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The painful shoulder.

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CURRENT METHODS OF TREATMENT
The Painful Shoulder
By THEODORE
B. BAYLES
W
E ARE concerned with pain in the shoulder area, and the possible
causes of this disorder make up a formidable list in view of the multiple
structures involved and the possible pathogenic mechanisms which may be
operating in any one of these structures. When one considers that there are
at least seventeen muscles and tendons, several bursae, several nerves, many
blood vessels and four joints involved in the shoulder mechanism and any one
or more of these may have degenerative, inflammatory or metabolic disorders
of a local or systemic nature, an exact working diagnosis may be difficult to
attain. Despite the complexity of the problem, the physician should carefully
analyze the problem and make at least a working diagnosis before instituting
therapy. Only about 5 per cent of painful shoulders are due to actual joint
disease, and the great majority of the rest are due to rather nonspecific degenerative changes in the other connective tissue structures, i.e., muscles,
tendons, tendon sheaths and bursae, so that one can strain toward a working
diagnosis and proceed with some assurance in therapy. An exact and detailed
history of past and present generalized diseases or of previous local pain syndromes is of crucial importance. Careful physical examination of the whole
patient and the shoulder, including inspection, careful palpation for areas of
tenderness in tendons, bursae or even trigger points in the region of the
scapula should be carried out. Active and passive motion of the shoulder joint
and of the scapular motion should be studied with care so that the exact
localization of the painful disorder can be ascertained. The treatment of degenerative local disease is usually quite different from that of rheumatoid inflammation of one of the shoulder bursae, and such involvement is often one
of the earliest symptoms cf rheumatoid arthritis. Roentgenologic studies are
essential to accurate diagnosis, but here again, for example, only one-third of
calcific deposits in tendons and bursae about the shoulder are causally related to symptcms about the shoulder and one should not be misled by the
diagncs;s of the radiologist which may play no part in the painful shoulder.
Finally, extrinsic causes, such as reflex sympathetic dystrophy of the upper
extremity I the shoulder-hand syndrome) which seems to result from viscerosensory afferent pain, will give the clinical impression of “bursitis,” i.e.,
shculder pain and stiffness, even though the underlying cause may be distant
in cervical arthritis, coronary heart disease with angina or visceral pain from
other systems in the neck and chest. I hope these complexities will not deter
the reader from making a diagnosis before treating the patient.
Since inflammation of connective tissue structures, usually degenerative, is
_____~_____________________
From the Departmont of Medicine, Haroard Medical School and the Medical Services,
Robert B . Brigham Hospital and Peter Bent Brigham Hospital, Boston, Mass.
272
ARTHRITIS& RHEUMATISM,VOL.5, No. 3
(JUNE),
1962
THE PAINFUL SHOULDER
273
the commonest cause of pain, the plan of treatment consists of antiphlogistic,
analgesic and rehabilitation measures:
Rest. It is most important that both the patient and the shoulder have rest.
This can be carried out at home but often better in the hospital. When the
patient is up, the use of a sling is often helpful and in very acute problems,
after the sling has been applied, rarely, strapping the arm to the chest wall is
necessary. With such immobilization of the shoulder areas there is a real
danger of loss of motion and, if it is possible, passive motion at least should be
used three times a day to maintain shouIder mobility.
Relief of p i n . Analgesics of various kinds up to and including narcotics
are essential to the plan of treatment of the painful shoulder. Pain must be
relieved, and some competent observers feel that morphine in a rather Iarge
dose is often the proper treatment of acute bursitis. Since all shoulder pain
does not require morphine, my own program consists of giving a basic analgesic
amount of salicylate usually in the form of acetyl salicylic acid, plain or buffered, up to the point of salicylism and then dropped slightly below this level.
