Scoliosis

Adhesive Capsulitis
Rotator Cuff Disorders
Low Back Pain
Rheumatoid Arthritis
Osteoarthritis
 Scoliosis is a common deformity in many
types of neuromuscular diseases
 most severe in nonambulatory patients
 the prevalence of spinal deformity in the
patient with a neuromuscular disorder is
much higher than in the general population

 It ranges from 20% in children with cerebral

palsy to 60% in patients with myelodysplasia.
 The prevalence rises to 90% in males with
Duchenne muscular dystrophy.

 In general, the greater the neuromuscular

involvement, the greater the likelihood and
severity of scoliosis.
 Neuropathic:
1. upper motor neuron lesions includes
diseases such as cerebral palsy,
syringomyelia, and spinal cord trauma

2. lower motor neuron lesions includes

poliomyelitis and spinal muscular atrophy
 Myopathic
- include muscular dystrophy, and other
forms of myopathy.
 The pathophysiology is not well understood.
 The evaluation of a patient with
neuromuscular scoliosis entails a thorough
assessment of all body systems.
 Accurate diagnosis of the underlying disease
entity is essential and may require muscle
biopsy.
 Assessing nutritional status and pulmonary
function is extremely important
 The orthopedic examination includes
assessment of all extremities and joints for
contractures.
 Spinal deformity, decompensation, and
shoulder balance are documented.
 Ambulatory status is also evaluated, and
patients are classified as walkers, sitters, or
nonsitters.
 Laboratory Studies
 Total lymphocyte count
 The total lymphocyte count should be greater
than 1500 cells/mm3.
 Hemoglobin
 Total protein
 Albumin: Patients with serum albumin levels
greater than 3.5 mg/dL have a much lower
incidence of postoperative wound infection
 Electrolytes
 Serum blood urea nitrogen
 Creatinine
 Transferrin
 Supine anteroposterior and lateral spinal
radiographs: These are ordered for very young
patients and older patients who cannot sit.
 Upright anteroposterior and lateral spinal
radiographs
 Standing upright radiographs should be used for
patients who can stand, and sitting radiographs
should be used for patients who cannot stand.
 Traction spinal radiographs: These
radiographs are obtained to evaluate the
flexibility of the curves.
 Medical Therapy
- The goal of nonoperative and operative
treatment of patients with neuromuscular
scoliosis is the same: to maintain the spine in a
balanced position in the coronal and sagittal
planes over a level pelvis.
-This goal is achieved with a custom molded
thoracolumbosacral orthosis (TLSO) and molded
seating supports.
- The aim is to control the curve during spinal
growth rather than to correct the spinal
deformity.
 The surgical principles in the management of
neuromuscular scoliosis differ from those in
idiopathic scoliosis.
 Fusion is necessary at a younger age, and the
fused portion of the spine is longer.
 Fusion to the sacrum is fairly common
because many of these children do not have
sitting balance or have pelvic obliquity.
 Combined anterior and posterior fusion is
common in the treatment of patients with
neuromuscular scoliosis:
- posterior elements are absent, as in
myelodysplasia
- necessary to gain correction in a rigid
lumbar or thoracolumbar curve and achieve a
spine fused in balance over a level pelvis
 The instrumentation used is segmental, with
either a multiple hook-rod system, with or
without the addition of sublaminar wires, or a
Luque rod and sublaminar wires or a unit rod
device.
 When fusion to the sacrum is necessary, it
can be performed with the Luque-Galveston
technique or with iliac screws
 Hospital stays are usually 7-10 days.
 Modifications in the child's wheelchair should be
made as soon as possible to accommodate the
new sitting position.
 The number of hours spent upright each day
should be gradually increased.
 The wound should be assessed 3 weeks
postoperatively.
 Radiographs should be obtained 6 weeks
postoperatively and again 3 and 6 months after
surgery.
 respiratory problems
 ileus
 nutritional problems
 hip problems
 crankshaft phenomenon.
 With care in surgical technique and adequate
postoperative care, complications can be
minimized. The patient can return to the
preoperative functional level with a
successful surgical result, which consists of a
solidly fused spine in balance in the coronal
and sagittal planes over a level pelvis.
 is the most common type of spinal deformity
confronting orthopedic surgeons.
 Its onset can be rather insidious, its
progression relentless, and its end results
deadly.
 Proper recognition and treatment of
idiopathic scoliosis help to optimize patient
outcomes.
 The precise etiology of idiopathic scoliosis
remains unknown, but several intriguing
research avenues exist.
 A primary muscle disorder has been
postulated as a possible etiology of idiopathic
scoliosis.
-The contractile proteins of platelets
resemble those of skeletal muscle, and
calmodulin is an important mediator of
calcium-induced contractility
 An elastic fiber system defect (abnormal
fibrillin metabolism) has been offered as one
potential etiologic explanation for idiopathic
scoliosis.
 Disorganized skeletal growth, probably with
its root cause at a gene locus or group of loci,
has been discussed as a possible etiologic
explanation for idiopathic scoliosis.
 Much has been written regarding the
potential influence of melatonin on the
development of idiopathic scoliosis.
 Some authors have suggested that a
posterior column lesion within the central
nervous system might be present in patients
who have idiopathic scoliosis
 The vast majority of patients initially present
due to perceived deformity.
-Adams forward-bending test (in conjunction
with the use of a scoliometer) has been found to
be an effective screening tool.
 Patient's history include information relative to
other family members with spinal deformity,
assessment of physiologic maturity (eg,
menarche), and presence or absence of pain.
 Physical examination should include a baseline
assessment of posture and body contour.
 Shoulder unleveling and protruding scapulae
are common.
 In the most common curve pattern (right
thoracic), the right shoulder is consistently
rotated forward and the medial border of the
right scapula protrudes posteriorly.
 Assessment of lower (and often upper)
extremity reflexes should be performed.
 Abdominal reflex patterns should also be
assessed.
 The presence or absence of hamstring tightness
should be investigated
 screening should be performed for ataxia and/or
poor balance or proprioception (ie, Romberg
test).
 One or two different methods of measuring leg
length will prove valuable, as a significant
percentage of patients presenting with scoliosis
have several centimeters of limb-length
discrepancy.
 The main treatment options for idiopathic
scoliosis may be summarized as "the 3 O's":
(1) observation
(2) orthosis
(3) operative intervention
 Infantile Idiopathic Scoliosis:
-defined by a seemingly arbitrary age limit
(<3 y at the time of diagnosis)
-only type of idiopathic scoliosis whose
most common curve pattern is left thoracic.
- only type of scoliosis that is more
common in boys.
- more common in European patients or
those of immediate European descent.
 - spontaneous resolution (20-92%)
- Nonoperative treatment of progressive infantile
idiopathic scoliosis predominates and may involve
the use of conventional thoracolumbosacral
orthosis (TLSO)–type braces, Milwaukee-type
braces, and even intermittent Risser casting
If surgical treatment becomes necessary, anterior
release and fusion followed by posterior spinal
fusion with instrumentation is considered to be
the functional treatment.
 rib vertebral angle difference (RVAD)
originally described by Mehta in 1972.
- measurement carried out at the apical
vertebra of the curve
 Curves less than 25° with an RVAD less than 20°
are preferentially observed and monitored with
spinal radiographs at regular intervals.

 Curves exceeding these parameters are typically

braced, with some consideration given to the
value of intermittent Risser casting.

