361 APril 1942] MOSELEY: SHOULDER PAIN 361

SHOULDER PAIN* BY H. F. MOSELEY Montreal pAIN is the characteristic feature referred to hesions will limit this rotation and proportional- in cases in this series-pain without radio- ly the abduction beyond 90 degrees. logical evidence of fracture, dislocation or gross Many factors possibly play a part in produc- organic disease. This communication is based ing lesions in this bursa. The important one is on a sequence of 158 cases during the past five trauma. The wear and tear of daily use is asso- years. ciated with the degenerative process of passing -years. Whether metabolic disorders, focal sepsis, TABLE I. and toxic absorption also play a part is not PAINFUL SHOULDER LESIONS clearly understood. Montreal .80 cases Whether acute trauma may give rise to a form London ..... 78 of Sudeck's atrophy of the shoulder region and " Total 158 " thus account for cases of frozen shoulder", ..... has for some time been under consideration. Diagnosis Montreal London Lesions of the bursa do not occur alone. Such are usually associated with changes in the under- Complete rupture ...... 4 3 Partial ruptures: lying rotator tendons and the joint capsule. In Recent ...... 9 30 Dr. believed that most Old ...... 13 3 fact, the late Codman

Tendinitis, "Frozen shoulder" .. . 13 processes in the bursa are secondary to ten- Calcified deposit ...... 17 dinitis, and my own operative observations agree Bands, villi ...... 7 Various ...... 17 with this view. In the partial ruptures of the supraspinatus I will confine myself to three groups of cases: with adherent bursitis there is a contracture of (a) subacromial bursitis; (b) calcified deposits; the short rotator muscles and indeed also of such (c) rupture of the short rotator cuff. adductors as teres major and pectoralis major. Subacromial bursitis.-The subacromial bursa This we see in the adducted shoulder with is situated above the gleno-humeral joint; its limited abduction characteristic of these cases base rests on the upper end of the humerus, when neglected. From the contracture of the partially covered by the short rotator cuff and muscles follows the highly placed humeral head, its roof is overlapped by the acromio-clavicular which position may also account for the restric- arch with the attached deltoid muscle. The tion of abduction. knowledge of the function and lesions of this Further, in bursitis associated with calcified bursa constitutes the key to the painful shoulder. deposits, there is no doubt whatsoever that the In order to recognize the limitations of move- calcification is initially in the tendons and only ments in these cases, an analysis of the shoulder secondarily erodes the bursal floor. If this mechanism must be considered. deposit recurrently irritates the bursa or breaks In the normal person, abduction of the arm to into it an adhesive bursitis develops from chemi- a right angle occurs chiefly at the gleno-humeral cal irritation. In fact it is my belief that many joint; abduction beyond this point, however, is cases of adherent bursitis have this origin. a more complicated problem. One factor is cer- Studies in referred pain.-It is necessary at tain, i.e., further abduction can only occur with this point to mention the recent work on referred external rotation of the humerus on its long axis, pain from fasciae, ligaments, bursse, periosteum and this rotation requires the normal function and other mesodermal tissues. This has been of the subacromial bursa. Further, any degree published by Lewis and Kellgren, who have of interference with the bursal surfaces by ad- shown that these structures when irritated will give rise to a pain referred at some distance from * From the Department of Surgery, Royal Victoria the trigger zone. The method used has been the Hospital. injection of small quantities of hypertonic saline Read at the Seventy-seeond Annual Meeting of the Canadian Medical Association, Winnipeg, June 26, 1941. into an area. Thus areas in the low back or 362 THE CAiqADiAN MmicAL AssmiATioN JouRNAL a, 1942 36:H AAINMrcI sscAINJUNL[pi14[Apri gluteal region on injection will give a sciatic bursitis without calcification. Each specialist radiation. The writer has used this method of publishes excellent results with the methods at investigation around the shoulder and elbow. his disposal, whether diathermy, x-ray, ionto- Injection of 0.5 c.c. 5 per cent saline into the phoresis, manipulation, splinting, surgical ex- area of the supraspinatus insertion will give cision or puncture, and so forth. The fact that pain referred to the insertion of the deltoid, and so many methods appear to give good results in larger amounts, the pain will pass to the must mean that a common denominator is elbow, forearm and even fingers. Further, in present. This denominator is the time factor operations in calcified deposits carried out under associated with the natural tendency of healing, local anaesthesia, pressure on the deposit through the vis medicatrix nature of the ancients, which the base of the bursa will.give excruciating pain is inherent in the living tissues. The part of the down the arm, elbow, forearm and fingers, and physician is to assist nature in this process, at also up the trapezius to the occipital region. In least not to interfere adversely. The indicator fact typical "brachial neuritis" is produced. of the effect of treatment is change in the clinical This of course, is only true in cases where the state, above all, in the symptom of pain. bursal floor is acutely inflamed from irritation In a previous paragraph, a short digression by the deposit. was made on this subject, and it was pointed out Symptoms.