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Shoulder pain
SHOULDER PAIN* MATHER CLEVELAND, M.D. NEW YORK
I
N order to reach an understanding of the various Iesions responsible for shotrIder pain, some conception of the anatomy and physioIogy of the shouIder joint is essentia1. I propose to review some of its anatomic features, using specimens recentIy prepared in the department of anatomy at Columbia University. The shouIder joint is an enarthrodia1 diarthrosis, or baII-and-socket joint, with motion in three pIanes at right angles to each other. The articuIating surfaces are the rounded head of the humerus and the shahow pyriform gIenoid fossa of the scapula. At first sight one can readiIy appreciate the fact that the gIenoid fossa does not accommodate or embrace the humeral head and the joint is therefore not a stabIe one by its conformation. The capsuIe is a Ioose structure attached around the circumference of the gIenoid and the anatomica neck of the humerus. In a macerated preparation there is considerable pIay between articuIar surfaces owing to the Iength of the capsme. The ligaments of any joint are mereIy thickenings or reenforcements of the capsule in response to stress and strain. The capsuIe of the shouIder joint is reenforced in front by the three gleno-humera Iigaments because the greatest strain is pIaced upon the capsuIe by hyperextension of the arm. The capsuIe is further strengthened b!- the coracohumera1 Iigament which extends from the base of the coracoid process of the scapuIa to the greater tuberosity of the humerus. The two projecting bony processes of the scapuIa, the coracoid and acromion, connected by the coracoacromia1 Iigament serve as an extra socket for the head of the humerus. They tend to protect the joint from minor injuries and in a measure
keep the deltoid (See Figs. 1-4.)
muscIe
off the capsuIe.
MUSCLES The joint is surrounded by powerfu1 muscles whose balanced tone keeps the articuJar surfaces in contact. One has onIy to observe a shoulder joint affected with the humeral head by poIiomyeIitis, faIIing we11 below the acromion process, to appreciate this action of the musculature in stabiIizing the joint. Of the muscIes acting on the shouIder joint we recognize six groups by their action; there is, of course, some 0verIapping of function in certain muscIes : I. Abductors: deItoid and supraspinatus. 2. Adductors: pectoralis major, teres major, Iatissimus dorsi, etc. 3. Medical rotators : subscapularis, etc. 4. LateraI rotators : infraspinatus and teres minor. 5. Flexors or protractors: pectoralis major, biceps, coracobrachialis, serratus anterior, etc. 6. Extensors or retractors : Iatissimus dorsi, teres minor and infraspinatus. It is, however, a great mistake to award to one muscIe a singIe isolated action. The cortex thinks in terms of an action, not in terms of this or that muscle or group of muscIes, and, the action being determined, a group of muscles is summoned for its fulIiIment. The relation of the Iong head of the biceps to the shoulder joint should be noted. It passes as a rounded tendon through the intertubercular groove beneath the transverse humeral Iigament across the joint to insert into the supraglenoid tubercIe. It is invested with svnovial membrane. From its situation it acts to prevent the humeral head from being displaced either upward or downs-ard.
* Front the cIinic of the New York Orthopaedic Dispensary and flospital. Read before the Clinicaf the Connecticut State Medical Societ;v, Sept. 1gz8. 783
Congress
of
784
American
Journal
of Surgery
CIeveIand-Shoulder
Pain
Injury to this tendon is occasionaIIy the cause of a disabiIity in a basebaI1 pitcher.
unti1 the fuI1 range of shouIder joint is accomplished. Adduction with the arm hanging at the
FIG. I. ShaIIow pyriform glenoid fossa of scapuIa with tendon of Iong head of biceps attached to supraglenoid tubercIe above and long head of triceps attached beIow. DeItoid attached to acromion and cIavicIe is reflected, showing supraspinatus muscle directIy over gIenoid fossa.
FIG. 3. CapsuIe of shouIder joint from front. Its attachment to circumference of gIenoid and to anatomica neck of humerus may be seen. Extra socket formed by coracoid and acromion processes of scapuIa connected by coracoacromia1 ligament is shown. CoracocIavicuIar ligament with its conoid and trapezoid elements is also cIearIy seen.
MOTION
AT
THE
SHOULDER
JOINT
The shouIder joint is extremeIy dependent on other joints for its motion. The
FIG. 2. Small shallow gIenoid fossa in reIation to rather large rounded humera head. Tendon of Iong head of biceps is shown in relation to gIenoid and humera head. (From SpaItehoItz.)
scapuIa takes part in aImost a11 its motions, sharing in it from the start and not waiting
side is not free apart from the presence of the body. Abduction is possible to 90’ before the
FIG. 4. Window cut in capsuIe of shouIder joint from behind, with part of humera head resected to show front of cap&e with three gIenohumera1 thickenings. Long tendon of biceps is cIearIy shown.
capsuIe interferes. Forward and backward motions are checked by the acromion process. Rotation with the arm abducted is about 90~.
