Glenohumeral articular and capsulitis pain are not well localized (e.g., the patient covers his shoulder with his hand). Pericapsular pain may be associated with SAI syndromes but may also be myofascial (typicall y) or referred from the cervicothoracic spine. \200 Bilateral shoulder pain should increa se suspicion of the presence of an in \202 ammatory polyarthritis such as RA (see Chapter 5), juvenile idiopathic arthritis (JIA, Chapter 7), psoriatic arthritis (see Chapter 8) or CPPD arthritis (see Chapter 15) \200\224 but these would be rare without other joint sympt oms. Diffuse pain across the shoulder girdle muscles in those over 55 years of age raises the po ssibility of PMR (see Chapter 14). This pain is often associated with immobility and stiffn ess, particularly early in the day. A deep aching pain associated with stiffness is characteristic of adhesive capsulitis (frozen shoulder). The use of the term frozen shoulder is popular, but often incorrectly applied. It is a condition that is rare in patients under 40 years of age . The condition occurs in three phase: a painful phase, an adhesive ( \200\234frozen \200 \235) phase, and a resolution phase. Phases often overlap and the duration varies, but long -term limitation of shoulder movement remains in up to 15% of patients. It is associated wi th diabetes. Does the pain vary? Movement- or posture-related pain may be a clue to its cause: \200 Ro tator cuff lesions often present to rheumatologists with an SAI pattern of pain \200\224tha t is, pain reproducibly aggravated by speci \201 c movements during each day such as reach ing up (overhead) with the arm. Articular, bone, and adhesive capsulitis pain is more likel y to be persistent. A history of recurrent bouts of shoulder pain in children and adolescents may suggest glenohumeral instability due to hypermobility SHOULDER PAIN 27 or previous trauma, e.g., a labral tear. In an unstable shoulder, pain may result from syno vitis, subchondral bone damage, or an SAI disorder. The frequency of recurrent anterior sub luxation is inversely proportional to the age at which the initial dislocation occurs. Are there spinal symptoms? There is an association between neck conditions and shoulder pai n. C4 nerve root pain is referred to the shoulder, while adhesive capsulitis is associated with cervical nerve root symptoms (the nature of the link is unknown). In \202 ammatory ne ck lesions caused by CPPD and psoriatic spondylitis can lead to pain referred to the should ers, mimicking PMR. Examination Visual inspection Inspect the neck, shoulders, and arms from the front, side, a nd back with the patient standing. \200 Abnormality of the contour of the cervicothoracic spine could indicate muscle imbalance/spasm or might be associated with a nerve root origi n of pain. Scapular asymmetry at rest is especially relevant when examining children and may indicate a congenital bony deformity. Subtle degrees of asymmetry are comm on and are not usually due to speci \201 c pathology. Diffuse swelling of the whole shoulder may suggest a shoulder effusion/hemarthrosis or subacromial bursitis. In the elderly, Milwaukee shoulder should be considered. Swelling of the AC joint occurs with joint diastasis, arthritis, and distal cl avicular bone lesions. Arm swelling and skin changes distally could indicate a complex regional pain syndrome (see Chapter 18). Elicit any tenderness Eliciting tenderness of discrete shoulder structures is often unrewar ding: \200 Tenderness of the AC joint, humeral insertion of the supraspinatus tendon, and the long head of biceps tendon may be clues to pathology, but palpation may not yield a speci \201 c diagnosis. An appreciation of trigger points associated with myofascial pain and tender points in \201 bromyalgia (see Chapter 18) is important in the interpretation of regional soft tissue tenderness. Document bilateral shoulder movements This aids diagnosis but also gives an indication of t he level of functional impairment and can help in monitoring changes over time (see Table 2 .3). The movements are \201 rst tested actively (the patient does the movement) and then passively (the clinician supports the limb). Muscle strength can also be assessed while tes ting active movement. \200 Observe arm elevation in the scapular plane from behind, notin g symmetry of scapular movement, the pattern of pain during elevation, and the range of eleva tion. Hunching of the shoulder at the outset of arm elevation often occurs with an impingem ent problem. A painful arc may suggest a rotator cuff lesion. Inability to lift the arm sug gests CHAPTER 2 Regional musculoskeletal conditions 28 a rotator cuff tear or weakness, capsulitis, or severe pain, e.g., acute calci \201 c supr aspinatus tendonitis. Observe and compare internal rotation of shoulders, which can be judged by how far up the back the hand can reach. Poor performance may