COMMON MUSCULOSKELETAL B. Vahdatpour M.D.

Professor of Physical
DISORDERS OF UPPER LIMBS Medicine & rehab.
ROTATOR CUFF TENDINOPATHY
IMPINGEMENT SYNDROME, ROTATOR
CUFF TENDINOSIS
impingement of the supraspinatus tendon under
the acromion, coracoacromial ligament, and
acromioclavicular joint.

The fibrotic changes seen in rotator cuff tendons

and subacromial bursa are caused by repeated
episodes of inflammation
SYMPTOMS:
a) shoulder pain (occur with internal and external
rotation and may affect daily self-care
activities)
b) Weakness
c) Loss of range of motion(impaired shoulder
function)
d) impairs sleep(due to pain)
PHYSICAL EXAMINATION
(INSPECTION, PALPATION )
asymmetry of upper body posture
atrophy of the supraspinatus and infraspinatus
muscles
abnormal scapulothoracic rhythm during shoulder
elevation
Tenderness at:
 the greater tuberosity
 subacromial bursa
 long head of the biceps
 acromioclavicular (AC) joint
 PHYSICAL
EXAMINATION ( RANGE
OF MOTION )
Total active and passive range of
motion in all planes

Painful arc: pain with elevation

between 60 and 120 degrees
PHYSICAL
EXAMINATION
(STRENGTH)
SPECIAL TESTS
 Neer's test(sign)

• subacromial
impingement

FIGURE 5. Neer's test for impingement

of the rotator cuff tendons under the
coracoacromial arch. The arm is fully
pronated and placed in forced flexion.
 Hawkin's test

• subacromial
impingement

• rotator cuff
tendonitis
FIGURE 6. Hawkins' test for subacromial
impingement or rotator cuff tendonitis. The
arm is forward elevated to 90 degrees, then
forcibly internally rotated.
 Supraspinatus

• "empty can" test (Jobe test)

FIGURE 3. Supraspinatus
examination ("empty can" test).
The patient attempts to elevate
the arms against resistance
while the elbows are extended,
the arms are abducted and the
thumbs are pointing downward.
 Speed's maneuver
• proximal tendon of the long
head of the biceps
 FUNCTIONAL LIMITATIONS:
Pain with overhead activities greatest above 90 degrees
of abduction.
Pain may also occur with internal and external rotation.
Affect daily self-care activities.
Work activities such as filing, hammering overhead, and
lifting can be affected.
Patient can be awoken by pain in the shoulder, which
impairs sleep.
DIAGNOSTIC STUDIES:
 Shoulder x-ray(AP): in the event of trauma and
complaints consistent with rotator cuff tendinitis,
the x-ray need to avoid missing an occult fracture
or dislocation

 MRI : choice when a patient is not progressing

with conservative management or to R/O an
alternative pathologic process ( rotator cuff tear).

 Diagnostic arthroscopy : in some cases ,

generally not necessary.

 Electrodiagnostic studies : to exclude alternative

diagnoses (cervical radiculopathy)
 Subacromial anesthetic injections : have been discussed as
diagnostic tools to assist in the confirmation of rotator cuff
tendinitis.
If the patient cannot provide good effort to abduction during
Ph/E inject anesthetic into subacromial space.

After injection, if there is significant reduction in the pain

level and patient can provide adequate and nearly maximal
abduction tendinitis is more likely than a rotator cuff tear.
TREATMENT
 Initial :
1- pain control and inflammation reduction :
Combination of relative rest from aggravating activities,
icing(20 minutes three or four times a day) &electrical
stimulation
Acetaminophen, NSAIDs
Sleep with a pillow between the trunk and arm for
decrease tension on the supraspinatus tendon
Rehabilitation :
Physical therapy may also help with pain management.
Initially : ultrasound to the posterior capsule followed by
gentle, passive, prolonged stretch .
 2-Restoration of Shoulder Range of
Motion :
Initiated after pain has been managed.
The focus of treatment in this early stage:
improvement of flexibility of the posterior capsular, and
postural biomechanics and restoration of normal
scapular motion.
Codman pendulum exercises, wall walking, stick or
towel
\
Stretching of post capsule & scapular stabilizers:
horizontal adduction
Postural biomechanics correction : excessive thoracic
kyphosis and protracted shoulders
Restoration of normal scapular motion (unstable scapula
secondarily cause glenohumeral joint instability
impingement

Scapular stabilization : wall pushups & biofeedback

 3-Strengthening :
Should be performed in a pain-free range.
Begin with the scapulothoracic stabilizers :
shoulder shrug , rowing , pushups
Then strengthening of rotator cuff
Rehabilitation program should start with static exercises
& co-contractions, progress to concentric exercises,
completed with eccentric exercises.