COSTRAST
OF
SHOULDER
AND
HIP
JOINTS
While the motion of the shoulder joint itself is not extensive, the arm enjoys an extremely wide range of motion, which leads to a brief contrast of the pectoral and pelvic girdIes. We find in the hip joint the femoral head deepIy socketed in the acetabulum formed by the three bones which comprise the pelvic girdle, the ilium, ischium and pubis. There is an actual negative pressure which resists an attempt to disIocate the joint and it is morphoIogitally stable. The pelvic girdle is soIidIy joined to the trunk bv the Iarge stabIe sacroiliac joint, which “in most instances has Iittle, if any, mobility. The posterior or inferior extremity is therefore idea1Iy designed for stability in weight-bearing. The range of motion possible in the hip joint is increased considerabIy by the Iong neck of the femur which props the inferior extremity away from the side of the body. In contrast to this tremendous stabiIity in the hip joint and pelvic girdIe, we see the shouIder or pectora1 girdle attached to the trunk mainIy by muscles, its onIy articulation being the SternocIavicuIar joint. The clavicle, acting as a prop to hoId the extremity away from the side of the body, increases the range of motion possibIe in the shouIder joint and scapuIa. This mechanism is quite idea1 to serve the tactiIe and prehensiIe Iingers with a wide range of motion, In a word, the contrast may’ be summed up as stability versus mobiIity. NERVE
SUPPLY
The shoulder joint receives its nerve suppIy through the suprascapular, axiIIary and subscapular nerves, mainIy from the fifth and sixth cervica1 roots. BURSAE
A bursa is primariIy a shock absorber situated between a bony point and the skin or between a bone and a muscIe or its tendon. There are a varying number of bursae adjacent to the shouIder joint.
There may be one beneath any or a11 of the muscles inserting into the tuberosities. Of the more constant bursae \ve find:
FIG. 5. 51. hlcG. No. 89840. 1926. DisIocation of right humerus, of six weeks’ duration, in woman aged seventy. Severe pain and inability to abduct arm. Head of humerus is seen beIow and‘in front of gIenoid fossa. I. The subacromia1 or subdeltoid is the largest, situated between the capsule and the coracoacromia1 Iigament and acromion process, extending beneath the deItoid muscIe. 2. The subcoracoid bursa lies between the coracoid process and the beginning of the coracohumeral Iigament and capsule. 3. The subscapular bursa lies between the tendon of insertion of the subscapularis muscIe and the capsuIe. To summarize briefIy the anatomical setting of the shoulder joint, we may note that it is a shaIIow ba11 and socket joint with a Ioose capsule, unstable in itseIf, depending for support on the surrounding muscuIature. Its apparent wide range of motion is largely due to the movement of the scapuIa and rest of the shouIder girdle. PAIN
FROM
EXTRA-SHOCLDEK
LESIONS
In dealing with shoulder pain we find a very considerabIe number of extra-shoulder lesions which are responsible for pain in the shoulder joint. The literature abounds
786
American Journal
of
Surgery
CIeveIand-Shoulder
with instances of these. The phrenic nerve arises from the third, fourth and fifth cervica1 nerves and pursues a long
Pain
APRIL, ,930
ing himself, for over a year, considered in turn neuritis, myositis, bursitis, arthritis, etc., which proved to be intradura1 tumor
FIG. 6. ScapuIa in which a new shouIder joint has been made by unreduced disIocation of hea d of hun lerus. A. New gIenoid fossa beneath overhanging coracoid process and to IateraI side of subscapuIar fossa. B. SmaII atrophic origina gIenoid fossa beIow acromion process with Iarge hypertrophied coracoid process in front of it. Note marked evidence of hypertrophic bone change.