be due to rotator cu ff weakness, weakness of the scapular stabilizing muscles, or pain (generally from shoulder impingement syndrome). This maneuver assumes normal elbow function. Observe the range of external rotation of the humerus from the front. Ask patients to \202 ex their elbows as if they were holding a tray, and then rotate the arms outwards. Min or degrees of restriction caused by pain are not speci \201 c, but severe restriction is c haracteristic of adhesive capsulitis. Passive range of motion should be tested with two hands: one hand guides the movement while the second rests on the shoulder. Many patients will subconsciously \202 ex the spine to compensate for restricted range of motion at the shoulder; using both hands can help detec t this and other abnormalities in movement at the joint. Test for subacromial impingement \200 Always compare the affected with the asymptomatic s ide and make conservative judgments about muscle weakness if there is pain impeding volunta ry effort. Most tests rely on their ability to narrow the distance between the humeral head and the CA arch, by driving the greater tuberosity under the CA arch as the hu merus rotates (see Figure 2.5). Whether the tests are speci \201 c for lesions of the subacromial structures or for the si te of impingement are unknown. Movement of the glenohumeral joint Move the glenohumeral joint passively in all directions by moving the upper arm with one hand and placing the other over the shoulder to feel for \200\234clunks \200\235, crepitus, and resistance to movement: \200 If the humeral head c an slide anteriorly (often with a \200\234clunk \200\235) without rotation in the glenoid it suggests instability. Grossly reduced passive shoulder movement (notably external rotation, with or without pain) is the hallmark of adhesive capsulitis. Pull down on both (hanging) arms. If the humeral head moves inferiorly (sulcus sign), there may be glenohumeral instability. Stress the acromioclavicular joint Stressing the AC joint may reproduce the pain. This is c onventionally done by compression or shear tests: \200 These tests should not normally be painful. Although painful tests have not proved to be speci \201 c for AC pathology (pain from SAI may also be present), a positive test may provide a clue that the AC joint is art hritic or dynamically unstable, or that impingement of structures in the subacromial space under the AC joint is occurring. Hold the patient \200\231s arm in forward \202 exion (90 ) and draw it across the top of the patient \200\231s chest. The resulting compression of the AC joint may produce pain. A C joint pain can also be elicited by passively SHOULDER PAIN 29 Table 2.3 Isolated muscle testing of shoulder girdle muscles Muscle: nerve root, peripheral nerve supply and muscle action Muscle position Isolated muscle test Common pathology affecting muscle strength/ bulk Tear or disuse following damage, e.g., after a fall, chronic overuse stress, or in athletes (throwing arm) Abduct arm from neutral against resistance From behind, seen and felt above the scapular spine at rest and when activated Supraspinatus: C5/C6. Suprascapular nerve. Initial humeral abduction and stability of raise d upper arm Infraspinatus: C5/ C6. Suprascapular nerve. External rotation and stability of humeral head From behind, seen and felt arising from medial scapular border passing laterally (below the scapular spine) External rotation of arm in neutral, elbow supported and \202 exed at 90 Tear or disuse following chronic damage Serratus anterior: C5 \200\223C7. Long- thoracic nerve. Pulls the scapula forward on the th oracic wall (extends forward reach of arm) Appreciated from behind when patient is pushing against a wall with arms outstretched in fr ont, in that scapula remains \201 xed Test by pushing wall with an outstretched arm or push-up. If paralyzed there will be liftin g and lateral excursion of the scapula Damage to long- thoracic nerve from trauma. Patient may also have SAI Deltoid: C5/ C6. Axillary nerve. Flexion, extension but mainly abduction of humerus Arises from the scapular spine and acromion, then swathes the shoulder inserting into the h umerus laterally Wasting may be obvious. Weakness in isometric strength of an arm abducted to 90 Lesions of axillary nerve damaged by anterior shoulder dislocation (external rotation may a lso be weak from denervation of teres minor) elevating the arm through 180 , bringing the hand to the ceiling. Pain is experienced in t he upper 10 or so of movement. Shoulder examination with the patient supine Examine the shoulders with the patient supine to test whether there is anterior cuff de \201 ciency, glenohumeral joint laxity, or a lab ral tear: this is especially important in young adults and adolescents to identify an \200 \234unsta- ble shoulder. \200\235 Hold and support the upper arm held in slight abduction