Shoulder & Elbow Disorders
Let passive motion and one good maneuver localize the lesion
Rotator cuff tendinopathy and subacromial impingement
Mechanism. The supraspinatus tendon and subacromial bursa run beneath the acromion and coracoacromial ligament. Repetitive overhead work or sport, an acromial spur, or weak scapular stabilizers pinch them during elevation, producing a continuum from tendinopathy to partial and then full-thickness tears, which become common after age 60.
Presentation. Pain sits over the lateral deltoid, worsens overhead, and wakes the patient lying on that side. Active abduction produces a painful arc between about 60° and 120°; pain only at the top of elevation (160–180°) suggests the AC joint. The Neer test (passive forward flexion with the arm internally rotated) and the Hawkins test (90° of flexion with forced internal rotation) reproduce the pain, while passive motion and strength are preserved.
Tendinopathy or tear? True weakness of abduction or external rotation, or a positive drop-arm test, suggests a full-thickness tear, confirmed by MRI or ultrasound. After a subacromial lidocaine injection, pain-limited weakness from tendinopathy resolves, whereas a torn cuff stays weak.
Management. No imaging is needed at first. Use activity modification, NSAIDs, and physical therapy that strengthens the cuff and scapular stabilizers, then a subacromial corticosteroid injection for persistent pain; arthroscopic decompression is reserved for months of failed conservative care. Acute traumatic tears in active patients are usually repaired early.
Arm pain reproduced by neck extension and rotation toward the symptomatic side (Spurling test) points to cervical radiculopathy, not the cuff. Pain unchanged by shoulder movement may be referred from the heart, diaphragm (Kehr sign), or an apical lung tumor.
Adhesive capsulitis
Pathology and risk. Frozen shoulder is inflammation followed by fibrosis and contracture of the glenohumeral capsule. Risk factors are diabetes (the strongest; often bilateral and slower to resolve), hypothyroidism, prolonged immobilization (stroke, surgery, or a sling kept on too long in an older or diabetic patient), and female sex between 40 and 60.
Diagnosis. The defining finding is global loss of both active and passive motion, worst in external rotation. Radiographs are normal and mainly exclude glenohumeral osteoarthritis, which also limits passive motion but shows joint-space narrowing and osteophytes.
Course and treatment. A painful freezing phase gives way to a stiff frozen phase and then a thawing phase, with most cases resolving over 1–3 years. Treat with range-of-motion physical therapy, NSAIDs, and intra-articular glucocorticoid injection, which helps most early. Manipulation under anesthesia or arthroscopic capsular release is reserved for refractory stiffness.
| Feature | Cuff tendinopathy | Full-thickness cuff tear | Adhesive capsulitis |
|---|---|---|---|
| Typical patient | Overhead worker or athlete | Older adult; fall or chronic wear | Diabetes, hypothyroidism, immobilization |
| Passive motion | Preserved | Preserved | Lost; external rotation worst |
| Strength | Normal (pain-limited) | Weak; drop-arm positive | Normal |
| Imaging | None at first | MRI or ultrasound | X-ray normal |
| First-line care | NSAIDs, PT, subacromial steroid | PT; early repair if acute in an active patient | PT, intra-articular steroid |
AC joint separation and clavicle fractures
AC separation. A fall onto the point of the adducted shoulder tears the acromioclavicular ligaments and, in higher grades, the coracoclavicular ligaments. Expect point tenderness, a step-off with the clavicle riding high, and pain on cross-body adduction. Grades I–II and most grade III injuries get a sling, ice, analgesics, and early motion; grades IV–VI (posterior, severe superior, or inferior clavicle displacement) are repaired surgically.
Clavicle fracture. About 80% are midshaft, from a fall onto the shoulder or an outstretched hand. Most heal in a sling with early motion; figure-of-eight bracing adds nothing. Fixation is indicated for an open fracture, skin tenting, or subclavian vessel or brachial plexus injury, and is considered for marked shortening or displacement, which raises nonunion risk. Displaced lateral-third fractures with coracoclavicular disruption are unstable and often fixed.