course through upper thoracic aperture between the pleura and pericardium to spread out over the diaphragm. When we recaI1 that the nerve suppIy of the shouIder joint is from the fifth and sixth cervica1 nerves we see the intimate connection between these nerve paths. CardiovascuIar Iesions, pIeura1 and puImonary and mediastina Iesions and intra-abdominal Iesions are frequentIy the cause of shoulder pain. Much has been written of this symptom in gastric and duodena1 uIcers, gaI1 bladder disease and even in ruptured ectopic pregnancy. Conditions of a neuroIogica1 nature, invoIving the fifth and sixth nerve roots directIy, are aIso described. CervicaI Pott’s disease, arthritis of the cervica1 spine and cervica1 ribs may cause the phenomenon of shouIder pain. One of my coIIeagues, a neuroIogist, recently toId me of a case of severe shouIder-joint pain which had been treated by a number of physicians, incIud-
invoIving the fifth and sixth cervica1 roots. SurgicaI remova was folIowed by subsidence of symptoms. PAIN
FROM
LESIONS
WITHIN
THE
JOINT
Pain due to Iesions within the shouIder joint or adjacent to it affords opportunity for a number of observations. I was impressed with two recent papers on this subject by King and Ho1mes.l In a series of 450 painful shouIders studied by them, the roentgenograms were negative in 300. Of the remaining 150, nearly two-thirds were fractures or disIocations, with infections of various types suppIying the other third. I shouId like to emphasize one point which they made, namely, that a negative roentgenogram is of IittIe value 1 King, J. M., Jr., and HoImes, G. W. Diagnosis and treatment of 430 painfu1 shouIders. J. A. M. A., 89: 1915.
1927.
Review of 450 roentgenograms Am. J. Roentgenol., @ Rad. Tberap.,
of the shouIder. 17: 214, 1927.
Iru
~HKILS
\/CDL. VIII.
CIeveIand-ShouIder
No. +
in attempting to rule out arthritis or bursitis because the lesion is frequently entireIy in the soft parts.
F1c;. 7. Al. H. No. 5 1944. Fracture of greater tuberosity and anatomica neck of humerus in woman aged thirty-one years. Very painfu1 swoIlen shouIder, almost complete range of motion after three weeks and painless in two months. Massage and active motion only treatment. TRAUMA
AS
A
CAUSE
OF
PAIN
Dislocation. Of a11 large joints the shoulder is perhaps more frequentIy disIocated than any other. As we have noted, the shouIder relies for support on muscle tone. The accident happens so rapidIy that the muscles are taken off their guard and this support is lacking. Most of these dislocations occur with the arm abducted and extended, and the tear in the capsuIe occurs at its lower part with the humera head precipitated downward, inward and forward beneath the coracoid process (Fig. 3). OccasionaIIy these are never reduced and the humera head remains dislocated, with a stiff and painfu1, limited arc of motion for the extremity (Fig. 6). With a simple dislocation properIy reduced, the rent in the capsule tends to repair,
Pain
American
J~~urnxl
OS Surycrg
-87
and pain and disabihty in time disappear. Recurrent or habitua1 disIocations of the shouIder, where the capsuIe repairs imper-
FIG. 8. P. C. No. 90517. Fracture at surgical neck and epiphysea1 Iine of right humerus in boy of scvcn years.
fectIy, form a probIem of grave importance. The multiplicity of operative procedures recommended for this painful disability bears eIoquent testimony to the serious nature of the task. Fractures of the anatomical neck and of the greater tuberosity are of frequent occurrence and occasionally are coincident with dislocation (Figs. 7-9). It is unwise to attempt to reduce a disIocation without having a roentgenogram of the shoulder if this is possible to obtain. WhiIe on the subject of fractures, one frequentIy sees a stiff and painful shoulder foIIowing prolonged immobiIization or disuse of the shouIder joint following a niceIy reduced Colles’ fracture. Any patient beyond middIe age with a fracture of the
788
American
Journal
of Surgery
CIeveIand-ShouIder
upper extremity should exercise the shouIder joint as often as possibIe. If the joint has to be immobiIized, fuI1 abduc-
FIG. 9. A. Q. No. 88301.
Boy of six years with fracture through bone cyst of upper third of shaft of humerus. Severe pain in shoulder and just betow it. SoIid union in five weeks. A type of fracture occasionaIIy seen.
tion should be considered the position of choice. Bursitis is middIe ground between trauma and infection. Any of the adjacent bursae may become inflamed but the one most often invoIved is the subdeItoid or subacromia1 bursa. Subdeltoid bursitis seems to faI1 into two types. In the first type an initia1 trauma : a small tear in the tendon of the supraspinatus muscIe sets up an inffammation. In the other type infection per se seems to pIay the important role. A chiIIing of the shouIder such as might foIIow an automobire ride is fohowed by the characteristic symptoms, pain on abduction of the arm and tenderness over the bursa.
