Shoulder Tendinitis PDF

3
GUIDE TO THE DIAGNOSIS OF

WORK-RELATED MUSCULOSKELETAL
DISORDERS
Work-related musculoskeletal injuries are one of the most common occupational
health problems for which physicians are consulted. There is solid scientific evidence that
these injuries may be occupational in origin.
This guide was designed to help physicians interpret the results of a medical
examination. By combining the standard clinical assessment procedure with guidelines
concerning the identification of etiological factors, it helps physicians identify the cause
of injury.
Shoulder
AUTHORS
Louis Patry holds a degree in medicine from Laval University and

a diploma in ergonomics from the Conservatoire National des Arts
et Metiers de Paris (CNAM). He is a specialist in occupational medi-
cine, an associate member of the Royal College of Physicians and
Surgeons of Canada, a professor in McGill University’s Department
of Epidemiology and Biostatistics and Occupational Health, and con-
sulting physician to the Direction de la santé publique (Public Health
Department), first in Québec City and currently at the Montréal-
Centre board.
Tendinitis
Michel Rossignol holds degrees in biochemistry and medicine
from the University of Sherbrooke, in epidemiology and community Louis PATRY, Occupational Medecine Physician, Ergonomist
health from McGill University, and in occupational medicine from Michel ROSSIGNOL, Occupational Medecine Physician, Epidemiologist
John Hopkins University. He is a professor in McGill University’s
Department of Epidemiology and Biostatistics and Occupational Marie-Jeanne COSTA, Nurse, Ergonomist
Health, co-director of the Centre for Clinical Epidemiology of the
Jewish General Hospital of Montréal, and physician-epidemiologist
Martine BAILLARGEON, Plastic Surgeon
at the Montréal-Centre board of the Direction de la santé publique
(Public Health Department).
Marie-Jeanne Costa holds a nursing degree from the Institut

d’études paramédicales de Liège and a degree in ergonomics from
the École Pratique des Hautes Études de Paris. She is an ergonomics
consultant and has collaborated on several studies of CTDs. She is
particularly interested in the development of participatory ergonom-
ics, specifically in the problem-resolution and diagnostic processes.
Martine Baillargeon holds a degree in medicine from the

Université de Montréal. She is a plastic surgeon and associate mem-
ber of the Royal College of Physicians and Surgeons of Canada.
After years of practising surgery she is now consulting physician,
mainly in the field of musculoskeletal injuries affecting the upper
limb, at the Montréal-Centre board of the Direction de la santé
publique (Public Health Board).
GUIDE TO THE DIAGNOSIS OF
WORK-RELATED MUSCULOSKELETAL
DISORDERS
Shoulder
Tendinitis
Louis PATRY, Occupational Medecine Physician, Ergonomist
Michel ROSSIGNOL, Occupational Medecine Physician, Epidemiologist
Marie-Jeanne COSTA, Nurse, Ergonomist
Martine BAILLARGEON, Plastic Surgeon
Canadian Cataloguing in Publication Data
Main entry under title:
Guide to the diagnosis of work-related musculoskeletal injuries
Translation of: Guide pour le diagnostic des lésions musculo-squelettiques
attribuables au travail répétitif.
Includes bibliographical references.
Contents: 1. Carpal tunnel syndrome – 2. De Quervain’s tenosynovitis – 3. Shoulder
tendinitis.
Co-published by: Institut de recherche en santé et en sécurité du travail du Québec.
ISBN 2-921146-70-3 (v. 1) – ISBN 2-921146-71-1 (v. 2) – ISBN 2-921146-72-X (v. 3)
1. Musculoskeletal system – Wounds and injuries – Diagnosis. 2. Overuse injuries –
Diagnosis. 3. Carpal tunnel syndrome – Diagnosis. 4. Tenosynovitis – Diagnosis.
5. Tendinitis – Diagnosis. 6. Occupational diseases – Diagnosis. I. Patry, Louis. II. IRSST
(Quebec). III. Workplace Safety & Insurance Board.
RC925.7.G8413 1998 616.7’075 C98-940950-3
Translation: Les Services Organon, Steven Sacks

Graphic design: Gérard Beaudry
Illustrations: Marjolaine Rondeau, Medical Illustration Department
of the Laval University Hospital Centre (CHUL)
Max Stiebel, Instructional Communications Centre (ICC),
McGill University
Rear-cover photographs: Gil Jacques
Legal deposit – Bibliothèque nationale du Québec, 1998
Legal deposit – National Library of Canada, 1998
ISBN 2-921146-72-X Éditions MultiMondes (Original edition: ISBN 2-921146-63-0)
© Éditions MultiMondes, 1998
Éditions MultiMondes Institut de recherche en santé
930, rue Pouliot et en sécurité du travail
Sainte-Foy (Québec) 505, boul. de Maisonneuve Ouest
Canada G1V 3N9 Montréal (Québec)
Tel.: (418) 651-3885 Canada H3A 3C2
Fax: (418) 651-6822 Tel: (514) 288-1551
Fax: (514) 288-7636
Régie régionale de la santé
et des services sociaux – Montréal-Centre
Direction de la santé publique
1301, rue Sherbrooke Est
Montréal (Québec)
Canada H2L 1M3
Tel.: (514) 528-2400
Fax: (514) 528-2459
PREFACE
The diagnosis of cumulative trauma disorders (CTDs) presents many unique problems,
especially for physicians. The absence of precise criteria upon which to establish a cli-
nical diagnosis of CTD or decide whether a musculoskeletal injury is related to occu-
pational factors was noted by several members of the advisory committee supporting
an international expert group mandated by the IRSST to review the literature on CTDs*.
To remedy this situation, in 1992 the IRSST asked a group of researchers to develop
diagnostic guides for carpal tunnel syndrome, De Quervain’s tenosynovitis, and ten-
dinitis of the shoulder.
The project team was initially composed of Louis Patry, occupational physician and
ergonomist, and Michel Rossignol, occupational physician and epidemiologist, but quickly
grew and increased the scope of its expertise through the addition of Marie-Jeanne Costa,
a nurse with ergonomics training, and Martine Baillargeon, a plastic surgeon. All four
team members participated in the drafting of the guides.
These guides were designed to help physicians arrive at a clinical diagnosis and
identify the most probable etiological agents. It should be noted that these guides were
not designed for administrative or legal purposes and that their reliability has not eva-
luated by the researchers.
The publication of these guides designed specifically for physicians is one more ad-
vance in the IRSST’s efforts to shed light on the phenomenon of cumulative trauma
disorders and provide specialists with appropriate tools with which to prevent these
injuries and reduce related risk factors.
Jean Yves Savoie

Director general
Institut de recherche en santé et en sécurité du travail du Québec
* Hagberg, M., Silverstein, B., Wells, R., Smith, M.J., Hendrick, H.W., Carayon, P., Pérusse, M. (1995), Work related muscu-
loskeletal disorders (WMSDs): a reference book for prevention, scientific editors: Kuorinka, I., Forcier, L., publishers Taylor
and Francis, London, 421 pages.
INTRODUCTION
This guide is the third in a series of practical summaries of current medical knowledge
on musculoskeletal injuries with well-documented occupational etiology, namely:
– carpal tunnel syndrome (CTS)
– De Quervain’s tenosynovitis
– tendinitis of the shoulder
When occupational in origin, these injuries are often referred to as “CTDs”, a term
applicable to “problems and diseases of the musculoskeletal system that include, among
their causes, some factor related to work” (Kuorinka et al., 1995). Whatever term is
used to designate them—occupational overuse syndrome (OOS), repetitive strain in-
juries (RSI) or cumulative trauma disorders (CTDs) in English, troubles musculo-sque-
lettiques (TMS), lésions musculo-squelettiques (LMS), lésions musculo-tendineuses (LMS),
lésions musculo-tendineuses liées aux tâches répétitives, or pathologies d’hyper-solli-
citation in French—their defining characteristic is the presence of an injury caused by
biomechanical strain due to tension, pressure, or friction which is excessively force-
ful, repetitive, or prolonged.
This guide is designed for physicians who are called upon in the course of their
practice to diagnose musculoskeletal injuries and establish the extent to which these
injuries are caused by their patient’s work. Its goal is to help physicians arrive at cli-
nical and etiological diagnoses. To this end, the guide first reviews the anatomical, phy-
siopathological, and etiological knowledge upon which diagnosis depends. This is fol-
lowed by guidelines for the evaluation of symptoms, the conduct of the clinical
examination, and the control of potential risk factors related to the development of the
injury.
Musculoskeletal injuries may have many causes. For carpal tunnel syndrome (CTS),
De Quervain’s tenosynovitis and tendinitis of the shoulder, these include not only oc-
cupational, sporting, recreational, and domestic activities, but also specific health pro-
blems and conditions. This guide was prepared in response to requests from physicians,
increasingly preoccupied by CTDs, for information and support on this subject. Although
the approach taken emphasizes the documentation of potential occupational risk fac-
tors—a subject little discussed in formal medical training—it does not neglect the eva-
luation of other potential causes of tendinitis of the shoulder.
This guide is meant to be used in a clinical setting. To help physicians collect the
information they need to diagnosis the injury and establish its causes, it therefore in- vii
cludes a series of questions, presented in readily identifiable text boxes, for them to
ask their patients. These questions were derived from psycho-physical scales used by
ergonomists to subjectively evaluate workload (Sinclair, 1992) and medical question-
naires developed for the diagnosis of CTS and the evaluation of functional capacity
(Katz et al., 1994; Levine et al., 1993; Rossignol et al., 1995).
Should however a physician remain unable to come to a definitive conclusion about
the work-relatedness of an injury after consulting this guide, she or he should conti-
nue to seek information which will enable her or him to better evaluate the occupa-
tional musculoskeletal strain to which her or his patient is subjected.
Finally, it should be noted that this guide does not address the issues of multiple
injuries and the psycho-social aspects of musculoskeletal injuries, important as they
may be for the global evaluation of the patient.
viii
TABLE OF CONTENTS
Chapter 1 – General Considerations