a nd external rotation (the elbow is \202 exed). Move the arm gently (cranially in the coro nal plane) and apply gradual degrees of external rotation. CHAPTER 2 Regional musculoskeletal conditions 30 (b) (a) Painful arc (active) Neer test (passive) Patient standing. Slow arm abduction (scapular plane). Pain onset (maximal) at (variable) a ngular range. Action: Action: Patient sitting/standing. Passive forward flexion. Scapula fixed. Pain at (variable) angle of flexion. Positive test: Positive test: (c) (d) Empty can (active) Kennedy \200\223Hawkins (passive) FIX Action: Patient sitting/standing. Active forward flexion to 90 then internal rotation \200\224 \200\230can empties \200\231. Action: Patient sitting/standing. Passive forward flexion (90 ). Fix elbow with hand. Passive internal rotation. Positive test: Positive test: Pain with flexion or rotation of arm. Pain at some stage of elevation or rotation. Fig. 2.5 Tests useful for eliciting subacromial impingement. De \201 ciency of anterior structures is suggested by patient apprehension that pain is imminent or that the shoulder will slip forward ( \200\234the apprehension tes t \200\235). With a labral tear there may be an audible or palpable \200\234clunk. \200 \235 Pressure downward on the upper arm (taking the pressure off anterior shoulder structures by an anteriorly translocated humeral head) may relieve this apprehension or the pain associa ted with it ( \200\234the positive relocation test. \200\235) SHOULDER PAIN 31 An unstable shoulder identi \201 ed with the tests just described may denote previous trau matic injury (e.g., shoulder dislocation) or a hypermobility disorder. Diagnosis and management The optimum initial imaging for investigating undiagnosed shoulder pain is disputed. Some clinicians advocate management of shoulder problems based on histor y and examination alone. This is a practical approach to a common problem because many prob lems get better in the short term. The long-term sequelae of such management strategies, ho wever, are unknown. Studies of shoulder pain in primary are suggest that chronic shoulder p roblems are common, often despite initial improvement. Radiographs \200 The standard projection for screening purposes is anteroposterior (AP), although the AP axial-lateral view taken with the arm abducted may add information ab out the relationship of the glenoid and humeral head. Look for calci \201 c deposits in so ft tissue (such as the basic calcium/ phosphate crystals seen in Milwaukee shoulder \200 \224see Chapter 7). Supraspinatus outlet views are often used to assess acromial con \201 guration and identify inferior acromial osteophytes in patients with SAI. If recurrent dislocation is suspected, associated humeral head defects may be identi \201 ed by an AP \201 lm with internal humeral rotation or a Stryker view. Bilateral \201 lm s distinguish anomaly (invariably bilateral) from abnormality. Bilateral AP AC joint views with the patient holding weights may identify and grade degrees of AC joint diastasis (separation). Distal clavicular erosion ma y be due to RA, hyperparathyroidism, myeloma, metastases, or posttraumatic osteolysis. Although characteristic patterns of abnormality are associated with SAI (see Plate 2), mino r age-related radiographic abnormalities are normal. Other imaging: ultrasound, arthrography, CT arthrography, MR, bone scan \200 Ultrasound s coring systems for locating and grading rotator cuff tears now exist. The technique permits examination of the rotator cuff with the shoulder in different positions, but is highly op erator dependent. \200 Patterns of rotator cuff abnormality and subacromial impingement a re well recognized with both arthrography and MR. However, there is no consensus about whet her ultrasound, MR, or arthrography is most accurate for detecting rotator cuff tears. Children, adolescents, and young adults suspected of having unstable shoulders should have an MR examination, because detailed views of the humeral head, glenoid labrum, periarticula r glenohumeral soft tissues, and subacromial area are important. MR is the modality of choice in young adults when instability is diagnosed. Rotator cuff le sions and labral abnormalities are best assessed with MR. Enhancement with IV contrast may increase the chance of detecting a labral tear. CHAPTER 2 Regional musculoskeletal conditions 32 No speci \201 c patterns of bone scan abnormality have been consistently recognized for is olated shoulder lesions, although a triple phase bone scan may be diagnostic for complex re gional pain syndrome in the upper limb. Other diagnostic procedures \200 Local anesthetic injection may help disclose the site of shoulder pain, although it is possible that by the time anesthesia occurs the injected ane sthetic has spread to areas not intended as a target. Joint aspiration is essential if infection is possible. Fluid