Pain
APRIL. ,930
The tender spot disappears when the arm is abducted fuIIy and the bursa roIIs beneath the acromion process. On Iowering the arm as it passes 90’ there is a painfu1 catch as the bursa roIIs out again. During the acute stage these patients are most comfortabIe with the arm abducted. In most acuteIy painfu1 shouIders, the position of abduction gives tremendous reIief and abduction together with traction is frequentIy advisabIe. In the chronic stage at times caIcifications form within the bursa and their operative remova has been recommended. In our hands the benefit from this procedure has been insufficient to warrant its use. These calcifications tend to disappear with the subsidence of symptoms. (See Figs. 10-13.) Our treatment is conservative, with attention paid to the various foci of infection which may be at fauIt. Neuritis. A true neuritis affecting the shouIder joint would involve the fifth and sixth cervical nerves through the suprascapuIar and axiIIary nerves principaIIy. This is occasionaIIy seen fohowing trauma such as cutting, tearing or gunshot wounds, fractures or disIocations. Pressure from a cervica1 rib or a crutch may be a factor to be reckoned with. Myositis. A traumatic myositis such as foIIows a tear of the deItoid muscle is an extremeIy painfu1 disabihty. INFECTIONS
Of the specific chronic infections of the shotrIder joint tubercuIosis occasionalIy occurs, but the incidence is smaI1. The weight-bearing joints are invaded by the tubercIe bacillus about nine times as frequently as are the non-weightbearing joints. The presence of tuberculosis is manifested by pain, spasm, atrophy, proceeding to actua1 destruction of the joint. (See Fig. 11.) The IocaI manifestation is almost invariabIy evidence that the patient has tubercuIosis in active or latent form eIsewhere. The treatment is primarily rest, and the most effective means of securing rest in the joint is by operative fusion. Tuberculosis.
Among the acute supOsteomvelitis. purative -infections of this region is osteoof the myelitis of the upper extremity
Iized at :o” to 80” of abduction, qiG of medial rotation and of flexion, as this is the most useful position.
FIG. 10. September z, 1928. Patient came to hospita1 compIaining of steady severe pain in Ieft shoulder for two or three days and occasional pain for one month previous. X-ray shows two caIcifications within subdcltoid bursa.
FIG. II. September 14, 1928. Symptoms cakifications increased in size and density.
FIG. I 2. October I, 1928. Very IittIe pain in shoulder. Large caIcitication has whoIIy disappeared and smaller 0nIy persists as minute spot.
FIG. 13. October 19, 1928. Shoulder now symptomlcss. Large CaIcifrcation gone, small one still present.
unchanged, drcrcased in
FIGS. 10-13. F. F., maIe aged thirty-two. Series showing rapid disappearance of calcifications within subdeltoid bursa in a month and a half, while massage and rest in a sling W:IS only therapeutic measure empIoycd.
humerus. If this is not promptIy drained it wiIl extend into the shouIder joint and destroy it (Fig. rjj. If the shouIder joint has been destroyed and bony ankyIosis is anticipated the arm should be immobi-
Arthritis. One approaches of arthritis with a feeIing of when we pause to reahze physicians are able to heIp A large percentage of those
the subject deep humility how littIe we the arthritic. patients who
790
AmericanJournaIof Surgery
CIeveIand-ShouIder
come to us compIaining of pain in the shouIder joint wiII be suffering from arthritis of one form or another. Our dispen-
Pain
type. Elimination of the foci of infection seems to have IittIe or no effect. The proIiferative type of arthritis, with marked
FIG. 15. J. McC. No. 93247. 1926. rative arthritis of shouIder joint years. Disease was acute ten X-ray shows irreguIar reparative with residua1 sepsis.
FIG. 14. R. S. No. 40603. 1927. TubercuIosis of right shoulder joint in ten-year-oId boy; severe pain, atrophy and muscIe spasm. Destruction of humera head is to be noted.
saries are crowded with this army of arthritics, a few are heIped here and there but the buIk of them pass from clinic to cIinic seeking the rehef which they seldom find. The patient complains of a painfuI shoulder. On examination there is crepitation within the joint, a littIe spasm on motion, and some atrophy. The roentgenogram may show a few spurs, or may be quite negative. The acromioclavicular joint is often the first in the shoulder girdle to show these changes. This is the arthritis of middle age, the so-cahed degenerative
APRIL,1930
ResuIt of suppuin boy of thirteen years previously. changes consistent
atrophy, pain and often pretty compIete disabiIity in the shouIder joint, one sees Iess frequentIy. In this type the foci of infection are of very great importance and must be carefuIly studied. In cIosing this discussion I frankIy admit that I have made no attempt to present an exhaustive treatise on shoulder-joint pain. I have omitted doubtIess many important causes of this symptom and perhaps stressed some unimportant facts. As physicians we must not lose sight of the individual with the pain, in our effort to analyse this symptom. The shotrIder joint is a beautiful mechanism, admirably adapted for its intended purpose, but it is not isoIated and its pains and aches are not isolated problems but are intimateIy bound up with the weIfare of the patient who consuIts us.