 Surgery is considered for curves not adequately

controlled with nonoperative measures.
 most closely mimics the epidemiology and
demographics of the adolescent version of
the disease.
 It is more common in females, and its most
common curve pattern is a right thoracic
curve.
 might be considered to be a malignant
subtype of adolescent idiopathic scoliosis
 Observation for curves less than 25° with
follow-up radiographs at regular intervals

 Bracing for curves that range from 25-40° and

at least consideration of bracing (based on
curve flexibility) for curves from 40-50°
 Bracing for smaller curves that demonstrate
rapid progression to the 20-25° range

 Surgical intervention for inflexible curves that

exceed 40° or virtually any curve that exceeds
50°.
 most common type of idiopathic scoliosis and
the most common type of scoliosis overall.
 Treatment recommendations for adolescent
idiopathic scoliosis are driven almost totally
by curve magnitude (the only caveat being
that brace treatment is thought to be
effective only in patients who are still
growing).
 observation for curves less than 30°, bracing
of curves that reach the 30-40° range, and
consideration of surgery for curves that
exceed 40°.
 most commonly referred to as frozen
shoulder (FS), is an idiopathic disease with 2
principal characteristics: pain and
contracture.
 In 1934, Codman stated, "This entity [FS] is
difficult to define, difficult to treat, and
difficult to explain from the point of view of
pathology." Codman's statement continues
to hold true today.
 In 1992, the American Shoulder and Elbow
Surgeons Society agreed on the following
definition of FS by consensus: a condition of
uncertain etiology that is characterized by
clinically significant restriction of active and
passive shoulder motion that occurs in the
absence of a known intrinsic shoulder
disorder.
 Pain
 Shoulder pain associated with FS is progressive
and initially felt mostly at night or when the
shoulder is moved close to the end of its range
of motion (ROM).
 It can be caused by certain combined
movements of the shoulder, such as abduction
and external rotation (eg, grooming one's hair,
reaching for a seatbelt overhead) or extension
and internal rotation (eg, reaching for a back
pocket or bra strap).
 In approximately 90% of patients with FS,
this pain usually lasts 1-2 years before
subsiding.
 Contracture
 The second principal characteristic of FS is
progressive loss of passive ROM (PROM) and
active ROM (AROM) of the glenohumeral
joint in a capsular pattern
 Evaluation of anatomic, histologic, and
surgical specimens from subjects affected by
idiopathic FS demonstrates that the
glenohumeral joint synovial capsule is often
involved in this disease process.
 active process of hyperplastic fibroplasia and
excessive type III collagen secretion that lead
to soft-tissue contractures of the
aforementioned structures (ie, the
coracohumeral ligament, soft tissues of
rotator interval, the subscapularis muscle, the
subacromial bursae)
 Shoulder pain is the third most common
cause of musculoskeletal disability after low
back pain (LBP) and neck pain.
 The prevalence of FS in the general
population is reported to be 2%, with an 11%
prevalence in unselected individuals with
diabetes.
 For patients with type I diabetes, the risk of
developing FS in their lifetime is
approximately 40%.
 FS may affect both shoulders, either
simultaneously or sequentially, in as many as
16% of patients.
 The frequency of bilateral FS is higher in
subjects with diabetes than in those without
diabetes.
 In 14% of patients, while FS still is active in
the initial shoulder, the contralateral shoulder
also becomes affected.

 Contralateral FS usually occurs within 5 years

of disease onset. A relapse of FS in the same
shoulder is unusual.
 FS most frequently occurs in subjects with
hyperthyroidism and hypertriglyceridemia.

 Although various authors report that heart

disease, tuberculosis, and many other
medical conditions are associated with FS
 FS will undoubtedly become increasingly
common as the baby-boom generation ages,
because this condition most frequently
occurs in the fifth and sixth decades of life.
 Patients who present with an idiopathic FS
when they are younger than 40 years should
definitely be examined to rule out occult
diabetes, hyperthyroidism,
hypertriglyceridemia, or concomitant
neurologic or systemic rheumatologic
disorder affecting the upper extremity.
 FS affects women more frequently than men,
with a female-to-male ratio of about 1.4:1.
Menopause is often reported as a cause of FS
in women.

 mean ages of onset are 52 years for women

and 55 years for men
 1. Phase 1 - The painful phase; the patient
describes an insidious onset of predominantly
nocturnal pain, usually without a precipitating
factor.
- The pain is not related to activity,
although the farthest ROM can increase the
pain. As the disease progresses, patients have
pain at rest.
- In this phase, which lasts 2-9 months,
ROM is not restricted, and the diagnosis may
remain unclear.
 2. Phase 2 - The frozen, or adhesive, phase; the
pain from phase 1 can persist, although it may
decrease.
- Progressive limitation in ROM occurs
in a capsular pattern (that is, in all directions).
Normal daily activities can be severely affected.
-Hallmarks of this phase are an inability
to move at great amplitude and an inability to
move on the affected side.
-Diagnosis is easier in this phase than in
phase 1. Although phase 2 is reported to last 3-9
months, it can persist longer than this.
 3. Phase 3 - The thawing, or regressive, phase;
pain progressively decreases, and limitations
in ROM progressively increase over 12-24
months.
- approximately 40% of patients have
slight, persistent limitations in ROM, only
10% have clinically significant long-term
functional limitations.
 Careful neurologic examination should be
conducted in all patients presenting with
signs and symptoms associated with FS.

 Patients who have a history of smoking

should undergo chest radiography with apical
views to rule out a Pancoast tumor irritating
the brachial plexus, which can cause FS.
 All patients should receive a thorough neurologic
examination of the upper extremities and neck to rule
out cervical radiculopathy and brachial plexopathy.

 Care also should be taken to look for signs of

Parkinson disease, because the prevalence of
shoulder pain in patients with this treatable condition
is 4-5 times that of the healthy population.

 Furthermore, shoulder pain often is an early

manifestation of Parkinson disease, and it sometimes
precedes the tremor by many years.10
 Proper and complete musculoskeletal and
integumentary examination should be
performed to rule out concomitant systemic
rheumatologic, inflammatory, metastatic, or
infectious disorders.
 Clinicians should also take the time to
properly examine the thyroid gland to rule
out concomitant hyperthyroidism.

 Physicians should remain alert to signs of

unsuspected diabetes, which may be present
in approximately 25% of subjects presenting
with FS.
 Laboratory Studies
- The scientific literature shows an elevated
incidence of diabetes, hyperthyroidism, and
hypertriglyceridemia in patients with FS.

a. Lequesne and colleagues found that 28% of 60

new patients who presented with idiopathic FS
had unsuspected diabetes.11
 b. This association should prompt possible
testing of thyroid-stimulating hormone (TSH),
serum triglyceride, and fasting blood sugar levels in
most patients, particularly those presenting with
bilateral disease and patients presenting with FS
who are younger than 45 years.
 Radiologic studies
 In general, idiopathic FS is considered a clinical
diagnosis that does not require confirmation with
radiologic imaging.
 Current radiologic studies do not seem to confer any
useful information, prognostic or otherwise, that
changes the way the patient is treated.
 For the moment, the principal utility of these
tests is in ruling out concomitant conditions that
may influence the treatment of an individual
patient
 Plain radiography
 All patients presenting with FS should undergo
plain radiography of the shoulder, with the
acquisition of soft-tissue views of the rotator cuff
to rule out a septic or metastatic process.
 A plain radiograph may also show evidence of a
large calcification of the rotator cuff in the painful
resorptive phase, an avascular necrosis of the
humeral head (that is, Milwaukee shoulder), or a
Charcot joint.
 Gallium nuclear scanning - Patients who are
immunocompromised, as well as those who
abuse intravenous (IV) drugs, should undergo
gallium nuclear scanning to rule out a septic
joint.
 Arthrography of the glenohumeral joint

 arthrography is used mostly to treat FS, rather

than to diagnose the condition.
 The injection of contrast medium into the
glenohumeral joint helps to determine its volume
and configuration. The normal volume of the joint
is 13 mL. In FS, the volume can be reduced to 5-8
mL.
 99m Tc methylene diphosphonate (MDP) bone
scanning
 -In general, the problem with bone scans in the
practice of musculoskeletal medicine is that they
are highly sensitive but not specific
 Other studies - Computed tomography (CT)
scanning, CT arthrography, ultrasonography,
and magnetic resonance imaging (MRI) are
sensitive imaging modalities that depict
specific signs for FS. However, use of these
modalities is rarely indicated.
 Rehabilitation Program
-Physical Therapy
---Although studies have shown the
efficacy of physical therapy, no current evidence
has suggested that physical therapy alone
improves function in the treatment of FS.
---physical therapy associated with an
intra-articular injection of corticosteroid
improves function and ROM more rapidly than
does intra-articular corticosteroid injection alone
 Therapeutic exercises