When strength is restored, a maintenance program should

be continued for fitness & prevention of reinjury.
 4-Proprioception :
To retrain the neurologic control of the strengthened muscles
Begin with closed kinetic chain exercises to provide joint
stabilizing forces.
As the muscles are reeducated, progress to open chain.
5-Task or Sport Specific :
Return to task- or sport-specific activities that is an advanced form
of training for the muscles
This is important that the task is performed correctly to eliminate
the possibility of reinjury or injury in another part of the kinetic
chain.
 Procedures :
Subacromial injection of anesthetic beneficial in differentiating a
rotator cuff tear from tendinitis.

Surgery :
If the patient fails to improve with a progressive nonoperative therapy
program of 3 to 6 months.
Include subacromial decompression arthroscopically or open.
(Frozen Shoulder)

 Definition
 Primary adhesive capsulitis : idiopathic ,progressive and self-
limited restriction of active and passive range of motion, with
an insidious onset 
 Three phases during the course of 1 or 2 years:
 painful phase
 freezing or adhesive phase
 resolution phase.

 3% of general population, preferentially women after the age of

50 years old
 Secondary causes including immobilization, diabetes, and
hypothyroidism
Diseases and Conditions Associated
with Secondary Adhesive Capsulitis

 Pathologic Process

 Painful phase ::: synovitis + capsular thickening +
reduction in synovial fluid

 Adhesive phase ::: fibrosis of the capsule +

thickening of the rotator cuff tendons + contraction
and obliteration of GH joint space

 Resolution phase ::: chronic inflammation +

resolution of joint space loss
 Symptoms

 Painful phase : pain is progressive ,worse nocturnal
and exacerbated by overhead activities + reduction
in ROM and decrease use of the affected shoulder

 Adhesive phase : reduction of pain + significant

reduction in ROM in all planes + stiffness of both
AROM and PROM

 Resolution phase : gradual increase in the pain free

ROM back to NL
 Physical Examination

 Painful phase : reduction in both AROM and PROM + motion
is painful particularly at extremes of external rotation and
abduction

 the shoulder is often painful to palpation around the rotator

cuff distally.

 Neurologic exam is usually normal

 The combination of myotomal weakness, altered dermatomal
sensation, reflex asymmetry and positive findings with cervical
spine provocative testing is more suggestive of a neurologic
cause of shoulder pain
 Functional Limitations
 Sleep disruption

 Inability to perform ADL e.g. combing the
hair
 Limitation of work activities particularly
overhead activities
 Diagnostic Studies

 Routine blood work and radiographs should be performed to
R/o secondary causes

 Radiographs are generally normal

 In advanced stages, joint space narrowing may be noted on
arthrograms

 If conservative managements fails MRI and arthrography may

be helpful in the confirmation of adhesive capsulitis and
evaluation of other causes of shoulder disease consistent with
adhesive capsulitis.
 Treatment

 General aim is to decrease pain and inflammation
while increasing the shoulder ROM in all planes

 ice
 anti- inflmmatories ( NSAIDs + short trial of oral
streoids + subacromial injection of corticosteroid )

 activity modifications
Subacromial injection

 Rehabilitation

 Restoration of ROM is of extreme importance in treatment
of adhesive capsulitis

 Pendulum exercise , overhead stretches and crossed

adduction of the affected arm

 If the patient shows continued progress, exercises should

be graduated to strengthening of rotator cuff muscles and
periscapular stabilizers.
Pendulum exercise

Overhead stretch , cross body reach ,
hand behind back

Twisting outward

 Procedures

 Are often performed in conjunction with physical
therapy

 Modalities including post-therapy icing , pre-therapy

and home moist heating sessions , TENS , US and
Iontophoresis

 Subacromial space injection

 Suprascapular nerve block
 Acupuncture
 Surgery

 The decision is based on failure of conservative treatment or
an unacceptable quality of life

 Methods are GH injections with saline or lidocaine and

manipulation under anesthesia

 Both are effective

 The majority of patients recover during a period of 6 to 8
weeks as opposed to 18 to 24 months noted with
conservative management

 If both fail , arthroscopic lysis of adhesions may be an

effective option
Myofascial pain syndrome
 Trigger points
• may occur in any muscle or muscle group of the body.
• caused by abnormal endplate potentials that lead to greater or
more frequent release of acetylcholine into the NMJ.