Terminology................................................................................................................... 1
Epidemiology................................................................................................................. 1
Anatomical Review........................................................................................................ 1
Structure of the Shoulder Joint .............................................................................. 2
Structure of the Tendon ......................................................................................... 2
Biomechanical Considerations ............................................................................... 3
Innervation .............................................................................................................. 5
Physiopathology ............................................................................................................ 6
Chapter 2 – Etiology
General Description of Risk Factors ............................................................................ 9
Specific Risk Factors for Shoulder Injuries ................................................................ 10
Occupational Sources of Musculoskeletal Strain ....................................................... 10
Strain Related to Sports-related, Recreational and Household Activities ................. 11
Strain in Musicians....................................................................................................... 11
Chapter 3 – Differential Diagnosis

Injury to Structures Surrounding the Rotator Cuff..................................................... 13
Subacromial Bursitis ............................................................................................. 13
Adhesive Capsulitis (Retractile Capsulitis, Frozen Shoulder) ............................. 13
Shoulder Pathologies................................................................................................... 15
Cervicobrachial Disorders .................................................................................... 15
Compression of the Supraclavicular Nerve ......................................................... 15
Cervical Root Injuries ........................................................................................... 15
Thoracic Outlet Syndrome ................................................................................... 15
Shoulder Instability ............................................................................................... 16
General and Systemic Pathologies ............................................................................. 16
Chapter 4 – Clinical Considerations

Symptoms..................................................................................................................... 17 ix
Location of Symptoms (Where?).......................................................................... 17
Onset of Symptoms (When?) ............................................................................... 18
Characteristics of Onset (How?)........................................................................... 18
Impact on Activities of Daily Living........................................................................... 18
Impact on Physical Activity ........................................................................................ 19
Chapter 5 – Recording of Information on Exposure Factors

Occupational History .................................................................................................. 21
Previous Work....................................................................................................... 21
Current Work......................................................................................................... 21
Current Work and Organisational Factors ........................................................... 22
Sports-related, Recreational and Household Activities.............................................. 24
Chapter 6 – Physical Examination of the Shoulder

General Evaluation ...................................................................................................... 25
Specific Evaluation ...................................................................................................... 27
Supraspinatus Tendinitis....................................................................................... 27
Infraspinatus Tendinitis ........................................................................................ 28
Subscapular Tendinitis and Teres Minor Tendinitis............................................ 28
Subacromial Impingement Syndrome.................................................................. 29
Rotator Cuff Tear .................................................................................................. 32
Tenosynovitis of the Long Head of the Biceps .................................................. 33
Chapter 7 – Summary of the Evaluation .................................................................... 35
Chapter 8 – Guidelines for Therapeutic and Preventive Interventions

Therapeutic Guidelines ............................................................................................... 37
Prevention Guidelines................................................................................................. 37
Conclusion........................................................................................................................ 39
Bibliography .................................................................................................................... 41
List of Figures
Figure 1.1 Structure of the Shoulder Joint ..................................................................... 2
Figure 1.2 Structure of Tendons ..................................................................................... 2
Figure 1.3a Muscles and Tendons of the Rotator Cuff (Anterior View)......................... 3
Figure 1.3b Muscles and Tendons of the Rotator Cuff (Posterior View) ....................... 3
Figure 1.4 Course of the Tendon of the Long Head of the Biceps.............................. 3
Figure 1.5 Action of the Rotator Muscles ....................................................................... 4
x Figure 1.6 Components of Rotary and Coaptation Forces During Shoulder
Movements ..................................................................................................... 4
Figure 1.7 Dermatomes and Sensory Innervation ......................................................... 5
Figure 1.8 Critical Zone of the Tendons of the Supraspinatus and the Long Head
of the Biceps Subjected to Premature Wear................................................. 6
Figure 2.1 Interrelation of Risk Factors .......................................................................... 9
Figure 3.1 Subacromial Bursitis..................................................................................... 13
Figure 3.2 Compression of the Supraclavicular Nerve ................................................ 15
Figure 3.3 Anatomy of the Cervicothoracoscapular Junction ..................................... 15
Figure 3.4 Structures Capable of Causing Shoulder Pain............................................ 16
Figure 4.1 Shoulder-Arm Diagrams .............................................................................. 17
Figure 6.1 Painful Points on the Shoulder ................................................................... 25
Figure 6.2 Painful Arcs .................................................................................................. 26
Figure 6.3 Resisted Abduction of the Arm ................................................................... 27
Figure 6.4 Jobe’s Manoeuvre......................................................................................... 27
Figure 6.5 Resisted External Rotation of the Forearm................................................. 28
Figure 6.6 Patte’s Manoeuvre........................................................................................ 28
Figure 6.7 Resisted Internal Rotation of the Forearm.................................................. 28
Figure 6.8 Mechanism of Impingement........................................................................ 29
Figure 6.9 Neer’s Sign.................................................................................................... 31
Figure 6.10 Hawkins’ Sign............................................................................................... 31
Figure 6.11 Drop-Arm Manoeuvre.................................................................................. 32
Figure 6.12 Resisted Elevation of the Arm..................................................................... 33
Figure 6.13 Resisted Flexion of the Elbow .................................................................... 33
Figure 8.1 Therapeutic Intervention Flow-Chart.......................................................... 38
Figure 8.2 Therapeutic Approach to Tears of the Rotator Cuff .................................. 38
List of Tables
Table 6.1 Stages of Impingement Syndrome .............................................................. 30
Table 6.2 Imaging Techniques for Tears of the Rotator Cuff .................................... 32
Table 8.1 Preventive Approach ................................................................................... 37
List of Boxes
Box 1.1 Innervation of the Rotator Cuff and Biceps Muscles................................... 5
Box 1.2 Contributory Factors for Tendinitis of the Rotator Cuff and
Tenosynovitis of the Long Head of the Biceps............................................ 7
Box 2.1 Movements Most Commonly Associated with the Development of
Shoulder Tendinitis ...................................................................................... 12
Box 3.1 Clinical Signs of Subacromial Bursitis......................................................... 14
Box 3.2 Clinical Summary of Adhesive Capsulitis ................................................... 14
Box 4.1 Questions about Activities of Daily Living ................................................. 18
Box 4.2 Presentation and Clinical Severity of Symptoms........................................ 19 xi
Box 5.1 Questions about Previous Jobs ................................................................... 21

Box 5.2 General Questions Concerning Occupational Activities and
Symptoms Associated with Them ............................................................... 22
Box 5.3 Questions about Activities that Stress the Shoulder .................................. 23
Box 5.4 Questions about Work Organisation........................................................... 24
Box 5.5 Questions about Sports-related, Recreational, and Household
Activities Involving the Shoulders............................................................... 24
Box 6.1 General Evaluation....................................................................................... 25
Box 6.2 Painful Arcs during Active Abduction of the Arm ..................................... 26
Box 7.1 Clinical Aspects ............................................................................................ 35
xii
1 General Considerations
TERMINOLOGY executed above shoulder height, because of the load

on the shoulder tendons (Hagberg et al., 1995).
Shoulder tendinitis is defined clinically as “pain in
Shoulder tendinitis has also been described among
the shoulder associated with tenderness to palpa-
athletes—especially baseball pitchers, swimmers,
tion over the head of the humerus” (Hagberg and
and tennis players—and professional musicians
Wegman, 1987) and corresponds to inflammatory
(Dupuis, 1995).
and degenerative injuries of the tendons of the ro-
tator cuff and the long head of the biceps. The term
“rotator cuff” is used to designate the tendons of ANATOMICAL REVIEW
the muscles which originate in the scapula, converge
The “shoulder” is in fact a collection of bony and
at the head of the humerus where they form a
ligamentous structures which depend on the in-
“cuff”, and insert on the greater or lesser tubero-
teraction of multiple muscle groups to stabilise the
sity. The tendon of the long head of the biceps ori-
humeral joint and perform movements. The muscles
ginates from the superior portion of the glenoid
of the rotator cuff stabilise the head of the hume-
fossa near the supraspinatus tendon and is gene-
rus in the glenoid fossa during movements of this
rally subject to the same strains as the rotator cuff
joint and account for 50% of the shoulder’s strength
tendons (Pujol et al., 1993).
during abduction and at least 80% of its strength
during external rotation (Marks et al., 1994). The
EPIDEMIOLOGY tendon of the long head of the biceps is involved
in flexion of the forearm, coaptation of the head
According to the Bureau of Labour Statistics of the
of the humerus, and abduction of the externally ro-
United States, shoulder pain is the second most
tated arm.
common complaint—after back pain—reported
during clinical consultations; furthermore, the pre-
valence of occupational shoulder pain is increasing
greatly (Sommerich et al., 1993).
There have been few epidemiological studies of

the relation between work and shoulder tendini-
tis, and exposure parameters in these studies have
been poorly defined. Despite this, it appears that
the incidence of shoulder tendinitis is related to the 1
performance of activities involving prolonged ele-
vation of the arms, repeated shoulder flexion, and
repetitive and forceful movements of the arms
(NIOSH, 1997; Hagberg et al., 1995). The risk of in-
jury is particularly high when repetitive activities are
Guide To The Diagnosis Of Work-Related
Musculoskeletal Disorders
Structure of the Shoulder Joint Most shoulder movements involve the simulta-
The shoulder joint is formed by: neous action of the glenohumeral and scapulo-
thoracic joints, associated with subacromial sliding
– three cartilaginous joints (the glenohumeral, and movement of the sternoclavicular and acro-
acromioclavicular, and sternoclavicular) mioclavicular joints, respectively (Déziel, 1995;
– two sliding surfaces (the subacromial and Murnaghan, 1988; Kapandji, 1983).
scapulothoracic) (Kapandji, 1983)
– the compartment formed by the ligamentous Structure of the Tendon
junction of the acromion and the coracoid pro- Tendons are composed of dense, regularly shaped,
cess (Figure 1.1) conjunctive tissue. Because of the parallel arrange-
Figure 1.1
ment of their constituent collagen fibres, they are
approximately 50% as strong as cortical bone. Some
Structure of the Shoulder Joint tendons are entirely covered by a fibrous synovial
sheath that protects them against friction with sur-
Acromioclavicular Scapulothoracic rounding bones and ligaments. The role of tendons
joint sliding surface is to transmit muscle force in order to stabilise joints,
perform movements or maintain posture (Fig-
Subacromial ure 1.2).
sliding surface
Sternoclavicular
joint
Glenohumeral
joint
Figure 1.2
Structure of Tendons
Fibrous tendon sheath
Bone Synovial membrane (outer layer)
Periosteum Synovial membrane Muscle