- Therapeutic exercises that have been

studied include articular stretching and pulley
therapy.
- Passive articular stretching exercises

improve ROM.
 Manual therapy
---Data from 2 studies support the use of
manual therapy to improve ROM in the short
term.
 Physical modalities
 Many electroanalgesic and thermoanalgesic
modalities are often used in physical therapy.
 Occupational Therapy
 Patients with severe FS may benefit from a
referral to an occupational therapist for
assistance and instruction in performing
activities of daily living (ADLs).
 The occupational therapist helps the patient
learn how to use adaptive equipment and
suggest home and workplace modifications that
may be necessary and beneficial for completing
professional activities and routine daily tasks
(eg, dressing, bathing, grooming)
 Duplay, the first person to describe the
syndrome of FS, in 1872, proposed treating
this condition with manipulation of the
glenohumeral joint, with the patient under
general anesthesia.
▪ --some orthopedic surgeons continue to practice this
technique, the benefits of this approach have not been
demonstrated in controlled clinical trials.
 A 2009 study by Jacobs et al also found no
evidence that manipulation provides a better
treatment outcome in FS.
 Various improvements in surgical techniques,
such as the advent of controlled capsular
release by using arthroscopic access to the
anterior glenohumeral joint capsule and the
coracohumeral ligament, appear to offer
promising treatments.
 However, the effectiveness of these surgical
techniques has yet to be demonstrated in
controlled clinical trials
 Considering the favorable prognosis for
patients with idiopathic FS, surgical
intervention should probably be reserved for
rare patients whose condition does not
respond to maximal conservative modalities
implemented over a sufficient period of time.
 The pathophysiology of rotator cuff
degeneration is a controversial topic that still
is not fully understood.
 2 hypotheses: extrinsic and intrinsic
 The extrinsic hypothesis
-In this theory, the lesion results mainly from
repeated impingement of the rotator cuff
tendon against different structures of the
glenohumeral joint.

1. The anterosuperior impingement syndrome

2. The posterosuperior impingement syndrome
3. The anterointernal impingement syndrome
 Impingement of the rotator cuff beneath the
coracoacromial arch is an established cause
of chronic shoulder pain.
 impingement occurs against the under
surface of the anterior third of the acromion,
the coracoacromial ligament, and at times,
the acromioclavicular joint.
 Located anterior to the coracoacromial arch
in the neutral position, the supraspinatus
tendon insertion to the greater tuberosity
and the bicipital groove must past beneath
the arch with forward flexion of the shoulder,
especially if internally rotated, causing an
impingement.
 Neer believed that 95% of tears of the rotator
cuff were initiated by impingement wear,
rather than circulatory impairment or trauma.
 He observed proliferative traction spurs at
the undersurface of the anterior acromion
that he explained by the repeated
impingement of the cuff.
 He stated that the variation in shape and
slope of the acromion could make people
more susceptible to impingement and tear,
making it appear logical to perform an
anterior acromioplasty at the time of every
cuff repair.
 Biglianni described 3 different shapes of
acromia in cadavers, according to the
anterior slope:
 Type 1 - Flat
 Type 2 - Curved
 Type 3 - Hooked
 Only 3% of tears are associated with a type 1
acromion.
 Curved and hooked acromia appear to be due
to a degenerative process with formation of
the osteophyte-enthesophyte complex at the
acromion-coracoacromial ligament junction
that is increasingly prevalent with age.
 Neer described impingement lesions in the
following 3 progressive stages:
- In stage 1, edema and hemorrhage result
from excessive overhead use and are
observed in patients younger than 25 years.
 -In stage 2, fibrosis and tendinitis affect
the bursa and the cuff following repeated
episodes of mechanical inflammation in
patients aged 25-40 years.
-In stage 3, bone spurs and incomplete and
complete tears of the rotator cuff and long
head of the biceps tendon are found almost
exclusively in patients older than 40 years.
 In 1991, Walch et al described, an
impingement occurring between the articular
side of the supraspinatus tendon and the
posterosuperior edge of the glenoid cavity.
 With the shoulder held at 120° of abduction,
retropulsion, and in extreme external
rotation, the labrum moves away from the
glenoid and the glenoid rim comes in contact
with the deep surface of the tendon,
producing repeated microtrauma and leading
to partial tears.
 This process has been confirmed by MRI
studies and may explain some of the articular
side tears, especially in overhead sport
athletes; however, it does not account for all
the tears observed in older patients.
 In 1985, Gerber described, from CT scan
studies and from surgery observations,
impingement of the cuff in the
coracohumeral interval