Blanched, tented skin over a clavicle fragment is an impending open fracture and needs surgical fixation, not a sling.
Elbow tendinopathy and olecranon bursitis
Lateral epicondylitis. Tennis elbow is a degenerative tendinosis of the extensor carpi radialis brevis origin from repetitive gripping and wrist extension. Tenderness lies just distal to the lateral epicondyle, and resisted wrist extension (Cozen test) or middle-finger extension reproduces the pain. Treat with activity modification, NSAIDs, a counterforce strap, and eccentric strengthening. Steroid injection helps for weeks but has worse 1-year outcomes and more recurrences than physiotherapy or waiting; most cases resolve within a year.
Medial epicondylitis. Golfer's elbow involves the flexor–pronator origin in golfers, throwers, and climbers, and is treated the same way. The ulnar nerve lies just behind the medial epicondyle, so check for cubital tunnel symptoms.
| Feature | Lateral (tennis elbow) | Medial (golfer's elbow) |
|---|---|---|
| Tendon origin | Extensor carpi radialis brevis | Pronator teres, flexor carpi radialis |
| Provocative test | Resisted wrist extension | Resisted wrist flexion and pronation |
| Typical activity | Gripping, backhand, keyboards, tools | Golf, throwing, climbing |
| Nearby nerve problem | Radial tunnel syndrome (tenderness more distal) | Ulnar neuropathy (ring and little finger tingling) |
Olecranon bursitis. The bursa swells from repeated leaning (student's elbow), trauma, gout, or rheumatoid arthritis. Elbow motion stays largely preserved, which separates bursitis from septic arthritis. A substantial minority of cases are septic, usually Staphylococcus aureus entering through a skin break.
- Look for infectionWarmth, erythema, fever, cellulitis, or an overlying abrasion suggest septic bursitis.
- AspirateBursal fluid for Gram stain, culture, cell count, and crystals; no steroid until infection is excluded.
- TreatSeptic: antistaphylococcal antibiotics with repeat aspiration, surgical drainage if refractory. Aseptic: compression, padding, avoiding pressure, NSAIDs.
Biceps ruptures and radial head fractures
Distal biceps rupture. A middle-aged man lifting or catching a heavy load with the elbow flexed at 90° feels a pop in the antecubital fossa, with ecchymosis, weak supination more than flexion, and a retracted muscle belly. The hook test is abnormal: the examiner cannot hook a finger under the tendon from the lateral side. MRI helps when the exam is equivocal. Surgical reattachment within about 2–3 weeks, before retraction and scarring, restores strength; nonoperative care leaves lasting supination weakness.
Proximal long-head rupture. Most biceps ruptures involve the long head at the shoulder in older adults with degenerative cuff disease: an anterior shoulder pop, then a distal arm bulge (Popeye deformity). The short head and brachialis preserve function, so treatment is a brief sling, ice, analgesics, and therapy; tenodesis is for young manual workers or cosmetic concern.
Radial head fracture. This is the most common adult elbow fracture, usually from a fall on an outstretched hand, with lateral elbow tenderness, painful forearm rotation, and limited extension. The fracture line is often invisible, but a hemarthrosis displaces the fat pads: a raised anterior fat pad (sail sign) or any visible posterior fat pad indicates an occult fracture, radial head in adults and supracondylar humerus in children. An occult or nondisplaced supracondylar fracture in a child gets a long-arm posterior splint at about 90 degrees and orthopedic follow-up in about 1 week.
Management. Nondisplaced fractures get a sling for a few days and then early active motion, because prolonged immobilization causes stiffness and loss of extension. Aspirating the hemarthrosis relieves pain. Displaced, comminuted, or blocking fractures need ORIF or radial head replacement. Examine the wrist so an Essex-Lopresti injury (radial head fracture with interosseous membrane tear and distal radioulnar joint disruption) is not missed.
The anterior fat pad is normally a thin visible line; a posterior fat pad is never visible in a normal elbow.