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.