Salicylates are often exhibited without producing any worth-while therapeutic effect, and this is a relatively useless procedure. In mild cases my next
choice of analgesic is Phenacetin, 0.3 or 0.6 Gm., every 3 or 4 hours around
the clock, and properly given this is often quite effective. Next choice of analgesic is Dextro Propoxyphene Hydrochloride (Darvon) and to relieve pain in
a more severe case 130 mg. every 3 hours is not excessive. Codeine is often
useful in 30 or 60 mg. doses every 3 or 4 hours. If pain is not relieved, one
moves ahead with analgesics, with Meperidine Hydrochloride ( Demerol) by
mouth or subcutaneously in 100 mg. doses every 3 or 4 hours. If this does not
relieve pain, the use of morphine in 15 or 30 mg. doses every 3 or 4 hours may
be necessary. Relief of pain by analgesics diminishes muscle spasm and has a
dramatic favorable effect on the course of the acute severe painful shoulder.
During this period of drug treatment, the patient should be told firmly and
honestly that the condition is self-limited and that the acute attack can be
relieved.
Anti-inflammatory measures. Since pain may well be coming from an inflammatory lesion in the tendon, bursa, or muscles, our next consideration is
with antiphlogistic agents since this may be the quickest way to relieve pain
and muscle spasm. I use antiphlogistics in this order: (1). salicylates administered as above ( 2 ) . phenylbutazone 400 to 800 mg. a day ( 3 ) . glucocorticoids for short periods of trial, up to 200 mg. of hydrocortisone or 40 mg.
of prednisone in equally divided doses daily. At times adrenocorticotrophic
hormone injections (40 to 80 units daily) are indicated or even intravenous
adrenocorticotrophic hormone (20 units in 500 cc. of 5 per cent dextrose over
an 8 hour period). The latter probably produces a high level of circulating
glucocorticoids in the body and therefore is a most effective way of administering glucocorticoids. One word of warning: some commercial preparations of
adrenocorticotrophic hormone are inactive and the physician has to be sure
that he is using an active agent. As a final method of antiphlogistic therapy in
the painful shoulder and in instances of markedly localized pain, perhaps the
most useful is the local injection of novocaine and hydrocortisone acetate in
274
DISCUSSIONS
aqueous suspension (25 to 100 mg) or the newer analogues directly into the
area of maximum tenderness as determined by physical examination. Do
not inject into the area of x-ray examination or into an area which is a theoretical source of trouble; inject into the tenderest area. It is useful to have the
x-ray film available at the time of injection, but it should not determine the
area injected. Many procedures, such as washing through of the bursa, have
been advocated in acute bursitis associated with calcific tendonitis, but my
belief is that the needling and changes in local circulation and tissue pressures
are more important than what is injected. As a final rule, failure of any of the
analgesics or antiphlogistic agents to relieve pain and inflammation in 48
hours requires the institution of the next and more potent agent.
The severity of the clinical syndrome will determine the order of these
regimens, and in an acute severe problem one may qo directly to morphine and
local adrenocorticoid injection without determining the efficacy of less efficient methods. After relief of pain a vigorous program of passive and active
exercises for the shoulder may be of paramount importance to re-establish normal motion and use. In patients with a low threshold for pain, a physiotherapist,
physician or member of the family should assist with the passive exercises and
they should be carried out firmly. Rarely, acute bursitis may have to be surgically explored and drained.
I cannot stress too emphatically the need for prompt and decisive therapy
to prevent chronic constrictive bursitis (or “frozen” shoulder syndrome) which
Codman in his classical book on “The Shoulder” described as “difficult to
define, difficult to treat, and difficult to explain from the point of view of pathology.” With this encouraging introduction we may discuss treatment of the
“frozen” shoulder. If intrinsic joint disease is absent one should be able to get
full range of motion after weeks or months of hard work by the patient, physiotherapist, the patient’s family, and the physician. Prior to manipulation under
anaesthesia the program consists of local injection of glucocorticoids, passive
stretching, active stretching with the help of pulleys and ropes on the patient’s
bed or in a suitable doorway. Persistence and patience are the essential ingredients in this program, but if no progress is being made, I believe firm manipulation of the shoulder under anaesthesia in the hospital is indicated. After this
procedure a full course of analgesics and antiphlogistic agents should be continued and relief of pain is essential to the rehabilitation program after manipulation. If the treatment is not complete and intensive after the manipulation,
the shoulder soon becomes frozen again.
Finally, unless there is permanent damage in the shoulder joint, the physician
may approach the treatment of the painful shoulder with optimism as in the
vast majority of cases the pain and limitation of motion can be relieved.