is usually aspirated easily f rom a grossly distended shoulder capsule. Hemarthrosis can occur in shoulders with degenera tive joint disease (often in association with chondrocalcinosis), hemophilia, trauma, and p igmented villonodular synovitis. Electrophysiological tests (EMG/NCV) may con \201 rm muscle weakness and help establish the presence of neuromuscular disease, e.g., myositis or neuralgic amyot rophy. Blood tests are required if looking for infection, in \202 ammatory disease, etc. \200 A normal creatine kinase (CK) and aldolase will rule out myositis in the majority of cases. Blood urea, electrolytes, creatinine, alkaline phosphatase, calcium, phosphate, thyroid fun ction tests, and myeloma screen should be considered if metabolic bone or myopathic disease is considered. Treatment (see Chapter 19) \200 Physical therapy should play a focal part in encouraging mobilization of the joint, and early assessment is prudent. The following principles are re commended: \200 Know whether there is an additional neck/spinal generated pain component (physical therapists are independent diagnosticians and some may erroneously aim therapy at cervicothoracic segments for individual shoulder lesions). Do not refer to physical therapy without knowledge of who will see the patient, and the app roach that will be taken for instability and rotator cuff weakness. \200 Simple analgesic s are often necessary. \200 Local steroid injections (see Plates 12 and 13) can be consid ered in the following situations: \200 tendonitis of the rotator cuff \200 adhesive capsulitis (see Plate 12) \200 AC joint pain \200 subacromial bursitis (see Plate 13). The principles of steroid injection and rehabilitation are dealed with in the last two sections of this chapter. There are several situations where local steroids should be avoided: \200 bicipital tendo nitis (which should be treated with rest, analgesia, and physical therapy); the \201 rst 6 weeks of an acute rotator cuff tear; SHOULDER PAIN 33 when symptoms have become chronic and conservative therapy has not helped for a presumptive clinical diagnosis. This requires reassessment, imaging, and a decision about whether surg ery may be required. Surgical intervention may take the form of subacromial decompression arthroscopy, synovecto my of the SC joint and AC joint, or excision of the distal end of the clavicle: \200 suba cromial decompression may be necessary for chronic rotator cuff tendonitis especially when imaging has shown inferior acromial osteophytes; other interventions include repair of a rotator cuff or biceps tendon rupture and joint rep lacement (mainly for pain relief rather than improvement in function). Lithotripsy does not offer advantages over steroid injection and physical therapy for calci \201 c supraspinatus tendonitis. CHAPTER 2 Regional musculoskeletal conditions 34 Pain around the elbow Functional anatomy \200 The humeroulnar articulation is the prime ( hinge) joint at the elbow. The radius also articulates with the humerus and, to allow forearm and hand supination/pron ation, with the ulna at the elbow (see Figure 2.6). \200 Normal extension results in a st raight arm, but some muscular people lack the last 5 \200\22310 of extension and some (es pecially women) have up to an extra 10 of extension (hyperextension). Normal \202 exion is to 150 \200\223160 and forearm supination/pronation range is around 180 . Owing to obliquity of the trochlea, extension is associated with a slight valgus that can be accentuated in women (up to 15 ). Unilateral acute traumatic or chronic overuse lesions of the elbow are common. Bilateral sy mptoms may occur in these situations, but also consider the possibility of an in \202 amma tory arthritis affecting the elbows or referred pain from the neck. Pain may also be referred from proximal neurologic lesions in the arm, the shoulder or even from distal lesions such as carpal tunnel syndrome (CTS). Taking a history Is the pain exclusively located in the elbow or referred from elsewhere? E stablish whether the pain is associated with neck pain and whether it has neurogenic qualit ies or is associated with paresthesias or numbness. There may be referral of pain from C6 o r C7 nerve roots, shoulder lesions, or even from compression of the median nerve in the wri st. Is there a history of acute or chronic (overuse) trauma? \200 Pain at the lateral epicond yle 1 \200\2232 weeks after a weekend of \200\234home maintenance \200\235 might suggest l ateral epicondylitis (tennis elbow) following excessive use of a screwdriver, for example. Other common sites of pain, where characteristic conditions related to overuse are recogniz ed, include the medial humeral epicondyle ( \200\234golfer \200\231s elbow \200\235) and th e olecranon bursa (repetitive pressure/ friction). Although typically acute in onset, these conditions may develop insidiously. Fractures