(inner layer)
Fibrous tendon
layer
Collagen fibres
2
Region of Region of Region of Region of
insertion tenosynovitis tendinitis myotendinitis
tendinitis and
peritendinitis
Tendon
Biomechanical Considerations The tendon of the long head of the biceps comes
The rotator cuff and the long head of the biceps into close proximity with the rotator cuff:
are central to the control of movements involving – Originating on the subglenoid tuberosity, it runs
the glenohumeral joint. The muscles of the rotators under the capsule of the glenohumeral joint, fol-
centre the head of the humerus, allowing it to pi- lows the curve of the head of the humerus, turns
vot in the glenoid fossa. 90°, slides through the bicipital groove where
it acquires a sheath, and finally inserts into the
The rotator cuff is formed by: biceps muscle (Figure 1.4).
– the ends of the tendons of the supraspinatus, in-
fraspinatus, teres minor, and subscapularis
muscles, all of which have their insertion on the Figure 1.4
superior humerus, just below its head (Figures Course of the Tendon
1.3a and 1.3b). of the Long Head of the Biceps
Figure 1.3a
Muscles and Tendons of the Rotator Cuff
Tendon of
(Anterior View) the long
head
Biceps of the biceps
(long head)
Supraspinatus
Subscapularis
During abduction and elevation, this group of

tendons depresses the head of the humerus, sliding
Figure 1.3b the greater tuberosity under the coracoacromial arch
Muscles and Tendons of the Rotator Cuff (Lacoste, 1993). This opposes the action of the del-
(Posterior View) toid muscle and raises the head of the humerus
against the acromial bursa. The role of the acromial
Infraspinatus bursa is to dampen various forces and facilitate the
sliding of the head of the humerus under the del-
toid muscle and coracoacromial arch (Dupuis-
Leclaire, 1986).
3
Teres minor
SHOULDER TENDINITIS
Action of the muscles of the rotator cuff and the Figure 1.5
biceps (Kendall Peterson and Kendall McCreary, Action of the Rotator Muscles
1988) (Figure 1.5)
1
Supraspinatus – abduction of the arm (1)
Subscapularis – internal rotation of the arm (2) 2
Infraspinatus – external rotation of the arm (3) 1
Teres minor – external rotation of the arm (4)
Long head of – flexion and abduction of the arm 3 5
the biceps with the humerus rotated (5) 4
– also involved with elbow flexion
The rotator cuff and the tendon of the long head

of the biceps are particularly important in coapta-
tion and rotation of the head of the humerus. “Co-
aptation” is the term used to describe the muscle
action which brings joint surfaces closer together (Williams et al., 1986). The components of the ro-
and maintains them in that position. Rotary force, tary and coaptation forces of the deltoid muscle are
in contrast, is responsible for moving the arm illustrated in Figure 1.6.
Figure 1.6
Components of Rotary and Coaptation Forces during Shoulder Movements
D Fr
Fc
D = force developed by the deltoid muscle; Fr = rotary force; Fc = coaptation force; G = weight of the arm
Innervation
The motor function of the rotator cuff and long head innervation is primarily provided by the sensory
of the biceps is controlled by the nerves origina- branches arising from the C4-D1 roots (Kendall
ting in the C4-C7 roots (Box 1.1), while sensory Peterson and Kendall McCreary, 1988) (Figure 1.7).
Box 1.1
Innervation of the Rotator Cuff and Biceps Muscles

Supraspinatus Suprascapular nerve; C5, C6
Infraspinatus Suprascapular nerve; C5, C6
Teres minor Axillary nerve; C5, C6
Subscapularis Superior and inferior subscapular nerves; C5, C6
Long head of the biceps Musculocutaneous nerve; C5, C6
Source: Kendall Peterson and Kendall McCreary, 1988, Tubiana and Thomine, 1990
Figure 1.7
Dermatomes and Sensory Innervation
DERMATOMES
C7 C7
C6 C4 C6
C5 C5
C3
D2
C8 C4
C8
D2
D1 D1
SENSORY INNERVATION
1
1
2
2 1. Suprascapular nerve C3,C4
4 2. Axillary nerve C5, C6 5
4 3. Radial nerve C5, C6
4. Intercostobrachial and medial brachial
3 3 cutaneous nerves, D1, D2
5. Medial antebrachial cutaneous nerve C8, D1
5
Anterior View Posterior View

Reference: Netter F.H. (1995), Atlas of human anatomy, 7th edition, Ciba-Geigy Corporation, New Jersey, 314 pages.
SHOULDER TENDINITIS
PHYSIOPATHOLOGY Figure 1.8
The most commonly advanced physiopathological Critical Zone of the Tendons

mechanism underlying rotator cuff tendinitis and te- of the Supraspinatus and the Long Head
nosynovitis of the long head of the biceps involves of the Biceps Subjected
mechanical phenomena related to the motor func- to Premature Wear
tion of the shoulder and anatomical instability of
Coracoacromial ligament
the joint. Critical zone
of the
supraspinatus
Codman, in 1934, was the first to describe da- tendon
mage to the rotator cuff in individuals who main-
tained awkward postures with the arms flexed or
abducted in the course of their daily or occupational
activities. In 1983, Neer described “impingement
syndrome”, a degenerative pathology associated
with friction of the supraspinatus tendon with the
anterior margin of the acromion, primarily during Critical zone of
elevation of the internally rotated arm (Leffert, 1992). the tendon of the long
This mechanical effect is exacerbated by muscular head of the biceps
exertion, e.g. the maintenance of certain postures,
which reduces local blood circulation. Jarvhölm et
al. (1990) demonstrated that flexion of the arm ex-
ceeding 60° or abduction exceeding 30° disrupts cir-
culation to the supraspinatus. Other arteriographi-
cal studies have revealed that lateral compression
of the tendinous and peritendinous vascular bed can of healing has different properties and not only
result in a virtually avascular state (Caillet, 1985). leads to a functional imbalance between the del-
In the shoulder, this phenomenon is most com- toid and supraspinatus muscles but also affects peri-
monly observed in the tendons of the supraspina- articular structures.
tus and of the long head of the biceps (Figure 1.8).
The other tendons of the rotator cuff (infra-
Interruption of normal healing processes appears spinatus, subscapularis, teres minor) are rarely af-
to be a factor in the development of inflammation fected on their own; damage to these structures
following tendon damage. If muscle strain is re- usually occurs in cases of tendinitis of the supra-
peated or prolonged, scar tissue will be produced spinatus or tenosynovitis of the long head of the
around the damaged tendon, predisposing it to fur- biceps with functional decompensation (Box 1.2).
ther damage. The stages in the development of this
pathology are (Lacoste, 1993):
GENERAL DESCRIPTION OF RISK FACTORS
1. Fibrin deposition
2. Continuous oedema with inflammation
3. Development of granulomatous tissue
4. Tissue calcification and ossification
6
The tissue formed as a result of this interruption
Box 1.2
Contributory Factors for Tendinitis of the Rotator Cuff and

Tenosynovitis of the Long Head of the Biceps
• Anatomical
– Presence of a critical avascular zone (Codman zone) approximately 1 cm from the insertion
of the tendons, especially the supraspinatus
• Mechanical
– Compression-related stress when the head of the humerus is elevated against the coraco-
acromial arch
– Inflammation as a result of repeated or prolonged stress
– Traction associated with throwing motions with the arm abducted or elevated
• Vascular
– Disruption of the circulation caused by arm flexion exceeding 30°
– Compression of the tendinous and peritendinous vascular bed
Source: Hagberg et al., 1995; Dupuis-Leclaire, 1986
SHOULDER TENDINITIS
2 Etiology
Establishing the cause of disorders affecting the disorders can be seen as the result of imbalances
shoulder tendons, in common with other CTDs, de- between load and functional capacity (Figure 2.1)
pends on the evaluation of: (Cnockaert and Claudon, 1994). The primary bio-
mechanical components are repetition, force, pos-
– individual factors such as age, sex, aging, phy-
ture, and duration of exposure. Functional capac-
sical fitness, and medical history
ity, on the other hand, is a function of individual
– biomechanical factors such as force, repetition,
characteristics, health status, and individual per-
and posture
ceptions of work tasks and organization.
– organisational factors such as the cadence and
rhythm of work activities
Although sometimes difficult to define and
From a clinical point of view, musculoskeletal
Figure 2.1
Interrelation of Risk Factors
Work Context
Duration
Repetition Force Posture
Load
Risk of injury =
Functional capacity
Individual characteristics Health status Psycho-social factors