• Active TP: presence of referred pain in addition to local pain

without palpation
• Latent TP: do not produce spontaneous pain and often do not
cause referral of pain beyond a local tender spot

• TP localized by deep palpation, provoked symptoms by

Passive or active stretching of the affected muscle
‫‪Myofacial pain syndrome‬‬
‫• وجود ‪ 5‬کرایتزیای ماژور ‪ 1 +‬کرایتریای‬
‫مینور‬
‫• ماژور‪:‬‬
‫‪Regional pain complain .1‬‬
‫‪ .2‬وجود درد یا تغییر حس در محدوده ائی که برای آن ‪TP‬‬
‫انتظار داریم‬
‫‪Taut band .3‬‬
‫‪ .4‬تندرنس نقطه ائی در مسیر ‪taut band‬‬
‫‪ .5‬درجاتی از محدودیت ‪ROM‬‬

‫• مینور‪:‬‬
‫‪ .1‬با فشار روی ‪ TP‬عالیم بالینی بیمار ایجاد شود‬
‫‪ .2‬ایجاد ‪twitch response‬‬
‫‪ .3‬کاهش درد با کشش عضله یا تزریق ‪TP‬‬
‫‪Treatment‬‬
‫• حذف فاکتورهای همراه‬
‫کبود ویتامین ها‬ ‫‪o‬‬
‫بهبود پوسچر و مکانیک بدن‬ ‫‪o‬‬
‫حذف ‪overuse‬در مناطق مبتال‬ ‫‪o‬‬
‫کنترل استرس‬ ‫‪o‬‬
‫بهبود خواب‬ ‫‪o‬‬

‫• درمان ‪motor dysfunction‬‬

‫کاهش درد)‪(HP + ES + massage‬‬ ‫‪o‬‬
‫بهبود ‪)stretching ex(ROM‬‬ ‫‪o‬‬
‫بهبود ‪)biofeedback(NM function‬‬ ‫‪o‬‬
‫بهبود ‪)aerobic ex.(fitness‬‬ ‫‪o‬‬
 ‫• درمان موضعی‬
Spray & stretch o
Needling & injection o
Ischemic massage o

Medication •
No NSAIDs o
Amitriptyline o
Cyclobenzaprine o
LATERAL EPICONDYLITIS
(TENNIS ELBOW)
 ‫‪ ‬اپی کندیلیت‪ :‬التهاب‪ ،‬درد و تندرنس در ناحیه‬
‫اپی کندیل داخلی و خارجی هومروس‬
‫‪ ‬از نظر بافت شناسی سلول های التهابی‬
‫شناسایی نشده اند‪.‬‬
‫‪ ‬می تواند ثانویه به نقص اتصال ماسکولوتندینوس‬
‫باشد که در نتیجه ی فیبروپالزی رخ می دهد‬
‫(تندینوزیس)‬
 ‫علت‪:‬‬
‫‪ ‬استرس های مکرر‪:‬‬
‫‪ ‬استفاده ی بیش از حد از ضربه با پشت راکت تنیس‬
‫(بخصوص ضربه با یک دست و با تکنیک ضعیف)‬
‫‪ ‬استفاده ی زیاد از کامپیوتر بخصوص از موس‬
‫‪ ‬گلف‪ ،‬شنا و بیس بال‬
‫‪ ‬کارهای دستی مکرر در خانه‬
‫‪.... ‬‬
 ‫عالیم‪:‬‬

‫‪ ‬درد در ناحیه پایین تر از اپی کندیل خارجی (‪+/-‬‬

‫انتشار به دیستال تر یا پروکزیمالتر)‬
‫‪ ‬درد در هنگام حرکت مچ و دست (مانند گرفتن‬
‫دستگیره ی درب و‪)...‬‬
‫‪ ‬گاهی اوقات تورم‬
 ‫معاینه بالینی‪:‬‬

