal joints (Bouchard's nodes) are less common. The metacarpophalangeal joints are spared.
Tender, painful, stiff joints characterize rheumatoid arthritis. Symmetric involvement on both sides of the body is typical. The proximal interphalangeal, metacarpophalangeal, and wrist joints are frequently affected; the distal interphalangeal joints are rarely so. Patients with acute disease often have fusiform or spindle-shaped swelling of the proximal interphalangeal joints.
As the arthritic process continues and worsens, chronic swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints appear. Range of motion becomes limited and the fingers may deviate toward the ulnar side. The interosseous muscles atrophy. The fingers may show aswan neck" deformities (i.e., hyperextension of the proximal interphalangeal joints with fixed flexion of the distal interphalangeal joints). Less common is a boutonnière deformity (i.e., persistent flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint).
Rheumatoid nodules may accompany either the acute or the chronic stage.
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Radial deviation of distal phalanx
Metacarpophalangeal joints uninvolved node
Metacarpophalangeal joints uninvolved
Radial deviation of distal phalanx node
Ulnar deviation en cx> o
TABLE 15-6 ■ Swellings and Deformities of the Hands (Continued)
Chronic Tophaceous Gout
The deformities that develop in longstanding chronic tophaceous gout can sometimes mimic those of rheumatoid and osteoarthritis. Joint involvement is usually not so symmetric as in rheumatoid arthritis. Acute inflammation may be present. Knobby swellings around the joints sometimes ulcerate and discharge white chalklike urates.
Ganglia are cystic, round, usually nontender swellings located along tendon sheaths or joint capsules. The dorsum of the wrist is a frequent site of involvement. Flexion of the wrist makes ganglia in this location more prominent; extension tends to obscure them. Ganglia may also develop elsewhere on the hands, wrists, ankles, and feet.
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