 the shoulder is held in flexion and internal

rotation
 the coracohumeral distance is reduced from
8.6 mm when the arm is at the side to 6.7 mm
 In this position, the lesser tuberosity, and
also the biceps tendon and the supraspinatus
tendon, become closer to the coracoid
process, creating subcoracoid impingement
and cuff lesions.
 Subcoracoid impingement can be:
 idiopathic (eg, large coracoid tip)
 iatrogenic (eg, following a Trillat procedure)
 following a fracture (eg, humeral head or neck
fracture).
 In this theory, the lesions result from
progressive age-related degeneration of the
tendon.
 Von Meyer was probably the first to introduce
the concept that degeneration of the tendon
plays a major role in the production of cuff
lesions.
 Observations from various sources (eg,
cadaver, surgical, MRI, ultrasonographic,
arthrographic studies) show that cuff tears
rarely are seen in patients before age 40
years and that the number observed after the
patient has reached 50 years increases
progressively.
 In 1934, Codman introduced the concept that
most tears originate on the articular side of
the tendon.
 Most of the tears have been observed on the
articular surface of the tendon, near its
insertion on the greater tuberosity, in an area
Codman called the critical zone.
 In all probability, the intrinsic and the
extrinsic theories coexist and explain the
pathophysiology of rotator cuff
degeneration.
 Shoulder pain is the third most common
cause of musculoskeletal disorder after low
back pain (LBP) and cervical pain.
 The annual incidence is estimated at 10 cases
per 1000 population, peaking at 25 cases per
1000 population in the age category of 42-46
years.
 In the population aged 70 years or more, 21%
of persons were found to have shoulder
symptoms, most of which were attributed to
the rotator cuff.
 No known race variation associated with
rotator cuff disease.
 predominance of male patients (66%)
seeking consultation for rotator disease, but,
in other studies, the male-to-female ratio is
1:1.
 Rotator cuff disease is more common after
age 40 years.
 average age of onset is estimated at 55
years.
 The shoulder joint is a complex structure
comprising not 1, but 5 joints :
 3 synovial joints
-sternoclavicular
- acromioclavicular
- glenohumeral joints
 2 physiologic joints
-scapulothoracic joint
-subdeltoid joint]
 5 joints fall into the following 2 groups:
 First group
 Glenohumeral joint, a true joint
 Subdeltoid joint, a physiologic joint
 Second group
 Sternoclavicular joint, a true joint
 Acromioclavicular joint, a true joint
 Scapulothoracic joint, a physiologic joint
 The rotator cuff is made up of 4 interrelated
muscles arising from the scapula and
attaching to the tuberosities.
 Their tendons form a continuous cuff around
the head that allows the cuff muscles to
provide an infinite variety of moments to
rotate and adjust the humeral head in the
glenoid fossa.
 providing the optimal muscle balance for precise
coordinated movements.
 The supraspinatus muscle arises from the medial
two thirds of the supraspinous fossa of the
scapula.
 This muscle passes under the acromion and
acromioclavicular joint and inserts onto the superior
aspect of the greater tuberosity and joint capsule.
 innervated by the suprascapular nerve (C4-C5-C6)
 Its primary role is to stabilize the head of the humerus
in the glenoid fossa and to abduct the shoulder.
 The infraspinatus muscle arises from the
medial two thirds of the infraspinous fossa of
the scapula and inserts on the middle facet of
the greater tuberosity and joint capsule
 This muscle is innervated by the suprascapular
nerve (C4-C5-C6).
 Its primary role is to stabilize and externally
rotate the head of the humerus
 The teres minor muscle arises from the upper
two thirds of the dorsal aspect of the lateral
border of the scapula and inserts onto the
lower facet of the greater tuberosity and joint
capsule.
 Its primary role is to stabilize and externally
rotate the head of the humerus.
 The subscapularis muscle arises from the
subscapular fossa of the scapula and inserts
to the lesser tuberosity and joint capsule.
 This muscle is innervated by the upper and lower
subscapular nerve (C5-C6-C7).
 Its primary role is to stabilize and externally
rotate the head of the humerus.
 The long head of the biceps tendon arises from
the supraglenoid tubercle of the scapula, runs
between the supraspinatus and subscapularis
muscles, exits the shoulder through the bicipital
groove under the transverse humeral ligament,
and inserts onto the tuberosity of the radius.
 The long head of the biceps is innervated by the
musculocutaneous nerve (C5-C6).
 Its primary role is to stabilize and flex the humeral
head and flex the elbow.
 Most glenohumeral motion, especially in
overhead activities, occurs around the plane of
the scapula, which is approximately 30-45°
anterior to the frontal plane.
 Any time the arm is raised in flexion or
abduction, movements from the scapula and the
clavicle accompany the glenohumeral joint
 In the first 30° of abduction or 45-60° of flexion,
the scapula moves either toward or away from
the spine to seek a position of stability on the
thorax.
 Consequently, the scapulothoracic joint does
not participate in the early elevation of the
arm, and the movement of the first 30°
comes from the glenohumeral joint.
 After stabilization has been achieved, the
scapula moves laterally, anteriorly, and
superiorly, causing an upward rotation of the
scapula and glenoid fossa.
 1. Maintains the glenoid fossa in an optimal
position to receive the head of the humerus,
thus increasing the range of motion (ROM)
 2. Permits the muscles acting on the humeral
head to maintain a satisfactory length-
tension relationship
 Beyond the first 30° of abduction (or 45-60°
of flexion), scapulothoracic motion occurs
and contributes to the scapulohumeral
rhythm.
 As the abduction progress, according to
widely accepted belief, there is a 2:1 ratio of
motion between the glenohumeral and
scapulothoracic motion.
 Toward the end of the elevation, the scapula
contributes more motion and the humerus
less.
 In total, the glenohumeral joint contributes
90-120° to shoulder abduction and the
scapulothoracic joint supplies 60°. The
contributing joint actions to the scapular
motions are 20° produced by the
acromioclavicular joint, 40° produced at the
sternoclavicular joint, and 50° of clavicle
elevation and 30° of posterior rotation.
 For the glenohumeral joint to realize 120° of
abduction, external rotation of the humerus
must occur.
 When internally rotated, the humerus can
abduct to approximately 90° before the greater
tuberosity hits the coracoacromial arch;
however, when externally rotated, the greater
tuberosity and cuff tendons avoid the
coracoacromial arch, and 120° of abduction can
be obtained.
