Primary Care Management of Shoulder Pain

Question 1

Hx of patient with shoulder pain?

Answer 1

• Pain - can be in neck, shoulder or upper arm
• Stiffness
• Deformity, e.g: AC joint prominence
• Loss of function, e.g: carrying, brushing hair, fastening bra and reaching up

Question 2

Causes of shoulder pain?

Answer 2

Trauma (not often); occasionally, there is a trauma Hx in the past

Other causes:
• Cardiac
• Gallbladder
• Referred pain from the neck
• Polymyalgia rheumatica (usually bilateral)

Question 3

Physical examination of shoulder pain?

Answer 3

Look:
• Watch how the patient manages to undress
• Asymmetry in the shoulder
• Deformity
• Scars 

Feel:
• Bony landmarks
• Any tenderness
• Check axilla
• Get patient to pinpoint the site of pain

Move:
• Abduction (allowed by GH joint and scapular rotation) - pain felt between 70-120 degrees indicates shoulder impingement syndrome
• Active and passive external and internal rotation (external rotation testing can pick up arthritis and frozen shoulder)

Question 4

Management of shoulder pain?

Answer 4

Encourage mobilisation

Short-term NSAIDs (if no contraindications)

Local injection of, e.g: depomedrone with lignocaine

Physiotherapy (mainstay of treatment for most cases of shoulder pain)

Time (most cases of shoulder pain last 1 year)

Question 5

Common causes of shoulder pain?

Answer 5

Shoulder impingement (pain is often felt in the upper arm):
• Rotator cuff problems, esp. supraspinatus tendonitis (35-65 years)
• Sub-acromial bursitis (pain is  generalised)

AC joint disease (e.g: trauma in younger adults and arthritis in elderly)

Question 6

Less common causes of shoulder pain?

Answer 6

Frozen shoulder (40-60 years AND more common in diabetics, RA and with steroids); it is rare in young people

OA/RA of the shoulder - pain is very specific and is pin-pointed to the AC joint

Recurrent dislocation and shoulder instability

Question 7

Ix with shoulder pain?

Answer 7

FBC to look at inflammatory markers, e.g: CRP, ESR , PV

X-ray (rarely required)

Question 8

DD of shoulder pain?

Answer 8

Supraspinatus tendonitis

Sub-acromial bursitis

Frozen shoulder (AKA adhesive capsulitis)

OA of the AC or shoulder joints

Referred pain from the neck or cardiac in nature

Question 9

3 conditions that prevent external rotation?

Answer 9

• Arthritis
• Frozen shoulder
• Locked posterior dislocation