(age, sex, physical fitness) (medical history) (perception of work
tasks and organisation)
Adapted from Cnockaert and Claudon, 1994
quantify, repetition has been clearly shown to be Musculoskeletal loading—be it occupational,

a risk factor for musculoskeletal injury (NIOSH, sports-related, recreational, or related to household
1997; Hagberg et al., 1995; Bjelle et al., 1981). In activities—is a recognized risk factor for shoulder
purely scientific terms, repetitious work involves cy- injuries. Injury to the shoulder tendons among mu-
clical movement of the same tissue. Repetitiveness sicians who play string and percussion instruments
is usually defined in terms of components of work is a particularly interesting example of such loading.
activities, e.g. production rate or work cycles per
unit time, although it may also be defined in terms
OCCUPATIONAL SOURCES OF
of an individual’s response to work activities.
MUSCULOSKELETAL STRAIN
Practically, it may be measured through analysis of
the speed of movements or of electromyographic Musculoskeletal loads which exceed a worker’s ca-
activity (Malchaire and Indesteege, 1997). pacity to adapt and work without pain cause soft-
tissue damage and modification of the peripheral
Force is easier to define, but difficult to measure. circulation. These changes are the underlying
Typically, it is measured in terms of electromyo- cause of load-related occupational injuries of the
graphic activity or loads to be lifted or maintained periarticular structures of the shoulder. The accu-
(Malchaire and Indesteege, 1997). rate determination of risk factors for such injuries
relies upon the discrimination between static and
The maintenance of awkward postures is a re- dynamic muscular work, e.g. prolonged mainte-
cognized risk factor for musculoskeletal injuries of nance of a posture, and repetitive movements, res-
the neck and cervicoscapular region, and tendon pectively. Static muscular work immobilises the
injuries of the shoulder, wrist, and hand (NIOSH, shoulder, allowing the hand to perform dynamic
1997; Hagberg et al., 1995). The most commonly work. Elevation of the arm, on the other hand, puts
observed high-risk situations are prolonged main- particular mechanical stress on the tendons of the
tenance of static postures, and postures associated supraspinatus and the long head of the biceps
with rapidly executed or continuous movements are (Hagberg et al., 1995; Lacoste, 1995).
the most commonly observed high-risk situations.
Prolonged maintenance of awkward pos-
The risk is particularly high when highly repetitive
tures, elevation or abduction of the arm, and
and forceful work is performed in awkward posi-
repetitive handling of heavy loads all increase
tions.
the risk of shoulder tendinitis (Dimberg et al,
1989; Kroemer, 1989), although the specific ten-
SPECIFIC RISK FACTORS FOR SHOULDER dons involved will vary as a function of the
INJURIES type of movement in question. For example,
anterior flexion of the arm primarily affects the
Although age-related degenerative phenomena
tendon of the long head of the biceps, while
may cause rotator cuff tendinitis and tenosynovitis
abduction of the shoulder primarily affects the
of the long head of the biceps, these conditions may
supraspinatus (Chipman et al., 1991).
also result from the mechanical effects of repeated
or prolonged musculoskeletal stress. Hyperplastic
modifications caused by repeated friction and mi- STRAIN RELATED TO SPORTS-RELATED,
crotrauma may reduce the capacity of tendons to
function adequately during attempted shoulder co-
10 aptation and mobilisation. Even if slight, such dys-
function tends to amplify degenerative tissue effects
at the tuberosities of the head of the humerus and
under the acromion.
RECREATIONAL AND HOUSEHOLD Playing musical instruments is a particularly effec-
ACTIVITIES tive way of stressing the joints of the upper limb.
Shoulder tendinitis has been observed among mu-
Shoulder tendinitis may be secondary to trauma or
sicians who play string instruments; the stress in this
develop insidiously following fine movements per-
case is believed to be caused by the bowing action,
formed repetitively or at the limit of the joint’s range
which combines repetitive movement with static
of movement (Lacoste, 1994). Patients suffering from
arm elevation (Dupuis, 1994). Among percussionists,
sports-related injuries are usually younger and may
the effort required to stabilise the instruments ge-
exhibit subclinical glenohumeral instability.
nerates stress on the rotator cuff.
Movements which exert traction on the joints are
Box 2.1 illustrates postures and movements typ-
among those associated with the highest risk of de-
ically associated with the development of shoulder
veloping painful shoulder syndromes (Hagberg
tendinitis.
et al., 1995; Lacoste, 1994). These include:
– throwing objects (balls, javelin, discus)
– sports such as handball, volleyball, tennis, and
swimming (butterfly stroke and crawl)
STRAIN IN MUSICIANS
11
SHOULDER TENDINITIS
Box 2.1
Movements Most Commonly Associated with the Development

of Shoulder Tendinitis
Avoid
Shoulder rotation Abduction and flexion of the shoulder
Avoid OK
Extension Shoulder flexion
Throwing objects Working with the arms elevated
CTD Risk Cofactors
– Exposure to cold
– Use of vibrating tools
– Wearing work gloves
12
Source: Kroemer, 1989; Dimberg et al., 1989; Hagberg, 1995; NIOSH, 1997
3 Differential Diagnosis
Many pathologies involving the structures surround- Figure 3.1

ing the rotator cuff and many regional, general, or Subacromial Bursitis
systemic conditions can cause shoulder pain.
INJURY TO STRUCTURES SURROUNDING

THE ROTATOR CUFF
Subacromial Bursitis
There are two forms of subacromial bursitis. The Calcified
acute form reflects subacromial swelling which pre- deposit
sents as intense pain which worsens at night
(Leduc, 1986). When the calcified deposit works its
way out of the tendon and ruptures into the sub-
acromial bursa, it produces severe irritation and pain
in the shoulder (Caillet, 1985) (Figure 3.1).
Local palpation is painful and patients may ex-

hibit reduced joint mobility. Activities involving re-
peated shoulder abduction may favour the devel-
opment of this condition, especially if they are Rupture into the
subacromial bursa
accompanied by lateral rotation of the shoulder
(Sommerich et al., 1993).
The chronic form presents with a more subtle

clinical profile which is often difficult to distinguish
from tendinitis of the supraspinatus, and reflects an
inflammatory thickening of the bursa, accompanied
by adhesions. Pain is usually localised at the distal sule of the glenohumeral joint. Typically, shoulder
insertion of the deltoid (Leduc, 1986). Box 3.1 lists mobility is reduced (Dupuis-Leclaire, 1986).
the main signs and symptoms of subacromial bur-
sitis. The primary form is particularly prevalent among 13
individuals older than 50 years suffering from limited
Adhesive Capsulitis (Retractile Capsulitis, shoulder mobility of variable etiology. The condi-
Frozen Shoulder) tion is generally progressive and may take as long
This condition is an inflammatory condition reflect- as 30 months to develop; spontaneous but some-
ing fibrous thickening, and retraction, of the cap- times incomplete recovery may occur (Dupuis-
Box 3.1
Clinical Signs of Subacromial Bursitis

Acute bursitis
– intense pain, worsening at night
– pain on local palpation
– possible reduction of active mobilisation of the shoulder
– inability to lie on the affected side; typically, patients adopt antalgic positions
Chronic bursitis
– pain near the distal insertion of the deltoid
– local cellulitis
– difficulty lying on the affected side
Source: Béliveau, 1993; Leduc, 1986
Leclaire, 1986). There is usually no apparent under- that lead the patient to adopt antalgic positions.
lying cause. The initial clinical profile of adhesive capsulitis
may resemble that of shoulder tendinitis.
The secondary form, even if often associated
Box 3.2 summarises the clinical signs and some
with inflammation of the joint or rotator cuff,
possible causes of adhesive capsulitis.
may result from a variety of health problems
Box 3.2
Clinical Summary of Adhesive Capsulitis

Signs upon examination
– painful spasm over the trapezius
– disrupted glenohumeral movement
– reduced active and passive mobilisation of the shoulder
Possible causes
Primary form
Progressive onset with no apparent cause. May initially appear in association with anxiety or stress.
Secondary form
14
Shoulder capsulitis may be related to: shoulder trauma, nervous system disorders, coronary heart
disease failure and other cardiac conditions, diabetes mellitus, hyperthyroidism, burns, inflamma-
tion, infection, and psychological factors.
Source: Dupuis- Leclaire, 1986
SHOULDER PATHOLOGIES Upon examination, patients exhibit weakness in
abduction and external rotation; atrophy of the in-
These pathologies include problems of both mus-
fraspinataous fossa may also be present.
cular and neurological origin.
Cervical Root Injuries
Cervicobrachial Disorders
Cervical root syndromes are characterised by damage
Cervical injuries may cause shoulder pain, usually
to one or more cervical nerve roots, most commonly
felt in the upper portion of the shoulder and over
C6 and C7 (Berger and Kleinert, 1991). Pain may
the upper and middle trapezius. The pain is gene-
appear suddenly or develop progressively. The acute
rally associated with the performance of repetitive
form usually is seen following trauma, while the
movements with the hands (assembly of electronic
chronic form results from a protuberant or dege-
parts, data entry) while the trunk, head or arms are
nerative discopathy.
maintained in static postures for prolonged periods
(Sommerich et al., 1993). Thoracic Outlet Syndrome
Compression of the Supraclavicular Nerve Clinical examination is the key to diagnosing tho-
racic outlet syndrome, whose primary cause is the
This condition may be mistaken for bursitis. The su-
compression of nerves or blood vessels at the base
praclavicular nerve originates in the brachial plexus
of the neck in the cervicothoracoscapular junction
and innervates the supraspinatus and infraspinatus
(Figure 3.3) (Vender et al., 1998; Leffert, 1992;
muscles. Its compression causes pain in the lateral
Leclaire, 1986). The neurological form is related to
and posterior shoulder. Common causes of com-
the compression of the lateral branches of the C8
pression include falls and carrying loads slung across
and D1 roots of the brachial plexus; its main signs
the shoulder or directly on the shoulder joint
are paresthesia, numbness, and pain in the ulnar ner-
(Sommerich et al., 1993) (Figure 3.2).
ve’s field. The vascular form is primarily associated
Figure 3.3
Anatomy of the Cervicothoracoscapular
Junction
Figure 3.2
Compression of the Supraclavicular Nerve
Scalenus medius Scalenus anterior