 Full abduction cannot be achieved without
trunk extension and contralateral flexion.
 A complete medical history should be
obtained in order to direct the physical
examination and make the right diagnosis.
 The following questions should help the
physician in assessing the patient:
 What is the patient's age?
 Shoulder pain in young overhead athletes suggests
underlying shoulder instability.
 In older patients, degenerative rotator cuff disease or
frozen shoulder is suggested by shoulder pain.
 What is the patient's occupation or sport?
Repetitive overhead activities and sports
predispose to rotator cuff tendinitis.
 What was the mechanism of injury?
 A fall on an outstretched arm could indicate a dislocation
of the glenohumeral joint or a fracture of the humeral
neck.
 Repetitive overhead motions can cause tendinitis and, in
the long run, chronic degenerative changes.
 A fall or a trauma on the tip of the shoulder can result in an
acromioclavicular sprain.
 What was the onset?
 Insidious slow onset may suggest tendinitis or
osteoarthritis.
 Sudden onset usually is due to a trauma causing a fracture,
dislocation, or a rotator cuff tear.
 Where is the pain located?
 Pain located on the superior or lateral aspect of the
shoulder suggests rotator cuff tendinitis.
 Pain on the anterior aspect of the shoulder may result
from bicipital tendinitis, an acromioclavicular sprain,
or anterior instability.
 Neck pain and radicular pain or paresthesias suggest a
cervical spine disorder.
 What is the severity of the pain?
 An acute burning pain could indicate an acute bursitis.
 An intermittent dull pain may be due to a
degenerative rotator cuff disease.
 What is the type of pain?
 Sharp burning pain suggests a neurologic origin.
 Bone and tendon pain is deep, boring, and localized.
 Muscle pain is dull and aching, not localized, and may be
referred to other areas.
 Vascular pain is aching, cramplike, poorly localized, and
may be referred to other areas.
 What is the duration of the symptoms?
 Frozen shoulder goes through 3 stages that can last up to
3-4 years.
 Acute bursitis has a short-term evolution and responds
well to nonsteroidal anti-inflammatory drugs (NSAIDs).
 What is the timing of the pain?
 Predominantly night pain suggests frozen shoulder.
 Morning pain and stiffness improved by activity may be
caused by a synovitis.
 Pain that increases with activity is usually the result of a
rotator cuff tendinitis.
 Which activities/positions increase the pain?
 Pain increased by overhead activities or arm-length
activities suggests rotator cuff tendinitis.
 Pain increased when throwing is likely to be due to
anterior instability.
 Pain increased by lying on the affected shoulder may be
caused by an acromioclavicular sprain.
 Which activities/positions relieve the pain?
 Is there any weakness or paresthesias in the
upper extremities? Neurologic symptoms are
caused by a cervical radiculopathy or
peripheral nerve entrapment/lesion.
 Are the symptoms constant or intermittent?
 Intermittent symptoms usually result from soft
tissues or joint disorders.
 Constant symptoms suggest a neurologic lesion.
 Are there any joint motion restrictions?
 Passive and active joint restriction in all directions of
ROM is caused by a frozen shoulder or glenohumeral
synovitis.
 Restriction in internal rotation suggests an
impingement syndrome due to rotator cuff tendinitis.
 Inability to perform active abduction suggests a
rotator cuff tear or a frozen shoulder.
 Is some crepitus noted?
 Crepitus is the result of degenerative rotator cuff
changes.
 Crepitus is not a normal finding in the shoulder.
 Are there any changes in the color of the
arm?
 Color changes may be due to ischemia secondary
to vascular insufficiency.
 Reflex sympathetic dystrophy (also called
complex regional pain syndrome, type 1) can
cause skin color changes.
 Has the patient had any treatments like oral
medication, injections, or physical therapy to
date?
 Has the patient had any diagnostic tests
performed to date?
 What is the evolution of the symptoms?
 Has the pain changed?
 Has the pain spread or moved?
 Has the pain subsided or increased?
 Physical
 A systematic examination of the shoulder region
includes a careful observation, the palpation of
the bones and soft tissues, passive and active
ROM, impingement and topographic tests
complemented, as needed, by instability tests,
labrum tests, and special tests.
 The examination is completed by a cervical spine
examination, along with neurologic and vascular
examination.
 Observation
 Palpation
 Range of motion
 Both active and passive ROM must be
evaluated. Although some authors suggest
that there is no need to assess passive ROM if
the patient is able to perform a complete
active ROM without pain, passive ROM must
be assessed systematically.
The following movements (with the normal
ranges provided) should be assessed:
 Abduction (70-180°)
 Adduction (30-45°)
 Flexion (160-180°)
 Extension (45-50°)
 External rotation (80-90°)
 Internal rotation (90-110°)
 Active movements are evaluated first.
 With the observer behind the patient who is standing,
active abduction is performed.
 The scapulohumeral rhythm is observed.
 If a painful arc (ie, pain or inability to abduct because
of pain) is observed between 45-120°, a subacromial
impingement syndrome is suggested.
 If the pain is greater after 120°, when full elevation is
reached, an acromioclavicular joint disorder is
suggested.
 If a reverse scapulohumeral rhythm (ie, an
abduction initiated by the scapulothoracic joint
rather than by the glenohumeral joint) is
observed, a frozen shoulder is suggested.
 Look for a winging of the scapula caused by a
trapezius or rhomboid muscle weakness.
 Active flexion also is evaluated.
 In the presence of a subacromial impingement
syndrome, this movement also can be painful.
 Active flexion also can elicit a winging of the scapula
caused by a serratus anterior weakness.
Passive range of motion
 The evaluation can be performed with the patient standing,
sitting, or lying down.
 For practical purposes, the examination is performed with
the patient standing.
 Passive abduction is assessed with the observer behind
the patient.
 Full abduction is performed first to evaluate the
combination of scapulothoracic and glenohumeral
motion.
 Then, the scapulothoracic joint is locked by
putting one hand over the scapula and the clavicle
to resist any motion of this joint.
 This maneuver allows for a more selective
evaluation of the glenohumeral joint (90-120°).
Impingement tests
 Positive impingement tests result from the
reproduction of the impingement of the
rotator cuff tendon by different provocative
maneuvers.
 In the case of an anterosuperior impingement
syndrome, the impingement takes place
underneath the coracoacromial arch;

