Upper limb soft tissue injuries

by Kirsty Berry, Shaun De Villiers & Marc Nortje

Learning objectives 1. Have an approach to upper limb soft tissue injuries. 2. Diagnose common soft tissue injuries of the upper limb. 3. Understand basic management principles of these injuries.

Introduction The rotator cuff consists of four muscles, Most of the ligament, tendon and muscle the subscapularis (Sc), supraspinatus (Sp), injuries of the upper limb can be treated infraspinatus (I) and teres minor (T). by trying conservative management. The These muscles are responsible for the majority of these injuries present to the movements of the glenohumeral joint. general practitioner and emergency units Strength Muscle Action and not the specialist orthopaedic surgeon. testing Weakness to resisted Initiates Rotator cuff injuries Supraspinatus elevation in abduction Tears of the rotator cuff tendons tend to Jobe position occur in people over the age of 50 years External External and may be due to general attrition of the Infraspinatus rotation in rotation tendon with age. There may or may not be 0° abduction External an associated injury. rotation in 90° External Teres minor abduction Applied anatomy rotation and 90° external rotation Internal Internal Subscapularis rotation in rotation 0° abduction

Actions of the rotator cuff muscles

Clinical findings Rotator cuff muscles around the shoulder History Pain . Insidious onset. . Often night pain. . It is exacerbated by overhead activities. 1 . In the event of a traumatic tear, the . Able to perform dynamic examination. pain and weakness are acute. . Relatively low cost, if available.

Weakness MRI . Loss of active range of motion with Expensive, so only use in a young patient greater passive range of motion. with traumatic tears or pain or weakness attributable to a rotator cuff tear that does Examination not improve with conservative The same as for impingement syndrome, management. but there is additional weakness on the resisted movement of the rotator cuff Management muscles. Non-surgical . Physiotherapy, activity modification, Additional injuries to note NSAIDs, subacromial corticosteroid The bruised shoulder with normal X-rays injections. following trauma: . The first line of treatment for most . The patient has an occult fracture or a tears. torn rotator cuff. Subscapularis tears are most commonly missed and are Surgical tested with the Belly Press and . Failure of conservative treatment. Gerber’s lift-off test. . Repair of rotator cuff +/- subacromial . If the patient is no better after ten days, decompression (open or arthroscopic). another careful examination and further imaging such as an ultrasound or MRI Tennis and golfer’s elbow are necessary. This is an overuse syndrome of the lateral

epicondyle (tennis elbow) and medial Imaging epicondyle (golfer’s elbow). X-rays Shoulder – look for: Applied anatomy . Calcific tendonitis of the supraspinatus tendon insertion. . Cystic changes in greater tuberosity are a sign of a chronic tear. . Proximal migration of the humerus can be seen with chronic RCT (acromiohumeral interval <7 mm). . Type III (hooked) acromion The flexor-pronator mass origin is affected in golfer’s elbow, and the common extensor tendon Ultrasound is affected in tennis elbow . Suspicion of rotator cuff pathology. 2 . Allow dynamic examination. Overuse injuries due to eccentric overload . Operator-dependant. at the common extensor tendon lead to . Shows areas of focal degeneration, but tendinosis and inflammation at the origin mostly normal. of ECRB, commonly known as tennis elbow. The same pathology exists for the MRI medial epicondyle where the flexor- . Not necessary for diagnosis. pronator mass origin is involved and is . Standard of care for medial known as golfer’s elbow. epicondylitis.

Clinical findings Management History Non-surgical Pain . Rest, ice, physiotherapy, activity . Insidious onset. modification, bracing and NSAIDs. . It is localised over medial or lateral . The first line of treatment for most. epicondyles. . Worse with wrist and forearm motion Surgical and gripping. . Open debridement of origin.

Examination Essential takeaways . Point tenderness 5-10mm distal and . Tears of the rotator cuff tendons anterior to the medial epicondyle tend to occur in people over the (golfer’s) and tenderness at ECRB age of 50 years. insertion into lateral epicondyle . (tennis). The bruised shoulder, with a . Provocative tests: normal X-ray after trauma, . Lateral epicondyle: resisted wrist should be investigated. extension with the elbow fully . Tennis elbow and golfer’s elbow extended. are primarily diagnosed with . Medial epicondyle: pain with clinical examination and history. resisted forearm pronation and wrist . Non-surgical management is the flexion. first line of treatment with most.

Imaging X-rays

. Usually normal.

. May show calcification in the tendons.

Ultrasound

. Not necessary for diagnosis. 3

References Assessment Amin NH, Kumar NS, A 40-year-old man presents to the Schickendantz MS. Medial clinic with three months of right epicondylitis: evaluation and elbow pain. He started playing management. JAAOS. 2015; squash four months previously. On 3(6):348–55 examination, he is tender over the lateral aspect of the elbow and pain Dines JS, Bedi A, Williams PN, et increases with resisted wrist al. Tennis injuries: epidemiology, extension. Which of the following pathophysiology, and treatment. muscles is involved in the JAAOS. 2001; 23(3): 181–9 pathophysiology of this disease? A. FCU – Flexor carpi ulnaris. Millett PJ, Warth RJ. B. FCR – Flexor carpi radialis. Posterosuperior rotator cuff tears: C. FDS – Flexor digitorum classification, pattern recognition, communis. and treatment. JAAOS. 2014 Aug; D. ECRB – Extensor carpi radialis 22(8):521–34. brevis. (D) is correct, as the patient

presents with lateral epicondylitis

which involves the origin of the

ECRB. The other muscles are all

flexor muscles and are involved in

medial epicondylitis.

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