Tendinitis of the short rotators
ADHERENT SUBACROMIAL BURSITIS—FROZEN SHOULDER
THIS is a class of cases which I find it difficult to define, difficult to treat and difficult to explain from the point of view of pathology. Yet these cases form a fairly distinct clinical entity, which I formerly described under the adherent type (Type II) of subacromial bursitis. The experience of the last fifteen years has led me to doubt the advisability of calling this entity "bursitis," for I now believe it is essentially a tendinitis, with only secondary involvement of the bursa. The typical case is one of "frozen shoulder," which shows no calcified deposit, and in which a history of trauma is absent, vague or not clearly associated with the onset of symptoms. These cases are usually diagnosed as "periarthritis" or "neuritis."
FIGURE 48. FROZEN SHOULDER
The term "Frozen Shoulder" covers the cases which are the subject of this chapter, but it also applies to many other conditions which cause spasm of the short rotators or adhesions about the joint or bursa. This figure shows the characteristic limitations of a severe case. The outline of the posterior edge of the scapula and the axis of the spine of the scapula and acromion are indicated. In the "frozen shoulder" the axis of the shaft of the humerus is nearly at right angles to the axis of the spine of the scapula, and remains so in whatever direction the arm is moved. Although determining the relation of the axis of the shaft of the humerus to that of the spine of the scapula is a primary one for the understanding of the diagnosis or treatment of many shoulder lesions, it seems best to dwell on its importance here. Cases without distinct traumatic history which show a frozen shoulder, and in which the X-ray gives no information, are likely to be cases of the condition described in this chapter. Unless the other joints of the body show pronounced evidence of arthritis, you may be quite sure that you are dealing with a case of tendinitis.
Perhaps it is best to attempt to describe the course of these cases clinically and to point out the ways in which they differ from arthritis on the one hand and cases of calcified deposits on the other. Perhaps it is only theoretically that they differ from arthritis, which we have already reduced to tendinitis in a previous chapter. The great clinical differences are that they are not a part of a generalized arthritis and that they run a self-limited course and clear up entirely without leaving the joint deformed or otherwise permanently damaged. They usually give the history of some slight trauma or overuse. Call some of them arthritis if you want to, but others will merge into the class of calcified deposits because the X-ray shows small flecks in the tendon. They might be called by whatever . name is best for that unsatisfactorily named group and given the same name without the "calcified" part, just as the term aleukemic leukemia is used. I have removed bits of tendon from these cases which under the microscope show the same necrotic changes which we find in the tendon substance adjacent to the deposits, or adjacent to the rents in the rupture cases. In all three there is the same change in the tendon substance as is depicted in Plate VI. It is a degeneration of the collagen without signs of inflammation as invasion of lymphocytes. One is tempted to say, "Oh, well, all three are arthritis in different phases!" Undoubtedly all three may be fundamentally tendinitis, but clinically there is great difference to the patient in point of what he may expect in the way of pain and in success of treatment, according to whether there is a calcified deposit (weeks), a tendinitis without calcification (months), or a complete rupture (years). Practically they are three different clinical entities, although they might be spoken of as the calcified, the uncalcified, and the ruptured forms of tendinitis.
Last year I had four of these non-calcified cases to treat at about the same time, and it may be more instructive if I write of them together. They had in common:
The condition had come on slowly; pain usually felt near the insertion of the deltoid; inability to sleep on the affected side; painful and incomplete elevation and external rotation; restriction of both spasmodic and mildly adherent type; atrophy of the spinati; little local tenderness; X-rays negative except for bone atrophy. The pain was very trying to every one of them, but they were all able to continue their regular habits and daily routine.
One was a doctor of 62, an active man who takes good care of himself. Number two was a very vigorous, muscular, unmarried woman, who has been a champion golf player and still competes with much success at 46. Number three was a feeble old maid of 70. Number four was a married woman of about 50, apparently in perfect health. All of them were a little "run-down" without anything particular the matter. In each there was a possible history of some slight accident.
The golf player, who was also an extremely busy lady in charitable affairs, when told that she would get well anyway in time, took no treatment and even played a little golf. The others submitted to the treatment I usually recommend to these cases; i.e., rest in bed with the arm in elevation. I do not always give an anaesthetic and break up the adhesions as I used to do many years ago, nor do I open the bursa and break them up with my finger as I did for a period. I simply put the patient to bed, apply a splint to the back of the forearm and tie each end of the splint with a loop over the railing at the head of the bed. The position of the patient's body usually acts as sufficient extension, although placing blocks under the legs at the head of the bed assures it. A light dose of morphine is given the first night to procure relaxation, but not enough to absolutely remove the pain for fear of letting the arm " go to sleep." In twelve to twenty-four hours the spasm relaxes, adhesions yield, the tuberosity passes under the acromion, and the arm becomes abducted and externally rotated and is more comfortable. In a- day or two I remove the splint and simply tie a bandage loosely around the wrist and to the head of the bed to remind the patient not to lower the arm. I get the patient up daily and begin the stooping exercises described on page 202. He stays in bed until he can freely move his arm about in any direction above his head. This is usually after one or two weeks. After discharge from the hospital he takes stooping exercises and for a few weeks sleeps at night with his arm in the hammock position.