‫‪ ‬وجود تندرنس در اوریجین عضالت اکستانسور (یک‬

‫انگشت پایینتر از اپی کندیل خارجی)‪.‬‬
‫‪ ‬درد با مقاومت در برابر اکستانسیون مچ‬
‫‪ ‬تست انگشت میانی‬
‫‪ ‬معموال عالیم حسی و حرکتی وجود ندارند‬
‫‪ ‬در موارد اپی کندیلیت خارجی مقاوم‪ ،‬تشخیص‬
‫گیرافتادگی عصب رادیال باید مورد توجه قرار گیرد‬
 ‫تشخیص‬

‫‪ ‬بر اساس معاینات بالینی‬

‫‪ MRI ‬در مواذد مقاوم به درمان‬
‫‪ ‬سونوگرافی‬
 ‫درمان اولیه‬
‫‪ ‬استراحت نسبی‪ ،‬دوری از حرکات تکراری مچ‪،‬‬
‫تعدیل فعالیت ها به منظور کاهش استرس روی‬
‫اپی کندیل‬
‫‪ ‬دارو های ضدالتهاب‬
‫‪ ‬مدالیته های دمایی مانند گرما و سرما‬
‫‪ ‬تعدیل ضربات در تنیس‬
‫‪ ‬بریس‪:‬‬
‫‪Counterforce brace ‬‬
‫‪Wrist hand splint ‬‬
 ‫توانبخشی‪:‬‬
‫‪ ‬کاهش درد با مدالیته های فیزیکی (اولتراسوند‪،‬‬
‫تحریک الکتریکی‪ ،‬فونوفورز‪ ،‬یونوفورز با کورتیزون‪ ،‬ریلیز‬
‫مایوفاشیال ‪ ،‬گرما ‪ ،‬سرما و ماساژ)‬
‫‪ ‬کاهش ناتوانی (آموزش ‪،‬کاهش استرس های مکرر‪،‬‬
‫و جلوگیری از حرکت)‬

‫‪ ‬زمانی که بیمار بدون درد شد‪ :‬برنامه ی تدریجی جهت‬

‫افزایش قدرت و استقامت(‪ )endurance‬اکستانسورهای مچ‬
‫وهمچنین کشش‪ ،‬اجرا میشود‬
‫‪ ‬محدودیت یا تعدیل موقتی کارها و فعالیتها‬
 ‫‪ ‬تزریق کورتیکوستروئید‬
‫‪ ‬تزریق ‪PRP‬‬
‫‪ ‬تزریق خون اتولوگ‬
‫‪Extracorporeal Shock ‬‬
‫‪Wave Therapy‬‬
‫‪ ‬جراحی در موارد مقاوم‬
‫به درمان‬
 Carpal Tunnel Syndrome
(CTS)
Definition :
Compression
of the
Median Nerve
in the
Carpal Canal
1/26/2025 64
The most common entrapment
neuropathy
(10-15% of general population have
symptoms).
Female>male
more in old age (Peak Age: 50 years)
Any abnormality resulting in
a reduction in available space
within the carpal tunnel.
 Idiopathic
 Anatomic: AbNL muscle & bone, thickened lig. Wrist ratio
 Metabolic: hypo/hyper thyroid, pregnancy , obesity,….
 Tumor: ganglion, fibroma, neuroma,….
 Inflammatory: RA, lupus, …
 Trauma /position:
-CTD,
-Repetitive Activities requires wrist flex./ext. & grasp/torsion &finger motion
with wrist extended
-Wt.bearing with wrist extended(Cycling,crutches)
-Immobilization with wrist flexed(colles`casts-sleeping)
-Hand vibration for prolonged time.
 Degenerative: OA, carpal collapse,…
 Neuropathic: DM, alcohol, double crush
 Infection: abscess, TB
 Vascular: aneurism, anomalies
 Numbness, Paresthesias, Pain.(Intermittent)
-Worse at night Flick sign(90%spec&sen)
-Appear in day:

( freq - Repetitive work)

 Sensory exam:
-Tip of second&third finger

 Provocative maneuvers:
-Stress the median nerve in the carpal tunnel
 Abnormal in 45-60% of patient with C.T.S.
 Abnormal in 30% of patient without C.T.S.
 Continuous diminished sensation
 Reduced ability to manipulate fine objects
 Dropping objects
 Burning sensation about the hand
 Feeling of Fullness
 Inability to make a tight fist
 Increase pain in hand or wrist that radiates to
elbow or even shoulder
 Mild thenar wasting
 Severe Sensory loss and atrophy
 Compromised hand function
The best objective
diagnostic test