-A knowledge of the above studies how the pain began around the shoulder and enables one to understand the pain in cases of spread along the deltoid to its insertion, then bursitis. In the acute cases the pain is all farther down the arm, especially on its outer around the shoulder and may radiate, as stated side and into the forearm and hand, and also above, to the occipital region and down the whole how this radiation was retraced as the bursitis extremity to the fingers, which feel swollen and subsided and was last centred at the deltoid in- stiff. If the process comes on gradually the pain sertion. Now it was axiomatic among the Eng- is first felt around the shoulder, then as the lish bonesetters, among whom there was a great process extends, the pain is referred more and deal of common sense, that the painful shoulder more distally. Further, as the bursitis subsides, should not be manipulated until the pain finally the referred pain retraces the steps, and in the localized at the deltoid insertion. Until this chronic cases, localizes at the deltoid insertion. time the principle of treatment was rest, with As we will see later, the understanding of this such adjuvants as heat and sedatives, after is of interest in treatment. which the principle of treatment was movement. The pain may be so severe that heavy doses If the movement caused an increase of the pain of morphia have little eiTect, and is characteristic as regards intensity and radiation, the movement cally worst at night. had been instituted too soon, and a further Signs.-The physical signs depend on the in- period of rest was enjoined. This has been for- tensity and stage of the bursitis. The range of mulated into a test by the greatest of English movement at the glenohumeral and subacromial bonesetters, Hugh Owen Thomas, and is called areas varies from zero in the completely Thomas' Test of Recovery. This has been my "frozen" shoulder to almost complete movement guide in the treatment of these most difficult in patients with mild bursitis. In the severe cases, and I sincerely commend it to your con- cases, marked atrophy of the deltoid and scapu- sideration. lar muscles is present. The joint capsule may In the approach to these cases, including those be difusely tender on palpation. in the acute stage, the speaker makes use of the Radiology.-The films usually show a decalci- therapeutic test of movement. This is carried fication of varying degree most marked in the out usually after a thorough injection of the greater tuberosity. Small, degenerative, cyst bursal area with 50 to 60 c.c. of 0.5 to 1 per cent formations may be present in the subcortical novocaine, followed by manipulation of the bone. The head of the humerus is held high in shoulder if possible throughout its full range, the glenoid in the severe cases. Depending on and followed again by 20 minutes' diathermy. classification, approximately 50 per cent of cases In some of the worst cases who have suffered with symptoms and signs of subacromial bursitis intensely with lack of sleep, one single treatment will show evidence of calcified deposits. has given sufficient relief to make sleep possible. Treatment.-There is certainly no agreement I can recall no case aggravated by this treat- on a single method of treatment for subacromial ment, and have therefore made it the basis of my : AprilApi1921942] Mour SHUDRPISHOULDER PAIN 3636 therapy. This is associated with all forms of The deposits are best visualized if a soft tissue heat, of which the electric pad used continuously film is taken and if the films are of an antero- at its lowest temperature, has proved the most posterior view with the shoulder in first internal efficacious. Massage, faradism to wasted muscles, rotation and then external rotation. The shadow and resistance exercises are also employed. may not show if this routine is altered. The Splints and slings are rarely used, but drugs statements made in the previous section on sub- such as aspirin are ordered as indicated. In the acromial bursitis and dealing with the symptoms, completely frozen shoulder, treatment over six signs, and conservative treatment are equally weeks is usually required and the writer en- true here. deavours that the initial seven to ten days will There is, however, the question of operative be spent in the hospital so that the patient intervention and it is the speaker's intention to learns method and co-operation. confine himself to this particular point. In concluding this section, I would emphasize Position of surgery in the treatment of calci- that here' ertainly is a field where a thorough fied deposits.-Most cases of calcified deposits practical knowledge of the methods of manipu- will disappear completely under a course of lative surgery makes the difference between three to six weeks' diathermy, associated with success and failure. intensive pulley exercises. There will be a Calcified deposits of the rotator cuffs.