Of the three patients thus treated, the feeble, elderly lady made the most prompt and satisfactory recovery. The doctor also did well. The other lady taught me a lesson. She was wilful and charming, and persuaded me to let up on the traction too soon. She was a very busy woman and rebelled against the restraint, for she was planning to go abroad. The result of my weakness in not insisting on keeping up the traction longer was that when she got up the arm came into the sling position again; the spasm recurred, and her continued restriction marred her trip. However, when she returned in two months the shoulder was almost well again.
This patient and another lady, whom I have since treated, exhibited a complication of this abduction treatment against which I wish to warn the reader. During the first few days they had intense abdominal discomfort which I now believe was due to acute dilatation of the stomach. A similar condition sometimes arises in cases where a plaster jacket is applied with the dorsal spine extended. The maintenance of the irritable shoulder joint in elevation has the effect of hyperextending the spine. I think this complication can be avoided by attention to the position of the patient's body and by permitting them to occasionally rise and walk about with the hand of the affected side held by the other hand over the head. In these two cases the suffering from the abdominal condition was worse than that from the shoulder.
Another infrequent complication of the elevation treatment is difficulty in getting the arm to the side again after having kept it up for a week or two. In a few very sensitive patients this trouble has occurred, but in most cases if the patients get up each day and do the stooping exercises with my encouragement, they are able to bring the arm to the side from the first. Occasionally spasm persists to such an extent that even when the adhesions have been broken up under ether and the arm placed in elevation, the muscles will remain rigid and hold the arm in this erect position without yielding even when the patient stoops.
This condition of affairs need give no anxiety, however. Strangely enough, it is not very painful. One lady in whom this occurred used to get up and walk about with the arm as erect as that of the traditional Hindu fakir. She would even read quite contentedly, or write letters with the other hand, resting the erect arm against the wall. This painless spasm persisted for three weeks, when I gave her some nitrous oxide and gently lowered the arm. No adhesions were felt to give, and there was no pain afterward. A few weeks later, she had complete use of the arm.
Since this experience I encourage my patients to lower the arm at least once a day. Even with this precaution one of my recent cases, a very severe one, showed a similar degree of spasm and even at the end of six weeks could not completely attain the sling position, although she could easily place her hand behind her head. My effort is always toward keeping the ability to use the arm in elevation. If this end of the range of motion be maintained, the normal uses of the arm bring it soon enough into the sling position.
Breaking up the adhesions even under ether is always an unpleasant process, and especially so in cases where the joint has been "frozen" for several months. Sometimes great force is required, and as the adhesions yield there is often a loud snapping noise which vibrates down the humerus and gives the sensation to the operator that the bone has been broken or the ligaments at the elbow torn. I have never broken the humerus in doing one of these manipulations, but I believe it might readily be done. In one case in which I had opened the bursa and ruptured the adhesions there with my finger, the joint still would not yield. With my finger still in the bursa I forced external rotation with my other hand, and distinctly felt some of the fibers of the subscapularis give way under my finger. I believe that unless great care is used such tearing in the fibers of the other rotators may thus occur. It would take but little force to bring this about when they are atrophied from months of nonuse, even if they are not actually partially necrotic.
I For these reasons my present custom is to secure all the stretching I can by slow traction for forty-eight hours before I give an anaesthetic. In fact, the slow stretching usually accomplishes the purpose in this time unaided by manipulation, and, if an anaesthetic is necessary, little force is required. If much force must be used the bursa should be opened and the adhesions in it broken or cut before attempting to stretch the short rotators.
A surgeon who attempts to break adhesions should know the normal motions of the shoulder described in Chapter II. The manipulations should be thorough and the joint moved to its normal extremes in all directions but not a bit beyond them. I prefer to begin with external rotation, but not to carry it to an extreme position at first. Some of the adhesions preventing internal rotation are then broken. Then abduction in the mid-position to a right angle with the body; then external rotation in abduction; then anteroposterior motions in the sagittal plane, and finally elevation to the pivotal position. After breaking some adhesions in each of these directions, perform the whole set over again, making sure that in each position the extreme is reached and not more than the extreme.
