Shoulder Pain Flashcards
Epidemiology
Prevalence 21-34% in primary care; 3rd most common MSK complaint; in oyug pts often related to injuries (GH joint instability or overuse); in older pts more commonly rotator cuff tendinitis, tears, adhesive capsulitis, and OA
Anatomy
Glenohumeral (GH), acromioclavicular (AC), and sternoclavicular (SC) joints; Rotator cuff (RC) “SITS” muscles; Supraspinatus (abduction and external rotation; most commonly injured), Infraspinatus (External rotation and abduction0, Terese minor (external rotation and abduction), & Subscapularis (Internal rotation)
Cervical Disease
Pain radiating below the elbow, decrease C-spine ROM
Labral tear
Fall on outstretched arm or repetitive overhead loading activities; p/w deep shoulder pain catching sensation, instability
RC Impingement & Tendinopathies
Anterolateral pain worse with abduction and/or reaching, typically in context of repetitive activity at or above level of shoulder (swimming, wt lifting, tennis, throwing)
Biceps tendinitis
Gradual onset anterior shoulder pain typically with heavy lifting
RC tear
Pain and weakness w/lifting shoulder (ie combing hair); suspect full thickness tear if pain w/abduction 60-120 degrees (painful arc sign), weakness with external rotation and + drop arm test
Adhesive Capsulitis
Progressive decrease active and passive ROM, w/pain, often at night in pts w/DM, thyroid disease, trauma, and restricted ROM (ie stroke); plain films and MRI typically nml; clinical dx.
Osteoarthritis
> 50y, pain w/activity, stiffness, decrease ROM, crepitus w/arm elevation; may affect AC (pain w/elevation of arm >90 degrees) or GH joint (pain w/external/internal rotation when arm is in neutral position); radiographs necessary to distinguish from adhesive capsulitis.
GH joint instability
Shoulder pain in throwing athletes
Other etiologies of shoulder pain
Fracture, referred pain from C-spine herniation, nerve entrapment, MI, septic arthritis, UE DVT, PE, avascular necrosis, PMR
Differential
Cervical disease Labral tear RC impingement and tendonopathies Biceps tendinitis RC tear Adhesive capsulitis Osteoarthritis GH joint instability
Exam
Examin C-spine, both shoulders and arms, palpate AC, SC and GH joints, biceps tendon, subacromial bursa, trapezius muscles; distinguish pain w/ active motion (muscular or tendon) from passive motion (concerning for joint involvement); distinguish rotator cuff tear from impingement or bursitis by assessing weakness w/external rotation & abduction; assess sensation, reflexes, & motor strength for nerve impingement
Apley scratch test
Touch superior and inferior aspects of opposite scapula
rotator cuff injury or OA
Drop-arm test
Cannot smoothly adduct arm/shoulder to waist
rotator cuff tear
Neer test
Full pronate arm then place arm in full flexion
Subacromial impingement
Hawkin test
Elevate arm forward to 90 degrees while forcible internally rotating the shoulder
Subacromial impingement
External rotation
Flex both elbows to 90 degrees while the examiner provides resistance against external rotation
Teres minor & infraspinatus tear or impingement
Empty can/full can test
90 degree elevation in the scapula plane and full internal rotation (empty can) or 45 degree external rotation (full can); examiner applies downward pressure at wrist
supraspinatus tear or impingement
Yergasson sign
Elbow flexion to 70 degrees; pt forces supination against reistance
Biceps tendinitis
Workup
Image if hx trauma concerning for fracture/dislocation, or exam concerning for joint involvement/RC tear, gross deformity, localized swelling/tenderness over AC or SC joint, joint instability; consider imaging in pts w/persistent shoulder pain despite w/2-3 mos of conservative RX; start with radiograph
Radiograph
True AP (glenohumeral joint) Axillary lateral Y view (AC joint)
MRI w/o contrast
95% Se and SP in RC tears; can identify abnormality in asx pts; indicated w/persistent pain, unrevealing plain films, nonspecific H&P.
Arthrography
Invasive, good at identifying complete RC tears, labral tears, or capsulitis
Ultrasound
Good for complete RC tears, bursitis, but operator-dependent
CT
May be useful for subtle dislocation, prosthetic joints
General treatment approach
For most shoulder pain in older adults without e/o joint instability, marked muscle weakness or atrophy, or infection, initial trial of NSAIDs +/- PT (if limited ROM or strength) for 2-4 weeks; if no improvement, consider nerve block or referral; if impingement, tendinitis, or bursitis, earlier injection may be useful
Shoulder impingement treatment
Ice, rest, PT, glucocorticoid injection in refractory cases
Adhesive capsulitis treatment
PT. APAP; glucocorticoid injection, prednisone, or surgery referral for manipulation under anesthesia or release in refractory/severe cases
Osteoarthritis treatment
generally NSAIDs, PT, rest
Rotator cuff tears treatment
Surgical repair of acute, complete tears; rest, ice, NSAIDs, PT, glucocorticoid injection for partial thickness and chronic full thickness tears w/surgical referral in refractory cases
Dislocation or fracture treatment
Relocation and immobilization bu w/early ROM to prevent adhesive capsulitis, PT indicated
When to refer
Urgent eval needed in fracture, dislocation, separation, rotator cuff tear, joint instability/infection; ortho referral if gross deformity or joint instability as joint separation may require surgery; injury in high-functioning athletes; suspect full labral tear or full thickness tear; if sx not improving w/3 mos of conservative mgmt. and PT.