 Iin the case of the posterosuperior impingement

syndrome, the impingement is on the
posterosuperior border of the glenoid cavity,

 In the case of the anterointernal impingement

syndrome, the impingement takes place in the
subcoracoid space or in the coracohumeral interval.
 The Neer impingement test
 With the examiner standing behind the patient, the
shoulder is flexed passively.
 When positive, this test produces pain
that is caused by the contact of the bursal
side of the rotator cuff on the anterior
third of the undersurface of the acromion
and the coracoacromial ligament, as well
as by contact of the articular side of the
tendon with the anterosuperior glenoid
rim.
 A positive test suggests an anterosuperior
impingement syndrome.
 The sensitivity of this test, assessed by operatively
observed anatomic lesions, is 89%
 The Hawkins-Kennedy test
 With the examiner standing behind the patient, the
shoulder is flexed passively to 90°, followed by
repeated internal rotation.
 When positive, this test produces pain that is caused
by the contact of the bursal side of the rotator cuff on
the coracoacromial ligament and by the contact
between the articular surface of the tendon and the
anterosuperior glenoid rim.
 Contact between the subscapularis tendon and the
coracoid process also is observed.
 A positive test suggests an anterosuperior or an
anterointernal impingement test.
 A modified version of this test with the shoulder
positioned initially at 90° of abduction and 30° of
flexion, in the plane of the scapula.
 With repeated internal rotation motion, the
shoulder is brought progressively to 90° of flexion.
 If pain is present when the shoulder is flexed at
30°, it is caused by an anterosuperior
impingement syndrome.
 If the pain is present only when the shoulder is
brought to 90° of flexion, reducing the
coracohumeral interval, an anterointernal
impingement syndrome is suggested.
 The sensitivity of this test is 87%.
 The Yocum test
 With the examiner standing behind the patient,
the hand on the ipsilateral side of the examined
shoulder is placed on the contralateral shoulder.
 The elevation of the elbow is resisted by the
examiner.
 When positive, this test produces pain caused by
the contact of the bursal side of the cuff tendon
with the coracoacromial ligament and possibly
the undersurface of the acromioclavicular joint.
 A positive test suggests an anterosuperior or an
anterointernal impingement syndrome.
 The sensitivity of this test is only 78%
 the sensitivity of the 3 tests together is 100%,
which justifies that the 3 tests should be
systematically performed together
 The posterior impingement test
 With the patient lying down, the shoulder is
positioned at 90-100° of abduction and maximally
externally rotated.
 When positive, this test produces pain in the
posterior aspect of the shoulder that is caused by
the impingement of the articular side of the cuff
tendon between the greater tuberosity and the
posterosuperior glenoid rim and labrum.
 The relocation of the humeral head, performed by
applying a posteriorly directed force to the
humeral head, causes a reduction in pain.
 The sensitivity of this test is 90%.
 Impingement tests confirm an impingement
syndrome; however, they do not determine the
location of the rotator cuff lesion.
 Topographic tests
- Using resisted isometric contraction of
specific muscles of the rotator cuff, it is
possible to identify the location of the tendon
lesion causing the impingement.
 The Jobe test
 The shoulder is placed at 90° of abduction and 30° of
flexion in the plane of the scapula.
 Shoulder elevation is resisted.
 The test is positive if pain is noted. When compared
with surgical observations, the sensitivity of this test
is 86%, and its specificity is 50%.
 The positive predictive value (the ratio of true positive
tests on all the positive tests) of the Jobe test is 96%,
and its negative predictive value (the ratio of all the
negative tests on all the negative tests) is 22%.
 The full can test
 The shoulder is placed at 90° of flexion and 45° of
external humeral rotation (thumb pointing upward,
like someone holding a full can, right-side-up).
 Shoulder elevation is resisted.
 The test is positive if it produces pain.
 An electromyographic (EMG) study showed that this
test results in the greatest supraspinatus activation
with the least activation from the infraspinatus.
 The infraspinatus isolation test
 The shoulder is positioned at 0° of elevation
(elbows against the waist flexed at 90°) and 45° of
internal rotation.
 Shoulder external rotation is resisted.
 The test is positive if it produces pain.
 EMG shows that this is the optimal infraspinatus
isolation test.
 The Patte test
 The shoulder is placed at 90° of abduction, neutral
rotation, and in the plane of the scapula.
 The examiner holds the elbow of the patient and
the external rotation is resisted.
 The test is positive if it produces pain.
 The sensitivity of the test is 92%, but its specificity
is only 30%.
 The positive predictive value is 29%, and its
negative predictive value is 93%.
 With the elbow held against the waist, the
shoulder is positioned passively in external
rotation.
 The test is positive when the patient is unable
to maintain the shoulder in external rotation,
suggesting a full tear of the external rotators.
 No specific teres minor isolation tests exist.
 The same tests used to test the infraspinatus
tendon serves for the teres minor.
 The Gerber lift-off test
 The shoulder is placed passively in internal
rotation and slight extension by placing the hand
5-10 cm from the back with the palm facing
outward and the elbow flexed at 90°.
 The test is positive when the patient cannot hold
this position, with the back of the hand hitting the
patient's back.
 The sensitivity and specificity of this test are 100%
when there is a full tear of the subscapularis.
 The Gerber push with force test
 The shoulder is placed in the same position as the
lift-off test; however, the patient has to keep his
hand away from the back and resists a push in the
palm of the hand.
 EMG shows that this is the optimal subscapularis
isolation test with minimal activation of the
pectoralis and latissimus dorsi muscles.
 The Speed palm up test
 The shoulder is placed at 90° of flexion with the
elbow in extension and the forearm in supination,
bringing the palm of the hand up.
 The flexion of the shoulder is resisted.
 The test is positive if it produces pain.
 The sensitivity of this test is 63%, but its
specificity is only 35%.
 The positive predictive value is 43%, and its
negative predictive value is 55%.
 Rotator cuff disease may result from a variety
of causes. Damage to the rotator cuff
commonly is caused by degeneration
associated with aging. Other causes of injury
to the rotator cuff may include tendinitis,
bursitis, or arthritis.
 These injuries are particularly common in
individuals who perform repetitive overhead
activities at work or through involvement in
sports.
 Throwing athletes are prone to this problem
secondary to the repetitive stress and trauma to
the rotator cuff.
 Rotator cuff disease also may be the result of a
traumatic injury (eg, a fall onto the shoulder,
motor vehicle accident).
 Laboratory Studies
 Laboratory studies are not necessary for
diagnosing rotator cuff disease.
 Imaging Studies
 A wide variety of radiological examinations
are offered to image the rotator cuff.
 To prescribe the most useful examination,
one must start with a good clinical history
and physical examination.
 Imaging should be used to confirm the
anomaly, describe its extension and the
associated findings.
 Plain film radiography
 Indication
▪ Plain films are not very specific or sensitive to rotator
cuff disease, but they remain the first examination to
perform.
▪ Radiographs give a gross evaluation of the
mineralization of the bone, the alignment,
posttraumatic changes, the normal variant of the
acromion shape, the presence of degenerative changes,
and the presence of fine soft tissue calcifications that
could be missed otherwise by other modalities.
 ▪ This is most useful test in trauma or chronic complete
tear.
▪ In the last stage of complete chronic rotator cuff tear, it
could be the only imaging modality needed to confirm
the diagnosis.