Brachial plexus
Scalenus
posterior
Axillary
artery
Axillary
vein
Median
nerve
15
Ulnar nerve
Carrying loads directly on or slung across the shoulder Pectoralis minor
SHOULDER TENDINITIS
with compression of the subclavicular artery and 1994). It is important to note that patients suffering
is characterised by coldness, sore muscles, and di- from glenohumeral instability also often suffer from
minished strength during continuous exertion damage to the rotator cuff, which may secondarily
(Vender et al., 1998; Leffert, 1992). These symptoms contribute to the instability of the shoulder.
may be accompanied by swelling and cyanosis of
the forearm and hand.
GENERAL AND SYSTEMIC PATHOLOGIES
There is controversy in the scientific literature Diffuse shoulder pain may result from general or
regarding the diagnostic tests for this condition and systemic pathologies (Béliveau, 1993). The existence
the anatomical structures involved in its patho- of such pathologies should be considered when the
genesis (Leffert, 1992; Berger et al., 1991; Dawson range of motion is unaffected, movement is pain-
et al., 1990). According to Leffert (1992), patho- free, and radiological examination is normal.
genesis is not solely a function of anatomy (cervi-
cal ribs, fibrous bands, birth defects) but is also asso- Examples of general pathologies capable of caus-
ciated with dynamic constraints related to growth, ing shoulder pain include cardiovascular conditions,
trauma, and posture. The commonly cited hazard- apical pulmonary tumours, and diaphragmatic ir-
ous postures are repeated or prolonged flexion of ritations with damage to the abdominal viscera
the shoulder at angles exceeding 60° and those that (Figure 3.4). Systemic conditions capable of causing
involve arm movements above the shoulders or diffuse pain include rheumatoid arthritis and the
force the shoulders backwards or downwards (e.g. shoulder-hand syndrome (reflex sympathetic al-
lifting and carrying loads) (Vender, 1998; Sommerich giodystrophy).
et al., 1993).
Shoulder Instability SYMPTOMS

Instability of the glenohumeral joint reflects the in-
ability to maintain the head of the humerus cen-
Figure 3.4
tred within the glenoid fossa (Jackins and Matsen,
1994). It is important to distinguish the trauma-re- Structures Capable of Causing
lated form of this condition from instability due to Shoulder Pain
other factors. Non-trauma-related instability is
usually associated with loose ligaments and often
affects both shoulders. The most common causes
of the trauma-related form, on the other hand, are
acute trauma, dislocation of the glenohumeral
joint, or microtrauma related to repeated movements
Cervical
above the shoulder (e.g. throwing objects, swim- spine
ming) (Sagerman et al., 1998; Iannotti, 1994).
Evaluation of patients exhibiting glenohumeral

instability requires detailed investigation of the Lungs Heart
symptomatology, in order to identify the movements
responsible for the initial injury or related to recur- Diaphragm
16 rences, and identify the direction of the instability.
This etiological evaluation is essential for the cha- Elbow
Gallbladder
racterisation of the type of instability and the de-
velopment of an appropriate therapeutic approach
(Marks et al., 1997; Iannotti, 1994; Jackins et al.,
4 Clinical Considerations
The symptoms of shoulder tendinitis may develop as intense pain on the superior-external face of the
progressively as a resulting of repetitive movements, shoulder, with possible radiation to the external face
significant exertion, or prolonged maintenance of of the shoulder and to the arm. Active movement,
awkward postures, or may appear suddenly follo- particularly abduction, increases the pain.
wing an accident or violent movements. The most
common symptom is pain on the external or an- Tenosynovitis of the long head of the biceps pre-
terior face of the shoulder (Bélisle and Croteau, sents as pain on the anterior face of the shoulder
1988), with possible radiation as far as the elbow with possible radiation to the arm. Resisted flexion
(Chipman et al., 1991). As symptoms progress, the elicits pain (Dupuis-Leclaire, 1986; Choquette,
pain may become constant and prevent patients 1988; Hazeltine, 1990).
from sleeping on the affected shoulder.
The following questions should be asked of all

patients exhibiting symptoms affecting the shoul- Figure 4.1
der: Shoulder-Arm Diagrams
– Where do you feel the pain?
– When did the pain begin?
– What did the pain feel like when it started?
– What does it the pain feel like now?
In addition, the impact of the symptoms on daily

living should be assessed.
Location of Symptoms (Where?)

The use of a shoulder-arm diagram is a useful means
of helping patients localise their symptoms (Fig-
ure 4.1). Damage to any of the tendons of the ro-
tator cuff however yields similar results, and ob-
jective examination is therefore the only way to
identify the specific tendons involved in these cases.
17
Tendinitis of the rotator cuff generally presents
Onset of Symptoms (When?) may trigger symptoms, and traction and exertion
It is essential to determine the time that has elap- may aggravate them.
sed between the onset of symptoms and the exami-
nation. Symptoms of tenosynovitis of the long head of
the biceps may appear during resisted elbow
Shoulder tendinitis is a painful condition which flexion, especially with the forearm supinated.
is usually unrelated to trauma. As every physical ac- They may also appear during movements com-
tivity generates a physiological response to external bining abduction, extension and rotation (e.g. put-
stress, it is necessary to establish whether exposure ting on a coat) or combining flexion and rotation
actually preceded the onset of symptoms. Patients of the forearm (e.g. using a screwdriver) (Lacoste,
should also be explicitly asked the reason for the 1993).
current visit.
Impact on Activities of Daily Living
Characteristics of Onset (How?) In addition to pain, patients may exhibit a dete-
Patients should be asked to describe the circum- rioration of their ability to perform movements re-
stances surrounding the onset of symptoms. Ten- quiring rotation, flexion, or abduction of the shoul-
dinitis of the rotator cuff may appear abruptly, in- der. Box 4.1 lists a series of questions that help
sidiously, or progressively. Certain movements of determine the impact of symptoms on the activi-
daily living such as dressing or brushing one’s hair ties of daily life.
Box 4.1
Questions about Activities of Daily Living

Which is your dominant hand? Right ❐ Left ❐
Never Sometimes Often Always
Do you have difficulty
– picking up objects located over
your shoulders?
– using your arms over your shoulders
(e.g. changing a lightbulb in the ceiling)?
– driving a car?
– putting on a shirt or coat?
– throwing something?
– brushing your hair or putting on makeup?
– peeling vegetables?
– holding a cup of coffee?
18
– knitting or turning a key in a lock?
– buttoning a shirt?
Impact on Physical Activity
There is a relation between the severity of mus-
culoskeletal damage and the ability to perform phy-
sical, occupational, sports-related, recreational or
household activities. Box 4.2 lists a scale with which
to grade the severity of damage.
Box 4.2
Presentation and Clinical Severity of Symptoms

Severity Symptoms
0. None No pain during physical activity
1. Slight Symptoms only after intense and repetitive activity
2. Moderate Symptoms only after light or occasionally activity
3. Severe Symptoms present regardless of activity
19
SHOULDER TENDINITIS
5 Recording of Information on
Exposure Factors
To establish the etiological link between shoulder Current Work

tendinitis and physical activity, it is essential to do- Patients should be asked to describe their current
cument the patient’s movements and postures. job in sufficient detail for physicians to clearly under-
Symptoms generally appear in the shoulder which stand the nature of their work and the conditions
is subjected to the most stress. This approach pro- under which it is performed. As it is generally dif-
posed here allows physicians to collect as much as ficult for physicians to visit workplaces, this guide
information as possible on the occupational acti- provides a series of questions designed to help
vities that are the most likely to play an important them:
role in the development of symptoms, and to col-
lect summary information on sports-related, re- – generally characterise the patient’s work
creational and household activities. (Box 5.2)
– identify occupational musculoskeletal strains
which favour the development of shoulder
OCCUPATIONAL HISTORY tendinitis (Boxes 5.3)
– estimate the work rhythm and degree of auto-
Previous Work
nomy associated with the work (Box 5.4)
The goal of collecting information on previous work
is to determine the extent to which previous jobs There are a multitude of work-related activities
exposed the patient to arm stress (Box 5.1). that cause musculoskeletal strain. Common activi-
ties which may present a risk for the development
Box 5.1
Questions about Previous Jobs

Work performed Starting date and Hours per day Risk factors or
duration in months or years cofactors*
21
* See Box 2.1
of shoulder tendinitis are listed in Box 5.3. If a pa- Current Work and Organisational Factors
tient’s activities correspond little or not at all to those Certain factors related to the rhythm, organisation,
on this list, it may be useful to ask her or him to and perception of a patient’s work may favour the
describe the activities or movements she or he finds development of musculoskeletal disorders.
difficult, and evaluate their biomechanical charac-
teristics (duration, frequency, force).
Box 5.2
General Questions Concerning Occupational Activities and

Symptoms Associated with Them
– Is your current job full- or part-time?
– Which arm do you use the most to perform your work?
– Was an accident or an abrupt, sudden, or unusual movement responsible for your pain?
– Did your pain appear progressively?
If so, how long did it take to appear and what form did it take?
– What activities and movements aggravate your symptoms?
22
Box 5.3
Questions about Activities that Stress the Shoulder

Activity Hours Frequency of movements Force exerted
per day low medium high low medium high
– Working with the hands above
the shoulder
– Handling objects or tools above
the shoulder or away from the body
– Lifting objects with the arms flexed
or abducted
– Pulling or throwing objects
– Performing movements with the arms
extended to the side
– Maintaining fixed postures with
the arms flexed or abducted
– Picking up or putting down objects
behind the back (extension)
– Applying pressure with the hand
Other (describe)
Comments
Cofactors which increase Never Occasionnally Regularly

musculoskeletal load
– Wearing work gloves
– Exposure to cold
– Use of vibrating or percussion tools
23
SHOULDER TENDINITIS
Box 5.4
Questions about Work Organisation

During your work Never Occasionnally Regularly
– Do you feed a machine tool at

a constant rhythm?
– Do you feel time or production pressures?
– Do you have to pay constant attention?
– Do you find your work monotonous?
– Can you vary your work rhythm?
– Do you work at several different

workstations?
Comments
SPORTS-RELATED, RECREATIONAL AND

HOUSEHOLD ACTIVITIES
As sports-related, recreational, and household ac- (Box 5.5). Swimming, baseball, and tennis appear
tivities may contribute to the development of to be particularly high-risk activities for this type of
shoulder tendinitis, it is important to establish the injury.
intensity with which these activities are practised
Box 5.5
Questions about Sports-related, Recreational, and Household Activities

Involving the Shoulders
Activity Hours per week Risk factors or cofactors*
24
* See Box 2.1