I
N order to reach an understanding of the various Iesions responsible for shotrIder pain, some conception of the anatomy and physioIogy of the shouIder joint is essentia1. I propose to review some of its anatomic features, using specimens recentIy prepared in the department of anatomy at Columbia University. The shouIder joint is an enarthrodia1 diarthrosis, or baII-and-socket joint, with motion in three pIanes at right angles to each other. The articuIating surfaces are the rounded head of the humerus and the shahow pyriform gIenoid fossa of the scapula. At first sight one can readiIy appreciate the fact that the gIenoid fossa does not accommodate or embrace the humeral head and the joint is therefore not a stabIe one by its conformation. The capsuIe is a Ioose structure attached around the circumference of the gIenoid and the anatomica neck of the humerus. In a macerated preparation there is considerable pIay between articuIar surfaces owing to the Iength of the capsme. The ligaments of any joint are mereIy thickenings or reenforcements of the capsule in response to stress and strain. The capsuIe of the shouIder joint is reenforced in front by the three gleno-humera Iigaments because the greatest strain is pIaced upon the capsuIe by hyperextension of the arm. The capsuIe is further strengthened b!- the coracohumera1 Iigament which extends from the base of the coracoid process of the scapuIa to the greater tuberosity of the humerus. The two projecting bony processes of the scapuIa, the coracoid and acromion, connected by the coracoacromia1 Iigament serve as an extra socket for the head of the humerus. They tend to protect the joint from minor injuries and in a measure
keep the deltoid (See Figs. 1-4.)
muscIe
off the capsuIe.
MUSCLES The joint is surrounded by powerfu1 muscles whose balanced tone keeps the articuJar surfaces in contact. One has onIy to observe a shoulder joint affected with the humeral head by poIiomyeIitis, faIIing we11 below the acromion process, to appreciate this action of the musculature in stabiIizing the joint. Of the muscIes acting on the shouIder joint we recognize six groups by their action; there is, of course, some 0verIapping of function in certain muscIes : I. Abductors: deItoid and supraspinatus. 2. Adductors: pectoralis major, teres major, Iatissimus dorsi, etc. 3. Medical rotators : subscapularis, etc. 4. LateraI rotators : infraspinatus and teres minor. 5. Flexors or protractors: pectoralis major, biceps, coracobrachialis, serratus anterior, etc. 6. Extensors or retractors : Iatissimus dorsi, teres minor and infraspinatus. It is, however, a great mistake to award to one muscIe a singIe isolated action. The cortex thinks in terms of an action, not in terms of this or that muscle or group of muscIes, and, the action being determined, a group of muscles is summoned for its fulIiIment. The relation of the Iong head of the biceps to the shoulder joint should be noted. It passes as a rounded tendon through the intertubercular groove beneath the transverse humeral Iigament across the joint to insert into the supraglenoid tubercIe. It is invested with svnovial membrane. From its situation it acts to prevent the humeral head from being displaced either upward or downs-ard.
* Front the cIinic of the New York Orthopaedic Dispensary and flospital. Read before the Clinicaf the Connecticut State Medical Societ;v, Sept. 1gz8. 783
Congress
of
784
American
Journal
of Surgery
CIeveIand-Shoulder
Pain
Injury to this tendon is occasionaIIy the cause of a disabiIity in a basebaI1 pitcher.
unti1 the fuI1 range of shouIder joint is accomplished. Adduction with the arm hanging at the
FIG. I. ShaIIow pyriform glenoid fossa of scapuIa with tendon of Iong head of biceps attached to supraglenoid tubercIe above and long head of triceps attached beIow. DeItoid attached to acromion and cIavicIe is reflected, showing supraspinatus muscle directIy over gIenoid fossa.
FIG. 3. CapsuIe of shouIder joint from front. Its attachment to circumference of gIenoid and to anatomica neck of humerus may be seen. Extra socket formed by coracoid and acromion processes of scapuIa connected by coracoacromia1 ligament is shown. CoracocIavicuIar ligament with its conoid and trapezoid elements is also cIearIy seen.