-The tendency to recurrence in the same or opposite rotator cuff is the most common site in the loco- shoulder. motor apparatus for the deposition of amorphous However, any person, lay or medical, who has calcium. The chemical nature of the deposit has seen a patient with fulminating symptoms at the been analyzed for me by Dr. J. F. MacIntosh, end of a week of sleepless nights, and who has and consists of calcium carbonate and phosphate. seen the immediate relief given by an evacuation The deposit is radiologically localized in one area under local or gas ansesthesia, will agree to the of varying size, but at operation it is obvious value of open operation in such cases. It is that the tendons are diffusely involved and are readily carried out and is always most successful on the whole in a degenerating state. in relieving symptoms. Evacuation can also be used in chronic cases with large deposits which At operation it is seen that the deposit areas have failed to disappear, or in which the symp- are frequently multiloculated, which must miti- toms have been aggravated by radiation therapy. gate against the successful evacuation by treat- be The speaker has found the operative needling. In the chronic state, there may ment of these cases most successful, and this little evidence of the deposit on exposing the agrees with the opinions of Dr. Codman and Dr. base of the bursa. On incising the deposit, it is Bosworth. Six cases operated upon during the found to be inspissated and difficult to remove past two years have been checked and found free without removing parts of the tendinous tissue. of recurrence, whereas the majority of cases In the acute state, the base of the bursa is con- treated conservatively and who have been traced gested and even hawmorrhagic and cedematous are improved, but have had recurrences. with fibrinous adhesions. On incision the deposit Ruptures of the short rotator cuff. -This exudes with force as if under tension. It is group includes every degree of severity from much more fluid than in the chronic stage, and minor rents, to cases of complete detachment of has the appearance of tooth paste. the rotator cuff. In some cases the bursa itself is full of a milky The clinical picture is that of a patient in fluid which is due to a rupture of the material middle life, who, after a strain from lifting, or into the lumen and subsequent chemical bursitis from a fall, feels a snap in the shoulder accom- with exudation to dilute the irritant. panied by severe pain and followed by muscle There is no accepted view on the reason for spasm. Six to twelve hours later the pain is this calcium deposit. In hospital practice, it is most intense, and the patient fails to sleep. obvious that the deposits are much more common On examination, at this stage, one notes that in women than men, in those of sedentary type, the shoulder' is held stiffly by the side, and any as compared with the active type, in those tend- attempt at movement, especially in abduction, ing to obesity, and especially among diabetics gives rise to pain and increased muscle spasm. and amongst the Jewish and Southeast European In mild cases, abduction to 70 degrees may be races. possible without pain, but as the area of the '36436 THEH CANADIAi-ZAAINMDCLASOITO3IEDicALAssociATioN JOURNALORA [AprilArl141942 lesion passes under the coraco-acromial ligament, Untreated, the mild cases gradually improve. severe pain is felt which disappears at 110 de- In the more severe cases the muscles pass from grees, to return over the same range in adduc- a state of spasm to contracture, and the head of tion. This is obscured by the altered scapulo- the humerus is held high in the glenoid and in humeral rhythm. Rotation likewise is prevented adduction. An adherent subacromial bursitis by spasm. The area of the lesion is tender and organizes from the tearing of its base. The there may be pain referred to the insertion of result is a shoulder in which abduction and rota- the deltoid. Radiology discloses a highly placed tion are greatlv limited and this loss of move- humeral head, but is otherwise negative. ment is obscured by the movements of the The full movements can be carried out, how- scapula. ever, by the injection of novocaine into the The treatment of these cases by strapping, tender area, or by preventing its impingement Velpeau bandage or the sling position, which on the coraco-acromial ligament by the relaxed constitutes the routine medical procedure, pre- muscle position or "the depression of the head disposes to the poor result. test ". The intensity of the symptoms varies with the TREATMENT extent of rupture. It is less marked in the aged. Recent partial ruptures. - In recent partial The surgeon's most difficult task is the selec- ruptures, the treatment has been immediate full tion of cases requiring operation. In this re- range of movement carried out by the relaxed spect practical experience in the treatment of a muscle position or by manipulative means with large number of cases develops judgment. In the use of massage, novocaine and diathermy for my experience, it is best to operate in cases of pain. The time required for complete relief in doubt, as cases of complete rupture without a good subject, is roughly 3 weeks, but in the operation usually end in stiff, weak and painful series of 30 cases previously published including joints. cases of compensation neurosis, the time factor The value of novocaine both as a diagnostic was seven and one-half weeks. and therapeutic agent cannot be overestimated. Old partial ruptures of the short rotators.- It has been used in this series from the first, and The principle of treatment here is movement. the ideas for its use were gained from the work Heat, massage, faradism, novocaine to the on sprains by Professor Leriche. scarred area, and stretching even with gas In the partial ruptures, novocaine infiltrated ancesthesia will restore the majority of these into the affected area will restore full painless cases to normal. The time factor for these cases movements with disappearance of the muscle however is usually about three months, although spasm. Furthermore, in the majority of cases, the clinic cases usually discharge themselves the pain is permanently lost to the extent of 30 before this time. to 60 per cent of its original intensity and in Recent complete ruptures.