During the thirty years in which I have tried to relieve these patients with frozen shoulders, I have tried and have seen tried many methods of manipulation and other forms of treatment. There have been few miracles performed and recovery is seldom rapid. A few cases already in a convalescent stage, with no pain but with restricted motion, have made prompt recoveries after snapping a few adhesions, but for most cases there have been many uncomfortable, restless nights and slow recoveries. However, recovery is always sure and may be confidently expected.
None of the patients I have ever had with this condition have had recurrences in the same arm, but some have had the same trouble in the other arm a year or two later. In one case I operated upon both shoulders and removed bits of tendon for examination which showed the same pathologic changes which I have always found in these cases or in the calcified or ruptured cases. I do not think the operations did either much good or harm, but the postoperative rest in elevation gave the desired effect both times.
Formerly before putting the arm in abduction I used to give ether and open the bursa. The appearances of the floors of the bursas were always the same—a congestion over the supraspinatus tendon on the base of the bursa like that of a "bloodshot eye. The congested area was usually circular with a whitish center much as in the calcified cases, but no macroscopic calcified material was present. Adhesions were often found. The congestion was in the synovia, not in the tendon beneath it. Although some cases made rapid recoveries, I gave up making an incision, not because it did any harm or caused any delay, but because I concluded that little was accomplished b}' it, and that the postoperative elevation was what really was doing the good by causing relaxation and therefore permitting the blood supply to accomplish its healing work more rapidly. In elevation also, the teres major, which has been constantly in spasm, is slowly stretched. Moreover, the old principle that adhesions will not form between the separated raw surfaces of the bursa also holds good. Perhaps, too, this position may approximate the synovial membrane at the edge of the cartilage. At any rate this treatment by rest in elevation is the best practical way to get these patients well with a minimum amount of pain so far as I know. This opinion was shared by the late Dr. Brickner of New York, who had great interest in shoulder cases. He used dumb-bell exercises afterward, while I prefer the stooping exercises as long as the joint is irritable.
If a patient cannot rest in bed for a week or two I advise diathermy, although I am not convinced that it does much good. A number of my patients have preferred, as did the golfing lady spoken of above, to do nothing except the stooping exercises. As a rule they have recovered almost as quickly as the cases treated by other methods. Some cases are so mild that they do not even consult a doctor. There is great variation in the degree of severity of symptoms and in the period of disability. Even the most severe cases recover with or without treatment in about two years. Although I have devoted much time to analysis of the one hundred cases shown in Chart I, on p. 124,1 have not been able to work out any new facts which are worth recording, except those already mentioned on pages 135 to 140 in connection with the sex, the age, the occupation and the menopause. Even such analysis as I can make of the End Results is not fruitful. What knowledge I have acquired in forty years about this class of cases is not such that I can transmit it, but so far as my own practice is concerned I have diminished the relative number of cases of this kind, because I have subtracted from them the more pronounced calcified cases on the one hand and the more definite incomplete ruptures on the other. If the reader will refer again to page 124 he may understand that when we learn to define the borderlines more clearly, more of these puzzling tendinitis cases will be cured by the treatment suitable for calcified deposits and still more will be prevented by prompt and appropriate attention to cases of incomplete rupture.
I would be more exact if I could in regard to the period these cases require to recover, but since recovery is always by degrees, it is pretty hard for even the patients to say just when they are well. They require my care about six weeks, but as their symptoms clear up gradually, they always cease coming to me before they fully recover from the last twinge. The whole course with or without treatment, from the first symptoms to the period when they forget to think of their shoulder each day, is more apt to be a year than six months. Nine months' pain and annoyance is a fair guess. One rarely sees a case until it has progressed for three months, because the onset is slow and insidious and the pain at first seems bearable. It is the restless nights rather than pain in the day which eventually drive them to a doctor. Since most of these cases follow some minor injury, it is "my hunch" that they are often due to irritation caused by the tearing away of a few fibers of the supraspinatus on the joint side, thus separating the synovial membrane from the edge of the cartilage. The irritation creates protective spasm, and efforts to use the arm or limber it up maintain the spasm. Thus this group of cases is not clearly separated from the group I have called incomplete ruptures of the supraspinatus. The main difference is in regard to the lack of distinct traumatic history.
Although the type of cases spoken of under this heading of "Tendinitis" is pathologically still a little vague, it is a pretty definite clinical entity. It would require greater knowledge than is available at present to separate it pathologically from arthritis, bursitis, calcified deposits or from "rim rents" of the supraspinatus. I cannot too often warn the reader that complete rupture of the supraspinatus tendon is a very different clinical thing from these minor ruptures which set up a tendinitis or bursitis and recover after six months or so. In complete rupture cases the shoulders are not "frozen."