MOTION
AT
THE
SHOULDER
JOINT
The shouIder joint is extremeIy dependent on other joints for its motion. The
FIG. 2. Small shallow gIenoid fossa in reIation to rather large rounded humera head. Tendon of Iong head of biceps is shown in relation to gIenoid and humera head. (From SpaItehoItz.)
scapuIa takes part in aImost a11 its motions, sharing in it from the start and not waiting
side is not free apart from the presence of the body. Abduction is possible to 90’ before the
FIG. 4. Window cut in capsuIe of shouIder joint from behind, with part of humera head resected to show front of cap&e with three gIenohumera1 thickenings. Long tendon of biceps is cIearIy shown.
capsuIe interferes. Forward and backward motions are checked by the acromion process. Rotation with the arm abducted is about 90~.
COSTRAST
OF
SHOULDER
AND
HIP
JOINTS
While the motion of the shoulder joint itself is not extensive, the arm enjoys an extremely wide range of motion, which leads to a brief contrast of the pectoral and pelvic girdIes. We find in the hip joint the femoral head deepIy socketed in the acetabulum formed by the three bones which comprise the pelvic girdle, the ilium, ischium and pubis. There is an actual negative pressure which resists an attempt to disIocate the joint and it is morphoIogitally stable. The pelvic girdle is soIidIy joined to the trunk bv the Iarge stabIe sacroiliac joint, which “in most instances has Iittle, if any, mobility. The posterior or inferior extremity is therefore idea1Iy designed for stability in weight-bearing. The range of motion possible in the hip joint is increased considerabIy by the Iong neck of the femur which props the inferior extremity away from the side of the body. In contrast to this tremendous stabiIity in the hip joint and pelvic girdIe, we see the shouIder or pectora1 girdle attached to the trunk mainIy by muscles, its onIy articulation being the SternocIavicuIar joint. The clavicle, acting as a prop to hoId the extremity away from the side of the body, increases the range of motion possibIe in the shouIder joint and scapuIa. This mechanism is quite idea1 to serve the tactiIe and prehensiIe Iingers with a wide range of motion, In a word, the contrast may’ be summed up as stability versus mobiIity. NERVE
SUPPLY
The shoulder joint receives its nerve suppIy through the suprascapular, axiIIary and subscapular nerves, mainIy from the fifth and sixth cervica1 roots. BURSAE
A bursa is primariIy a shock absorber situated between a bony point and the skin or between a bone and a muscIe or its tendon. There are a varying number of bursae adjacent to the shouIder joint.
There may be one beneath any or a11 of the muscles inserting into the tuberosities. Of the more constant bursae \ve find:
FIG. 5. 51. hlcG. No. 89840. 1926. DisIocation of right humerus, of six weeks’ duration, in woman aged seventy. Severe pain and inability to abduct arm. Head of humerus is seen beIow and‘in front of gIenoid fossa. I. The subacromia1 or subdeltoid is the largest, situated between the capsule and the coracoacromia1 Iigament and acromion process, extending beneath the deItoid muscIe. 2. The subcoracoid bursa lies between the coracoid process and the beginning of the coracohumeral Iigament and capsule. 3. The subscapular bursa lies between the tendon of insertion of the subscapularis muscIe and the capsuIe. To summarize briefIy the anatomical setting of the shoulder joint, we may note that it is a shaIIow ba11 and socket joint with a Ioose capsule, unstable in itseIf, depending for support on the surrounding muscuIature. Its apparent wide range of motion is largely due to the movement of the scapuIa and rest of the shouIder girdle. PAIN
FROM
EXTRA-SHOCLDEK
LESIONS
In dealing with shoulder pain we find a very considerabIe number of extra-shoulder lesions which are responsible for pain in the shoulder joint. The literature abounds
786
American Journal
of
Surgery
CIeveIand-Shoulder
with instances of these. The phrenic nerve arises from the third, fourth and fifth cervica1 nerves and pursues a long
Pain
APRIL, ,930
ing himself, for over a year, considered in turn neuritis, myositis, bursitis, arthritis, etc., which proved to be intradura1 tumor
FIG. 6. ScapuIa in which a new shouIder joint has been made by unreduced disIocation of hea d of hun lerus. A. New gIenoid fossa beneath overhanging coracoid process and to IateraI side of subscapuIar fossa. B. SmaII atrophic origina gIenoid fossa beIow acromion process with Iarge hypertrophied coracoid process in front of it. Note marked evidence of hypertrophic bone change.