DISCUSSIONS
DR. BAYLEShas concisely telescoped the
presently accepted ideas on the subject. I
can present here only a few observations
and emphases from a different viewpoint.
The painful shoulder most frequently is of
a transient, intercurrent postinfectious or
W E PAINFUL SHOULDER
traumatic origin. The troublesome, nonarthritic, painful shoulder considered here
immediately raises the question whether it
is due to involvement of the shoulder structures originating locally (intrinsic) or to
distant pathology (extrinsic) producing referred or reflex symptoms there. Sometimes
both intrinsic and extrinsic factors are responsible. The most common extrinsic cause
is degenerative disease of the cervical vertebrae and discs. The intrinsic types of
painful shoulder are: lesions of the musculotendinous cuff, calcific tendinitis ( and
bursitis ) , bicipital tenosynovitis, scapulohumeral capsulitis (frozen shoulder), and
the shoulder-hand syndrome. Degenerative
processes of the connective tissue underlie
nearly all of them, but simultaneous or
superimposed acute or low grade inflammation activates the symptoms. They are presented therefore in acute, subacute, or
chronic form. These disorders are identified
by accepted clinical characteristics, and certain therapeutic measures are more effective
in each.
Calcific tendinitis or bursitis in acute
form nearly invariably is self-limiting, SO
the measures used should be as simple as
the patient’s understanding and tolerance
permit. In acute or subacute stages local
injection at the calcific tendinitis or bicipital tendon now constitutes the simplest,
most direct approach. When the calcification
is under the acromion, where it occurs most
frequently, injection into a tender point
inferior to the acromion, instead of beneath
it, is apt to prove ineffective. The really
acute or hyperacute condition requires deliberate care, gentle anesthesia of the skin,
and introduction of procaine ( 1 per cent,
5 to 10 cc.) before injection of the corticosteroid solution, or preferably hospitalization overnight for the more comforting care
and bedside procedure it permits. In scapulohumeral capsulitis ( frozen shoulder ) manipulation still is regarded generally as a
traumatic procedure with benefits of doubtful duration. Recent studies report better
results when the manipulation is combined
with intraarticular or periarticular introduction of a corticosteroid or its systemic administration. Injection of corticosteroid at
a set of three points-subacromially, intraarticularly and at the bicipital tendon-has
been found effective by one group. It is a
275
promising but heroic method requiring
further observations.
Exercise is the most helpful physical
measure in all the intrinsic disorders of the
shoulder. In acute conditions, such as calcific tendinitis, a respite from exercise is
indicated until good control of pain has
been obtained. In this disorder spontaneous
recovery of function occurs gradually within 1 to 5 weeks, after the acute discomfort
has improved or resolved. In slower recovery, as well as in subacute or chronic
conditions, passive and active movements
on a graded basis within the bounds of
tolerance are systematically employed.
The shoulder-hand syndrome usually is
of extrinsic origin but develops intrinsic
changes: the features of a “frozen shoulder”
in combination with a Sudeck-like state, or
reflex dystrophy, of the hand.
All these painful disabilities tend to produce a chronic symptom-picture, with natural, long term recovery as a rule. A small
percentage ( 5 to 15 per cent) of irreversible
disability may occur. The purposes of treatment, therefore, are to relieve pain, (not
to increase it with poor timing of exercises
and physical modalities), to shorten the
period of disability, and to prevent or
overcome potentially irreversible changes.
Whether the disturbance is acute, subacute,
or chronic, the choice of procedures mentioned by Dr. Bayles and their avoidance
must be guided by the likely outcome, the
patient’s sensitivity to pain and the peculiarities of a short-lived or prolonged, greatly
troublesome or low grade, inflammatory
process.