 Technique: Plain films are acquired routinely

in 3 planes (ie, neutral, internal, external
rotation)
  Partial rotator cuff tear: All of the above can
be present, but no specific signs can help in
the diagnosis of a partial tear, as tendons are
not visible on plain film.
 Complete rotator cuff tear:
 In acute tears, the presence of synovial effusion or
hemorrhage can subluxate the humeral head
caudally.
 Chronic tears, the humeral head migrates superiorly
as the rotator cuff loses its ability to stabilize the
humeral head in the glenoid cavity.
▪ Radiographically, an acromiohumeral
space less than 6 mm, with or without
erosion, on the inferior aspect of the
acromion is a good semiologic landmark
for chronic complete tear.
 Rotator cuff tendinitis
Signs of chronic tendinitis without tear:
▪ subchondral sclerosis of humeral head
▪ flattening and geode of the greater tuberosity
▪ sclerosis of the acromion
▪ calcifications located in the presumed area of rotator
cuff
▪ acromion, or a type 2 or 3 acromion.
▪
 Tendinitis Partial Tear Complete Tear
Normal X X X

Soft tissue X X X
calcification(s)
Greater tuberosity X X X
flattening or
hypertrophy

Humeral head cysts X X X

Acromial sclerosis X X X

Acromial spurs X X X

Acromion type 2 X X X
and 3
Acromioclavicular X X X
osteoarthritis

Upward migration X
of humeral head (
 Arthrography
 Indication
▪ The main indication of arthrography is to identify
complete rotator cuff tears and intra-articular
infiltration of corticoid.
▪ As a diagnostic tool, it is combined generally with
arthro-CT.
 Magnetic resonance imaging
 Indication
 Magnetic resonance imaging (MRI) is the state-
of- the-art diagnostic tool for a full evaluation of
the shoulder.
 MRI allows a fine evaluation of the bone
marrow, tendons, muscles, ligaments, capsules,
bursae, and labrum.
 MRI combines the advantage of visualization of
the bony structures, as well as all the soft tissues
about the shoulder and in any plane desirable.
 Ultrasonography
 Indication: The main purpose of ultrasonography is to
study the soft tissues.
 In experienced hands, ultrasonography has a
sensitivity of 93-100% and a respective specificity of
85-97% for complete tear and a sensitivity of 69-93%
for partial tear.
▪ The advantages of this technique reside in its low cost, high
availability, and high resolution. Ultrasonography is a
dynamic study for demonstrating impingement syndrome.
▪ The disadvantages are that it is time consuming for the
radiologist and is operator-dependent. Ultrasonography
cannot study bone structures, as sound does not penetrate
bone very well.
 Nuclear medicine imaging: Bone
scintigraphy is not used routinely in the
rotator cuff disease imaging.
 Physical Therapy
 Physical therapy can be a useful adjunct in
the conservative treatment of patients with
degenerative rotator cuffs.
 The conservative treatment of the
degenerative rotator cuff
 Pain relief
 Avoidance of painful motions and activities
 Simple analgesics
 Nonsteroidal anti-inflammatory drugs
 Physical modalities
 Manual physical therapy
 Subacromial corticosteroid injection
 A new promising procedure called the bupivacaine
suprascapular nerve block
 Restoration of motion
 Stretching of the glenohumeral capsule and
muscles
 Manual physical therapy of the glenohumeral,
scapulothoracic, acromioclavicular, and
sternoclavicular joints and the parascapular and
scapula-stabilizer muscles
 Normal scapulohumeral rhythm must be restored.
 Manual therapy of the cervicodorsal
spine, because of its close
relationship with the shoulder, often
is necessary.
 Restoration of strength and function: -
- Restoration of strength is achieved
by strengthening of the rotator cuff
muscles, the scapula-stabilizer muscles
and the long humeral depressor muscles
(latissimus dorsi and pectoralis major).
 Proprioception: In a young individual who has
premature degenerative rotator cuff changes
because of shoulder instability, proprioceptive
exercises must complement strengthening
exercises.
 Sport-specific rehabilitation
 In a young individual or athlete, sport-specific
exercises must be included before resuming normal
sport activities.
 With the aging of the active population, this aspect of
the rehabilitation, combined with progressive return
to sport activities should not be omitted.
 Physical modalities for rotator cuff disease
 Physical modalities are used widely in the
treatment of rotator cuff disease.
 Based on review studies, it appears that
ultrasonographic therapy, transcutaneous
electrical nerve stimulation (TENS),
magnetotherapy, and different methods of
thermotherapy are not effective in the
treatment of shoulder disorder
 Pulsed electromagnetic field therapy and low
power laser could have short-term efficacy as
compared with placebo.
 Ultrasonography
 - This theory may explain why the use of
ultrasonography is only significantly effective in
the short term.
 The short-term efficacy of ultrasonographic
therapy has been demonstrated only in calcifying
tendinitis.
 Another modality that looks promising is
extracorporeal shock wave therapy.
 Passing a strong electric current through a flat
coil inducing a magnetic field generates shock
waves.
 Manual therapy
 Exercises
 Surgical Intervention
 Other Treatment
 Subacromial corticosteroid injection
 Bupivacaine suprascapular nerve block
 Edetate disodium (disodium EDTA)
 Analgesic
 A follow-up visit should be scheduled 6-8
weeks following the initial evaluation.
 Following visits depend on the
responsiveness to the treatment.
Recommend 2 months of follow-up visits
until the condition has improved or stabilized.
 Deterrence
 No medication or homeopathic agent is known to
prevent tendon degeneration.
 Avoidance of highly repetitive activities or
sustained shoulder posture with greater than 60°
of flexion or abduction is probably the best
prevention.
 Acute LBP if it has a duration of about one
month or less.
 Chronic LBP is usually defined by symptoms
of two months or more.
 Both acute and chronic LBP can be further
defined by the presence or absence of neurologic
symptoms and signs.
 Nonspecific or nonradicular LBP is not associated
with neurologic symptoms or signs.
 In general, the pain is localized to the spine
and/or paraspinal regions and does not
radiate into the leg.
 In general, nonspecific LBP is not associated
with spinal nerve root compression.
 LBP may or may not be associated with
significant pathology on magnetic resonance
imaging (MRI) and is often a result of simple
soft tissue disorders such as strain, but may
also be caused by serious medical disorders
arising in the bony spine, parameningeal, or
retroperitoneal regions
: Differential Diagnosis of Low Back Pain
Mechanical Causes Nonmechanical Causes
 Malignancy
 Idiopathic (sprain, strain)
 Infection
 Spondylosis (disk, annulus,
 Inflammatory
facet)
spondyloarthropathy
 Compression fracture (ankylosing spondylitis,
psoriatic spondylitis, Reiter's
 Traumatic fracture
syndrome, inflammatory
 Alignment disorders bowel disease)
(kyphosis, scoliosis,
 Osteochondrosis
spondylolisthesis)
 Paget's disease of bone
Causes of Referred Pain
 Pelvic disease (prostatitis,
endometriosis, pelvic
inflammatory disease)
 Renal disease (kidney
stones, pyelonephritis,
perinephric abscess)
 Aortic aneurysm
 Gastrointestinal disease
(pancreatitis, cholecystitis,
penetrating ulcer)
 LBP accompanied by spinal nerve root
damage is usually associated with neurologic
signs or symptoms, and is described as
radiculopathy.
 Low back pain is second only to upper
respiratory illness as a cause for visiting a
physician
 Up to two thirds of the population will have
low back symptoms at some time in their
lives
 Among individuals with chronic LBP without
neurologic deficits, a number of factors play a
role in the length of disability.
 Recurrent LBP and prolonged disability tend to
correlate with:
 prior history of LBP
 advancing age
 job dissatisfaction
 emotional distress
 heavy or repetitive lifting and physical work
 prolonged sitting or standing
 the presence of a worker's compensation claim or
pending litigation.
 Lumbosacral radiculopathy and radicular LBP
are less common than nonspecific LBP.
 L5 radiculopathy is the most common
lumbosacral radiculopathy, usually produced by
disk herniation between the fourth and fifth
lumbar vertebral bodies.
 S1 radiculopathy is the next most common,
followed by L3 to L4 radiculopathy.
 The pathophysiology of nonradicular LBP is
usually indeterminate.
 Pain may arise from a number of sites, including
the vertebral column, surrounding muscles,
tendons, ligaments, and fascia
 Stretching, tearing, or contusion of these tissues
may occur after sudden unexpected force applied
to the spine from events such as heavy lifting,
torsion of the spine, and whiplash injury.
 The pathophysiology of radicular spine pain
and lumbosacral radiculopathy is usually
more obvious.
 Disk herniation through the annulus fibrosis does
not in itself produce pain, but compression by disk
of the dural lining around the spinal nerve root
sleeve is one likely explanation for the back pain
associated with acute disk herniation.
 History and physical examination are critical
to the diagnosis and thus to the formulation
of a rational approach to management.
 Warning Signals of Systemic Disease Underlying Back Pain
Cancer
1. Prior history of malignancy
2. Advanced age
3. Unexplained weight loss
4. No pain relief with bed rest
5. Pain duration greater than 4 to 6 weeks
6. Failure to respond to standard therapies
Spinal infection
1. History of intravenous drug use
2. Urinary tract infection
3. Skin infection
Compression fracture
1. Advanced age
2. Trauma
3. Prolonged corticosteroid use
Rheumatologic disorders
 Rheumatologic disorders
 Waddell and colleagues have described a
number of historical features that point to
nonorganic causes for low back pain,
predicting delayed recovery and suggesting
the need for a multidisciplinary approach to
treatment.
 Historical Symptoms Suggesting Nonorganic Causes of Back Pain

Pain at the tip of the tailbone

Whole-leg pain in global distribution

Whole-leg numbness in a global distribution

Sudden give-way weakness of the leg

Absence of even brief periods of relative pain relief

Failure or intolerance of numerous treatments

Numerous urgent care visits or hospitalizations for back pain

 A general examination should be performed to
identify potential systemic disorders, such as
rheumatologic disease, skin disease, or bony
deformities.
 The spine should be inspected for alignment,
curvature, range of motion, focal tenderness,
and overlying skin abnormalities such as a tuft of
hair or pore.
 Mechanical maneuvers to elicit radicular and
hip-joint symptoms should be considered,
including straight-leg raising, reverse straight-
leg raising, Patrick's test, and Lasègue's sign.
 A careful neurologic examination should be
undertaken to exclude motor and sensory deficits.
 Muscle strength in the L2 through S1 myotomes
should be examined.
 The sensory examination should include soft-touch and
pain sensation in the same segmental distributions.
 Muscle stretch reflexes should be elicited at the knee
for the L3 to L4 segment and at the ankle for the S1
segment, and can also be performed in the posterior
thigh at the tendinous insertion of internal hamstrings
for the L5 segment.
 Signs on the Physical Examination Indicating Nonorganic
Causes of Low Back Pain