around the elbow and fractures/dislocations in the forearm are common. Dislocation of the radial head alone is rare and is usually associated with con current fracture of the ulna (radiographs may not easily identify the fracture). If not ass ociated with fracture (and especially if recurrent), the condition may be associated with g eneralized hypermobility (see Chapter 16) or shortening of the ulna owing to bone dysplasia . In children, a strong pull of the forearm or wrist (occurring primarily in preschool childr en) can lead to a partial dislocation of the elbow ( \200\234nursemaid \200\231s elbow \200 \235), which can be corrected by supinating and \202 exing the forearm while supporting t he radial head. PAIN AROUND THE ELBOW 35 Humerus Medial supracondylar ridge Lateral supracondylar ridge Olecranon process Medial epicondyle Trochlea Lateral epicondyle Capitellum Head and neck of the radius Coronoid process Tuberosity for brachialis Radial tuberosity for biceps Radial notch and proximal radioulnar joint Ulna Radius Fig. 2.6 Bony con \201 guration at the (right) elbow (anterior view) In children, osteochondritis of the humeral capitellum can occur in mid to late childhood (Panner \200\231s disease), typically following repeated trauma. Does the pain radiate distally? \200 Forearm pain may be an additional clue to C6 or C7 r adicular pain, but may also be due to the spread of musculoskeletal pain along the extensor group of muscles from lateral epicondylitis or from entrapment of the median nerve in the elbow region. Peritendinitis crepitans is pain, tenderness, and swelling in the forearm associated with occupational overuse. It is thought to be due to damage of the long wrist/h and \202 exors and extensors at the muscle \200\223 tendon junction. Diffuse pain in the forearm can occur as a result of overuse injury, particularly in musici ans and typists, although there is overlap with regional pain syndromes. Pain around the forearm may also arise from in \202 ammation at the wrist (see the next se ction) particularly in De Quervain \200\231s tenosynovitis. Is there prominent stiffness with the pain? \200 Stiffness is often nonspeci \201 c but may denote in \202 ammation such as synovitis of the joint or olecranon bursa and, therefo re, raises the possibility of an autoimmune rheumatic or crystal deposition disease. \200 In the middle aged and elderly, gout (see Chapter 15) of the olecranon bursa and surroundi ng soft tissues, particularly overlying the border of the ulna, is not uncommon and is ofte n misdiagnosed as a cellulitis. Ask about locking Locking of the elbow in either \202 exion or supination/pronation may b e due to loose intra-articular bodies. A single loose body is most commonly due to osteocho ndritis dissecans of the capitellum (e.g., in children with over- CHAPTER 2 Regional musculoskeletal conditions 36 use throwing injury \200\224 \200\234Little League elbow \200\235) and multiple loose bodie s are associated with OA or synovial chondromatosis. Is the pain unremitting and severe? This type of pain suggests bony pathology: \200 Altho ugh nonfracture bone pathology is rare in the elbow region, local bony pain might suggest o steochondritis or avascular necrosis, or, if part of a wider pattern of bony pain, metaboli c bone disease. In the elderly and others at high risk for osteoporosis, supracondylar and other fractures may occur with surprisingly little trauma. Are there symptoms in other joints? Ask about other joints, low back (sacroiliac) pains, an d risks for gout: \200 Elbow synovitis alone is an uncommon presenting feature of adult R A. \200 Elbow synovitis occurs in children presenting with JIA (see Chapter 7) but is rare (3%). Periarticular enthesitis is a recognized feature of spondyloarthropathy (SpA) (see Chapter 8) and may mimic tennis elbow. The periarticular tissue around the elbow is a moderately common site for gout. Examination Look for abnormalities, then palpate with the thumb. Observe the active, passiv e, and resisted active range of joint and related tendon movements and consider examining f or local nerve lesions. A complete assessment should include examination of the neck, shoul der, and wrist. Visual inspection Look for obvious deformity or asymmetry in the anatomical position: \200 Up to 10 of extension from a straight arm is normal. More extension might suggest a hypermobility disorder. A child with an elbow lesion typically holds the extended arm close to the body, often in pronation. Look for swelling or nodules: \200 Swelling due to joint synovitis is dif \201 cult to s ee in the antecubital fossa unless it is \202 orid: it is most easily seen (and more easi ly felt) adjacent to the triceps tendon insertion. The olecranon bursa, which may be in \202 amed, overlies the olecranon and does not as a rule communicate with the joint. Overlying erythema, although nonspeci \201 c, may be associated with infection or gout. Nodules over the extensor surface or ulna border may be associated with RA (see Chapter 5). Psoriatic plaques are commonly found at the elbow extensor surface. Observe active \202 e xion and supination/pronation with the elbows held in 90 of \202 exion: \200 Although the range of movement may be affected by extra-articular pain, loss of range usually implies an intra-articular disorder. PAIN AROUND THE ELBOW 37 Palpate the lateral epicondyle of the humerus \200 In lateral epicondylitis ( \200\234ten nis elbow \200\235) there is tenderness, which may extend a little distally. Wrist and \201 nger extension against resistance with the elbow in extension or passively stretching the tendons (by having the patient make \201 st, \202 ex wrist, pronate forearm, then e xtend elbow) may reproduce the pain. Lateral epicondyle tenderness may be due to in \202 ammation of the radiohumeral bursa that lies under the extensor tendon aponeurosis. \200 Note that tender ness of lateral and sometimes medial epicondyles can occur in chronic pain syndromes. In th ese cases, however, the relevant extensor or \202 exor tendon provocation tests are likel y to be negative. Palpate the medial humeral epicondyle \200 Tenderness suggests traumatic medial epicondyl itis ( \200\234golfer \200\231s elbow \200\235), a regional or chronic pain syndrome, or en thesitis. Con \201 rm the site of the pain by stretching the wrist \202 exors \200\224su pinate the forearm, then passively extend both the wrist and elbow simultaneously. Resisted palmar \202 exion of the wrist or forearm pronation with elbow extension may also cause pain. Tasks that rely on this repetitive movement are often the provoking cause. Consider osteochondritis of the medial humeral epicondyle as a cause of persistent pain fol lowing an injury. The 8 \200\22315-year-old age group is at particular risk as this is a si te of secondary ossi \201 cation. Passively \202 ex and extend the elbow joint Passively \202 ex and extend the joint and note the range of movement and \200\234end-feel \200\235 (the feel of resistance at the e nd of the range of passive joint movement): \200 \200\234End-feel \200\235 may tell you whether there is a block to full \202 exion or extension from a bony spur or osteophyte (solid end-feel) or from soft tissue thickening/ \201 brosis (springy, often painful). Note any crepitus (often associated with intra-articular pathology) and locking (caused by loose bodies in the joint). Supinate and pronate the forearm Passively supinate and pronate the forearm supporting the elbow in 90 of \202 exion with your thumb over the radioulnar articulation: \200 Ther e may be crepitus or instability/subluxation associated with pain. Instability might sugges t a tear or damage to the annular ligament (due to trauma or chronic/aggressive intra-artic ular in \202 ammation). Test peripheral nerve function if there are distal arm symptoms \200 Given its course aro und the lateral epicondyle, the integrity of the radial nerve should always be tested when a lateral elbow lesion is suspected. The median nerve runs in the antecubital fossa and may be affected in traumatic elbow lesio ns. It is particularly susceptible where it runs between the two heads of pronator teres (f rom medial epicondyle and the coronoid process of the ulna) and separates into anterior int erosseous and terminal median nerve branches. CHAPTER 2 Regional musculoskeletal conditions 38 The ulnar nerve lies in the groove behind the medial epicondyle. Bony or soft tissue abnorm ality in this area may affect nerve function and lead to reduced sensation in the little \201 nger and weakness in the small muscles of the hand, the \202 exor carpi ulnaris (FCU ), the extensor carpi ulnaris (ECU), or the abductor digiti minimi (ADM). The median and ul nar nerves are dealed with in more detail in the later sections, Wrist Pain and Symptoms in the Hand. Diagnostic procedures Radiographs and other imaging \200 Standard AP and lateral radiogra phs are the most straightforward way of imaging the elbow initially. CT or MR may then be n eeded if the diagnosis is still obscure and referred pain can be ruled out. Look for periosteal lesions and enthesophytes (new bone spurs at clear entheses like the tr iceps insertion). Periosteal apposition and enthesophytes are typical in psoriatic arthriti s (see Chapter 8). \200 A lateral radiograph may show displacement of the anterior fat pa d caused by a joint effusion or hemorrhage (the \200\234sail sign \200\235). Dislocations of the radial head and associated ulna fractures in children are easily missed . To make this diagnosis, a high degree of suspicion and further imaging are often needed. Needle arthrocentesis/olecranon bursocentesis \200 Arthrocentesis/bursocentesis with \202 uid sent for microscopy and culture should always be done in suspected