Shoulder pain

Question 1

Probability diagnosis

Answer 1

Cervical spine dysfunction (referred pain)

Rotator cuff tendonopathy ± a tear

Adhesive capsulitis (glenohumeral joint)

Glenoid labral tears

Bicipital tendonopathy

Question 2

Serious disorders not to be missed

Answer 2

Cardiovascular:

• angina
• myocardial infarction

Neoplasia/cancer:

• Pancoast tumour
• primary or secondary in humerus

Infection:

• septic arthritis (especially children)
• osteomyelitis

Others;

• Axillary vein thrombosis
• Rheumatoid arthritis
• Intra-abdominal pathology, e.g. bleeding

Question 3

Pitfalls (often missed)

Answer 3

Polymyalgia rheumatica

Cervical dysfunction

Gout/pseudogout (uncommon)

Osteoarthritis of acromioclavicular joint

Winged scapula–muscular fatigue pain

Question 4

Masquerades checklist

Answer 4

Depression

Diabetes esp. adhesive capsulitis

Drugs, e.g. steroids, anabolic steroids

Thyroid disorder (rarely)

Spinal dysfunction

Question 5

Is the patient trying to tell me something?

Answer 5

Shoulder is prone to (uncommonly);

• psychological fixation for secondary gains
• depression and
• conversion reaction

Question 6

Key history

Answer 6

Indicate whether the neck or the shoulder (or both) is responsible for pt’s pain.

Enquire about features of movement:

• stiffness and restriction
• excessive movement/instability
• weakness
• rough versus smooth.

Question 7

Key examination

Answer 7

Examine the cervical spine then the affected shoulder;

• inspection
• palpation
• movement
• special tests for tendonopathies

Look for impingement and a painful arc with adduction

Undertake resisted movements for each tendon:

• • adduction for supraspinatus
• • internal rotation for subscapularis
• • external rotation for infraspinatus
• • elbow flexion for biceps

Question 8

Key investigations

Answer 8

ESR (polymyalgia rheumatica)

rheumatoid factor and anti-CCP

ECG (if ischaemic heart disease suspected)

imaging according to hx and exam e.g. high resolution USS

Question 9

Diagnostic tips

Answer 9

Consider dysfunction of the cervical spine, especially C4–5 and C5–6 levels, as a cause of shoulder pain.

Modern ultrasound is the investigation of choice for painful disorders of the rotator cuff.

An older person presenting with bilateral shoulder girdle pain has PMR until proved otherwise.