6 Physical Examination of
the Shoulder
The shoulder is a complex joint and it sometimes of points which are sensitive to palpation helps
proves difficult to precisely identify the origin of orient clinical diagnosis (Figure 6.1).
symptoms. The goal of this section is to provide phy-
sicians with a structured approach to guide the dia-
gnosis of shoulder tendinitis. Following a presen- Figure 6.1
tation of the general elements of shoulder evaluation, Painful Points on the Shoulder
tests and manoeuvres that allow precise identifica-
tion of the site of the injury will be described.
2 5
↑
GENERAL EVALUATION ↓
3 6
↑
↑
The general evaluation includes: ↑
↑
↑
7
– observation 1
4
↑
– palpation and identification of painful points 8
– evaluation of joint mobility
– detection of painful arcs
Observation of the affected shoulder and com-

parison with the unaffected one allows physicians
to identify the postures adopted by the patient, eva- Anterior view Posterior view
luate functional limitations, and determine the limits
1. Sternoclavicular arthritis or arthrosis
of the affected shoulder. Box 6.1 summarises the 2. Acromioclavicular arthritis
main elements of the visual examination. 3. Supraspinatus tendinitis and subacromial bursitis
4. Tenosynovitis of the long head of the biceps
5. Cellulitis of the trapezius
Palpation is performed to confirm the impres- 6. Tendinitis of the tip of the scapula
7. Tenderness over the supraspinatus
sions formed during observation, manually evaluate 8. Tenderness over the infraspinatus
the state of the tissues and determine whether defor- Source: Leduc, 1986
mation or painful points are present. The presence
Box 6.1
General Evaluation
25
Appearance of the limbs – antalgic posture of the shoulders or cervical region
– appearance of the head of the humerus and of the sca-
Observation
pula
– deformation of various joints
Passive and active evaluation of joint mobility Figure 6.2

helps establish the extent of any functional limi- Painful Arcs
tations. Passive evaluation, performed by the exam-
iner, helps establish the mobility of the head of the
humerus in the glenoid fossa. Active evaluation, on
the other hand, is performed by the patient her- or
himself and establishes the ability of the muscle-li-
gament system to raise the arm or maintain it at an
a specified angle (Figure 6.2). More specifically, it
allows the physician to determine:
– the symmetry and active amplitude of move-
ments
– the glenohumeral rhythm during abduction,
through observation of the elevation and low-
ering of the arm
– the existence of painful arcs (Box 6.2) (Chipman
et al., 1991; Bélisle and Croteau, 1988; Dupuis-
Leclaire, 1986).
Active abduction of the arm may trigger a painful arc.
Box 6.2
Painful Arcs during Active Abduction of the Arm

Between 60° and 120° – Painful friction of the bursa-tendon complex as it passes
under the coracoacromial arch
Between 120° and 180° – Problems involving the acromioclavicular joint
Source: Dupuis-Leclaire, 1986; Bélisle and Croteau, 1988; Marshall, 1993
26
SPECIFIC EVALUATION Figure 6.3
Resisted Abduction of the Arm
The specific evaluation of shoulder function involves
the use of resisted movements to reproduce pain
reported by the patient. The reaction to these mo-
vements helps identify the structures which are da-
maged and are responsible for observed symptoms.
This section presents the diagnostic manoeuvres that
help assess the following conditions: tendinitis of
of the various tendons of the rotator cuff, sub-
acromial impingement syndrome, tears of the ro-
tator cuff, and tenosynovitis of the long head of the
biceps.
Supraspinatus Tendinitis
Damage to this tendon causes pain over the bici-
pital groove, where the tendon attaches to the grea-
ter head of the humerus. Pain radiates to the “V”
of the deltoid muscle, but the range of motion is
unaffected (Bélisle and Croteau, 1988). Figure 6.4
Jobe’s Manoeuvre
Diagnostic Manoeuvres
Resisted abduction (Figure 6.3) is accomplished by placing the
patient’s arm at an angle of 30° and asking her or him to push
against the examiner’s hand. Pain during this manoeuvre usually
indicates damage to the tendon of the supraspinatus.
Jobe’s manoeuvre (Figure 6.4) is performed by abducting

the patient’s hand, thumbs down, to an angle of 90° and an-
gling it 30° forward. The patient is then asked to resist pres-
sure on the arm. Pain in the absence of weakness usually in-
dicates tendinitis of the supraspinatus. Inability to resist the
examiner’s downward force usually indicates a tendon tear.
27
SHOULDER TENDINITIS
Infraspinatus Tendinitis Subscapular Tendinitis and Teres Minor

This insertion tendinitis is primarily linked to external Tendinitis
rotation (Béliveau, 1993). It may also develop into These conditions appear with advanced functional
a tear and favour the development of supraspina- decompensation of the shoulder, and rarely occur
tus tendinitis. independently. They are however difficult to demon-
strate.
Diagnostic Manoeuvres
Symptoms are usually elicited by resisted external rotation of Diagnostic Manoeuvres
the forearm with the elbow pressed against the body and flexed Symptoms are elicited on resisted internal rotation of the fo-
at an angle of 90° (Figure 6.5). rearm with the elbow pressed against the side of the body and
flexed to an angle of 90° (Figure 6.7)
Patte’s manoeuvre (Figure 6.6) consists of resisting the pa-
tient’s active external rotation of the arm abducted to 90° and
in a position similar to that of a baseball pitcher’s. Pain on re-
sisted movement constitutes a positive test result.
Figure 6.5 Figure 6.7

Resisted External Rotation of the Forearm Resisted Internal Rotation of the Forearm
Figure 6.6
Patte’s Manoeuvre
28
Subacromial Impingement Syndrome There are several distinct stages to this syndrome,
This syndrome reflects a disruption in the sub- described by Neer (1983), reflecting different degrees
acromial region and may be caused by damage (ten- of dysfunction or incapacity of the glenohumeral
dinitis, bursitis) to tissue in the coracoacromial arch joint (Table 6.1). The existence of subacromial im-
or reduction of the space through which the ten- pingement syndrome or impingement syndrome
dons of the supraspinatus and long head of the bi- may be detected through demonstration of Neer’s
ceps pass. This space, termed the supraspinatus out- sign (Figure 6.9) or Hawkins’ sign (Figure 6.10).
let, is bounded by the anterior portion of the
acromion, the coracoacromial ligament, and the
acromioclavicular joint (Markes et al., 1994) (Fig-
ure 6.8).
Figure 6.8
Mechanism of Impingement
Coracoacromial ligament Relative avascular zone
Supraspinatus
tendon
Compression zone
ABDUCTION ADDUCTION
A B
Normal subacromial space Reduced subacromial space
29
SHOULDER TENDINITIS
Table 6.1
Stages of Impingement Syndrome
Stage Symptoms Examination results Physiopathology
First, or acute, Diffuse pain in the anterior- Normal passive and active Corresponds to an inflamma-
stage* lateral portion of the shoulder. movements. Painful arc tory phase: inflamed tendon,
Pain generally follows present. edematous bursa, bursal
prolonged work with the microhaemorrhages.
arm elevated anteriorly and
internally rotated.
Second stage Pain upon elevating the arm, Signs of bursitis and Bursal fibrosis, with either
(chronic state)* ceasing with the arm at rest. tendinitis, in addition to tendinitis of the supraspina-
the above. tus or tenosynovitis of the
long head of the biceps.
Third stage Constant pain. Nocturnal pain Passive movements are Corresponds to a degenera-
prevents patients from usually complete. tive phase, with more signifi-
sleeping on the affected cant tendon damage.
shoulder.
Weakness in anterior eleva- Active movements are Possible degenerative

tion or in abduction indicates reduced and painful. rupture of supraspinatus or
the beginning of a tear. More the long head of the biceps.
significant difficulty indicates a Infraspinatus may also be
massive tear. affected.
* According to the author, the order of appearance of the first and second stages may be reversed.
Source: Neer, 1983
30
Figure 6.9 Figure 6.10
Neer’s Sign Hawkins’ Sign
90°
90°
Diagnostic Manoeuvre Diagnostic Manoeuvre

To perform Neer’s test (Figure 6.0), the examiner stands be- To perform Hawkins’ test (Figure 6.10), the examiner flexes
hind the patient and stabilises the scapula by placing a hand the arm and elbow of the patient to 90°, brings the arm ho-
on the shoulder. With the other hand, the examiner takes the rizontally in front of the chest, and then lowers the forearm,
patient’s arm in order to perform assisted active flexion. Pain forcing the shoulder into internal rotation. Pain indicates re-
in the range of 60°-120° constitutes a positive test result. This duced tendon mobility under the coracoacromial ligament
test reproduces the rubbing of the tendons of the rotator cuff (Pujold, 1983).
against the anterior border of the acromion and the inferior
face of the coracoacromial ligament (Pujold, 1993).
31
SHOULDER TENDINITIS
Rotator Cuff Tear Figure 6.11
The rotator cuff is very sensitive to tears, such tears Drop-Arm Manoeuvre
being found on autopsy in 40% of subjects older
than 50 years (Leduc, 1986). These may result from
microtrauma associated with repeated or prolonged
stress of the muscle and tendons of the shoulders,
as well from degenerative changes associated with
aging (Iannoti, 1994). The clinical profile of partial
tears is often asymptomatic and essentially mirrors
that of shoulder tendinitis.
Total rupture of the rotator cuff, corresponding