A carefully
performed

Electro
diagnosis
Cervical radiculopathy in C5 to T1 distribution
Brachial plexopathy
Proximal median neuropathy
Ulnar or radial neuropathy
Generalized neuropathy
Arthritis of carpometacarpal joint of thumb
de Quervain tenosynovitis
Tendinitis of the flexor carpi radialis
Raynaud phenomenon
Hand-arm vibration syndrome
Arthritis of the wrist
Gout
 Conservative:
-Wrist-Hand Splint
-Modification of activities (especially sustained positioning
or repetitive and forceful flexion or extension of the wrist)

-Underlying conditions ( hypothyroidism, RA or DM)

should be treated

-Therapeutic Interventions:
U.S., Iontophoresis, Ice, Gentle stretching &
strengthening exercises ,Myofascial release…
Wrist-Hand splint
-NSAIDs & Vit.B, Duretic
-Corticosteroid injection(no lidocaine)
Symptom decreased in 75% & NCV improved
In 75% of these patient Complete symptom relief by
6weeks
Mild symptoms should be treated early to prevent
recurrence
 Conservative vs. Surgery
 Some persons seems to respond best to surgery
Why :Most have some job related exacerbation of
symptoms
 Conservative: Little benefit
80% return of symptom in
1 year
 Surgical decompression
of the transverse carpal
ligament.
-Active motion of the hand and wrist should start
immediately postoperatively
-Passive motion after 4 weeks
DE QUERVAIN TENOSYNOVITIS
 stenosing tenosynovitis of the synovial sheath of
tendons of the abductor pollicis longus and
extensor pollicis brevis muscles in the first
compartment of the wrist due to repetitive use.

 the result of intrinsic, degenerative mechanisms

rather than of extrinsic, inflammatory ones.

 linked to repetitive use of the wrist:
 including household chores
 playing piano

 Bowling

 Fishing

 excessive use of the text-messaging on a cellular

phone
 Work related activities such as:
 Pinching
 Grasping
 Pulling
 Pushing

 Gradual onset, usually without Hx of acute

trauma & onset
 Women, 35-55 yrs
SYMPTOMS:

 pain in the lateral wrist during grasp and thumb

extension.
 Pain with palpation over the lateral wrist

 Swelling

 Sometimes stiffness

 Without paresthesia


PHYSICAL EXAM

 local tenderness and moderate swelling around

the radial styloid
 +ve Finkelstein test

 +ve Eichhoff test


 The Brunelli test maintains the wrist in radial
deviation while forcibly abducting the thumb
 Pain over the radial styloid from these provocative
stretch maneuvers differentiates de Quervain
tenosynovitis from arthritis of the first metacarpal
joint

 Assessment of the first carpometacarpal joint,

including:
 ROM
 palpation for tenderness
 crepitus
 radiographic test
DIAGNOSTIC STUDIES

 clinical diagnosis and a positive Finkelstein is

pathognomonic
 Wrist X-Ray

 Sonography

 Bone scan

 MRI
 NSAIDs
 Physical modalities such as ice, heat, TENS,
ultrasound, and iontophoresis.
 friction massage and active exercises

 Thumb spica splint

 Local anesthetics and corticosteroids injection

• snapping ,triggering or
locking of the finger as
it is flexed or extended

• Thickening and
disproportionate
narrowing of
retinacular sheat
Adult: thumb(33%) and ring finger (27%)
Pediatrics: thumb (90%) & bilateral(25%)

Secondary:
DM, RA, hypothyroidism, histiocytosis
, Amiloidosis, gout
Clicking
Limitation in ROM
Swelling
stiffness
Localization of the disorder at the level of MCP joint
Neurogenic exam
Flexion contracture
Clicking
Diagnose is clinical.
MRI can confirm tenosynovitis of flexor sheat.
Ultrasound can show tendon nodules, tenosynovitis,
and active triggering.
Initial:
Conservative activity modification
anti inflammatory
splint
Local steroid injection
Occupational therapy
Physical therapy
Modalities: US, iontophpresis, ice massage, contrast
bath, paraffin
Local steroid injection
splinting and relative protection for one week
less effective in multiple involvement and longer
than 4 months
betamethasone is frequently recommended
Surgical intervention is highly successful for
conservative treatment failures and should be
considered for patients desiring quick and definitive
relief.
Individuals with diabetes, rheumatoid arthritis,
multiple joint involvement, and younger age at onset
are more likely to require surgery.