course through upper thoracic aperture between the pleura and pericardium to spread out over the diaphragm. When we recaI1 that the nerve suppIy of the shouIder joint is from the fifth and sixth cervica1 nerves we see the intimate connection between these nerve paths. CardiovascuIar Iesions, pIeura1 and puImonary and mediastina Iesions and intra-abdominal Iesions are frequentIy the cause of shoulder pain. Much has been written of this symptom in gastric and duodena1 uIcers, gaI1 bladder disease and even in ruptured ectopic pregnancy. Conditions of a neuroIogica1 nature, invoIving the fifth and sixth nerve roots directIy, are aIso described. CervicaI Pott’s disease, arthritis of the cervica1 spine and cervica1 ribs may cause the phenomenon of shouIder pain. One of my coIIeagues, a neuroIogist, recently toId me of a case of severe shouIder-joint pain which had been treated by a number of physicians, incIud-
invoIving the fifth and sixth cervica1 roots. SurgicaI remova was folIowed by subsidence of symptoms. PAIN
FROM
LESIONS
WITHIN
THE
JOINT
Pain due to Iesions within the shouIder joint or adjacent to it affords opportunity for a number of observations. I was impressed with two recent papers on this subject by King and Ho1mes.l In a series of 450 painful shouIders studied by them, the roentgenograms were negative in 300. Of the remaining 150, nearly two-thirds were fractures or disIocations, with infections of various types suppIying the other third. I shouId like to emphasize one point which they made, namely, that a negative roentgenogram is of IittIe value 1 King, J. M., Jr., and HoImes, G. W. Diagnosis and treatment of 430 painfu1 shouIders. J. A. M. A., 89: 1915.
1927.
Review of 450 roentgenograms Am. J. Roentgenol., @ Rad. Tberap.,
of the shouIder. 17: 214, 1927.
Iru
~HKILS
\/CDL. VIII.
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in attempting to rule out arthritis or bursitis because the lesion is frequently entireIy in the soft parts.
F1c;. 7. Al. H. No. 5 1944. Fracture of greater tuberosity and anatomica neck of humerus in woman aged thirty-one years. Very painfu1 swoIlen shouIder, almost complete range of motion after three weeks and painless in two months. Massage and active motion only treatment. TRAUMA
AS
A
CAUSE
OF
PAIN
Dislocation. Of a11 large joints the shoulder is perhaps more frequentIy disIocated than any other. As we have noted, the shouIder relies for support on muscle tone. The accident happens so rapidIy that the muscles are taken off their guard and this support is lacking. Most of these dislocations occur with the arm abducted and extended, and the tear in the capsuIe occurs at its lower part with the humera head precipitated downward, inward and forward beneath the coracoid process (Fig. 3). OccasionaIIy these are never reduced and the humera head remains dislocated, with a stiff and painfu1, limited arc of motion for the extremity (Fig. 6). With a simple dislocation properIy reduced, the rent in the capsule tends to repair,
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and pain and disabihty in time disappear. Recurrent or habitua1 disIocations of the shouIder, where the capsuIe repairs imper-
FIG. 8. P. C. No. 90517. Fracture at surgical neck and epiphysea1 Iine of right humerus in boy of scvcn years.
fectIy, form a probIem of grave importance. The multiplicity of operative procedures recommended for this painful disability bears eIoquent testimony to the serious nature of the task. Fractures of the anatomical neck and of the greater tuberosity are of frequent occurrence and occasionally are coincident with dislocation (Figs. 7-9). It is unwise to attempt to reduce a disIocation without having a roentgenogram of the shoulder if this is possible to obtain. WhiIe on the subject of fractures, one frequentIy sees a stiff and painful shoulder foIIowing prolonged immobiIization or disuse of the shouIder joint following a niceIy reduced Colles’ fracture. Any patient beyond middIe age with a fracture of the
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upper extremity should exercise the shouIder joint as often as possibIe. If the joint has to be immobiIized, fuI1 abduc-
FIG. 9. A. Q. No. 88301.
Boy of six years with fracture through bone cyst of upper third of shaft of humerus. Severe pain in shoulder and just betow it. SoIid union in five weeks. A type of fracture occasionaIIy seen.
tion should be considered the position of choice. Bursitis is middIe ground between trauma and infection. Any of the adjacent bursae may become inflamed but the one most often invoIved is the subdeItoid or subacromia1 bursa. Subdeltoid bursitis seems to faI1 into two types. In the first type an initia1 trauma : a small tear in the tendon of the supraspinatus muscIe sets up an inffammation. In the other type infection per se seems to pIay the important role. A chiIIing of the shouIder such as might foIIow an automobire ride is fohowed by the characteristic symptoms, pain on abduction of the arm and tenderness over the bursa.