to a tear of the tendon through its entire thickness,
is rather rare. It most commonly affects the tendon
of the supraspinatus, followed by the tendons of
the infraspinatus and subscapularis. Falls are a fre-
quent cause. If the rupture is recent, abduction is
impossible and patients will exhibit a character-
istically raised shoulder when attempting abduction
(Leduc, 1986). Three types of manoeuvres may help
diagnose partial or complete tears of the rotator cuff:
Jobe’s test (Figure 6.4) for the supraspinatus ten-
don, resisted active external rotation of the forearm
(Figure 6.5) for tears involving the infraspinatus, and
the falling arm manoeuvre (Figure 6.11) for com-
plete tears of the rotator cuff. Clinical evaluation may Diagnostic Manoeuvre
be complemented by medical imaging techniques The examiner completely abducts the arm of the patient, who
such as radiography, arthrography, sonography, and attempts to lower it slowly and progressively. In cases of com-
magnetic resonance (Table 6.2). plete rupture of the supraspinatus tendon, progressive lowe-
ring of the arm fails abruptly at approximately 90° of abduc-
tion, due to pain.
Table 6.2
Imaging Techniques for Tears of the Rotator Cuff
Radiography Arthography Magnetic Resonance Echography
Imaging
Tear of Normal in the early Reference technique. This diagnostic test is Allows
the rotator stages. Reduced Presence of contrast becoming the technique identification
cuff subacromial space medium between the of choice. of damage to
in later stages. glenohumeral and Validity the rotator cuff
subacromial joints Partial tear: primarily
32 indicates a complete – Sensitivity: 67-89% involving
tear of the rotator cuff. – Specificity: 84-89% the supraspinatus
Validity Total tear: tendon.
– Sensitivity: 71-100% – Sensitivity: 80-97% Validity
– Specificity: 71-100% – Specificity: 93-94% Unknown
Source: Irwin et al., 1998; Cuomo et al., 1997; Murnaghan, 1988; Marks et al., 1994; Ladd, 1994
Tenosynovitis of the Long Head of the Biceps Figure 6.12
Damage to the long portion of this tendon gene- Resisted Elevation of the Arm
rally presents as well-localised pain over the ante-
rior shoulder, with possible radiation as far as the
elbow (Chipman et al., 1991). The physiopatholo-
gical process reflects:
– the long course of the tendon, with a 90° turn
and a encasement of the tendon in the inter-
tuberal groove
– mechanical stress (traction, friction), maximal
over the curve of the lesser tuberosity (Lacoste,
1993; Dupuis-Leclaire, 1986)
Palm-up, or Speed’s test
Diagnostic Manoeuvres Figure 6.13

Tenosynovitis of the long head of the biceps may be demon- Resisted Flexion of the Elbow
strated by resisted elevation of the arm with the forearm su-
pinated (Figure 6.12). This manoeuvre, also known as Speed’s
test or the palm-up test, reproduces the mechanism which
causes pain. This test is also positive in cases of partial rup-
ture of the tendon of the long head of the biceps. Such rup-
ture may occur following the appearance of tendinitis, and may
cause swelling at the entry to the bicipital groove during re-
sisted flexion of the elbow (Figure 6.13).
33
SHOULDER TENDINITIS
7 Summary of the Evaluation
Box 7.1
Clinical Aspects
EXTENT OF PROBLEMS None Slight Moderate Severe
Symptoms reported
– Frequency and intensity of symptoms (p. 17 and 18)
– Disruption of activities of daily living (p. 18)
Physical examination
– Abnormalities observed (p. 25)
– Abnormalities palpated (p. 25 and 26)
– Abnormalities noted during shoulder movements
(p. 26)
– Abnormalities noted during specific manoeuvres
(p. 27 to 33)
Details:
Differential diagnosis Yes No
– Damage to the structures surrounding the rotator cuff
(p. 13 and 14) ❏ ❏
– Damage in the cervicoscapular region (p. 15 and 16) ❏ ❏
– General or systemic damage (p. 16) ❏ ❏
Musculoskeletal stress None Slight Moderate Severe
– During previous work (p. 21)
– During current work (p. 21 to 24)
– In sports-related, recreational, or household activities
(p. 24)
Diagnosis and opinion on the relation to work 35

8 Guidelines for Therapeutic
and Preventive Interventions
This section presents some fundamental therapeu- PREVENTION GUIDELINES

tic and preventive principles, rather than describing
In cases of shoulder tendinitis in which it is pos-
specific interventions in detail. These principles
sible to identify probable causes of stress it may
should prove useful in developing an approach to
prove useful to suggest preventive measures.
the management of shoulder tendinitis. It is impor-
Table 8.1 lists preventive measures that take into ac-
tant to note that therapeutic success depends on a
count the specific diagnosis and extent of mus-
knowledge of etiological factors and requires full
culoskeletal strain.
understanding of the anatomy and biomechanics of
the scapular region.
This preventive approach incorporates corrective
measures which address activities which strongly in-
THERAPEUTIC GUIDELINES fluence the development of shoulder tendinitis. The
implementation of these measures is essential to pre-
The goal of the therapeutic approach is to reduce
vent aggravation and recurrence of injury, and ac-
pain, reestablish joint mobility, improve function,
centuation of the symptoms with return to or conti-
strength the shoulder muscles, and prevent ag-
nuation of work.
gravation and recurrence (Marks et al., 1994). The
algorithms presented in Figures 8.1 and 8.2 describe
the therapeutic regime for patients suffering from
shoulder tendinitis or rupture of the rotator cuff.
Table 8.1
Preventive Approach
Musculoskeletal strain
Diagnosis Significant Not significant

+ –
Evidence of shoulder + – Modification of activities – Treatment of causal factors
tendinitis – Reduction of musculoskeletal strain – Modification of activities 37
– Corrective ergonomic interventions
No evidence of shoulder – – Reduction of musculoskeletal strain – Information on risk factors

tendinitis – Corrective ergonomic interventions
Figure 8.1
Therapeutic Intervention Flow-Chart
Shoulder tendinitis
▲
▲ ▲
Identification of risk factors
Acute + Chronic
Control of pain
– rest
▲
▲
– ice
– NSAID
▲
▲ ▲
Improvement No improvement
▲ ▲
– Progressive mobilisation Consider

Improvement
▲
▲
– Muscle strengthening infiltration*
– Functional reeducation
▲ ▲
Interventions to modify risk factors No improvement
▲
After 6 months,
consider surgery
*Repeated infiltrations may lead to tendon atrophy.
Figure 8.2
Therapeutic Approach to Tears of the Rotator Cuff
Incomplete
Tears of the rotator cuff Physiotherapy ▲

▲
Complete Persistant pain lasting more

than 3 months or significant
functional impairment
▲
38 Arthrography or
magnetic resonance imaging
▲ ▲
Acute, patient Surgery
▲
older than 60 years

CONCLUSION
This guide was designed to help physicians, who in recent years have been faced
with an increase in the number of consultations for musculoskeletal problems of pos-
sible occupational etiology. The core elements of current knowledge on the subject
have been reviewed and an approach that facilitates the documentation of the inju-
ry’s clinical aspects and its dependence on occupational musculoskeletal strain pre-
sented. Furthermore, a therapeutic approach that integrates preventive elements de-
signed to reduce the impact of risk factors has been outlined.
39
BIBLIOGRAPHY
BÉLISLE, C., CROTEAU, S., 1988, “La tendinite sus-épineuse”, DÉZIEL, J., 1995, Introduction à l’anatomie clinique. Sys-
Le Médecin du Québec, July: 25-31. tème locomoteur, Faculté de médecine, Université de
Montréal, Département d’anatomie.
BÉLIVEAU, P., 1993, “Mouvements répétitifs du membre
supérieur”, Colloque sur les mouvements répétitifs DIMBERG, L., OLAFSSON, A., STEFANSSON, E., ODEN, A.,
du membre supérieur, Montréal, Association des ANDERSON, G.B.J., HANSSON, T., HAGERT, T., 1989, “The
médecins du travail du Québec. correlation between work environment and the
occurrence of cervicobrachial symptoms”, Journal
BERGER, A.C., KLEINERT, J.M., 1991,“Work related vascular
of Occupational Medicine, 31(5): 447-458.
injuries and diseases”, in Occupational Hand and
Upper Extremity Injuries and Diseases, Kasdan, M.L. DUPUIS, M., 1995, “La tendinite du musicien: thème et
(dir.), Philadelphie, Hanley & Belfus, p. 319-339. variations”, 2nd Conférence scientifique internationale
sur la prévention des lésions musculo-squelettiques
BJELLE, A., HAGBERG, M., MICHAELSON, G., 1981, “Occu-
liées au travail (PREMUS ’95), Montréal, Institut de
pational and individual factors in acute shoulder-neck
recherche en santé et en sécurité du travail du Québec.
disorders among industrial workers”, Bristish Journal
of Industrial Medicine, 38: 356-363. DUPUIS, M., 1994, “Tendinites et autres lésions dues aux
gestes répétés du musicien”, Actualité médicale,
CAILLET, R., 1985, L’épaule. Collection de rééducation
March: 11-14.
fonctionnelle et de réadaptation, 2nd edition, Paris,
Masson, 144 pages. DUPUIS, M., LECLAIRE, R., 1986, Pathologie médicale de
l’appareil locomoteur, Saint-Hyacinthe, Edisem, and
CHIPMAN, J.R., MORTON, L.K., GAMACHO, G., 1991, “Tendi-
Paris, Maloine, 999 pages.
nitis of the Upper Extremity”, in Occupational
Hand and Upper Extremity Injuries and Diseases, HAGBERG, M., SILVERSTEIN, B., WELLS, R., SMITH, M.J.,
Kasdan, M.L. (dir.), Philadelphie, Hanley & Belfus, HENDRICK, H.W., CARAYON, P., PÉRUSSE, M. (1995), Work
p. 403-431. related musculoskeletal disorders (WMSDs): a refer-
ence book for prevention, scientific editors: Kuorinka,
CHOQUETTE, D., 1988, “Bursites et tendinites ou le signe
I., Forcier, L., publishers Taylor and Francis, London,
de la douleur”, Le clinicien, June: 65-86.
421 pages.
CNOCKAERT, J.C., CLAUDON, L., 1994, “Biomécanique des
HAGBERG, M., WEGMAN, D.H., 1987, “Prevalence rate and
tissus mous; modèles biomécaniques d’analyse des
odd ratio of shoulder-neck diseases in different
contraintes au poste de travail dans le contexte des
occupational groups”, British Journal of Industrial
TMS”. Document pour le médecin du travail. INRS,
Medicine, 445: 602-610.
58: 140-147.
HAZELTINE, M., 1990, “L’épaule douloureuse: comment s’y
CUOMO, F., LONNER, J.H., SPIVAK, J.M., ZUKERMAN, J.D., 1997,
reconnaître”, Le Clinicien, November: 47-57.
“Clinical evaluation of the neck and the shoulder”,
in Musculoskeletal Disorders in the Workplace, IANNOTTI, J.P., 1994, “Evaluation of the painful shoulder”,
Nordin, M., Andersson, G.B.J., Pope, M.H. (dir.), Journal of Hand Surgery, 7(2): 77-83. 41
St-Louis, Mosby, p. 360-377.
DAWSON, M.D., HALLETT, M., MILLENDER, L.H., 1990, Entrap-

