Shoulder Pain Flashcards
Joint Exam
- Inspection
- Palpation
- Range of Motion
- Specialty testing
Extremity Exam
- Inspection
- Palpation
- Range of Motion
- Specialty testing
- Reflexes
- Assess Neurovascular status
Shoulder Pain
• 3rd most common musculoskeletal complaint
• The only joint in the human body where tendons (rotator cuff) pass between bones (acromion and humerus)
– great flexibility
– Great Susceptibility to injury
Inspection
• Look at the joint. • Look at the extremity. • Compare them to the opposite side • What do you see? – Splinting? – Symmetric? – Color? – Scars? – Abrasions? – Injuries? – Swelling? – Ecchymosis? – Deformity?
Palpation
• Is the joint warm when compared to the opposite joint?
• Is there tenderness to palpation? – Where is the tenderness?
• Is there edema?
• Is there an Effusion?
• What hurts?
– The entire joint?
– Only one area?
Range of Motion
(A) Flexion. (B) Extension. (C) Abduction. (D) Adduction. (E) Internal rotation. (F) External rotation. (G) Horizontal abduction. (H) Horizontal adduction.
Specialty Test for Shoulder
• Tests for subacromial impingement and rotator cuff tendon injury – Painful Arc test – Neer impingement sign – Hawkins impingement sign – Yergason sign – Empty Can test – Drop Arm test • Tests for Acromioclavicular joint/ligament injury – Cross arm test
Painful Arc Test
• Tests for subacromial impingement and rotator cuff tendon injury
• Positive LR = 3.7 / Negative LR = .36
• Highest positive LR of all Rotator
cuff maneuvers
• Lowest Negative LR of all rotator cuff maneuvers
• A positive test is shoulder pain from 60 to 120 degrees
– indicates subacromial impingement and/or rotator cuff injury
How do I Evaluate a Patient with Joint Pain?
- Determine stability of patient and stabilize if needed
- Develop and Work Through Differential Diagnosis
- Assessment and Plan
DDX: Causes of Shoulder Pain
- Brachial plexus injury •
- Fracture •
- Bursitis •
- Cervical radiculopathy •
- Glenohumeral dislocation •
- Frozen shoulder (Adhesive Capsulitis) •
- Referred pain •
- Impingement •
- Osteoarthritis….
Shoulder Pain–> Traumatic
- Bone (fractures, dislocations)
- Soft Tissues (myofascial, rotator cuff…)
- Joint (cartilage, joint capsule…)
Shoulder Pain–> Atraumatic
- Intrinsic-the shoulder as a whole (overuse, shoulder instability, subacromial bursitis…)
- Extrinsic/Referred - no shoulder pathology at all with normal shoulder exam
Fractures
- Clavicle Fractures (mainly children)
- Proximal Humeral Fractures (mainly the elderly)
- Scapular Fracture (associated with blunt trauma)
Glenohumeral Dislocation
• 50 percent of all major joint dislocations • 3 types – Anterior dislocation • most common • accounting for 95 to 97 percent of cases – Posterior dislocation • 2 to 4 percent – Inferior dislocation (luxatio erecta, which means "to place upward") • 0.5 percent
Acromioclavicular Joint Injuries
• usually occurs from direct trauma to the superior or lateral aspect of the shoulder (acromion) with the arm adducted, such as a direct blow or falling onto the shoulder
• Physical Exam
-tenderness directly over the AC joint, possibly associated with deformity
Rotator Cuff Injuries
• Physical exam
– tenderness over the affected musculature or focal subacromial tenderness at the lateral or posterior- lateral border of the acromion
– the location of the rotator cuff deep to the deltoid makes palpation difficult and unreliable.
Rotator Cuff Diagnostics
- X-rays are not helpful
- MRI/Ultrasound are the tests of choice
Rotator Cuff Treatment
- Initial management is rest, ice, physical therapy
- Later management: orthopedic referral (if initial shows now improvement/if patient is suspect of a tear)
Impingement Syndrome
-Rotator Cuff
– symptoms resulting from compression of the rotator cuff tendons and the subacromial bursa between the greater tubercle of the humeral head and the lateral edge of the acromion process
Tendinopathy
-Rotator Cuff
– chronic injury to the supraspinatus (abduction) and/or infraspinatus (external rotation) tendons.
– develops as a consequence of repetitive activity, generally at or above shoulder height, which leads to tendon degeneration and microvascular insult.
Tendon Injury
-Rotator Cuff
– Sprain or Tear (partial or complete)
– occur as the end result of chronic subacromial impingement, progressive tendon degeneration, traumatic injury, or a combination of these factors.
– Most injuries occur primarily in the supraspinatus tendon
Extrinsic (referred) Causes of shoulder pain
• Neurologic – Cervical radiculopathy (C5-C6) – Brachial plexus lesions – Herpes Zoster – Spinal cord lesion – Cervical Spine DJD – Thoracic Outlet Syndrome • Cardiovascular – Acute Myocardial Infarction – Axillary vein thrombosis • Abdominal – Hepatobiliary disease – Diaphragmatic irritation • Intraperitoneal blood, perforated viscus • Pulmonary – Upper lobe Pneumonia – Apical lung tumor – Pulmonary Embolism
Intrinsic Causes of Shoulder Pain
- Overuse injuries
- Shoulder instability
- Rotator cuff tendinopathy or impingement syndrome
- Subarcomial bursitis
- Synovitis
- Adhesive capsulitis
- Bicepital tendinitis
- Osteoarthritis
- Myofascial pain
- Septic arthritis
- Gout/pseudo gout
Top Causes of Acute Shoulder Pain
• Rotator cuff injuries – the most common cause of shoulder pain in primary care • Fractures/dislocations – Fractures • clavicle and proximal humerus • Dislocations – glenohumeral joint • Acromioclavicular joint injuries – Sprains, tears • Myofascial injury