OTTOSTEINBROCKER
THEOPENINGof this article, stating that
there are at least seventeen muscles and
tendons involved in the shoulder-joint
mechanism, was most stimulating. However, the subsequent discussion of drug
therapy was based upon the working diagnosis of a “painful shoulder,” rather than
upon any anatomic one. With any musculoskeletal disease or disturbance, it is important both in our clinical practice and
teaching, that their treatment should be
based upon knowledge of anatomic structures and their function. For example, the
supraspinatus muscle initiates the first 35
degrees of abduction at the shoulder joint
DISCUSSIONS
with the deltoid muscle completing the final
55 degrees of abduction. Therefore, any
disease in the supraspinatus muscle, such
as a tendonitis, with or without calcification,
will result in a painful abduction arc during
the first 35 degrees of movement, whereas
a subacromial bursitis will present as a
painful abduction arc between 45 and 90
degrees when the bursa is ‘‘cushioning” the
greater tuberosity of the humerus. Further
abduction and elevation of the upper extremity beyond this range will produce pain
in the acromioclavicular joint if it is diseased. These clinical features help to confirm a local disease process rather than
symptoms being referred from disease elsewhere.
X-ray examination is emphasized for an
accurate diagnosis, but it is also important
to exclude other pathology such as a primary or secondary malignancy. Indeed, it
has been the writer’s experience during the
last 6 months, to see, in the head of the
humerus, a chondrosarcoma and a metastasis from an adenocarcinoma presenting
as a “painful shoulder.” It would be of interest to learn about Dr. Bayles’ series in
which only one-third of calcific depo;its
about the shoulder were causally related
to symptoms, especially as regards the
diagnosis in the other two-thirds of the
cases.
In the treatment described, there is rightly emphasis on proper rest of the limb, but
a minor point in its immobilization is to
support the weight of the upper arm by
bandaging around and below the elbow.
It should be emphasized also that in much
of our work and our leisure the upper limbs
are abducted and flexed to 45”. Therefore,
the patients should be taught to do everything with the elbow of the involved shoulder held tightly to their side, to prevent
aggravation of any shoulder pathology.
The range of drugs described is certainly
extensive and in dosages more than adequate. Muscle relaxants and phenyl-butazone
have been most disappointing in the writer’s
hands, and the improvement with either
systemic glucocorticoids or systemic ACTH
has not been obvions in alleviating the
progress of the various diseases around the
shoulder. Injections of novocain, with or
without hydrocortisone, must be made into
the anatomic site of the disease rather than
into any areas of referred tenderness or
pain. A small point of management of the
patient is that if the injection is made in
the correct area with increase in local pressure, there is often an aggravation of the
pain, especially during the night. The patient should be reassured about this and
well sedated; otherwise the doctor may
share in the disturbed night. It should also
be emphasized that short wave diathermy
to the area and occasionally radio therapy
and indeed surgery, especially in cases of
supraspinatus tendonitis and calcification,
are all worthy of serious consideration in
cases in which there has been failure with
more conservative therapy. However, surgery with open drainage is rarely if ever
carried out for these conditions.
The condition of “frozen shoulder” or
pericapsulitis, which is an extensive process
of fibrosis involving all structures around
the shoulder joint, is usually the result of
too enthusiastic and too early physiotherapy
and/or manipulation. Dr. Bayles rightly
points out how it is only after relief of pain
that one should initiate a vigorous program
of nonresisted, active exercises, rather than
passive exercises. Fortunately, manipulation
under general anesthesia is rarely indicated
and, indeed, is difficult to perform satisfactorily. Neither systemic nor local corticoids in therapeutic dosages have been
shown to prevent further adhesion formation or continuance of the disease process,
if the manipulation or resisted active exercises are carried out too early.
This syndrome of “degenerative” disease
around the shoulder joint produces much
morbidity and distress in the working and
elderly age groups and in spite of their
complexities must be diagnosed anatomically
in order to achieve good results and grateROBERTB. DUTHIE
ful patients.
THE PAINFUL SHOULDER
Theodore B. Bayles, M.D., Clinical Associate in Medicine,
Harvard Medical School; Visiting Physician and Director of
Research, Robert B . Brighum Hospital; Senior Associate in
Medicine, Peter Bent Brighum Hospital, Boston, Mass.
Otto Steinbrocker, M.D., Chief, Department of Rheumatology,
Lenox Hill Hospital; Consulting Physician in Rheumatology,
Hospital fm Joint Diseases; Assistant Professor of Clinical
Medicine, N. Y. U . Postgraduate Medical School, New York,
N . Y.
Robert B . Duthie, M.D., Professor of Orthopadie Surgery,
The University of Rochester School of Medicim and Dentistry,
Rochester 20, N. Y.
277
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