ment neuropathies, Boston, Toronto, London, Little,
Brown and Company, 434 pages.
IRWIN, J.P., AARON, J.O., PETERSON, G.H., THEBERT, A.R., 1998, LEFFERT, R.D., 1992, “Disorders of the neck and shoulder
“How the radiologist can help to evaluate injuries in workers”, in Occupational Disorders of the Upper
and disease of the upper extremity”, in Occupational Extremity, Millender, L.H., Louis, D.S., Simmons, B.P.
Hand and Upper Extremity Injuries and Diseases, (dir.), New York, Churchill Livingstone, p. 177-200.
Kasdan, M.L. (dir.), Philadelphie, Hanley & Belfus,
LEVINE, D.W., SIMMONS, B.P., KORIS, M.J., DALTROY, L.H.,
p. 409-436.
HOHL, G.G., FOSSEL, A.H., KATZ, J.N., 1993, “A self-
JACKINS, S., MATSEN, F.A., 1994, “Management of shoulder administered questionnaire for the assessment of
instability”, Journal of Hand Surgery, 7(2): 99-106. severity of symptoms and functional status in carpal
tunnel syndrome”, Journal of Bone and Joint Surgery,
JÄRVHOLM, U., PALMERUD, G., KARLSSON, O., HERBERTS, P.,
75-A: 1585-1592.
KADEFORS, R., 1990, “Intramuscular pressure and
electromyographic in four shoulder muscles”, Journal MALCHAIRE, J., INDESTEEGE, B., 1997, Troubles musculo-
of Orthopaedic Research, 9: 600-619. squelettiques, analyse du risque, Bruxelles, Institut
National de Recherche Scientifique sur les Conditions
KAPANDJI, I.A., 1983, Physiologie articulaire, tome 1:
de Travail (INRCT), 122 pages.
Membre supérieur, Paris, Maloine, 296 pages.
MARKS, P.H., FU, F.H., 1997, “Treatment of shoulder dis-
KATZ, J.N., GELBERMAN, R.H., WRIGHT, E., LEW, R.A., LIANG,
orders”, in Musculoskeletal disorders in the workplace,
M.H., 1994, “Responsiveness of self-reported and
Nordin, M., Andersson, G.B.J., Pope, M.H. (dir.), St-
objective measure of disease severity in carpal tunnel
Louis, Mosby, p. 394-410.
syndrome”, Medical Care, 32: 1127-1133.
MARKS, P.H., WARNER, J.J.P., IRRGANG, J.J., 1994, “Rotator
KENDALL PETERSON, F., KENDALL MCCREARY, E., 1988, Les
cuff disorders of the shoulder”, Journal of Hand
muscles. Bilan et étude fonctionnelle, 3rd edition,
Therapy, 7(2): 90-98.
Paris, Maloine, 325 pages.
MURNAGHAM, J.P., 1988, “Uncovering the causes of
KROEMER, K.H.E., 1989, “Cumulative trauma disorders:
shoulder pain”, Medecine North America, October:
Their recognition and ergonomic measures to avoid
4807-4818.
them”, Applied Ergonomics, 20(4): 274-280.
NEER, Charles S., 1983, “Impingement lesions”, Clinical
LACOSTE, P., 1993, Les tendinites et les gestes répétés,
Orthopedic and Related Research, 173: 70-77.
diagnostic et traitement, 25th symposium de phy-
siatrie de l’hôpital Notre-Dame. NIOSH, 1997, Musculoskeletal Disorders and Workplace
Factors: a critical review of epidemiologic evidence
LACOSTE, P., 1994, “Tendinites et gestes répétés du
for work-related musculoskeletal disorders of the neck,
sportif. Le cahier de formation médicale continue”,
upper extremity and low back, Cincinnati, National
L’Actualité médicale (suppl.), March: 4-10.
Insitute for Occupational Safety and Health.
LADD, A.L., 1994, “Diagnostic Imaging of the shoulder”, PUJOL, M., 1993, Pathologie professionnelle d’hyper-
Journal of Hand Surgery, 7(2): 84-89. sollicitation: atteinte périarticulaire du membre
LECLAIRE, R., 1986, “Rachis cervical”, in Pathologie médicale supérieur, collection de monographies de Médecine
de l’appareil locomoteur, Dupuis, M., Leclaire, R. (dir.), du travail, Paris, Masson, 168 pages.
Saint-Hyacinthe, Edisem, and Paris, Maloine, p. 173- ROSSIGNOL, M., PATRY, L., BAILLARGEON, M., COSTA, M.J.,
221. CENTOMO, P., DAVID, M.J., HAIJAN-TILAKI, K.O., HANLEY,
LEDUC, B., 1986, “L’Épaule”, in Pathologie médicale de J.A., SACKS, S., 1997, Document de support aux
42 Guides pour le diagnostic des lésions attribuables
l’appareil locomoteur, Dupuis, M., Leclaire, R. (dir),
Saint-Hyacinthe, Edisem, and Paris, Maloine, p. 477- au travail répétitif. Jurisprudence. Cadre de la prati-
505. que clinique au Québec. Bilan des connaissances
scientifiques. Montréal, Institut de recherche en santé
LEFFERT, R.D., 1992, “Thoracic Outlet Syndrome”, in Hand et en sécurité du travail du Québec, 169 pages.
Clinics, Ghazi M. Rayan (dir.), Philadelphie, W.B.
Saunders, p. 285-297.
SAGERMAN, S.D., TRUPPA, K.L., 1998, “Diagnosis and man- TUBIANA, R., THOMINE, J.-M., 1990, La main, anatomie
agement of occupational disorders of the shoulder”, fonctionnelle et examen clinique, Paris, Masson,
in Occupational Hand and Upper Extremity Injuries 210 pages.
and Deseases, Kasdan, M.L. (dir.), Philadelphie,
TUBIANA, R., 1981, The Hand, vol. 1, Philadelphia, W.B.
Hanley & Belfus, p. 277-284.
Saunders, 755 pages.
S INCLAIR , M.A., 1992, “Subjective assessment”, in
VENDER, M.I., RUDER, J.R., POMERANCE, J., TRUPPA, K.L., 1998,
Evaluation of Human Work: A Pratical Ergonomics
“Upper extremity compressive neuropathies”, in
Methodology, Wilson, J.R., Corlett, E.N. (dir.),
Occupational Hand and Upper Extremity Injuries
Washington (DC), Taylor and Francis, p. 58-88.
and Diseases, Kasdan, M.L. (dir.), Philadelphie,
SOMMERICH, C.M., MCGLOTHLIN, J.D., MARRAS, W.S., 1993, Hanley & Belfus Inc., p. 83-96.
“Occupational risk factors associated with soft
WILLIAMS, M., LISSNER, H.R., LEVEAU, B., 1986, Biomé-
tissue disorders of the shoulder: A review of recent
canique du mouvement humain, Ville Mont-Royal,
investigations in the literature”, Ergonomics, 36(6):
Décarie Éditeur, and Paris, Éditions Vigot, 250 pages.
697-717.
43
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3

GUIDE TO THE DIAGNOSIS OF

Louis Patry holds a degree in medicine from Laval University and

Marie-Jeanne Costa holds a nursing degree from the Institut

Martine Baillargeon holds a degree in medicine from the

Translation: Les Services Organon, Steven Sacks

Jean Yves Savoie

Chapter 1 – General Considerations

Chapter 3 – Differential Diagnosis

Chapter 4 – Clinical Considerations

Chapter 5 – Recording of Information on Exposure Factors

Chapter 6 – Physical Examination of the Shoulder

Chapter 7 – Summary of the Evaluation .................................................................... 35

Chapter 8 – Guidelines for Therapeutic and Preventive Interventions

Box 5.1 Questions about Previous Jobs ................................................................... 21

TERMINOLOGY executed above shoulder height, because of the load

There have been few epidemiological studies of

Bone Synovial membrane (outer layer)

Periosteum Synovial membrane Muscle

During abduction and elevation, this group of

The rotator cuff and the tendon of the long head

Innervation of the Rotator Cuff and Biceps Muscles

Anterior View Posterior View

PHYSIOPATHOLOGY Figure 1.8

The most commonly advanced physiopathological Critical Zone of the Tendons

Contributory Factors for Tendinitis of the Rotator Cuff and

Source: Hagberg et al., 1995; Dupuis-Leclaire, 1986

Repetition Force Posture

Individual characteristics Health status Psycho-social factors

quantify, repetition has been clearly shown to be Musculoskeletal loading—be it occupational,

Movements Most Commonly Associated with the Development

Shoulder rotation Abduction and flexion of the shoulder

Extension Shoulder flexion

Throwing objects Working with the arms elevated

CTD Risk Cofactors

Many pathologies involving the structures surround- Figure 3.1

INJURY TO STRUCTURES SURROUNDING

Local palpation is painful and patients may ex-

The chronic form presents with a more subtle

Clinical Signs of Subacromial Bursitis

Clinical Summary of Adhesive Capsulitis

Scalenus medius Scalenus anterior

Carrying loads directly on or slung across the shoulder Pectoralis minor

Shoulder Instability SYMPTOMS

Evaluation of patients exhibiting glenohumeral

The following questions should be asked of all

In addition, the impact of the symptoms on daily

Location of Symptoms (Where?)

Questions about Activities of Daily Living

Presentation and Clinical Severity of Symptoms

To establish the etiological link between shoulder Current Work

Questions about Previous Jobs

General Questions Concerning Occupational Activities and

Questions about Activities that Stress the Shoulder

Cofactors which increase Never Occasionnally Regularly

Questions about Work Organisation

– Do you feed a machine tool at

– Do you feel time or production pressures?

– Do you have to pay constant attention?