cases of sepsis . Fluid should be sent for polarized light microscopy in cases of bursitis that may be due to gout. Serum urate is worth requesting but may not be raised in acute gout. Examination of \202 uid for crystals should always be considered in cases of monoarthritis in the elderly or patients on dialysis. Electrophysiology If nerve entrapment is suspected and there is some uncertainty after clin ical examination, then electrophysiological tests may provide useful information. Testing c an help identify the degree and likely site of nerve damage and can help to discriminate be tween a peripheral and nerve root lesion. Treatment \200 The management of fractures is beyond the scope of this text. \200 Epico ndylitis is best managed early on with rest, splinting, analgesia, and local steroid inject ions. The ef \201 cacy of physical manipulation has not been proven, although there are th eoretical reasons why ultrasound therapy could be of value (because it passes through the m yofascial planes and concentrates near bone). Resistant cases may bene \201 t from surgery \200\224a \200\234lateral release. \200\235 Steroid injections may be of value in the following situations: lateral or medial epicondylitis (hydrocortisone) \200 in \202 ammatory arthritis (usuall y long-acting steroid) \200 olecranon bursitis \200 ulnar nerve entrapment. PAIN AROUND THE ELBOW 39 See Corticosteroid Injection Therapy and Principles of Rehabilitation at the end of this ch apter; also see Plates 12 \200\22315. \200 Surgical procedures include excision of nodule s and bursae, transposition of the ulnar nerve, synovectomy, excision of the head of the radius, and arth roplasty. Arthroplasty in in \202 ammatory arthritis is best reserved for intractable pain and shoul d be undertaken by an experienced surgeon. Lesser procedures such as proximal radial head e xcision can be effective to improve pain and function if forearm pronation and supination a re poor. CHAPTER 2 Regional musculoskeletal conditions 40 Wrist pain Functional anatomy of the wrist \200 The wrist includes radiocarpal (scaphoid and lunate) and intercarpal articulations. The ulna does not truly articulate with the luna te but is joined to it, the triquetrum, and the radius (ulnar side of distal aspect), by th e triangular \201 brocartilage complex. The intercarpal joints are joined by intercarpal ligaments and are most stable when the wri st is in full extension. The anterior carpal ligaments are stronger than the posterior ones and are reinforced by the \202 exor retinaculum. Wrist and \201 nger \202 exor tendo ns, the radial artery, and the median nerve enter the hand in a tunnel formed by the carpal bones and the \202 exor retinaculum (carpal tunnel). Flexion (70 ), extension (70 ), radial and ulnar deviation (about 20 and 30 from midl ine, respectively) occur at the wrist but supination/ pronation of the wrist and hand is du e to radiohumeral movement at the elbow. The \202 exor carpi radialis (FCR) and ulnaris (FCU) are the main \202 exors of the wrist, although the palmaris longus (pl) also helps (see Figure 2.6). All arise from the medial humeral epicondyle. \200 All carpal extensors arise from the lateral humeral epicondyle (see Figure 2.7). Radial deviation (abduction) occurs primarily when radial \202 exors and extensors act to gether. Ulnar deviation (adduction) occurs primarily when ulnar \202 exors and extensors act together. Taking a history Table 2.4 details the major diagnoses for painful conditions of the wrist and hand. Determine the exact location of the pain \200 Pain localizing only to the wrist most like ly comes from local tissue pathology. Cervical nerve root pain as a result of a C6, C7, or C8 lesion and pain from peripheral nerve lesions is likely to be located chie \202 y in th e hand. Pain at the base of the thumb, aggravated by thumb movements, in middle and old age is typi cal of OA (see Chapter 6) of the trapezium- \201 rst metacarpal joint. Pain in this area m ight also be due to tenosynovitis of thumb tendons. Trauma history \200 Injury/post-injury conditions are common. A history of trauma is important. Common fractures in adults are: scaphoid and base of the \201 rst metacarpal (Bennett \200\231s), and head of the radius (Colles \200\231). \200 Distal rad ioulnar physeal injuries may occur in children. \200 Posttraumatic chronic wrist pain fol lowing injuries may be due to ligamentous injury and chronic carpal instability or osteonec rosis (lunate). WRIST PAIN 41 (a) Digital flexor tendon sheaths Flexor pollicis longus tendon sheath Common flexor tendon sheath Flexor retinaculum Flexor digitorum superficialis and flexor digitorum profundus tendons Flexor carpi radialis tendon sheath Extensor digitorum communis and extensor indicis propius (fourth compartment) (b) Extensor digiti minimi (fifth compartment) Extensor pollicis longus (third compartment) Extensor