Review Question - QID 220111

The patient is exhibiting signs and symptoms of an overuse-type injury to the shoulder, most consistent with rotator cuff tendonitis (painful Jobe) and likely biceps tendinitis (positive Speed's test). The best initial treatment in the setting of a full-strength, reassuring physical exam, is a trial of nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and possible subacromial injection prior to ordering advanced imaging.

Subacromial impingement and biceps tendinitis are among the most common causes of shoulder pain. Subacromial impingement and resultant rotator cuff tendinitis occurs as a result of compression of the rotator cuff muscles by superior structures (AC joint, acromion, CA ligament), leading to inflammation and the development of bursitis. The diagnosis can be made on physical examination with positive Neer and Hawkins impingement tests, as well as painful Jobe testing when the cuff is involved, with initial treatment being largely non-operative. MRIs are indicated for acute injuries, failure of non-operative treatment, or concern for significant structural damage (i.e., large rotator cuff tear) as indicated by significant clinical weakness or associated findings.

Factor et al. reviewed the current concepts surrounding rotator cuff tendinopathy. The authors reviewed 43 articles and found that it is increasingly evident that intrinsic mechanisms play a greater role than extrinsic mechanisms in this process. They concluded that emphasis should be placed on patient information (i.e. background information and personal description of symptoms) and imaging/injection techniques in order to aid in diagnosis, with future treatment technologies such as cell therapy and biological engineering offering the hope of improving patient outcomes and quality of life.

Weber et al. published the AAOS clinical practice guideline summary for the management of rotator cuff injuries. The authors note that shoulder disease is a major cause of musculoskeletal disability in the United States, with chronic shoulder pain estimated to affect approximately 8% of all American adults, second only to chronic knee pain in our society’s burden of musculoskeletal disease. They conclude that strong evidence supports that clinical examination can be useful to diagnose or stratify patients with rotator cuff tears

Figures A-C are normal AP, Grashey AP, and axillary lateral radiographs of the shoulder.

Incorrect Answers:
Answer 1: There is no clinical or radiographic evidence of symptomatic AC joint arthritis.
Answer 2: There is strong clinical evidence against subacromial decompression for rotator cuff tendinitis as an initial treatment.
Answer 3: The patient's equivocal O'brien's test in the vignette points away from symptomatic labral pathology, for which an MR arthrogram would not be ordered prior to a trial of therapy.
Answer 4: Though an MRI may be needed in the setting of an acute rotator cuff tear with clinical weakness, a trial of non-operative management should be attempted in the setting of a benign clinical exam pointing toward subacromial impingement and biceps tendinitis.