As a clinical entity, tendinitis is diagnosed rather by exclusion than by special symptoms. All severe cases present a "frozen shoulder," and thereby complete rupture of the supraspinatus is excluded. Careful X-rays rule out a calcified deposit. The lack of involvement of other joints excludes arthritis ; so does complete recovery within a few months under appropriate treatment. These cases can only be separated from incomplete ruptures by the absence of a distinct traumatic history, and this is practically a difficult line to draw. The discovery of abscessed teeth, suppurating tonsils or other possible portals for toxic absorption would tip the balance of judgment away from trauma as a cause. Even then we must not forget that a tendon made brittle by toxins may rupture.
The reader should not judge the relative frequency and importance of this group of cases by the length of this chapter compared to that of other chapters. He may, however, so judge any knowledge of the subject which I have to communicate to him. These are common cases, but it does not take a long chapter for me to tell all I know about them. I could write a whole book on my experiences with cases of this type, but it would have to deal more with human nature than with demonstrable pathology or remarkable success in treatment. The art rather than the science of medicine is called for in these cases, but in the cases of calcified deposit and in the complete rupture cases, cold, definite, prompt efficiency is more desirable.
Since the symptoms in these cases vary greatly in degree, prognosis is difficult at best, and since patients vary greatly in their ability to bear the same conditions, a great variety of puzzles are offered for solution. Some patients have little restriction and much pain; others have stiff, painless joints, and there are all degrees between. I am confident that I can shorten the convalescence of any case by the elevation treatment outlined above, but in most cases I do not advise it, and the mere assurance that they will recover in time seems to be of wonderful therapeutic value. If pain is severe enough to keep them awake much at night or to prevent them from earning their living, or from following their favorite sports, I advise the above treatment. Massage is a help. Light stooping exercises seem to me to be of great benefit. Attention to the general well-being of the patient is most important. For instance, a good vacation under pleasant, healthful circumstances seems to me more desirable than any form of therapy if the pain is bearable. If the arm is not well enough to make a vacation enjoyable, it can soon be made so by the elevation treatment.
Since this chapter was written a thoughtful article has appeared. (Jour. A. M. A., Dec. 31, 1932, Vol. 99, No. 27, pages 2252-2257. "Periarthritis of the Shoulder, An Analysis of Two Hundred Cases," by James A. Dickson, M.D., and Edward H. Crosby, M.D., Cleveland.)
While there are many minor points on which I could not agree, I feel that this article is the most reasonable, recent attempt to cope with the problem which I have tried to present in this chapter. It is an earnest, painstaking study of an unsolved question.
The especial point on which I cannot agree with the authors is that they state from a clinical point of view that there is little difference between the cases which show a calcified deposit and those which do not. My experience does not confirm this. I regard the calcified cases as very simple and easy to relieve as compared to the adherent, non-calcified cases. The results of operations on the calcified cases have, from the first, been as satisfactory as any surgical operations which I know of. Only in a few long-standing cases has the return of function been a matter of months. On the other hand, in the true non-calcified cases the convalescence is practically always a matter of months and sometimes of years.
Another fair criticism of this article is that the authors seem to have assumed that because they find infected foci in many patients, the condition of the shoulder is due to these foci. It is my belief that as large a percentage (38.5%) of infected teeth would be found among any two hundred persons of the same average age and class in life. The relation to the menopause is much more striking than that to the teeth. See p. 138, Chart III. Their last paragraph, which I quote verbatim, shows an admirable degree of intellectual honesty.
"The study of the cases reported in the literature and of our series of 200 cases has shown us most strikingly that an exact evaluation of the importance of any one of the factors which may be involved in the causation of the disease, or of the relative value of the various therapeutic measures, is practically impossible. For, in our series, it has been found that in all cases, whether the evidence pointed to infection, metabolic disturbances or trauma as the important etiologic factor; whether the treatment stressed was eradication of foci, physical measures, manipulation or operation, that the time required for recovery and the total duration of the disease was remarkably constant throughout. This suggests that in these cases there must be some general physiologic disturbance as a common denominator, which cannot be explained or accounted for at present. We reiterate this statement because this fact seems to have been lost sight of by many workers in their enthusiasm for one particular type of treatment, or in their zealous endeavor to attribute the symptoms to some particular etiologic factor"
I would be inclined to swallow this paragraph whole if it were salted with just a little optimism.
Turn to those following Chapter VI, and note especially the remarks on Duplay's contributions.