pollicis brevis and abductor pollicis longus (first compartment) Extensor carpi ulnaris (sixth compartment) Extensor carpi radialis longus et brevis (second compartment) Extensor retinaculum Fig. 2.7 Flexor (a) and extensor (b) tendon sheaths crossing the wrist. Flexor carpi radial is (FCR) inserts into the second and third metacarpals. Flexor carpi ulnaris (FCU) inserts into the pisiform, hamate, and \201 fth metacarpal. Extensor carpi radialis longus (ECRL) inserts into the base of the second, extensor carpi radialis brevis (ECRB) into the third, and extensor carpi ulnaris (ECU) into the \201 fth metacarpal, respectively. CHAPTER 2 Regional musculoskeletal conditions 42 Table 2.4 Painful conditions of the wrist and hand: major diagnoses Articular disorders In \202 ammatory arthritis (e.g., RA, JIA) Degenerative arthritis* Crystal arthritis Ligamentous lesions* Carpal instability (e.g., lunate dislocation) Periarticular disorders De Quervain \200\231s tenosynovitis Tenosynovitis of common \202 exor/extensor tendon sheath Flexor pollicis tenosynovitis Distal \202 exor stenosing tenosynovitis (trigger \201 nger or thumb)* Ganglia*, subcutaneous nodules, tophi Diabetic cheiroarthropathy Dupuytren \200\231s contracture* Bone pathology Fracture* Neoplasia Infection Osteochondritis (lunate \200\224Kienb ck \200\231s; scaphoid \200\224 Prieser \200\231s) (see Chapter 16) Neurologic Median nerve entrapment (carpal tunnel* or at pronator teres) Anterior interosseous nerve syndrome Ulnar nerve entrapment (cubital tunnel or in Guyon \200\231s canal in wrist) Posterior interosseous nerve entrapment Radial nerve palsy Brachial plexopathy Thoracic outlet syndrome Cervical nerve root irritation or entrapment* Complex regional pain syndrome (see Chapter 18) Spinal cord lesions, e.g., syringomyelia Common conditions. Unusual or \202 orid pain descriptors suggest a regional pain syndrome (e.g., re \202 ex sympathetic dystrophy). Following trauma, regional pain syndromes are not uncommon in chil dren, adolescents, or young adults. Are there features to suggest synovitis? \200 Pain due to wrist joint synovitis may be as sociated with stiffness and be worse at night or in the early morning. Stiffness in the han d may WRIST PAIN 43 have various causes, but these will include multiple tendon/small joint synovitis, diabetic cheiroarthropathy, or even scleroderma (see Chapter 12). Wrist synovitis occurs commonly in adult RA and in children with both systemic and rheumato id factor positive JIA. It occurs in 5% of oligoarticular JIA cases (see Chapter 7). In the elderly, wrist synovitis may be due to calcium pyrophosphate dihydrate (CPPD) crystals (see Chapter 15). The quality of the pain \200 Although primary bone pathology is rare, local bony pain (un remitting, severe, preventing sleep) might suggest avascular necrosis in those at risk or, if part of a wider pattern of bony pain, metabolic bone disease (e.g., physeal pain in chil dren with rickets). Radicular pain may be burning in quality and is typically associated with numbness and pare sthesias. Such neurogenic pain is commonly due to nerve root irritation or compression. Other joint/musculoskeletal symptoms \200 Wrist and extensor tendon sheath synovitis is a common presenting feature of adult RA. Other joints may be affected. CPPD arthritis commonly involves the wrist and can mimic RA in its joint distribution and presentation in the elderly. Wrist synovitis and enthesitis occur in SpA. Pain may be considerable, although swelling is minimal. There may be in \202 ammatory-type symptoms of spinal pain a nd enthesitis elsewhere. Ask speci \201 cally about job/leisure activities \200 Repetitive lateral and medial wri st movements with thumb adducted can cause tenosynovitis of the abductor pollicis longus (A PL) or the extensor pollicis brevis (EPB), commonly called De Quervain \200\231s tenosynovi tis. If there is no obvious history of trauma, tendonitis may be a presenting feature of a systemic autoimmune rheumatic disease or even gonococcal infection in adolesce nts and young adults. Overuse pain syndromes may occur as a result of repetitive activity. The term repetitive st rain injury is controversial. Objective assessment of pain, location of swelling, etc., fro m the outset is invaluable in assessing the response to treatment. Lack of objective \201 ndings (if imaging is normal) suggests a regional pain disorder. Examination Visual inspection Inspect the dorsal surface of both wrists looking for swellin g, deformity, or loss of muscle bulk. \200 Diffuse swelling may be due to wrist or extens or tendon sheath synovitis. A prominent ulna styloid may result from subluxation at the distal radioulnar joint due to synovitis or radioulnar ligament damage. \200 Prominence ( \200\234squaring \200\235) of the trapezoid \200\223 \201 rst metacarpal joint commonly occurs in OA of this joint.