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The tender spot disappears when the arm is abducted fuIIy and the bursa roIIs beneath the acromion process. On Iowering the arm as it passes 90’ there is a painfu1 catch as the bursa roIIs out again. During the acute stage these patients are most comfortabIe with the arm abducted. In most acuteIy painfu1 shouIders, the position of abduction gives tremendous reIief and abduction together with traction is frequentIy advisabIe. In the chronic stage at times caIcifications form within the bursa and their operative remova has been recommended. In our hands the benefit from this procedure has been insufficient to warrant its use. These calcifications tend to disappear with the subsidence of symptoms. (See Figs. 10-13.) Our treatment is conservative, with attention paid to the various foci of infection which may be at fauIt. Neuritis. A true neuritis affecting the shouIder joint would involve the fifth and sixth cervical nerves through the suprascapuIar and axiIIary nerves principaIIy. This is occasionaIIy seen fohowing trauma such as cutting, tearing or gunshot wounds, fractures or disIocations. Pressure from a cervica1 rib or a crutch may be a factor to be reckoned with. Myositis. A traumatic myositis such as foIIows a tear of the deItoid muscle is an extremeIy painfu1 disabihty. INFECTIONS
Of the specific chronic infections of the shotrIder joint tubercuIosis occasionalIy occurs, but the incidence is smaI1. The weight-bearing joints are invaded by the tubercIe bacillus about nine times as frequently as are the non-weightbearing joints. The presence of tuberculosis is manifested by pain, spasm, atrophy, proceeding to actua1 destruction of the joint. (See Fig. 11.) The IocaI manifestation is almost invariabIy evidence that the patient has tubercuIosis in active or latent form eIsewhere. The treatment is primarily rest, and the most effective means of securing rest in the joint is by operative fusion. Tuberculosis.
Among the acute supOsteomvelitis. purative -infections of this region is osteoof the myelitis of the upper extremity
Iized at :o” to 80” of abduction, qiG of medial rotation and of flexion, as this is the most useful position.
FIG. 10. September z, 1928. Patient came to hospita1 compIaining of steady severe pain in Ieft shoulder for two or three days and occasional pain for one month previous. X-ray shows two caIcifications within subdcltoid bursa.
FIG. II. September 14, 1928. Symptoms cakifications increased in size and density.
FIG. I 2. October I, 1928. Very IittIe pain in shoulder. Large caIcitication has whoIIy disappeared and smaller 0nIy persists as minute spot.
FIG. 13. October 19, 1928. Shoulder now symptomlcss. Large CaIcifrcation gone, small one still present.
unchanged, drcrcased in
FIGS. 10-13. F. F., maIe aged thirty-two. Series showing rapid disappearance of calcifications within subdeltoid bursa in a month and a half, while massage and rest in a sling W:IS only therapeutic measure empIoycd.
humerus. If this is not promptIy drained it wiIl extend into the shouIder joint and destroy it (Fig. rjj. If the shouIder joint has been destroyed and bony ankyIosis is anticipated the arm should be immobi-
Arthritis. One approaches of arthritis with a feeIing of when we pause to reahze physicians are able to heIp A large percentage of those
the subject deep humility how littIe we the arthritic. patients who
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come to us compIaining of pain in the shouIder joint wiII be suffering from arthritis of one form or another. Our dispen-
Pain
type. Elimination of the foci of infection seems to have IittIe or no effect. The proIiferative type of arthritis, with marked
FIG. 15. J. McC. No. 93247. 1926. rative arthritis of shouIder joint years. Disease was acute ten X-ray shows irreguIar reparative with residua1 sepsis.
FIG. 14. R. S. No. 40603. 1927. TubercuIosis of right shoulder joint in ten-year-oId boy; severe pain, atrophy and muscIe spasm. Destruction of humera head is to be noted.
saries are crowded with this army of arthritics, a few are heIped here and there but the buIk of them pass from clinic to cIinic seeking the rehef which they seldom find. The patient complains of a painfuI shoulder. On examination there is crepitation within the joint, a littIe spasm on motion, and some atrophy. The roentgenogram may show a few spurs, or may be quite negative. The acromioclavicular joint is often the first in the shoulder girdle to show these changes. This is the arthritis of middle age, the so-cahed degenerative
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ResuIt of suppuin boy of thirteen years previously. changes consistent
atrophy, pain and often pretty compIete disabiIity in the shouIder joint, one sees Iess frequentIy. In this type the foci of infection are of very great importance and must be carefuIly studied. In cIosing this discussion I frankIy admit that I have made no attempt to present an exhaustive treatise on shoulder-joint pain. I have omitted doubtIess many important causes of this symptom and perhaps stressed some unimportant facts. As physicians we must not lose sight of the individual with the pain, in our effort to analyse this symptom. The shotrIder joint is a beautiful mechanism, admirably adapted for its intended purpose, but it is not isoIated and its pains and aches are not isolated problems but are intimateIy bound up with the weIfare of the patient who consuIts us.