Approach to Shoulder Pain

Question 1

Most common extrinsic cause of shoulder apin and others

Answer 1

Cervical spine abnormalities

Cardiac, lung/pleura, intraabdominal, neurologic

Question 2

Atrophy of muscles above and below scap spine

Superior porminance of distal clavical

Medial porm of SC joint

Answer 2

Chornic supraspinatus - above

Chronic infraspinatus - below

Dislocation

Dislocation

Question 3

Tenderness over

Clavicle
AC joint
Inferior to AC joint
Bicipital groove
Sternoclavicular

Answer 3

Fracture

Separation or arthritis

Aubacromial burisits

Bicipital tendinopathy or tear

Fracture

Question 4

Active vs. passive ROM

Answer 4

Active only - RC tenidnopathy, biceps tendinopathy, or subacromial burisits

Both - glenohumeroal joint (RA or frozen) or AC sep/OA

Question 5

Abduction between 60 and 120 (painful arc)
Abduction between 120 and 180
Ext rotation pain
Int rotation pain

Answer 5

RC dz
AC joint
Teres minor or infraspinatus
Subscapularis

Question 6

Jobe test

Answer 6

PLace arm in 90 of abduction, 30 degrees of forward flexion and internal rotation..ask to resist dowward

Pain or weakness is RC tendinopathy or tear (supraspinatus)

Question 7

Neer impingeent sign

Answer 7

One hand stabilizes scap while other flexes with patient’s straight arm

Pain suggests RC tendinopathy or impingmeent syndrome

Question 8

Hawkins Kennedy test

Answer 8

One hand stabilizes scap while other hand internally roates the part flexed 90 degrees at elbow

Pain or discomfort is RC tenidnopathy or impingement syndrome

Question 9

RC injury

Answer 9

Traumatic, overuse, or combo

Most common supraspinatus

Shoulder weakness and anterolateral pain worse at night and with overhead motion

Pain between 60 and 120 abduction and inability to abduct beyond 90

Weakness in empty can abduction

Question 10

Labral tear

Answer 10

Superior labrum anterior to posterior tear is common if throwing

Usually acute from falling on outstreatched or direct blow

Decline in throwing function or anterior pain in shoulder

Question 11

AC separation

Answer 11

Direct trauam to superior or laterla shoulder or flal on outstretched

Rupture the AC ligament

Pain loalized worse with apssive adduction across the body

X-ray will confirm

Question 12

Biceps tendon tear

Answer 12

Acute onset after lifting

Hx of anterior shoulder pain aggravated by carryning or overhead reaching

Tenderess of bicipital groove, lump above the antecubital fossa or weakness of elbow flexion

Question 13

GH disclocation

Answer 13

Anterior dislocation from abducted, externally roated and extedned arm (blocking a shot)

Holds arm abducted and extenrally roates and resists GH movement

Loss of normal shoulder appearance with prominent acrominon

Axillary nerve injured so loss of sensation just distal to deltoid

Question 14

Transient brachial plexopathy

Answer 14

Actue trauamtic contact ot neck or aneterior shoulder

Sfeeling in supraclvicular area raditating dwon arm in cricumferential, non dr mpattern

Motor deficits of C5-C6 (deltoid and supraspinatus)…weakness of abduction and/or empty can shoulder abduction

Question 15

Clavicle fracture

Answer 15

Fall onto shoulder

Middle thrid of the bone…followed by distal

Localized pain over clavicle worse with arm movement

May have ecchymosis or hematoma

Point tenderenss/crepitus

Most nondisplaced tx with immobilization

Question 16

RC tendinopathy

Answer 16

Older adolescents and young adults in throwing sports

impingement narrowing between acromon and RC tendons…acromion rubs against tendons and subacromial bursa

Most commonly supraspinatus

Shoulder weakness and anterolateral hsoulder pain worse at night and with overhead

Pain with active abduction between 60 and 120 and pain with empty can abduction

Question 17

Proximal humeral epiphysiolysis

Answer 17

Little lead shoulder between 10 and 15

Torque of humerous leadsto microtrauam and irritatin of proximal humeral physis…widing of the physis

Worsening lateral shoulder pain

Question 18

GH instability

Answer 18

Young women with poor muscular development or atheletes iwht constant overhead throwing

Giving way or looseness of the joint

Anterior instability and wors ewith shoulder abduction and rotation

Exam may show increased ROM of the GH joint and patient apprehension with extreme abduction and extenral rotation

Question 19

Labral tear

Answer 19

SLAP is most common

Clikc when parm placed in throwing position

Click on any manuever that compresses and rotates the head into the glenoid

MRI needed

Question 20

Biceps tendinopathy

Answer 20

Uncmmon by inteself but accompanies GH instability in younger

Anteriro shoulder radiating to distal biceps with tenderness of bicipital groove

Question 21

RC injury older

Answer 21

Stillsame sx but may have acute onset

Question 22

AC joint separation older

Answer 22

Same as in younger

Question 23

Biceps tendon tear older

Answer 23

Degerative tendinosis plus actue injry

Most have hx of anterior shoulder pain
Sudden painful extension of a flexed elbow after full contraction

Question 24

Pseudogout

Answer 24

Think sudden onset of shouder pain and another joint

Question 25

Adhesive capsulitis

Answer 25

Gradual development of limited active and passive motion

Diabetes, thyroid, prolonged immobilization ad shoulder injuries

Inflammation of joint capsule followed by fibrosis of synovial lining

40-70 y/o

Initial inflam phase with diffuse pain worse at night and with sitffnesss

Fibrotic second phase with loss of motion 4-12 months

On exam, patients have limited ROM in multiple planes

PT and intra-artc GCs

Question 26

RC tendinopathy

Answer 26

Most common cause of recurrent pain in older adults

Looks like a tear

Question 27

Subacromial burisits

Answer 27

Supraspinatus tendon passes through space between acromion and subacromial bursa…inflammation of bursa rubs tendon against acromion and subacromial bursa

identical to RC tendinopathy

Question 28

Ac joint OA

Answer 28

Pain localized worse with passive adduction across the body

Xpray can confirm with typical OA findings

Question 29

RA

Answer 29

Symmetric hsoulder involement with small joints of hands

Question 30

PMR

Answer 30

Over 50

Symmetric pain with lots of morning stifness

Elevated ESR and low-dose GC response