-In the complete some, the one injection removes the pain perma- ruptures the principle of treatment is accurate nently and entirely. suture at the earliest moment, followed by rest In the complete ruptures, novocaine injection for 3 weeks. Then active mnovemeiets gently will often again relieve all pain and muscular restored with heat, massage and faradism to the spasm. The movements will reappear, and will shoulder muscles. In the two cases of complete be full in extent under voluntary control. Some rupture of the supraspinatus operated on within gentle massage or manipulation may be neces- a week of the accident, the results were perfect. sary before this is achieved. In these cases In the one case of complete rupture of the however, there is marked weakness in maintain- rotator cuff operated on within a week, the ing abduction against any resistance, or the arm result was good, but the patient was unable to when abducted may just fall to the side. This do heavy work. is the "drop arm sign" for severe ruptures of Bosworth states these latter cases are best the rotator cuff. treated by arthrodesis of the shoulder, but I I decide on exploration if there are the clinical have not been convinced on this point. features of a severe injury with negative In the cases of complete rupture where radiology, and where there is marked weakness suture has not been possible, shoulder function in maintaining abduction after novocaine. can be secured as satisfactorily as late suture April 1942] DEADMAN: THE PATHOLOGIST 365

results, if early movements and strengthening SUMMARY AND CONCLUSIONS exercises are carried out under careful super- Shoulder pain is a symptom of many local vision. In this group we have two cases with and distal lesions. 70 to 80 per cent function of the shoulder. Both these cases, however, are in the 70 year The key to the painful shoulder is in under- age group, and such results are not adequate standing the importance of the subacromial in the young patients. bursa. Old complete ruptures.-The question for de- Many, if not most, cases of brachial neuritis cision here is whether the age, general health have their origin in the bursal area. and economic position of the patient justifies The work of Lewis and Kellgren on referred interference. pain has been applied to the painful shoulder. In cases where operation is justifiable, a The relative positions of rest and movement shoulder with three-quarters to seven-eighths have been stated as clearly as possible. of its function can be secured. This is shown value of Leriche's work on soft part after the The in a case operated upon three months with immediate movement after novo- and also by injuries accident and previously published, corroborated in diagnosis and a case seen with Dr. Magee in Peterborough, caine, has been sutured one month after the accident. therapy of shoulder lesions. The time required after operation to secure The principle of movement constitutes the good function is again about six months, with key to therapy in the shoulder disorders under further improvement after this period. discussion.

THE ROLE OF THE PATHOLOGIST* BY WILLIAM J. DEADMAN Hamilton, Ont. TO the individual keenly alive to his human mediate or sublimated, underlies most if not all environment nothing is more fascinating than human actions, individual or collective. So long the study of history. In spite of the opinion as human beings remain human, it must inevit- attributed some years ago to an internationally ably be so. known industrialist, history is not "bunk". Reason would teach us that, if we are to pre- "Humanity with all its fears, with all its hope dict the future course of human events with any of future years, is hanging breathless on the degree of accuracy, if we are to safeguard in- fate" of the British Empire, and indeed on that telligently our own future and that of those who of the whole Anglo-Saxon system of civilization. follow us, we must base such predictions and Humanity, when the present critical struggle the actions which they dictate, on a knowledge shall have been resolved in favour of those who of what the human being has been doing over the cling to Anglo-Saxon ideas of liberty, will need past 7,000 years of recorded history. Human in the future to pay considerably more attention nature has changed little, if at all, over that to the lessons of history than has been the case period; the technique of human reactions alone in the past, or than Canadians have paid during has changed. Over the past 1,900 years, it is the last twenty years. Reason, the power of de- difficult to be convinced that the principles of duction, and the ability to base future conduct Christianity have been adopted to the point of on the past experiences of himself and of others banishing the old Adam, or that the practical ap- are presumed to be prerogatives of the human plication of the fundamental principle of Chris- being; unfortunately, they appear to be exercised tian doctrine, the raising of the dignity and the by the minority rather than by the majority. safeguarding of the inherent rights of the in- Man is biologically an animal; human nature is dividual has yet reached satisfactory heights or fundamentally selfish; and self-interest, im- has been at all generally accepted by the two billion human inhabitants of this planet. Un- * Being the Presidential Address at the Fourth Annual mindful of the halting and laborious course of Convention of the Ontario Association of Pathologists.