Superficial tenderness over the lumbar region to light touch

Nonanatomic tenderness

Exacerbation of pain by applying a few pounds of pressure with

the hands to the top of the head

Exacerbation of pain by simulated rotation of the spine

Ability to sit up straight from a supine position, but intolerance of

the straight-leg-raising test

Nonanatomic distribution of sensory changes

 Routine Radiographs of the Spine
 Computerized Tomography (CT) and
Magnetic Resonance Imaging (MRI)
 CT-Myelography
 Electrodiagnosis
 The initial management of acute spine pain
must be directed toward determining if a
serious neurologic condition exists
 If there is a history of recent trauma or
serious underlying medical illness, more
aggressive evaluation is warranted.
 Acute spine pain is very common, and the
likelihood of spontaneous recovery is in the
range of 80% to 90%.
 Prolonged inactivity will prolong recovery.
 treatment regimens tend to be nonspecific.
 There is general agreement that patients
with acute nonspecific spine pain or
nonlocalizable lumbosacral radiculopathy
(without neurologic signs or significant
neurologic symptoms) require only
conservative medical management.
 The initial treatment of the patient with
lumbosacral radiculopathy presenting with
sensory symptoms and pain without
significant neurologic deficits is not different
from the approach for the patient with
uncomplicated low back pain.
 Patients require observation for possible
worsening of their neurologic status.
 The treatment plan should fit the severity of
the symptoms and signs.
 The management approach for radiculopathy
covers the gamut from avoidance of heavy
lifting to laminectomy and fusion.
 In acute radiculopathy, the goals of
treatment should be the reduction of pain
and the stabilization or amelioration of
neurologic deficits.
 When symptoms of spine pain extend beyond
4 to 8 weeks, the condition has moved from
the acute to the chronic phase.
 In the face of true radiculopathy with new or
worsening neurologic deficits, a surgical
opinion should be considered.
 The standard approach to the patient with
nonspecific chronic spine pain is physical
therapy.
 By 3 to 4 weeks after onset of symptoms,
unless there is serious underlying structural
disease, there is no reason the patient should
not be enrolled in an aggressive program of
mobilization, postural improvement, and
increased endurance.
 The long-term outlook is good for significant
spontaneous recovery in patients with
lumbosacral radiculopathy.
 The pain of acute radiculopathy can persist
beyond 3 or 4 weeks, becoming chronic, at
which point acute remedies such as rest,
analgesics, and cervical traction may be less
effective and other therapeutic options must
be sought.
 Another local injection procedure, selective
nerve root block, has been used for diagnostic
and therapeutic purposes at the lumbosacral
and cervical levels.
 This diagnostic technique has been used when
there is lack of agreement between clinical and
neuroimaging findings, when there is atypical
limb pain, and when there is a history of failed
surgery at the level in question.
 Nerve root blocks are contraindicated in the
presence of systemic infection, local infection, or
bleeding diathesis.
 For the therapeutic procedure at the cervical
level, it is standard practice to use a
combination of 0.5 mL of 1% Xylocaine
(lidocaine HCl) and a long-acting
corticosteroid.
 The therapeutic injection is preceded by a
localization procedure under fluoroscopic
guidance using a nonionic contrast medium
to outline the selected nerve root.
 Some patients have chronic spine pain
without evidence of structural intraspinal
pathology, others have had previously
treated structural lesions, and some have had
multiple previous surgical interventions—a
condition described as the failed-back
syndrome.
 The goal in these patients is to improve the
ability to perform activities of daily living and
to diminish pain perception.
 Recurrences of low back pain are common.
- Studies have shown recurrence rates
between 30% and 75% within 3 years of the
first episode
 For patients with radiculopathy, there is less
likelihood of early recovery; however, about
50% of patients can return to work after 4 to
6 weeks without surgery
 Low back pain is usually caused by
mechanical disorders of the spine, with or
without involvement of the spinal nerve
roots, but it may be a result of nonmechanical
causes or may be referred from
retroperitoneal sources.
 Diagnosis starts with a careful examination,
followed by consideration for neuroimaging
studies and electrodiagnostic studies.
 Specific management decisions are based on
the duration of symptoms and the presence
or absence of neurologic deficits.
 Chronic pain syndromes are often
perpetuated by nonmedical factors.
Treatment requires a multidisciplinary
approach.
 Rheumatoid Arthritis (RA) is a chronic,
progressive, systemic inflamatory disorder
which affecting the synovial joints and can
lead to joint destruction.
 no known cure
 The goal of treatment now aims toward
achieving the lowest possible level of arthritis
disease activity and remission if possible, the
minimization of joint damage, and enhancing
physical function and quality of life.
 The optimal treatment of RA requires a
comprehensive program that combines
medical, social, and emotional support for
the patient
 There are three general classes of drugs
commonly used in the treatment of
rheumatoid arthritis: non-steroidal anti-
inflammatory agents (NSAIDs),
corticosteroids, and disease modifying anti-
rheumatic drugs (DMARDs).
 NSAIDs and corticosteroids have a short
onset of action while DMARDs can take
several weeks or months to demonstrate a
clinical effect.
 DMARDs include methotrexate,
sulfasalazine, leflunomide, etanercept,
infliximab, adalimumab, abatacept,
rituximab, anakinra, antimalarials, gold salts,
d-penicillamine, cyclosporin A,
cyclophosphamide and azathioprine .
 Because cartilage damage and bony erosions
frequently occur within the first two years of
disease, rheumatologists now move more
aggressively to a DMARD agent early in the
course of disease, usually as soon as a
diagnosis is confirmed.
 Rheumatoid arthritis is the most common
form of inflammatory arthritis
 It is an apparent autoimmune response that
involves synovium, articular cartilage, and
soft tissue.
 The joints of the hand are most commonly
involved, but wrists, feet, knees, and hips are
frequently affected.
 This disease is often symmetric, i.e., both
knees and both hands.
 Patients frequently suffer from morning
stiffness.
 Subcutaneous nodules may be palpated,
especially at the proximal ulna. The
rheumatoid arthritis (RA) factor is positive in
approximately 80% of patients.
 Radiographic changes in rheumatoid
arthritis:
▪ -severe destruction of radiocarpal articulation with
subluxation and ulna deviation at the wrist
▪ loss of ulnar styloid bilaterally
▪ dislocation of the proximal interphalangeal joint of the
left thumb and dislocation of the right fourth and fifth
finger metacarpophalangeal joints and left
metacarpophalangeal joint
▪ diffuse joint space narrowing of many interphalangeal
joints.
 Typical radiographs show loss of articular
cartilage, osteopenia, and periarticular
erosions
 A typical hip deformity of the femoral
protruding medially into the pelvis (protrusio
acetabulum) is not uncommon.
 These patients can have vasculitis,
pericarditis, and pulmonary involvement.
 Treatment is initially medical and often by a
rheumatologist.
 A variety of medications are available that
can either relieve symptoms or possibly alter
the course of the disease (disease-modifying
agents).
 Intra-articular cortisone injections can be a
benefit in an acute flare.
 For those with persistent joint damage, total joint
replacement is the most beneficial method to relieve pain
and disability and to restore function.
 When endotracheal intubation is a possibility it is wise to
obtain cervical spine radiographs.
 Instability of the cervical spine is not rare and this should be
checked prior to the manipulations required for anesthetic
intubation.
 Patients with systemic lupus erythematoid (SLE) may
have a rheumatoid arthritis-like syndrome.
 many also develop osteonecrosis as a result of the
common treatment of their disease with corticosteroids.
 MRI is useful in making the diagnosis of osteonecrosis.
 Osteoarthritis (OA) is the most common form of
arthritis, with up to 40 million people in the United
States having been diagnosed with it.
 Also known as degenerative joint disease
 generally considered to be noninflammatory.
 the same cytokines and interleukins seen in
inflammatory arthritis are also seen in
osteoarthritis, although in lesser quantity.
 Theories of etiology include both primary
biomechanical, or primary biochemical effects
and secondary biomechanical-derived effects
leading to a gradual loss of articular cartilage.
 Many patients do not have a clearly identifiable
source for their OA

 Other patients may demonstrate problems such

as chronic instability, malalignment, prior injury,
crystalline disease, past history of
meniscectomy, or excessive and repetitive
loading
 A genetic predisposition is present in some
patients.
 The knee is the most commonly affected joint.
 Radiographic evidence of OA is common by age
40 years, but clinically significant osteoarthritis is
less common until about age 60 years
 Typical findings on a radiographic
examination reveal loss of articular cartilage
shown by "joint narrowing" especially on
weight-bearing films.
 Osteophytes and subchondral cysts are
common radiographic findings.
 Physical examination reveals pain upon
walking (an antalgic gait pattern) or motion
of the involved joint.
 Patients have some degree of limitation of
motion, pain and/or crepitus with that
motion.
 Usually there is an effusion in the joint.
 The initial treatment includes
 activity modification
 weight reduction if indicated
 the use of a cane for lower-extremity problems
 nonsteroidal anti-inflammatory and nonnarcotic
analgesic medications if required.
 Patients should be encouraged to maintain
their joint motion and muscular strength.

 Rarely, an intra-articular corticosteroid

injection can be used for an acutely painful
joint, but it is only a temporary solution
 Surgical options are based on the dramatic
success of joint replacement to relieve pain
and restore function to the arthritic joint.
Clinical Example Normal Noninflammatory Inflammatory Septic (Bacterial)
(Osteoarthrosis) (Rheumatoid)

Color Clear Clear yellow Opalescent yellow Turbid yellow to

green

Viscosity High High Low Low

WBC/mm3 200 200–2000 200–100,000 >100,000

% PMM <25% <25% >50% >75%

leukocytes
Culture Negative Negative Negative Positive
Mucin clot Firm Firm Friable Friable
Glucose (% of 100% 100% 50–75% <50%
serum glucose)

Total protein Normal Normal Elevated Elevated